Home sweet medical home

ACP has championed patient-centered medical homes (PCMHs) as a way of invigorating primary care that would also potentially improve outcomes and lower costs. The idea is to ensure that primary care practices are organized in a way that revolves around patients' needs and expectations—patient-centered care—while freeing physicians up to do what they do best: Provide comprehensive, compassionate, and timely care to patients.

Of course, good primary care has always been patient-centered. What makes the PCMH different is that it is:

• a delivery model that incorporates innovative “best practices” known to improve access and quality (like multidisciplinary teams, after-hours access, same-day scheduling, and registries, supported by health information technology and systems to ensure that everyone involved in patient care is working together),
• a payment and financing model that compensates physicians and others on the team for the work involved in coordinating care effectively and for acquiring the personnel and systems needed, and
• a means to ensure accountability by measuring the effectiveness of the practices in achieving patient-centered outcomes in an efficient and effective way.

That's the idea, anyway. But there is a healthy dose of skepticism from beleaguered primary care doctors who have been burned before on the latest fad that was supposed to make their lives easier but didn't. It also comes from payers who ask whether putting more money into PCMHs will really lower costs and improve quality. It comes from health services researchers who note the absence of controlled studies comparing outcomes in PCMHs with non-PCMH practices. And it comes even from patients, who don't quite grasp what a PCMH is. (Some equate it with a nursing home, which is not usually a positive association.)

Some recent studies and reports may begin to chip away at such skepticism, however, by reporting that payers are spending tens of billions of dollars to support PCMHs. Insurers, and the employers that contract them, do not put money into something unless they believe it will improve outcomes and save money.

The New York Times reported in July on a survey of Blue Cross and Blue Shield plans, among the “most dominant” plans in the country, showing that they collectively have invested $65 billion in new “value-based” models, including PCMHs, involving “215,000 physicians affecting more than 24 million members, including some in Medicare Advantage plans.”

The results so far are encouraging not only in terms of demonstrating better outcomes for patients, but also in making practice more satisfying for the physicians involved and providing better compensation for their services. The Times reported, “The experiments include paying for care delivered in a medical home, which is not a place, but rather a model where patients are closely followed and their care is coordinated. In its program, Horizon Blue Cross Blue Shield of New Jersey pays a primary care doctor roughly $5 per patient a month to manage a patient's care. The doctor can earn an additional $11 a month per patient by meeting certain quality and efficiency goals. A practice with 1,000 patients could make an extra $60,000 to $192,000 a year.”

The story cites the case of a New Jersey physician, Marc Feingold, MD, whose practice is enrolled in a PCMH program through Horizon, the local Blue Cross and Blue Shield plan. Dr. Feingold reported that “The extra money he receives from Horizon and a similar program allows him to remain independent,” bucking the trend of becoming a salaried employee of a large group practice or selling his practice to a hospital.

Similarly, Kaiser Health News speculated that health reform may be bringing new respect to primary care physicians, citing a PCMH program launched by CareFirst, a plan affiliated with Blue Cross and Blue Shield and the largest insurer in the Washington, D.C., metropolitan area. The story stated, “Beginning in 2011 CareFirst increased reimbursement for what would soon be most of its primary care doctors in Maryland, the District and Virginia. It began paying even more if they reduced duplicative, unneeded or overly-expensive treatment while maintaining or improving quality. Doctors who scored well have gotten raises of more than $40,000 on top of round-the-clock nursing assistance for their sickest and riskiest patients, according to physicians and the insurance company.”

The article notes that “policy experts are far from agreeing that medical homes cut costs in the long run. But even though industrywide spending has slowed, CareFirst credits its medical home for helping keep total patient expense growth at 3.5 percent last year, the lowest rate in memory.” The CEO of CareFirst was quoted as saying that the company had saved “hundreds of millions of dollars in accumulated, avoided costs.”

Healthcare Finance News reported that Aetna's PCMH contract with a large, multispecialty practice was so successful that it plans to expand the program to other practices. The report stated, “In the first year of the medical home contract, Aetna's 5,650 members being treated by WESTMED [group practice] physicians saw a 35 percent reduction in hospital admissions and had relatively fewer ER visits and hospital readmissions. WESTMED doctors also met almost all of the 10 goals targeting cancer screenings and proactive management of diabetes and heart disease. According to Aetna, those results earned WESTMED some $300,000 in incentive payments.”

PCMHs may not be for everyone, and by themselves they may not reverse the crisis in primary care that has resulted from decades of indifference, neglect, lack of respect, and misguided policies from payers, from the government, and within the medical profession itself. Their long-term impact on outcomes, cost, and patient and physician satisfaction remains an open question. But it is clear that PCMHs are coming into their own, backed by billions of dollars from payers and embraced by growing numbers of physicians and their practices. They are beginning to show results—better pay and better respect for primary care, better outcomes for patients, and cost savings for payers. They are showing that when it comes to medical care, there may be nothing better than “home sweet home.”