Is the patient-centered medical home a win-all or lose-all proposition for ObGyns?

You can increase reimbursement by adopting this model, but be prepared to completely overhaul your practice in the process

Senior Editor, OBG Management

It might surprise you to know that the concept of the patient-centered medical home (PCMH) dates all the way back to 1967, when the American Academy of Pediatrics (AAP) conceived of it as a way to improve the quality and continuity of care.

The idea gained considerable traction as health-care reform became a reality. Now the prevailing view is that the PCMH model will not only improve patient care but also save health-care dollars in the process.

The medical home is a primary-care construct, however, and ObGyns are specialists, so why consider this concept at all?

One answer to that question may not be something that you want to hear: The health-care dollars that are shifted to primary care through implementation of the PCMH have to come from somewhere—and one likely target is you. By improving primary care and making it more comprehensive, the health-care system may indirectly reduce the number of specialist visits.

You may not find the alternative appealing, either: Construct your own PCMH, with a women’s-health focus. You stand to benefit from higher reimbursement, but you’ll have to completely—emphasis on completely—transform your practice in the process. That transformation includes implementing health information technology, adding staff, extending office hours, increasing the patient’s access to her physician (including same-day appointments and e-mail contact), and overseeing all her other health-care contacts as well.

So, is the PCMH a win-all or lose-all proposition for ObGyns? In this article, we attempt to answer that question by focusing on 8 others:

• What exactly is a medical home?

• Why does the concept suddenly have legs?

• Do we have any data on the effects of the PCMH model?

• Is the PCMH another version of the gatekeeper model?

• What impact will the PCMH have on specialist care?

• How many PCMH practices are there?

• What’s involved in establishing a PCMH?

• Where can I find out more?

1. What exactly is a patient-centered medical home?

The PCMH is a type of primary-care practice that strives to meet the majority of a patient’s health-care needs over her lifetime. It is centered on a close relationship between the patient and the “personal physician” of her choice, who assumes responsibility for overseeing all of her health care, including coordination with other practitioners and specialists. It emphasizes evidence-based medicine, improved access to care, a new payment paradigm, and other measures.

One of the strengths of the model is its focus on “the patient-physician relationship as the basis for high-quality, appropriately delivered health care,” notes the American Medical Association (AMA).¹ The AMA also applauds the model’s “explicit focus on the value of patient-centered care management work that falls outside the face-to-face patient visit.”¹

In 2007, the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and the American Osteopathic Association (AOA) formulated Joint Principles of the Patient-Centered Medical Home:

• The patient has a continuing relationship with a personal physician who is “trained to provide first contact, continuous, and comprehensive care”

• The personal physician heads a team at the practice that takes collective responsibility for the patient’s care

• The personal physician provides health care directly to the patient or arranges care with other “qualified professionals”

• All care is coordinated across specialists, hospitals, nursing homes, and home health agencies

• Quality and safety are priorities, and should be ensured through use of careful planning, evidence-based medicine, decision-support tools, information technology, participation of the patient in decision-making, and other means

• The patient has “enhanced access to care” through expanded hours, expanded communication platforms, and open scheduling

• Payment for health care reflects the added effort and oversight by the primary care physician and practice.²

In February 2009, ACOG developed its own set of principles for a PCMH for women, to achieve “the shared goal of helping American women grow up healthy, stay healthy, and age well.”³ ACOG’s PCMH principles mirror those of the AAFP, AAP, ACP, and AOA.

For example, the first principle emphasizes the importance of providing “a seamless continuum of care for women across their life spans.” ACOG elaborated: “A medical home for women links wellness and preconception care with prenatal care and family planning; these are linked with medical care, screening and follow-up care for health needs later in life.”³

2. Why does the PCMH suddenly have legs?

The answer is pretty straightforward: As it is currently practiced, health care costs too much, and too many people slip through the cracks. Consider this scenario: A physician sends a woman for a mammogram, which reveals microcalcifications in her right breast. Although the physician advises her to see a surgeon, the patient does not do so, and the physician fails to follow-through. By the time her cancer is diagnosed and treated, it has advanced to the point that she requires chemotherapy as well as radiation and surgery. Had her care been coordinated by a personal physician, this scenario likely would have had a very different—and less costly—outcome.

Another important reason the PCMH model has gained traction is the increase in the number of people who have chronic conditions. According to the AMA, 125 million Americans (45% of the population) had one or more chronic condition in 2000, and that figure is expected to rise to 157 million by 2020. The direct medical costs associated with chronic conditions were $510 billion in 2000 and will rise to $1.07 trillion by 2020.⁴

The increasing incidence of chronic conditions is especially problematic because most health-care practitioners continue to focus on “episodic, acute care instead of the coordinated, continuous care needed to effectively manage chronic conditions.”⁴

The Centers for Medicare and Medicaid Services (CMS) anticipates that the PCMH model will produce substantial savings for Medicare, in part by improving management of chronic conditions.¹

3. Do we have any data on the effects of the PCMH model?

Yes. In a briefing prepared for the Patient-Centered Primary Care Collaborative—a coalition of major employers, consumer groups, health plans, labor unions, hospitals, clinicians, and others—Grumbach and coworkers summarize findings from recent assessments of various PCMH initiatives.⁵ These studies include data on patients who had private insurance, Medicaid, SCHIP, or Medicare benefits or who were uninsured. Despite the diversity of insurance settings, Grumbach and coworkers found that “investments to redesign the delivery of care around a primary care PCMH yield an excellent return on investment:

