Medical home 2.0 The present, the future

Introduction

The patient-centered medical home (PCMH) is a way of organizing primary care so that patients receive care that is coordinated by a primary care physician (PCP), supported by information technologies for self-care management, delivered by a multi-disciplinary team of allied health professionals, and adherent to evidence-based practice guidelines. The goal of the PCMH is to deliver continuous, accessible, high-quality, patient-oriented primary care.

The American Academy of Pediatrics (AAP) introduced the medical home concept in 1967; more recently (2006), it was used in pilot programs for Medicare enrollees. PCMH’s potential to improve population-based outcomes and reduce long-term health care costs has its underpinning in the 2010 Patient Protection and Affordable Health Care Act (PPACA), under which new pilot programs are funded.

Our previous report¹ examined medical home models, their savings potential, and the implications for policy makers and key industry stakeholders. In this report, we outline the current state of the PCMH under new federal health reform legislation, review primary results from several pilots programs, and discuss how PCMHs may evolve going forward.

The medical home, pre- and post-reform

The PCMH is an innovative model of primary care delivery that espouses the coordination of care as a necessary replacement for volume-based incentives that limit PCP effectiveness. It is widely touted by the American Academy of Family Physicians (AAFP), AAP, the American Osteopathic Association (AOA) and the American College of Physicians (ACP) as a means of reducing long-term health care costs associated with chronic diseases.²

In 2007, these four societies released the Joint Principles of the Patient-Centered Medical Home, which are summarized in Figure 1.

Figure 1: Summary of joint principles of the patient-centered medical home

The “patient-centered medical home” is referenced 19 times in PPACA³ in the context of five major initiatives, which are detailed in Figure 2.⁴

Figure 2: PCMH references in the PPACA

Pilot programs and preliminary results

While trade and peer-reviewed literature references more than 100 planned or established PCMH pilot programs, results reporting (e.g., cost savings, population health improvements) is scarce. The referenced programs (a few of which are listed in Figure 3) vary widely in structural characteristics, scope of patient enrollment, disease mix, operating models, and sponsorship.

Figure 3: Pilot medical home programs in the U.S.

Academic research: Systematic review of results

Of the few substantive, academically rigorous studies conducted on PCMHs, three of the more robust are summarized below:

Study #1—Researchers at Harvard Medical School, Brigham and Women’s Hospital, and the Beth Israel Deaconess Medical Center identified 26 ongoing PCMH pilots,⁶ encompassing 14,494 physicians in 4,707 practices and five million patients. The team’s analysis spotlighted the highly variable structural, financial, and operational features of these PCMHs (Figure 4). In addition, the team observed that PCMHs employ one of two basic practice models: (1) a collaborative learning chronic care management model or (2) an external consultant-facilitated model.

Figure 4: Variability of 26 ongoing PCMH pilots⁷

Study #2—A 2010 study led by researchers at Harvard Medical School analyzed seven medical home programs (Figure 5) to assess the features of those deemed successful.⁸ Sponsors of these programs included prominent commercial health plans, integrated health systems, and government-sponsored programs: Colorado Medical Homes for Children, Community Care of North Carolina, Geisinger Health System, Group Health Cooperative, Intermountain Health Care, MeritCare Health System and Blue Cross Blue Shield of North Dakota, and Vermont’s Blueprint for Health. The selected programs were measured on improvements in the number of hospitalizations and savings per patient.

Figure 5: Analysis of seven PCMH pilot programs⁹

Despite the sample’s heterogeneity, the research team concluded that four common features were salient to the seven programs’ success:¹⁰

• Dedicated care managers
• Expanded access to health practitioners
• Data-driven analytic tools
• New incentives

Study #3—The National Demonstration Project (NDP) published its preliminary results in 2010 after examining medical home programs between 2006 and 2008. Designed by TransforMED, a subsidiary of the AAFP, the project was the first systematic test of PMCH effectiveness across 36 family practices in several states.¹¹ The research team concluded that the PCMH model is potentially effective in reducing costs and improving health status but requires significant investment and operating competencies that might be problematic for traditional practitioners.^12,13,14 Among the study’s major takeaways:

• Change is hard. Both facilitated and self-directed practices implemented 70 percent of NDP PCMH model components; however, implementation was challenging and disruptive.
• Some practices are better at changing than others. The study suggested that facilitation improved practices’ ability to change, termed “adaptive reserve.” Additionally, the practices’ “adaptive reserve” weakly correlated with their ability to put PCMH components in place.
• Practices that received help had an easier time. Facilitation also increased the adoption of PCMH components.
• IT implementation is easier than changing care delivery. While both the facilitated and self-directed groups easily implemented EMRs, practices struggled to implement e-visits, group visits, team-based care, wellness promotion, and population management.
  • Practices had to shift from physician-centered to patient-centered care—a difficult transition for physicians used to being responsible for the entire patient encounter.
  • Care pathways required front- and back-office coordination and significant training efforts.
• Patients may not be quick to appreciate the change. On the whole, patients did not perceive the transformation to be beneficial, likely because of disruption in the practice and lack of communication about the benefits of a medical home—e.g., the accessibility of nurse practitioners as opposed to waiting for a doctor’s appointment.

