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Primary care is certainly in the news today, with pro-found work force shortages predicted for primary care physicians by 2020, fewer medical students choosing primary care as a specialty, disgruntled in-practice physicians who are overworked and underpaid, and the uncertain position of primary care in the health care reform arena as major concerns for physicians and patients alike.
Is primary care–based health care a solution for our nation’s health care issues?
More than 300 payors, physician groups, insurers, and national consumer organizations who comprise the Patient-Centered Primary Care Collaborative (PCPCC) would offer a resounding “yes” in the form of the Patient-Centered Medical Home (PCMH) concept.
Principles of the Patient-Centered Medical Home
Personal physician: Each patient has an ongoing relation-ship with a personal physician trained to provide first con-tact, continuous, and comprehensive care.
Physician-directed medical practice: The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
Whole-person orientation: The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life: acute care, chronic care, preventive services, and end-of-life care.
Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
Quality and safety are hallmarks of the medical home:
- Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are de- fined by a care-planning process driven by a compassion- ate, robust partnership between physicians, patients, and the patient’s family.
- Evidence-based medicine and clinical decision–support tools guide decision making.
- Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.
- Patients actively participate in decision-making, and feedback is sought to ensure patients’ expectations are being met.
- Information technology is used appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication.
- Practices go through a voluntary recognition process by an appropriate nongovernmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the medical home model.
- Patients and families participate in quality improvement activities at the practice level.
Enhanced access to care is available through systems such as open scheduling, expanded hours, and new options for communication between patients, their personal physicians, and practice staff.
Payment appropriately reflects the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:
- It should reflect the value of physician and nonphysician staff patient-centered care management work that falls outside of the face-to-face visit.
- It should pay for services associated with coordination of care both within a given practice and between consult- ants, ancillary providers, and community resources.
- It should support adoption and use of health information technology for quality improvement.
- It should support provision of enhanced communication access such as secure e-mail and telephone consultation.
- It should recognize the value of physician work associated with remote monitoring of clinical data using technology.
- It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management ser- vices that fall outside of the face-to-face visit, as de- scribed before, should not result in a reduction in the payments for face-to-face visits).
- It should recognize case mix differences in the patient population being treated within the practice.
- It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.
- It should allow for additional payments for achieving measurable and continuous quality improvements.
Medical Home demonstration projects across the country have yielded high-quality care, significantly decreased cost of care, and enhanced reimbursement for physicians.
Recognition as a medical home has been developed by the National Committee for Quality Assurance (NCQA) in the form of 10 standards in three levels of recognition. This process serves to document the quality of coordinated care delivered by physicians. Although the requirements of levels of Medical Home recognition may vary by payor, higher reimbursement will be afforded higher levels of recognition. I encourage you to look at the NCQA website (http:// www.ncqa.org) to obtain comprehensive information about the recognition process.
The ACOFP Patient-Centered Primary Care Task Force is working to assist ACOFP members with the recognition process. I have charged my Board members and the other physician leaders who comprise the Task Force to continue their hard work so that all members will have the tools to become a recognized Medical Home.
In my mind, the PCMH concepts and osteopathic family medicine are synonymous. Osteopathic family physicians deliver the high-quality care our patients need and deserve. Join us in the journey for Medical Home recognition. Join us in the journey for providing the health care that we believe will serve as the backbone for health care reform in this country.
Osteopathically Yours,
Jan D. Zieren, DO, MPH, FACOFP dist.
ACOFP President