ACEP Position on Medical Home Sparks Forceful Response From AAFP

A recently issued position statement on the patient-centered medical home, or PCMH, from the American College of Emergency Physicians, or ACEP, has elicited a firm response from the AAFP. The statement demonstrates ACEP's lack of understanding about the intent of the medical home and its true impact on the nation's health care system, says AAFP President Jim King, M.D., of Selmer, Tenn.

In the statement, ACEP says it endorses the concept and basic tenets of the PCMH, as long as eight issues are addressed. However, some of the concerns raised by ACEP are narrow in focus, and they fail to take into consideration continuity of care and other issues, such as preventive services that keep patients out of the emergency room while improving care and saving costs, King says.

"I think (ACEP) is defending their area of expertise," says King. "But we have to look at the full picture of the health care system, not just one area."

ACEP's position statement acknowledges the critical importance of primary care, saying, for example, that the health care of every individual would improve by having access to a personal physician who could provide ongoing care while helping patients navigate a complex health care system. It also decries the lack of access to primary care services and cites data from the CDC estimating that 12.1 percent of visits to ERs are for nonurgent reasons. Many of these visits could be prevented or mitigated if patients had access to primary care.

The statement also says, however, that "a shifting of financial and other resources to support the patient-centered medical home could have adverse effects on sectors of the health care system that are already experiencing serious challenges. … The widespread implementation of a loosely defined primary care medical home model might negatively impact our nation's continued access to high quality emergency care."

"We are not talking about shifting money from one place to another," says King. "We don't see less payment for emergency room services or other services that are provided."

With a greater focus on primary care and the PCMH, fewer ER visits and hospitalizations will occur, making more money available to support the medical home, King says. "People can start receiving care in the medical home instead of emergency departments. This will take the strain off of emergency rooms in this country," he notes.

AAFP EVP Douglas Henley, M.D., responded to ACEP's position statement on a point-by-point basis, agreeing with most, but not all, of the organization's eight points. For example, the AAFP supports ACEP's call for the use of performance measurements, evidence-based medicine and information technology to optimize patient care, communication and education. The AAFP also concurs with ACEP's support for health care payment reforms that ensure all medical providers are fairly compensated for the care they provide patients. This includes additional compensation to primary care physicians for the medical home services they provide.

However, Henley takes issue with ACEP's statement that "research must prove the value of the medical home before it is widely adopted."

"Provision of comprehensive and continuing primary care to populations of patients has already been shown to be highly effective in improving the quality and cost-effectiveness of care," says Henley.

In addition, according to ACEP, patients should have the right to choose the medical home they want without restriction and to switch providers and choose "whom they wish for their medical home."

"The AAFP would agree that the patient will have the ability to choose their designated medical home and to move to another designated medical home if they wish," says Henley; however, the PCMH should serve as a "gateway for the patient in seeking care throughout the health care system and should, in fact, be the result of a shared decision between the patient and their family physician based upon the best available quality, cost and outcomes data for institutions and consulting physicians."

ACEP also notes that, once a patient's medical home is established, that medical home should continue to provide care regardless of the patient's insurance status or ability to pay.

"Many Americans go through transitions when they become unemployed or otherwise lose their health insurance coverage," says the statement. "Essential to the improvement of health care for patients using the primary care medical home model is an ongoing relationship in which a physician provides continuous and comprehensive care. While the medical home does not purport to provide health care for millions of uninsured Americans, there should be a requirement as part of this model that once a person is enrolled in a primary care medical home, the provider must continue to deliver care to those individuals whether they continue to have insurance or not."

Henley responds that the AAFP is unlikely to "support a mandate to require primary care physicians to enroll or maintain all patients who do not have health insurance coverage."

"We do not agree with this relative to the emergency department, nor would we agree to this for other physicians," Henley says. But most family physicians provide care for those who enroll in their practices regardless of their health insurance status, he notes.

ACEP also says that "resources used to test the patient-centered medical home should not undermine or further compromise the crumbling emergency medical care system."

The AAFP agrees with the intent of this principle, says Henley, pointing out that the medical home provides relief to the current burden shouldered by ERs for health care conditions that are more appropriately treated in other venues, such as the PCMH.