Transcript The Patient-Centered Medical Home

The Patient-Centered Medical Home
Prepared by:
Kelly Doran, MD
NYU/Bellevue Emergency Medicine
Introduction
• What is a patient-centered medical home?
• What does it mean for emergency
medicine?
• Will the PCMH model improve health
care?
Objectives
• Discuss the development and key features
of the PCMH model
• Understand implications of the PCMH
model for emergency medicine
• Delineate ACEP’s position on the PCMH
• Explore current implementation of the
PCMH
What is a Patient-Centered
Medical Home?
• “An enhanced model of primary care in which care
teams attend to the multi-faceted needs of patients and
provide whole person comprehensive and coordinated
patient-centered care.”
• “A model of care where each patient has an ongoing
relationship with a personal physician who leads a team
that takes collective responsibility for patient care.”
History of the PCMH
• 1967: Concept first introduced by the American
Academy of Pediatrics (AAP)
• 2001: The IOM’s Crossing the Quality Chasm: A New
Health System for the 21st Century states that “the
system of care should revolve around the patient.”
• 2004 & 2006: The American Academy of Family
Physicians (AAFP) and American College of Physicians
(ACP) put forth their own statements regarding medical
homes
History of the PCMH
• 2006: Fewer medical students entering primary care
• 2006: The Patient Centered Primary Care Collaborative
(PCPCC) was formed, representing employers, medical
specialty societies, health insurance plans, and other
stakeholders
• 2007: Joint Principles of the Patient-Centered Medical
Home is put forth by the AAP, AAFP, ACP, and AOA
(American Osteopathic Association)
Joint Principles of the PCMH
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Personal physician
Physician directed medical practice
Whole person orientation
Care is coordinated and/or integrated
Quality and safety
Enhanced access to care
Payment reform
The PCMH and Emergency Medicine
• The PCMH model is hoped to:
– Decrease “non-urgent” emergency
department use
– Help patients control their chronic illnesses to
avoid needing emergency care
– Reduce hospital admissions
– Improve patient care overall
ACEP’s Response
“The realities of our current dysfunctional
healthcare system stand in stark contrast
to the laudable goals of the PCMH.”
- ACEP Policy Statement
ACEP Policy Statement
“Important specifics must be addressed before
moving forward with widespread adoption of the
PCMH model. Nowhere is caution more
important than in the way implementation of the
PCMH model might negatively impact the
emergency department.”
- ACEP Policy Statement
The PCMH and Emergency Medicine:
The Concerns
• Resources used to develop the PCMH model
might reduce support available for emergency
medicine
• The PCMH model might draw attention away
from an emergency system that is the “ultimate
safety net” for patients
ACEP Policy Statement
• ACEP agrees with the basic principles of
the PCMH…
• With the caveat that eight critical issues
should be addressed
ACEP Critical Issues
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“ACEP supports high quality, safe, and
efficient medical care”
“ACEP supports health care payment reforms
that ensure all medical providers are fairly
compensated for the care they provide to
patients”
– Must compensate physicians for EMTALAmandated services
ACEP Critical Issues
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“Enhanced access must be demonstrated”
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“Once established, the medical home should
continue regardless of insurance status or
ability to pay.”
ACEP Critical Issues
• “Universal health insurance coverage is
necessary for the PCMH model to be most
effective.”
• “The medical home must include the
safety net of emergency care.”
ACEP Critical Issues
• “Patients must have freedom to switch medical
homes, select specialists of their choosing, and
access emergency medical care when they feel
they need it.”
– Patients, not gatekeepers, should decide what is an
emergency by “prudent layperson” standards
• “Research must prove the value of the medical
home before it is widely adopted.”
Current Implementation
• Medical home initiatives exist in all states
– Both publically and privately funded
• CMS to start a 2010 demonstration project in
400 practices in 8 regional sites
• Bills promoting the PCMH model have been
introduced in at least 16 states
How to Evaluate the PCMH?
• National Committee for Quality Assurance
– Set nine standards that practices must sufficiently
meet to attain recognition as a PCMH
– Voluntary
• Criticisms of NCQA Standards
– Too much emphasis on information technology and
not enough on patient-centeredness
Results of Initial Research: The Good
• Geisinger Health System in Pennsylvania 
20% reduction in hospital admissions and 7%
savings in overall medical costs (Paulus 2008)
• Study of asthmatic children on Medicaid in North
Carolina (Domino, et al. 2009)  Fewer ED
visits and hospitalizations but higher costs
• One PCMH in Seattle (Reid 2009)  Increase in
patient-level markers, no change in costs
Results of Initial Research: The Bad
• “Initial lessons” from AAFP demonstration
project of 36 family practices 
– “Our early analysis raises concerns that current demonstration
designs seriously underestimate the magnitude and time frame
for the required changes, overestimate the readiness and
expectations of information technology, and are seriously
undercapitalized.” (Nutting, et al.)
• Commonwealth Fund study of 35 practices 
Higher IT costs for PCMH, otherwise no
significant increase in costs for higher “medical
homeness”
Conclusions
• PCMH model is being implemented
– Looked to as important part of health care reform
• PCMH has major issues not resolved
– “Society must get the home it is paying for”
– Need to address fundamental concerns
• Potential is there, but further data needed
References
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Abrams MK, Davis K, Haran C. Can patient-centered medical homes transform health care delivery? Commonwealth Fund: From the
President. 27 Mar 2009.
American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association.
Joint principles of he patient-centered medical home. 2007.
Berger E. Medical home: A solution to “hamster health care” or a drain on emergency care? Annals of Emergency Medicine. 2008;52(6): 654-7.
CQ State Track Free Nationwide Bill Search. Available at http://www.trendtrack.com/. Search conducted 26 Jul 2009.
Domino ME, Humble C, Lawrence WW, Wegner S. Enhancing the medical homes model for children with asthma. Med Care. 2009;47:1113-20.
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NCQA News Release. NCQA program to evaluate patient-centered medical homes. 8 Jan 2008. Available at www.ncqa.org. Accessed 8 June
2009.
Nutting PA, et al. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann
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Starfield B, Shi L. The medical home, access to care, and insurance: a review of the evidence. Pediatrics. 2004;113(5 Suppl):1493-8.
Zuckerman S, et al. Incremental cost estimates for the patient-centered medical home. Commonwealth Fund Report. Oct 2009. Available at
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