What You Should Know About the Patient-Centered Medical Home

The PCMH is not designed to be a gatekeeper system wherein the physician is charged with limiting care. Rather, it is predicated on the concept that PCPs and their staff, who know and coordinate everything about an individual’s health, will care effectively for chronic conditions, prevent unnecessary hospitalizations and duplication, and foster healthier attitudes and habits. The model differs from past proposals by recognizing that such a system requires significant effort beyond the patient-physician encounter (i.e., communicating with other physicians, monitoring data, coordinating care, etc.) and including payment for those activities.

Current discussions focus on primary-care practices serving as PCMHs, and these discussions have yielded a set of principles that address how the medical home will function and the capabilities the PCMH will require. These describe a practice-based, physician-led care model that addresses the whole person and, when appropriate, the family. The physician and his or her staff are the information center for the patient’s health information, and, as such, they coordinate all care. The model has an appreciable component of patient education to encourage healthier choices and informed participation by patients in their own care. As a result, it is envisioned that patients will contact their medical home for follow-up lab tests and for discussions of the results. The added compensation for being a medical home is designed to account for time spent coordinating data and communicating with patients, including use of telephone and e-mail.

Currently, there are demonstration projects beginning to see how effective the PCMH model will be. To participate, practices must fulfill specific criteria to qualify as a medical home. A point system determines at which of three levels a practice will be recognized. Specific criteria and points can be found on the Web sites of most primary-care professional organizations and in the New England Journal of Medicine Perspective article written by Elliot S. Fisher, MD, MPH (N Engl J Med. 2008. 359:1202-1205). Basically, practices must satisfy standards in five broad areas: 1) patient access and appropriate communication mechanisms; 2) use of electronic systems for tracking patient data and communicating with hospitals and consultants; 3) evidence-based care management and ongoing care coordination; 4) patient education; and 5) performance reporting and quality-improvement mechanisms.

Meeting these standards is not a trivial undertaking and may be modified over time. The required investments in technology and extra personnel could be substantial for practices that currently don’t fulfill these requirements. The funding mechanism for these investments is not yet clear. Potential proposals include a proposed extra per-month, per-patient payment to compensate for increased cost of practice and a proposal for physicians sharing systemic savings. Although initially the overall costs will increase to employ PCMHs, proponents of the model believe savings from more efficient care of chronic conditions, elimination of mistakes and redundancies, and fewer hospitalizations will yield the dollars to pay for the system in the long run.

This vision of the PCMH has focused on primary care, and it is not clear how specialists such as hematologists will be integrated into this system. For instance, hematology practices may need technology compatible with that of the PCMH (i.e., one has to be a suitable “neighbor” to the medical “home”), yet funding sources for those investments have not been identified. Likewise, the PCP needs to communicate with hematologists, meaning that non-patient encounter efforts are also important for consultants. Conceivably, more robust communication capabilities will allow the PCP to do more of the follow-up and care of uncomplicated patients, such as those with iron deficiency, leaving the more complicated and, by inference, more remunerative patients for hematologists to concentrate on. However, no modeling has been done to determine whether this is likely to be true.

In addition, for some patients with complex or serious diseases, the hematologist becomes the de facto PCP. It is unclear at this time how specialists will fit into this model and whether the necessary technology and non-physician support for a minority of a practice’s patients will be practical to implement.

Despite the many unanswered questions, the PCMH concept clearly has momentum. The PCMH has the backing of many primary-care societies, insurance companies, large employers, and several health policy experts. There is consensus that improving America’s health care requires creating a viable primary-care capability and that requires that we value and pay for coordination of care differently. Whatever form this eventually takes, it will have a significant effect on hematologists, and thus we must pay attention to and participate in the discussions.

ASH has not taken a position on PCMH in the current health reform discussions because there are several unanswered questions, such as:

• Will the hematologist be able to meet all the criteria required to be the PCMH?

• If the hematologist assumes the role of the PCMH, how will the payment for complex case management be structured?

• Do hematologists want to become the PCMH?

ASH has been working with other internal medicine subspecialty organizations to better understand the model, seek clarifications and modifications affecting the role of the specialist, and identify other health-care delivery models that would benefit hematologists and, more importantly, patients with chronic blood disorders.

Many of my colleagues and I manage comprehensive hemophilia centers. I don’t think it’s a stretch to consider our centers as Medical Homes. Our life-long involvement in so many aspects of our patient’s medical lives includes providing or coordinating care with surgeons, dentists, physical therapists, psychosocial and genetic counselors. Furthermore, our practices are strongly evidence-based; we use electronic medical records and report data to funding agencies, and we participate in two strong national networks involved in clinical research. And most importantly, life-long family and patient education provided by our Centers results in significant patient autonomy in self-management.

Richard Lipton, MD, FACP Hemophilia Treatment CenterNew Hyde Park, NY