The ability of insurers and payers to promote and sustain the patient-centered medical home, or PCMH, model depends on four core elements that can make or break the medical home process, according to a new report issued jointly by the Center for Studying Health System Change and Mathematica Policy Research Inc., or MPR.
The report identified the four core elements as follows:
New Study Expounds on Four Key Elements of PCMH
Report Focuses on Payment Reform, Need for IT
By James Arvantes
1/7/2009
- What capabilities and services will insurers and payers require physician practices to demonstrate to qualify as medical homes?
- How will insurers and payers match patients to medical homes?
- How will they promote the engagement of patients and other health care professionals in working with medical homes to coordinate care?
- How will they pay practices for serving as medical homes?
"The goal of the medical home is simple: Improve the quality and reduce the cost of health care by reducing uncoordinated and fragmented care, the redundancy of tests and treatments, and by eliminating the provision of treatments that do not follow clinical guidelines," says Deborah Peikes, Ph.D., a co-author of the study and a senior researcher at MPR. "Getting these four operational issues right will ensure that insurers reward patient-centered care, not simply the use of more services, more technology, and more tests and procedures."
The report lays out the benefits of each of the core elements, explaining the processes and procedures currently in place to support them and how each can be improved. For example, the study notes that "payers recognize that medical home services, such as care coordination, are difficult to itemize, may occur outside face-to-face patient visits, and can legitimately vary in type and intensity across different patients over time."
"Payment approaches for medical homes under current fee-for-service payment systems essentially focus on additional payment for currently uncovered services," the report says. However, paying for medical home services requires some sort of fixed per-patient fee, says the report.
"Extra payment is going to help a lot, particularly as practices begin to provide more care through e-mail and telephone calls, which they cannot bill for in most fee-for-service arrangements," said Peikes.
Most public and private payers are more focused on paying for the process that medical homes engage in than on the outcomes of those processes. The report's authors, however, note that payment should first reflect the costs of providing extra services expected of a medical home, which requires estimating the costs of acquiring and maintaining medical-home capabilities, such as disease management and "open access" scheduling.
Payers also can set payments to be budget-neutral by estimating the total amount they expect to spend for eligible patients and by making assumptions regarding the savings medical home services might generate through more efficient delivery of care. This also would entail setting fees to equal any theoretical savings.
The report lays out the benefits of each of the core elements, explaining the processes and procedures currently in place to support them and how each can be improved. For example, the study notes that "payers recognize that medical home services, such as care coordination, are difficult to itemize, may occur outside face-to-face patient visits, and can legitimately vary in type and intensity across different patients over time."
"Payment approaches for medical homes under current fee-for-service payment systems essentially focus on additional payment for currently uncovered services," the report says. However, paying for medical home services requires some sort of fixed per-patient fee, says the report.
"Extra payment is going to help a lot, particularly as practices begin to provide more care through e-mail and telephone calls, which they cannot bill for in most fee-for-service arrangements," said Peikes.
Most public and private payers are more focused on paying for the process that medical homes engage in than on the outcomes of those processes. The report's authors, however, note that payment should first reflect the costs of providing extra services expected of a medical home, which requires estimating the costs of acquiring and maintaining medical-home capabilities, such as disease management and "open access" scheduling.
Payers also can set payments to be budget-neutral by estimating the total amount they expect to spend for eligible patients and by making assumptions regarding the savings medical home services might generate through more efficient delivery of care. This also would entail setting fees to equal any theoretical savings.
Information Exchange
The report also calls for creating a medical home information exchange to promote effective communication between medical homes and their patients. According to this type of arrangement, the patient agrees to tell the medical home when he or she wants to see another primary care physician or a subspecialist and why. In return, the medical home agrees to oversee the entirety of the patient's care.
Not surprisingly, the report criticizes the fee-for-service payment system for "lacking incentives for primary care physicians to consistently play an active role in integrating and coordinating care." It suggests a hybrid approach that combines claims-based processes with physician-driven and patient-driven approaches to build medical home relationships while honoring existing patient-physician relationships.
"For example, insurers could send practices a list of their potential patients -- those whose claims indicated they saw the physician one or more times in the prior two years," the report says. "The physicians would then be expected to obtain the patient's consent to be matched to their practice, and the physician could explain medical home features to the patients. This approach also ensures that patients can decline if they prefer another medical home."
Not surprisingly, the report criticizes the fee-for-service payment system for "lacking incentives for primary care physicians to consistently play an active role in integrating and coordinating care." It suggests a hybrid approach that combines claims-based processes with physician-driven and patient-driven approaches to build medical home relationships while honoring existing patient-physician relationships.
"For example, insurers could send practices a list of their potential patients -- those whose claims indicated they saw the physician one or more times in the prior two years," the report says. "The physicians would then be expected to obtain the patient's consent to be matched to their practice, and the physician could explain medical home features to the patients. This approach also ensures that patients can decline if they prefer another medical home."
Pilot Projects
The report notes that most medical home demonstrations and pilots measure whether physician practices have attained the status of PCMH through the National Committee for Quality Assurance's Physician Practice Connections -- Patient Centered Medical Home tool, or PPC-PCMH.
"The PPC-PCMH tools has notable strengths, first of which is its support from payers, specialty societies and the National Quality Forum," the report states.
However, it adds, "many of the measures in the PPC-PCMH did not focus on primary care but on such issues as information technology or condition-specific performance reporting. So a practice could potentially score well on the PPC-PCMH without providing patient-centered primary care."
The PPC-PCMH also places a great deal of weight on information technology, or IT, capabilities; 77 of the 166 measures relate to IT, according to the study. But as the study points out, "it may be premature to require practices to have more than a searchable patient registry."
"Many primary care physicians, particularly those in small practices that make up the bulk of the U.S. primary care infrastructure, lack the economics of scale that facilitate purchasing and maintaining an electronic medical records, or EMR, system," the report says.
Many practices do not want an EMR until "an affordable and interoperable option is widely available," the report notes.
"The PPC-PCMH tools has notable strengths, first of which is its support from payers, specialty societies and the National Quality Forum," the report states.
However, it adds, "many of the measures in the PPC-PCMH did not focus on primary care but on such issues as information technology or condition-specific performance reporting. So a practice could potentially score well on the PPC-PCMH without providing patient-centered primary care."
The PPC-PCMH also places a great deal of weight on information technology, or IT, capabilities; 77 of the 166 measures relate to IT, according to the study. But as the study points out, "it may be premature to require practices to have more than a searchable patient registry."
"Many primary care physicians, particularly those in small practices that make up the bulk of the U.S. primary care infrastructure, lack the economics of scale that facilitate purchasing and maintaining an electronic medical records, or EMR, system," the report says.
Many practices do not want an EMR until "an affordable and interoperable option is widely available," the report notes.
