By Jennifer Larson, contributor 

April 20, 2012 - How do you deliver high-quality, patient-focused healthcare while keeping costs down? It’s a daunting challenge, but proponents of the patient-centered medical home model say it’s not impossible to achieve.  And a growing number of patient-centered medical home programs are flourishing, while making progress toward that overriding goal.

“The reason that I think [the model] has really taken off is because it’s an innovation that happens to meet the needs of pretty much all the stakeholders, including the providers, which is really important if you want to get change,” said Robert Graham, M.D., director of the Robert Wood Johnson Foundation’s  Aligning Forces for Quality (AF4Q) initiative national program office. 

The patient-centered medical home, or PCMH, is a model with a team-based approach to delivering primary care. The team tracks and coordinates the care that its patients receive and strives to be more responsive to each patient’s needs. Some, notably The Joint Commission, refer to it as the primary care medical home.

“I like the term ‘relationship-based care,’” said Lisa LeTourneau, M.D., MPH, executive director of Maine Quality Counts, one of several participants in a statewide collaborative that’s piloting a PCMH project in Maine.

The Maine PCMH Pilot is one of a group of alliances participating in the AF4Q initiative that are piloting PCMH programs. It launched several years ago with the goal of providing “effective, efficient, and accessible health care supported by appropriate payment, and to deliver sustainable value to patients, providers, purchasers, and payers,” according to its vision statement.  

“Our hope that is with this medical home model, people are getting the kind of care they would like to be getting, and that it’s truly of higher value as well,” Letourneau said.

Development of the concept 

The concept has its roots in pediatrics. The American Academy of Pediatrics introduced the term “medical home” in 1967, and it has evolved to more fully describe a partnership approach of primary care delivery. It gained broader support from numerous other healthcare organizations, including the Institute of Medicine in the 1990s. In 2010, the landmark health reform law, the Patient Protection and Affordable Care Act, included provisions to encourage the adoption of the PCMH model.

Today, there are four organizations that offer PCMH accreditation or recognition programs: the Accreditation Association for Ambulatory Health Care (AAAHC), the National Committee for Quality Assurance (NCQA), URAC and The Joint Commission. The Joint Commission began offering a PCMH accreditation option for ambulatory care organizations last July.

NCQA is the largest and most dominant of the accrediting bodies. According to the latest data available from NCQA, more than 8,300 clinicians in approximately 1,500 practices have received NCQA PCMH recognition.

James Holly, M.D., chief executive officer of Southeast Texas Medical Associates, noted that he expects all four programs to survive and prosper. And he expects that the PCMH movement will continue to grow, too. But like many things, it will take some time.

“It’s aflame with those who are involved and those who are around those who are involved,” said Holly, whose organization is a multi-specialty practice with 32 providers and has been recognized by NCQA.  “It will all work out, but it’s slow.”

“It does require a change,” Letourneau said. “It requires a shaking-up of current ways of thinking and of payment models.”

The future of the PCMH model 

What needs to happen to support PCMHs and help them grow? Many say that there is a need to align reimbursement more directly to all the activities that happen in a medical home model.  The current reimbursement system isn’t set up to accommodate many of the care coordination and management activities that are the hallmarks of a patient-centered medical home.

A 2011 status report from the Maine PCMH noted that the current fee-for-service model does not accommodate all the services necessary to deliver true patient-centered care. “The PCMH Guiding Principles recognize that payment for primary care must change to reflect the added value of this model,” the report stated.

Another question that has yet to be answered is the potential impact of the Affordable Care Act.  The Supreme Court heard arguments over the constitutionality of the law in March, but is not expected to issue a decision on the case until June, leaving the future uncertain.

But PCMH proponents say they expect that the medical home concept will continue to gain traction, regardless of whether the law is struck down or not.

The concept is sound, so the momentum is likely to continue, said Nwando Olayiwola, M.D., chief medical officer of Community Health Center, Inc., in Connecticut, which received Level 3 PCHM recognition from NCQA and PCMH certification from The Joint Commission.

“What is likely is that it will evolve,” she said.

Graham noted that even if the law gets thrown out, purchasers will not want to pay more for benefits than they’re already paying, and an important aspect of PCMH is keeping costs down through care coordination.

“If you’re running a complicated healthcare system, and you’re looking down the road and you think your revenue stream is going to change, and you’re going to have to manage the risk, you want people doing what they’re doing in a medical home,” he said.

He continued, “This is no longer an experiment. It will come in different time frames to different markets, but 10 years from now, the vast majority of adult primary care practices will be operating in the medical home model and will be reimbursed for it and will be happier for it.”

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