The Patient-Centered Medical Home

1. The Patient-Centered Medical Home Prepared by: Kelly Doran, MD NYU/Bellevue Emergency Medicine

2. Introduction • What is a patient-centered medical home? • What does it mean for emergency medicine? • Will the PCMH model improve health care?

3. Objectives • Discuss the development and key features of the PCMH model • Understand implications of the PCMH model for emergency medicine • Delineate ACEP’s position on the PCMH • Explore current implementation of the PCMH

4. What is a Patient-Centered Medical Home? • “An enhanced model of primary care in which care teams attend to the multi-faceted needs of patients and provide whole person comprehensive and coordinated patient-centered care.” • “A model of care where each patient has an ongoing relationship with a personal physician who leads a team that takes collective responsibility for patient care.”

5. History of the PCMH • 1967: Concept first introduced by the American Academy of Pediatrics (AAP) • 2001: The IOM’s Crossing the Quality Chasm: A New Health System for the 21st Century states that “the system of care should revolve around the patient.” • 2004 & 2006: The American Academy of Family Physicians (AAFP) and American College of Physicians (ACP) put forth their own statements regarding medical homes

6. History of the PCMH • 2006: Fewer medical students entering primary care • 2006: The Patient Centered Primary Care Collaborative (PCPCC) was formed, representing employers, medical specialty societies, health insurance plans, and other stakeholders • 2007: Joint Principles of the Patient-Centered Medical Home is put forth by the AAP, AAFP, ACP, and AOA (American Osteopathic Association)

7. Joint Principles of the PCMH • Personal physician • Physician directed medical practice • Whole person orientation • Care is coordinated and/or integrated • Quality and safety • Enhanced access to care • Payment reform

8. The PCMH and Emergency Medicine • The PCMH model is hoped to: • Decrease “non-urgent” emergency department use • Help patients control their chronic illnesses to avoid needing emergency care • Reduce hospital admissions • Improve patient care overall

9. ACEP’s Response “The realities of our current dysfunctional healthcare system stand in stark contrast to the laudable goals of the PCMH.” - ACEP Policy Statement

10. ACEP Policy Statement “Important specifics must be addressed before moving forward with widespread adoption of the PCMH model. Nowhere is caution more important than in the way implementation of the PCMH model might negatively impact the emergency department.” - ACEP Policy Statement

11. The PCMH and Emergency Medicine: The Concerns • Resources used to develop the PCMH model might reduce support available for emergency medicine • The PCMH model might draw attention away from an emergency system that is the “ultimate safety net” for patients

12. ACEP Policy Statement • ACEP agrees with the basic principles of the PCMH… • With the caveat that eight critical issues should be addressed

13. ACEP Critical Issues • “ACEP supports high quality, safe, and efficient medical care” • “ACEP supports health care payment reforms that ensure all medical providers are fairly compensated for the care they provide to patients” • Must compensate physicians for EMTALA-mandated services

14. ACEP Critical Issues • “Enhanced access must be demonstrated” • “Once established, the medical home should continue regardless of insurance status or ability to pay.”

15. ACEP Critical Issues • “Universal health insurance coverage is necessary for the PCMH model to be most effective.” • “The medical home must include the safety net of emergency care.”

16. ACEP Critical Issues • “Patients must have freedom to switch medical homes, select specialists of their choosing, and access emergency medical care when they feel they need it.” • Patients, not gatekeepers, should decide what is an emergency by “prudent layperson” standards • “Research must prove the value of the medical home before it is widely adopted.”

17. Current Implementation • Medical home initiatives exist in all states • Both publically and privately funded • CMS to start a 2010 demonstration project in 400 practices in 8 regional sites • Bills promoting the PCMH model have been introduced in at least 16 states

18. How to Evaluate the PCMH? • National Committee for Quality Assurance • Set nine standards that practices must sufficiently meet to attain recognition as a PCMH • Voluntary • Criticisms of NCQA Standards • Too much emphasis on information technology and not enough on patient-centeredness

19. Results of Initial Research: The Good • Geisinger Health System in Pennsylvania  20% reduction in hospital admissions and 7% savings in overall medical costs (Paulus 2008) • Study of asthmatic children on Medicaid in North Carolina (Domino, et al. 2009)  Fewer ED visits and hospitalizations but higher costs • One PCMH in Seattle (Reid 2009)  Increase in patient-level markers, no change in costs

20. Results of Initial Research: The Bad • “Initial lessons” from AAFP demonstration project of 36 family practices  • “Our early analysis raises concerns that current demonstration designs seriously underestimate the magnitude and time frame for the required changes, overestimate the readiness and expectations of information technology, and are seriously undercapitalized.” (Nutting, et al.) • Commonwealth Fund study of 35 practices  Higher IT costs for PCMH, otherwise no significant increase in costs for higher “medical homeness”

21. Conclusions • PCMH model is being implemented • Looked to as important part of health care reform • PCMH has major issues not resolved • “Society must get the home it is paying for” • Need to address fundamental concerns • Potential is there, but further data needed

22. References • Abrams MK, Davis K, Haran C. Can patient-centered medical homes transform health care delivery? Commonwealth Fund: From the President. 27 Mar 2009. • American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of he patient-centered medical home. 2007. • Berger E. Medical home: A solution to “hamster health care” or a drain on emergency care? Annals of Emergency Medicine. 2008;52(6): 654-7. • CQ State Track Free Nationwide Bill Search. Available at http://www.trendtrack.com/. Search conducted 26 Jul 2009. • Domino ME, Humble C, Lawrence WW, Wegner S. Enhancing the medical homes model for children with asthma. Med Care. 2009;47:1113-20. • Homer CJ, Cooley WC, Strickland B. Medical home 2009: what it is, where we were, and where we are today. Ped Ann. 2009;38(9):483-90. • Kaye N, Takach M. Building medical homes in state Medicaid and CHIP programs. National Academy for State Health Policy and The Commonwealth Fund. June 2009. Available at www.nashp.org • NCQA News Release. NCQA program to evaluate patient-centered medical homes. 8 Jan 2008. Available at www.ncqa.org. Accessed 8 June 2009. • Nutting PA, et al. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;7(3):254-60. • The Patient-Centered Medical Home. ACEP Policy Statement. Approved by the ACEP Board of Directors August 2008. Available at: http://www.acep.org/practres.aspx?id=42740 • Patient-centered medical home building evidence and momentum: a compilation of PCMH pilot and demonstration projects. Patient-Centered Primary Care Collaborative. 2008. Available at: http://www.pcpcc.net/content/pcpcc_pilot_report.pdf • Patient-Centered Primary Care Collaborative web site. http://www.pcpcc.net/ • Paulus RA, Davis K, Steele GD. Continuous innovation in health care: implications of the Geisinger experience. Health Affairs. 2008;27(5):1235-45. • Reid RJ, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Managed Care. 2009;15(9):e71-e87. • Rittenhouse DR, Shortell SM. The patient-centered medical home: will it stand the test of health reform? JAMA. 2009;301(19):2038-40. • Steiner BD, et al. Community Care of North Carolina: improving care through community health networks. Ann Fam Med. 2008;6(4):361-7. • Starfield B, Shi L. The medical home, access to care, and insurance: a review of the evidence. Pediatrics. 2004;113(5 Suppl):1493-8. • Zuckerman S, et al. Incremental cost estimates for the patient-centered medical home. Commonwealth Fund Report. Oct 2009. Available at www.commonwealthfund.org