PCMH: A closer look at a trend changing healthcare delivery

The Patient-Centered Medical Home (PCMH) holds great hope for primary care physicians in improving care and reaping rewards from a value-based reimbursement model. But it will also require seismic changes in the way most practices operate.

According to family physician Conrad Flick, MD, the biggest change when his Raleigh, North Carolina, practice became a PCMH was that roles and tasks for clinical and clerical staff were more clearly defined. “The PCMH expectation is that we are responsible for providing the best care we can as a team, not as a group of individual providers,” says Flick.

Adopting the PCMH model also prompted Flick and his colleagues to communicate with patients in a more organized fashion. “Quality care is a two-way conversation between patient and provider,” Flick adds.

Indeed, becoming a PCMH requires going from episodic patient care to continuously accessible communication and care, explains Joseph E. Scherger, MD, a family physician in La Quinta, California, and a Medical Economics editorial consultant. This means fewer but longer office visits-about 10 or 12 per day for most practices, according to Scherger-as well as increased online contact with patients.

The patient-centered approach

Jeffrey J. Cain, MD, a family physician in Denver, Colorado, and president of the American Academy of Family Physicians, sees numerous pluses in the PCMH model. “The PCMH helps achieve the triple aim of improved quality and outcomes, and reduces costs while helping to increase physician satisfaction,” he says.

In establishing a PCMH, Fred Ralston, Jr., MD, an internist in Fayetteville, Tennessee, and past president of the American College of Physicians, says that his practice, in effect, “set up a process of continuous quality improvement without the level of pain I would have expected. It is very refreshing to have others working with you in a team-based approach to reach common goals.”

For some PCMHs, the advantages are financial as well as professional. Payers are finding that PCMH practices help patients avoid unnecessary trips to the hospital, says Peggy Reineking, director of clinician recognition programs for the National Committee for Quality Assurance, one of the key organizations that certify PCMHs. According to Reineking, savings are also realized when PCMHs reconcile medications to avoid errors, tests are coordinated to avoid duplication, and referrals to other clinicians are synchronized to reduce the likelihood of conflicting care plans.

For these and other reasons, payers-both public and private-are offering monetary incentives to practices that become PCMHs. Cain notes that the Centers for Medicare and Medicaid Services (CMS) is taking the lead with the Comprehensive Primary Care Initiative, in which private payers join with Medicare and Medicaid to offer practices enhanced payment for effectively providing patient-centered care. “This is part of a movement to shift payment from volume-that is, fee for service-to quality,” says Cain, whose practice has achieved PCMH recognition.

Independent of CMS, some commercial payers, including Blue Cross Blue Shield, provide financial rewards to physicians who successfully establish PCMHs. Blue Cross Blue Shield of Tennessee, for instance, launched its Patient-Centered Medical Home program in 2008. “We began with a small pilot and now work with 30 physician groups across Tennessee,” says Kevin N. Raynor, the company’s senior project manager.

Like other payers that endorse the medical home model, Blue Cross Blue Shield of Tennessee (BCBST) monitors the performance of its PCMH participants. “We’ve seen tremendous improvements in quality of care that we expect will, over time, reduce emergency room visits and inpatient admissions,” says Raynor.

BCBST’s “performance bonus model” enables physicians to earn extra dollars based on defined performance metrics. “Our measures are HEDIS-based (see “Defining and Measuring Success” below) and are applied to six chronic conditions-diabetes, asthma, coronary artery disease, congestive heart failure, hypertension, and COPD,” says Raynor, who adds that a PCMH practitioner can earn an additional $12,000 to $15,000 annually, depending on patient panel size. “Performance targets are set for each measure,” he says. “We intend to move to outcome-based measures as the program matures.”

Where insurers won’t pay, patients might. “In California, with so much capitated managed care, insurance payers have not been providing PCMH care coordination payments,” says Scherger. Instead, the patients in Scherger’s practice who want to participate in the PCMH pay an annual membership fee that provides them with unlimited online communication directly to their doctor, longer visits, and better care coordination.

In addition, health policy analysts have stated that practices that have achieved PCMH recognition will be much better prepared than their counterparts to participate in accountable care organizations (ACOs). Much like a PCMH, an ACO is defined on www.healthcare.gov, a Web site managed by the U.S. Department of Health & Human Services, as “a group of healthcare providers who give coordinated care, chronic disease management, and thereby improve the quality of care patients get.” In accordance with the Patient Protection and Affordable Care Act of 2010, payment for ACOs is tied to achieving healthcare quality goals and outcomes that result in cost savings.

Time, resources and reimbursements

When it comes to reimbursements and bonuses, there are still a host of unanswered questions.

“At this point,” says Flick, “many insurers in the area where I work want what PCMH practices have to offer. But few are providing any increased payment or different payment structures to assist practices in transformation or help them maintain the process once initiated.”

Moreover, becoming a PCMH takes work, Cain acknowledges. “It can be very challenging for a busy primary care practices to transform into a PCMH, and there are often up-front costs,” he says. These expenses may include the purchase and implementation of an electronic health record, conducting patient satisfaction surveys, and training staff to engage in team-based care and support patients in self-managing their health.”

Cain continues, “Negotiating the varying expectations and requirements of multiple payers can create difficulties for new PCMHs. It takes time and can even hinder productivity initially when practices are working out the kinks as they re-engineer processes and the way they do business.”

There is a commitment of staff time and financial resources, and Flick says that a return on investment is not assured.

“Our government and payers seem to agree that developing a PCMH is the right thing to do,” he says. “What we lack, however, is reliable data about how the transformation will affect practices-especially independent practices-financially. Will it allow them to expand services and coverage, or will it be a financial burden? As the accrediting organizations’ standards and regulations increase, the cost of doing business also increases-with no guarantee that payments will increase to cover the additional expenses. That said, we still believe it is the right thing to do for our patients and our community.”

Defining and measuring success

The success of a PCMH in meeting its chief goals-in particular, improving patient health via coordination of care-is commonly gauged by using the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS). “There are national benchmarks for these HEDIS criteria and they allow for PCMH practices to be compared with other groups,” says Scherger.

Among the areas looked at:

Percentage of patients receiving certain preventive services, such as mammography, colonoscopy, and other cancer screenings.

Percentage of patients with chronic diseases-including diabetes, hypertension, hyperlipidemia, asthma, and heart failure-in good control.

For example, how well controlled are diabetic patients’ sugars? Are patients who have diabetes getting annual eye

and foot exams?

Percentage of patients age 65 and older who received a pneumococcal vaccination.

Percentage of patients age 18 and older who were queried about tobacco use and who received cessation intervention.

Nonclinical evaluation measures include:

Extent to which physicians provide continuous care.

Extent to which physicians coordinate care with other clinicians.

Use of information technology to enhance patient care, communication, and education.

Patient satisfaction scores.

Because PCMHs are about providing high-quality and efficient patient care-the right care at the right time in the right place-you must prove this through electronic documentation, Flick says. Benchmarks need to be agreed upon and then met. “It is no longer sufficient to ‘feel’ like we are doing a great job with our patients; we need to able to show we are making a difference and that the processes we put in place change our metrics for the better. It is not enough to say we saw X number of diabetics with decreased hemoglobin A1Cs in the last couple of weeks. The question has now become: ‘What does your data from the last two years show?’ And then we must constantly update our benchmarks to continuously improve.”