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In Focus: Are Medical Homes Primary Care's Answer?

By Vida Foubister

With the National Committee for Quality Assurance's (NCQA) release of new standards for patient-centered medical homes in early January, health care providers and purchasers now have a means to differentiate these practices and assess whether they add value to patient care.

"People are familiar with the concept," says Xavier Sevilla, M.D., a Florida pediatrician. "The problem is there hasn't really been, up to now, a tool or a way to recognize what practice is a medical home vs. one that isn't.… If you ask all pediatricians if their practice is a medical home, probably 100 percent of them would tell you their practice is a medical home."

But few physician offices—in pediatrics or other primary care specialties—would qualify for recognition as a patient-centered medical home under the new NCQA standards. "It's more than just a medical home, it's a medical home that's responsive to the needs of patients," says Paul Grundy, M.D., M.P.H., director of healthcare, technology, and strategic planning for IBM Global Wellbeing Services and Health Benefits and chairman of the Patient Centered Primary Care Collaborative, a coalition of national employers, insurers, medical specialty societies, and consumers.

There is widespread agreement that primary care is in crisis. Patients aren't satisfied with the care they're receiving, purchasers and insurers are disappointed with its cost and quality, and medical students aren't choosing to practice primary care medicine.

Patient-centered medical homes promise to change the status quo by enabling physicians to provide comprehensive primary care through stronger partnerships with their patients. Those that choose to integrate elements of this new model into their practices now have a mechanism to prove this distinction to patients. But in order for these enhanced services, such as same-day appointments and pre-visit planning, to be sustainable, this designation will also have to be recognized and rewarded by payers.

"Payment reform has to go hand-in-hand with practice redesign for this to work," says Christine A. Sinsky, M.D., an internist at Medical Associates in Dubuque, Iowa, and a charter member of NCQA's Committee on Physician Programs. "We can't come up with another set of expectations for primary care physicians that are unfunded."

A New Approach to Care
The American Academy of Pediatrics (AAP), one of the four professional societies that have come together in support of this new model of care, first used the term "medical home" in 1967 in reference to the care of children with special needs. More recently, the AAP, along with the American Academy of Family Physicians, American College of Physicians, and the American Osteopathic Association, has refined the concept and expanded it to the care of all patients. As jointly defined by the four professional societies, patient-centered medical homes encompass the following seven principles:
  • each patient receives care from a personal physician;
  • the personal physician leads a team of providers who are responsible for a patient's ongoing care;
  • the personal physician is responsible for the "whole person";
  • a patient's care is coordinated across the health system and community;
  • quality and safety are hallmarks of the practice;
  • enhanced access to care is offered through open scheduling, expanded hours, and new care options such as group visits; and
  • the payment structure recognizes the enhanced value provided to patients.
NCQA developed the Physician Practice Connections—Patient-Centered Medical Home standards in parallel to these efforts. The original recognition program, which has been in place since 2004, grew out of two processes: research funded by the Robert Wood Johnson Foundation to develop a practical tool that assesses an ambulatory practice's use of the Chronic Care Model, and work with GE in the early stages of the Bridges to Excellence incentive program using the Six Sigma approach to identify errors in office practice.

More recently, efforts to develop practice-level, patient-centered care measures and reach consensus on these measures among NCQA and the four medical specialty societies, funded through Commonwealth Fund grants, led to the addition of 18 such measures to the Physician Practice Connections standards. NCQA's revised recognition program includes nine standards for medical practices to meet, focused on patient access and communication, patient tracking and registry functions, care management, patient self-management support, electronic prescribing, tracking of patient tests, referral tracking, performance reporting and improvement, and advanced electronic communications (see NCQA's Web site for more details). Practices must pay an application fee, which varies with the number of physicians at the practice site and may be discounted through participation in recognized programs, and apply for recognition every three years. NCQA requires practices to document how they meet specific requirements and randomly audits 5 percent of those that apply.

"If done right, this will be very transformational for primary care," says Greg Pawlson, M.D., M.P.H., executive vice president of NCQA. He expects the Physician Practice Connections—Patient-Centered Medical Home program, like NCQA's other recognition and certification programs, to evolve, adding new elements as practices start meeting the current standards.

Among the changes John H. Wasson, M.D., professor of community and family medicine at Dartmouth Medical School, would like to see in future iterations of the recognition program is more information from patients about their care experiences, as opposed to relying on provider documentation of medical processes. "The simplest way to ask about access is to just ask the patient," he says. Others have recommended including a measure that assesses practices' cultural competency and community involvement.

Proving the Model
Since 2004, 283 practice sites, representing 3,499 physicians, have been recognized by the Physician Practice Connections program. However, most of these sites—97 percent—received this recognition as part of the Bridges to Excellence program, and thus had a financial incentive to provide medical home services in their practices.

Because most primary care physicians working in small groups do not have access to, and those within academic medical centers might not have direct control of, sufficient resources to create and sustain patient-centered medical homes, several pilot programs are being developed to test the effectiveness of payment mechanisms that reimburse physicians for their value—and anticipated cost savings.

Among the reimbursement models that have been proposed for this model of care is the American College of Physicians' hybrid payment structure. It would include a fee-for-service component; a coordination of care monthly fee to cover care provided outside of face-to-face visits and implementation of health information technology and other systems, which would be risk-adjusted for patients' illness burden; and a pay-for-performance bonus. Another, outlined in a recent Journal of General Internal Medicine article, features monthly, per-patient payments with incentives for providing effective, efficient, and patient-centered care.

