Here's the View From Outside the Medical Home Vortex

These days we're spinning in a whirlwind of activity regarding practice transformation and health care reform: Medicare's patient-centered medical home, or PCMH, demonstration (3-page PDF; About PDFs) should blast off soon, many other PCMH pilots and programs are gearing up or under way, the economic stimulus bill will boost funding for health information technology, and the AAFP is co-sponsoring a National Medical Home Summit in March.

But I sometimes hear from members standing outside that vortex of activity, perplexed by the Academy's emphasis on the PCMH. "Why can't I just get paid adequately for doing what I've been doing for years?" they ask. "Doesn't anybody respect the work I do?"

If that sounds like you, AAFP leaders hear your frustration. We know today's toxic health care environment puts immense pressure on your practice -- our practices feel that pressure, too.

But that's exactly why we've embraced the PCMH concept. We truly believe that encouraging practices to move in this direction is in our members', our patients' and our country's best interest. That's why the AAFP established TransforMED, and why we've developed products like our new guide to simplifying the National Committee for Quality Assurance, or NCQA, PCMH recognition process.

We're acutely aware that there is little or no additional compensation associated with NCQA recognition at this time, except through PCMH pilots, but we feel we must help members prepare their practices to take advantage of emerging payment models.

If you're on the fence about transforming your practice, I hope I can show you why you should proceed.

First, I want to review what the PCMH is. Think of the medical home as both a place and a process of care. You as an individual family physician will not be designated as a medical home. It will be your practice that receives this designation. If your practice were to become a PCMH, the process carried out within it would integrate and coordinate the care of your patients in a comprehensive, patient-centered way that would maximize your patients' health outcomes.

The concept is built on the personal relationship you have with your patients, but your entire practice team, under your leadership, would collectively take responsibility for the patient's ongoing care. The new process of care would enable you to practice family medicine in its most optimal and, hopefully, most satisfying form.

Thanks to promotion of the PCMH by the Academy and others, including the Patient-Centered Primary Care Collaborative, Americans finally grasp the advantages of a health system based on reinvigorated primary care. Therefore, we're able to make a strong case for the "blended" payment reform we're seeking for medical homes, which consists of

The amount of the care-management fee varies substantially from pilot to pilot. Most encouraging is the Medicare demonstration's proposed fee -- an average of $40.40 or $51.70 per beneficiary, per month, depending on whether a practice qualifies as a "typical" or "enhanced" PCMH. Other pilots pay less; some sources have estimated $3 to $6 per patient, per month, but that's for commercial populations, not Medicare's older, sicker patients. Practices that don't transform and become designated will be completely shut out from this additional source of revenue -- not because the Academy says so, but because buyers and payers will pay only for what they believe will be of clinical value to their employees or their insured patients and show cost savings and improved health care outcomes.

Regarding the many practices already moving ahead with transformation, we salute and deeply respect their trailblazing efforts. We also appreciate their frustrations with the NCQA recognition process, which will evolve over time. What we have now is also being piloted and will most assuredly be changed to better align with patient centeredness, integration and comprehensiveness.

We also hear their concerns about the cost of practice transformation. It's encouraging to hear voices other than ours suggesting that payers are in a better position than FPs to bear that expense. At least one pilot is covering some practice transformation costs.

However, I'm not holding my breath. It's pretty clear that payers, employers and the government want to see, via pilots, what enhanced payment to PCMHs will buy before they commit to large-scale reform.

That's why it's so important for as many practices as possible to transform now, so we can show payers the value, so they'll show us the money. Once we do that, and payment reform is in place, more medical students should select family medicine -- which will generate the workforce needed in the new health care system. That's the big picture we all need to keep in mind.

In closing, I'd like to say that if you don't plan to transform your practice, I respect your decision. We'll continue to fight for better pay for you in the current health care system, toxic though that system is. We hope you'll join the transformation movement when the time is right for you.

We appreciate member input as we establish the Academy's priorities and invest its resources. I encourage you to provide that input through your chapter and the AAFP Congress of Delegates.

Finally, thank you for your passion on behalf of family medicine. Please trust that the Academy is working on your behalf to set you up for success. Onward and upward!