The Patient Centered Medical Home, Part 1: What Is It and Where Will PAs Fit In?

Connie Goldgar, MS, PA-C
Director at Large

As the former PAEA liaison to and a current member of the Society of Teachers of Family Medicine (STFM), the concept of the patient centered medical home (PCMH) is a familiar concept, one that has been espoused in the family medicine community for several years. I had some notion this was common parlance among all medical providers but it is apparent that currently it is discussed more commonly in primary care settings.

As PA educators who are training students in the primary care model, we need to educate ourselves about policies that may have a large effect on how we as a profession position ourselves for a change that is certain to come, whether in the form of the “medical home” or some other model. (Part II of this article on the PCMH, which will be forthcoming in a future issue of the Networker, will focus on the issues PA educators may need to be considering for their curricula and students, should this model continue to gain momentum toward broad application.) An editorial in JPAE at the end of last year from the past president of the American College of Physicians (ACP) described the essential features of the PCMH model, but this landscape is changing quickly, and I would like to address the issue again here.

My exposure to the PCMH and its focus within STFM is not incidental. In a health care system that is perilously close to collapse and seemingly handcuffed in its ability to deliver health care to all of its citizens, primary care “generalists” (versus partialists?) see themselves as uniquely positioned to deliver the high-quality health care that has been demonstrated by, as Barr has put it, “robust primary care systems in other countries as well as in the US.” (“The Need to Test the Patient-Centered Medical Home,” JAMA. 2008; 300(7):834-835). Unfortunately, in the United States, primary care specialties are losing ground, and family medicine is all too aware that its residencies are decreasing in size, if not disappearing from many institutions altogether.

In its current iteration, as described in Talking points of the American Academy of Family Physicians (AAFP),  the PCMH is based on the premise that the best health care is “not episodic and illness oriented, but rather high-quality care that is patient centered, physician-guided, on-going, and cost efficient.” The AAFP lists the following as attributes of an optimal PCMH. These practices will:

• Use evidence-based guidelines in the treatment of chronic conditions, acute illness, and injury, and the provision of preventive care
• Coordinate care across all settings — practices, hospitals, nursing homes, consultants, and other components of the complex health care network
• Serve as the patient’s “library” of medical records, where the essential elements of a patent’s history and health care interactions would be stored
• Use a team approach, capitalizing on the expertise of midlevel practitioners and medical subspecialists
• Use, or commit to using, health information technology (e.g., registries, electronic prescriptions, electronic health records, personal health records, secure e-mail) to guide and facilitate each patient’s care

The PCMH model has been championed by both the AAFP and the ACP, and these organizations have advanced policies to “advocate for change in the health care delivery and reimbursement system.” In early 2007, AAFP and ACP were joined by the American Osteopathic Association (AOA) and the American Academy of Pediatrics (in which the concept of the pediatric medical home was originally described in the 1960s for children) to publish a position paper promulgating the principles of the PCMH.          

In March 2007 the Patient Centered Primary Care Collaborative (PCPCC) was formed when the ERISA Industry Committee (ERIC) was approached by several large national employers with the objective of reaching out to the ACP, AAFP, and other primary care physician groups in order to (1) facilitate improvements in patient-physician relations, and (2) create a more effective and efficient model of health care delivery. To achieve these goals, the PCPCC has become one of the major developers of and advocates for the PCMH model in America. Just a year and a half later, the PCPCC represents more than 160 national business leaders (IBM being one of the initial proponents), consumer groups, organizations representing primary care physicians, and other health care stakeholders, including the American Academy of Physician Assistants.The PCPCC advocates on behalf of the PCMH model, potential new methods proposed for its reimbursement, and the transformation of clinical practice.

Overshadowing all of this, however, is the fact that a call for testing of the PCMH is now mandated by Congress through the Tax Relief and Health Care Act of 2006 (TRHCA). Several demonstration projects are currently being developed in rural, urban, and underserved areas in up to eight states. Only physician practices will be able to directly receive “care management fees” for providing such services. And only those physician practices that are considered a “medical home” can participate in the demonstration.

What practices actually qualify? A recent study by Rittenhouse et al, entitled “Measuring the Medical Home Infrastructure in Large Medical Groups” and published this year in Health Affairs (2008;27(5):1246-1258), looking only at large practices across the country, showed that most “lag in key areas needed to create a medical home.” Further, the authors reported: “The largest medical groups in the study (those with more than 140 physicians) and those owned by a hospital or health maintenance organization (HMO) scored highest on the four critical areas of a medical home model … which may be because they have more resources to invest.”

It is apparent that family and internal medicine are now feeling pressured to make this model happen. As press coverage of the PCMH increases, there is some backlash surrounding how primary care can really achieve this model in a failing system. Who will pay for the changes needed to become a PCMH? How will reimbursement for such services actually occur, and are they worth the cost of what it will take to qualify as a PCMH? What about practices that are too small to qualify as PCMHs? The demonstration projects are currently limited to physicians and do not clearly address the midlevel practitioner role — in terms of reimbursement or otherwise.

It is important to note that the medical home model remains controversial for many groups for many reasons. For one, what is the American Medical Association’s (AMA’s) perspective on all of this? The rules and fee structures drafted for the medical home model that the government and insurers are planning were released on April 29 by an AMA committee, the AMA/Specialty Society Relative Value Scale Update Committee, also referred to as the RUC. This committee was established to ensure that physician services across all specialties are well represented in policy making. Developed for the Centers for Medicare and Medicaid Services at the Department of Health and Human Services, the RUC recommendations give a much more realistic picture of the care that consumers can expect with government health care coverage. The RUC’s recommendations have been met with great criticism. It is believed that their recommended payment mechanisms are unfair to already overworked and underpaid primary care physicians. The RUC is made up of 29 physicians, only five of whom belong to primary care specialties. You can imagine the response of the primary care community… .

Stay tuned.

Click here for more information on the PCMH.