Other research led by the Urban Institute, and cofunded by the American College of Physicians and The Commonwealth Fund, aims to evaluate the investment necessary for practices to implement patient-centered medical homes. "Nobody fully understands yet what it will cost for a practice to transform itself into a patient-centered medical home, both the start-up and transition costs and the ongoing costs beyond that," says Deidre S. Gifford, M.D., M.P.H., chief of health policy and programs at Quality Partners of Rhode Island.

Equally important, these pilots will test the effectiveness of patient-centered medical homes. There is substantial empirical evidence supporting features of the model, such as an international survey led by The Commonwealth Fund and published in Health Affairs, which found accessible, coordinated care is associated with better preventive care and chronic disease management as well as better patient experiences. However, little research has been done to demonstrate that patient-centered medical homes, as a whole, have better quality and efficiency.

Another aspect of this model that will be watched closely is its effect on health care disparities. Commonwealth Fund research suggests patient-centered medical homes could ameliorate or even eliminate racial and ethnic health disparities.

Multiple Pilots
NCQA's new standards will enable researchers to "do some apples-to-apples comparisons in terms of effectiveness and pace of implementation" across these demonstration programs, Gifford says.

Funded by the American Academy of Family Physicians, TransforMED, in June 2006, launched a 24-month demonstration project with 36 family medicine practices from across the United States. Among the patient-centered medical home features that have been found to be important, says Terry McGeeney, M.D., M.B.A., president and CEO of TransforMED, are using technology, managing access to care, accessing evidence-based reminders at the point of care, providing patients with the option of group visits, and ensuring the right people are doing the right jobs.

A three-year Medicare Medical Home Demonstration will be launched in eight states in 2009. It will provide physicians who participate in the program with a "care coordination fee" for managing the care of Medicare beneficiaries with multiple chronic conditions. Physicians also will be able to share in any system-wide savings that may result.

Other pilots are working to engage multiple payers, so that practices have a financial incentive to participate. "In any given market, you need to have [enough patients] enrolled so that doctors aren't doing something for just a tenth of their population," says Grundy of the Patient Centered Primary Care Collaborative.

These pilots include a multi-payer, public-private demonstration led by Quality Partners of Rhode Island, which is in the final stages of coming to an agreement between providers and payers on specific elements of the program. The physician payment structure, a core component of the pilot, has been a sticking point. "The payers are looking at it from the standpoint of being cost neutral and the providers are looking at it also in terms of being cost neutral, but they're coming at it from opposite angles," Gifford says. "The payers obviously don't want to invest lots of money in a program where they don't think they'll see a return in either cost or quality. The practices don't want to commit to providing a set of services if the payment coming from the payers isn't going to cover those services."

UnitedHealth Group has plans for a multi-payer pilot in several geographic regions. However, its first demonstration, a "proof of concept" pilot to launch early this year, will test the patient-centered medical home model among Florida practices with a high number of UnitedHealthcare patients. As part of the implementation process, UnitedHealthcare will support practices' efforts to engage patients—for starters, by choosing a personal physician, something that to them might sound familiar to a "gatekeeper." Says Dawn Bazarko, R.N., M.P.H., the insurer's senior vice president of clinical innovation: "We're going to remove every barrier possible for [patients] to seek care in a medical home," perhaps even waiving copayments.

Group Health Incorporated and HIP Health Plan of New York are also planning a two-year demonstration. Central to this project is the random assignment of 50 adult primary care practices to either supported or comparison groups. The supported group will receive revised reimbursement, and assistance with care management and practice redesign, as they transition to patient-centered medical homes. An evaluation of the two groups' success, supported by The Commonwealth Fund, will use NCQA's new recognition program to assess the extent to which medical practices adopt the principles of medical homes. Other data will be used to assess clinical outcomes and patient experiences.

Pushing Forward
With the NCQA standards in place, patients might soon have higher expectations for the care they receive through recognized primary care practices. "It's a little like going into a Starbucks," says McGeeney of practices that meet the highest recognition level. "You know what you're going to get, the quality is going to be the same, and the service will be the same."

However, primary care providers and others will need to educate patients about patient-centered medical homes, as many might not be familiar with this new model of care. "Consumers are going to need to hear about this through trusted sources, so they see it as a system of care that will benefit them—not a gatekeeper system or yet another attempt to limit care or reduce cost," says Debra L. Ness, president of the National Partnership for Women & Families. "The medical home has a lot of promise for creating a system in which patients have an ongoing relationship with a primary care provider who can help them get the care that they need."

Physicians who have transitioned their practice to a patient-centered medical home are likely to be strong advocates of the model. "For me, the motivator was getting home at a reasonable time and actually dealing with patients who were not going to shout at me about why I was coming into the room an hour after they've been there," says Sevilla, who led a Florida multi-specialty group practice's transition to a patient-centered medical home. "Practicing like this is very different. It's challenging to surrender a little bit of power and authority and give it to the patient and, at the same time, really rewarding because you really feel that connection with the patient."

Sinsky, whose Iowa practice integrated processes that have subsequently been labeled as elements of a patient-centered medical home, says both she and her patients have benefited from the changes. Its higher nurse-to-physician ratio gives her more time to bond with patients and involve them in medical decision-making. Pre-visit planning, which includes planning for the next appointment at the conclusion of each visit, ensures that laboratory results and other diagnostics are scheduled in advance and available to discuss with patients in real time.

"The medical home can be a good roadmap for physicians as we attempt to redesign our practices and, fully implemented, I think it can greatly improve the quality of care," she says.

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