• Quality of care, patient experiences, coordination of care, and access are demonstrably better

• Investments to strengthen primary care result, within a relatively short time, in a reduction in emergency department visits and inpatient hospitalizations that produce savings in total costs. These savings at a minimum offset the new investments in primary care in a cost-neutral manner, and in many cases appear to produce a reduction in total costs per patient.”⁵

Here is a sampling of findings from this briefing:

• HealthPartners Medical Group BestCare PCMH Model reduced the rate of hospitalization by 24% and the rate of emergency room (ER) visits by 39%

• Geisinger Health System ProvenHealth Navigator PCMH Model reduced the rate of hospital admissions by 14% (relative to a control group) and experienced a trend toward a 9% reduction in total medical costs at 24 months

• Johns Hopkins Guided Care PCMH Model reduced the total number of inpatient hospital days by 24%, ER visits by 15%, and annual net Medicare savings by $1,364 per patient

• Community Care of North Carolina reduced the rate of hospitalization for asthma by 40% and the rate of ER visits by 16%.⁵

Additional data on Community Care of North Carolina, which encompasses 15 not-for-profit networks that care for about 74% of the state’s Medicaid recipients, indicate that it saved the state roughly $80 million in fiscal year 2005 and as much as $170 million in fiscal year 2006.¹

A study by Reid and coworkers, which focused on a medical home pilot project in Seattle, comparing it with the traditional model of practice, found a reduction of 29% in ER visits among patients in the medical home, along with 6% fewer hospitalizations.⁶ It also found a lower rate of burnout among practitioners and a greater degree of patient satisfaction.⁶

4. Is the PCMH another version of the gatekeeper model?

In the gatekeeper model, the physician is rewarded for providing less care to the patient. The PCMH is supposed to increase the quality of care, and sometimes the quantity as well, by focusing on preventive and well-person initiatives rather than simply treatment of a disease process. However, many critics are skeptical that gatekeeping will be completely excluded from the model. For example, the American College of Emergency Physicians (ACEP) expressed concern in a 2008 policy statement that “a shifting of financial and other resources to support the PCMH model could have adverse effects on sectors of the health-care system that are already experiencing serious challenges.”⁷ The ACEP also noted that “proponents of the PCMH insist that it is not a gatekeeper model. Yet in order for there to be the cost savings touted by proponents, there will undoubtedly be pressure for medical home providers to limit choices and restrict access of patients to certain providers.”⁷

The AMA also observed that there are “strong concerns that the medical home model could become synonymous with a ‘gatekeeper’ for participating patients” and emphasized the need “to ensure that patients continue to have access to specialists without having to receive approval from their primary care physicians.”¹

ACOG also called on the AMA to ensure “that patient access to necessary quality specialty care without a gatekeeper is preserved.”¹

5. What impact will the PCMH have on specialist care?

Some primary care physicians argue that specialists are ill-equipped to provide primary care. For example, in an article in Pediatrics, Starfield and Shi observed that “there is evidence that specialty services, even when provided in the community rather than in hospitals, are much less likely to meet requirements for adequate primary care than are services provided by family physicians, general internists, or general pediatricians.”⁸

Statements such as this one suggest that ObGyns will be excluded from a patient’s care whenever possible under the PCMH model.

As a result, some specialists are concerned about the implications of the PCMH model for their practice. Writing in the New England Journal of Medicine, Casalino and coworkers pointed out that proponents of the PCMH model “advocate reforms that would increase payments to practices that qualify as medical homes; these payments might well come, directly or indirectly, from funds that would otherwise have been used to pay specialists.”⁹

They also pointed out the significant challenges involved when setting up a PCMH. “Research to date suggests that it will not be easy to meet these standards, even for primary care practices or multispecialty practices that include primary care physicians.”⁹

“Given the goals of the PCMH, it is clear that serving as a medical home requires much more than merely providing primary care,” they write.⁹

The burden may fall especially hard on small practices. The AMA expressed concern that “the requirements—both infrastructure and administrative—associated with qualifying as a formal medical home would be too great, resulting in denial of financial incentives associated with the medical home designation.”¹

6. How many PCMH practices are there?

By the end of 2009, there were 26 pilot projects underway involving more than 14,000 physicians and 5 million patients.¹⁰

It can’t be determined whether any of these projects focuses exclusively on women’s health.

7. What’s involved in establishing a PCMH?

ACOG has developed a medical home “toolkit” that can help you assess what will be involved in converting your practice to a PCMH.¹¹ (Warning: It’s a lengthy document.) Consider Step 1 under the heading of “Patient/Practice Partnership Support,” which involves compilation (on the Web or in print, or both) of bios, photos, and job descriptions for each practitioner and employee in the practice, including receptionists and billing personnel. Also involved is development and dissemination of a clear outline of the procedures for obtaining a prescription refill, appointment, referral, and other needs, and a list of contact persons for various common scenarios.

Step 1 also involves development of a process by which a patient can obtain a same-day appointment for an urgent problem, choose her personal physician, and contact her caregivers by e-mail and phone (including estimated response times). And the list goes on.

8. Where can I find out more?

ACOG is a good place to start. See the Congress’ information sheet entitled, “Medical home—answers to some questions,” at http://www.acog.org/departments/dept_notice.cfm?recno=19&bulletin=5027.³ Also available at the ACOG Web site is the toolkit, at http://www.acog.org/departments/dept_notice.cfm?recno=19&bulletin=5203.¹¹ Another useful repository of information is the Patient-Centered Primary Care Collaborative at http://www.pcpcc.net.

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