PCMH Likely to Form Basis of Federal Health Care Reform

Primary Care High on List of Possible Fixes

February 17, 2009 03:55 pm James Arvantes

Primary care and the patient-centered medical home, or PCMH, are necessary components of any national health care reform package. That philosophy has shown up repeatedly at all levels during the ongoing health care reform debate, say health care analysts.

"A large and growing number of people recognize that the key to health care reform in the long run is turbocharging primary care," says Len Nichols, Ph.D., director of the health care policy program for the New America Foundation in Washington.

Chris Jennings, president of Jennings Policy Strategies in Washington and a former senior health care advisor to President Clinton, says the medical home has been "cited by the Obama administration as something they want to integrate into their broader policy reforms."

"I also think it is something that Congress, the committees of jurisdiction on both sides of the Capitol and both sides of the political divide, are looking at," says Jennings, who wrote major parts of the Democratic Party platform on health care in 2008.

The Obama administration and congressional leaders agree on the need for a two-pronged approach to health care reform, an effort that encompasses health care expansion, as well as delivery system reform, says Nichols. "If we just expand coverage, then we fail to address the problem of health care costs."

In economic terms, reforming delivery systems requires bending the cost growth curve to ensure that resources that are spent provide the highest possible value, according to Nichols. In a larger sense, delivery system reform is based on a series of interlocking pieces such as health information technology, or health IT, and payment reform. Within this context, the PCMH plays an integral role, serving as the underlying grid that supports and allows each of the roads in the health care delivery system to intersect and complement each other.

During the past few years, the PCMH has become synonymous with primary care and care coordination, says Nichols. It is a way to provide a regular source of care that improves quality and enhances access while saving costs. In the process, the PCMH has emerged as a metaphor for payment reform. "This is about paying more for quality and paying more for coordination," says Nichols.

There is a need to modernize the nation's health care delivery system to focus on quality and value, Jennings explains. This, in turn, requires implementation of three core elements:

  • health IT,
  • quality standards and comparative effectiveness studies that provide best practice information to physicians and patients, and
  • realignment of payment and incentives to encourage adoption of best practice clinical protocols and approaches to enhance quality.

"In that context, the family physician has to be the focal point," Jennings says.

He compares these three core elements to a three-legged stool. Family physicians are interested in engaging in all three legs of the stool, says Jennings, particularly because they have been "the victims of a very biased and warped payment policy under Medicare, where their services are undervalued."

Chronic Conditions

Like other analysts, Jennings identifies patients with chronic illnesses as the drivers behind increased health care costs. "If we are going to deal with quality, value and cost, we will need to do a better job of prevention and caring for the chronically ill," he says.

"I can think of no physician group better positioned to make that case than family doctors," says Jennings, who refers to family physicians as the "first line of defense" in the health care system.

Not surprisingly, Jennings and Nichols are convinced that the PCMH provides the greatest benefit to patients with chronic illnesses.

"A lot of patients who have chronic conditions end up being … rather intermittently and badly managed by (sub)specialists as opposed to having a primary care patient-centered medical home," says Nichols.

Many in Congress share his sentiments. For example, legislators created a three-year PCMH demonstration project as part of the Tax Relief and Health Care Act of 2006. The project, which is just getting started, will be conducted in eight states and will involve 400 practices, 2,000 physicians and 400,000 Medicare beneficiaries. It will target Medicare patients with chronic illnesses.

In addition, in 2007, Sen. Ron Wyden, D-Ore., introduced the Healthy Americans Act, a bipartisan bill that reflects the values of both the Democratic and Republican parties, making it a viable vehicle for health care reform. The measure, which was co-sponsored by Sen. Robert Bennett, R-Utah, encourages Medicare beneficiaries to choose a PCMH and pays physician practices a fee for serving as medical homes.

According to the legislation, Medicare would be required to create a chronic disease management program and provide a chronic disease management payment to any physician who manages patients with any of the five most prevalent chronic diseases as identified by the HHS secretary.

Last November, Sen. Max Baucus, D-Mont., chair of the Senate Finance Committee, unveiled a health care reform blueprint that places a strong emphasis on prevention and primary care. The 98-page white paper describes primary care as a "common element of high-performing health systems," and says "strengthening the role of primary care will require a multi-pronged approach." It calls for ensuring accurate prices for primary care services in Medicare, providing an add-on bonus payment for primary care services, and encouraging further testing and implementation of the PCMH model.

"It is hugely important and extremely relevant that the chairman of the Senate Finance Committee has made such a big deal of (health care)," says Jennings.

The Baucus proposal represents a need to move toward thoughtfully designed incentives for primary care with appropriate use of subspecialty care, says Jennings. "(Baucus) is not saying that every element of care does not have a place. He is saying that our incentives are warped and out of place. I think that is a view shared by Democrats and Republicans alike."

Great Expectations

Many health care experts also say they believe that the current economic crisis will accelerate the need for health care reform. The Obama administration and congressional leaders view economic and health care issues as interrelated. That's why the economic stimulus package recently passed by Congress includes several health-related provisions, including health IT, more federal Medicaid money for states and funds to help the recently unemployed retain their health care benefits.

However, although the prospects for the PCMH are good in terms of health care reform, the medical home is far from a "done deal," says Jennings. Questions still linger in the minds of some lawmakers on Capitol Hill, he notes. Some lawmakers question whether physician practices are really ready to serve as medical homes or whether subspecialists will push back against the medical home.

"There also are questions about how you coordinate and design incentives and how you appropriately pay without overpaying," Jennings says. Nevertheless, family physicians should be "hopeful, optimistic and cognizant that they have a seat at the table."

"I assume family physicians will see very positive changes integrated into the debate both as they saw during the presidential campaign and in the Baucus white paper," Jennings says. "The trend line is good."