Patient Centered Medical Home (PCMH)

Success of the PCMH model has been linked to collaboration between primary care physicians, specialists, and other providers within the so called “medical neighborhood.” In October 2010, the American College of Physicians (ACP) published a position paper on the medical home “neighbor,” which highlights the important role of specialty practices within the PCMH model.

Some analysts wonder whether a specialist’s practice could function as a medical home. There is concern that specialists are not willing to serve as a primary care provider. A nationally representative telephone survey of single–specialty practices, showed that a “small minority of specialists report serving as primary care physicians for a substantial number of patients” but majority of specialists don’t. Yet there may still be a place for specialists who provide the majority of care (not primary care) to be the “home” for a patient, while the primary care physician still fills the rest of the role of the primary care provider.

Read the ACP clarification on the Patient–Centered Medical Home and Specialty and Subspecialty Practices.

What constitutes a Patient Centered Medical Home?
According to the Agency for Healthcare Research and Quality (AHRQ), a medical home has five functions:

1. Provides care that is patient–centered with a strong focus on a physician–patient relationship and active participation of patients and their families.
2. Provides comprehensive care and is accountable for all of patients’ healthcare needs.
3. Coordinates care for its patients in all healthcare settings, including specialty care, hospitals, home care and community services.
4. It is accessible to patients, which includes shorter wait times for appointments and a possibility to contact physicians via phone or email.
5. It is engaged in activities that improve quality of care such as using evidence–based medicine and shared decision making, as well as utilizing quality measures, including measures of patient’s satisfaction.

The National Committee for Quality Assurance (NCQA) developed a set of standards, updated in January 2011, for becoming a patient centered medical home. However, there is no consensus on a PCMH definition and no standardized tool for identifying medical homes to include them in pilot demonstrations. For that reason, the Urban Institute conducted a comparative analysis of current assessment tools to assist CMS with decision as to “what instruments may be most appropriate.”

In the 1960s, the American Academy of Pediatrics (AAP) originally introduced the concepts of PCMH to provide better care for children with special needs. Later the concept was expanded and implemented by the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP).

In 2007, AAP, AAFP, ACP along with the American Osteopathic Association (AOA) release Joint Principles of the Patient–Centered Medical Home to describe characteristics of the earlier models.

The Accountable Care Act (ACA), signed into law in March 2010, introduced many policies to strengthen and reform primary care, among them testing patient–centered medical home models. Since then, the Center for Medicare and Medicaid Innovation (created by the ACA) introduced new medical home initiatives, among them a Multi–Payer Advanced Primary Care Practice Demonstration that started July 1, 2011.

Learn more about national PCMH demonstration projects and states initiatives at the National Center for Medical Home Implementation webpage.

A 2010 nationwide survey of PCMH demonstration projects identified 26 pilot demonstrations that included 14,494 physicians in 4,707 practices caring for 5 million patients. A majority of demonstrations were single payer and almost all utilize standard FFS payment supplemented by per person per month payments for eligible patients – the supplement in payment compensated for the added work of coordination of care, quality reporting and increased accessibility.

The medical home model has been widely accepted within the Department of Veterans Affairs (VA) healthcare system. According to the Commonwealth fund report, the VA launched an initiative to create PCMHs in more than 900 primary care clinics over a three–year period beginning in 2010.

According to Merell and Berenson (2009) there are multiple approaches to structure medical home payments, including:

• Enhanced payments for evaluation and management services that are currently not paid for under traditions FFS, including non–face–to–face communication by phone and e–mail and care coordination
• Additional codes for medical home activities services for which codes do not exist, for example for services performed to facilitate transitions between different care settings
• Per patient per month (capitation) medical home supplemental payments for non–encounter–based activities
• A risk–adjusted, comprehensive per patient per month payments instead of FFS