The quest for metrics

The scarcity of academic and trade industry research on PCMHs is problematic. Similarly, the fact that half of the PCMH pilots to date identified metrics for calculating results a priori is troublesome.¹⁵ Fortunately, credible organizations are making strides to bridge the gap in the quest for valid and reliable PCMH metrics. For example, the National Committee for Quality Assurance (NCQA) issued scoring guidelines that are widely used by pilot programs.¹⁶ Its Physician Practice Connections—Patient-Centered Medical Home (PPC-PCMH), shown in Figure 6, provides nine “must pass” standards, scored on a scale of up to 100 points, with three levels of recognition.¹⁷

Other notable measurement efforts include the Primary Care Assessment Survey,¹⁸ the Primary Care Assessment Tool,¹⁹ the Components of Primary Care Instrument,²⁰ the Patient Enablement Instrument, the Consultation and Relational Empathy measure, the Consultation Quality Index, and the Medical Home Intelligence Quotient.^21,22

Implications

The medical home model’s clinical and economic potential is promising; however, the precise features of an optimally successful program are somewhat elusive. Our findings:

• With significant investment, the PCMH yields results. Pilot data suggest that patient outcomes improve and costs are lower with PCMH implementation, but start-up and maintenance costs are high. In particular, fixed costs for information technologies and a multi-disciplinary care team are substantial.
• Physician adoption is a major challenge. Among the core competencies required of PCPs to effectively participate in medical home models are: (1) willingness to develop, update, and adhere to evidence-based clinical guidelines; (2) flexibility to incorporate feedback from care team members and patients; (3) willingness to use health information technologies (HITs) in diagnostics and treatment planning and routine patient interaction; and (4) willingness to take risk in contracting with payors (health plans/employers). Notably, these principles were espoused as the basis of the “future of medicine” by the Institute of Medicine (IOM) and are now incorporated in clinicians’ medical training. However, established practitioners are prone to discount these principles in favor of an overly simplistic preference that they be paid more and not be exposed to risk.
• HIT is the essential front-end investment. For patients to receive appropriate care and care teams to effectively manage and monitor patient behavior, a robust HIT investment, including electronic medical records, broadband transmission, personal health records, decision support and web-based services to facilitate access, are necessary. HIT represents a major investment; most practices will require assistance with its purchase and implementation.
• One size does not fit all. The pilots and academic research suggest wide disparity in PCMH approaches and operating features. Also, existing data is not conclusive enough to define the features and incentives that work best for given patient populations. Conceivably, medical home 2.0 has the ability to serve consumer needs across the care continuum—preventive, chronic, acute, and long-term.
• Access to an adequate supply of primary care service providers is an issue. PCPs account for 35 percent of the U.S. physician workforce, compared to 50 percent in most of the world’s developed health systems.²³By 2025, the U.S. will face a 27 percent shortage of adult generalist physicians. Even with increased supply via the expansion of residency programs, demand for primary care services will exceed the supply of providers.²⁴ Expanding the scope of practice for advanced practice nurses, mitigating frivolous liability claims, improving respect for the profession among medical peers, increasing e-visits, distance/telemedicine, group visits, and changes in clinical processes are essential to bolstering the practice of primary care medicine.
• Incentives must be aligned and realistic.The Patient-Centered Primary Care Collaborative proposed a clinician payment model (used in a number of pilots), which includes three pragmatic incentive elements:
  • A monthly care coordination payment to support the medical home structure
  • A visit-based, fee-for-service component relying on the current fee-for-service system
  • A performance-based component that recognizes the achievement of quality and efficiency goals²⁵

These elements seem to form a reasonable foundation for payment transformation in primary care. However, one issue could impact the third element: the validity and reliability of metrics used to define “quality” and “efficiency” and the timeframe (in months or years, depending on the patient population) in which they’re captured. As these metrics evolve, the relationships between medical homes and specialty practices will necessarily need refinement; also, metrics will need to be developed that reward appropriate inclusion of specialty medicine in targeted patient populations.

Figure 6: PPC-PCMH content and scoring correlated to seven “Joint Principles”²⁶

Adapted from Landon BE, Gill JM, Antonelli RC, and Rich EC. “Prospects For Rebuilding Primary Care Using The Patient-Centered Medical Home,”
Health Affairs, May 2010; 29(5): 827-834.

Closing thought

The medical home of the future will likely be a refinement of the assorted pilots and programs currently under way. We remain supportive and optimistic about its potential, as well as realistic that answers to its challenges will not be quickly available.

Medical home 2.0 is an innovation whose time has come. The confluence of rising health costs, an aging and less healthy population, payment reforms shifting volume to performance, and increased access to clinical information technologies that enhance coordination and connectivity between care teams and consumers suggests that the medical home will likely be a permanent, near-term fixture on the U.S. health care landscape.