The Rise of the Patient Centered Medical Home: What is it? What does it mean?

By Mona Sarfaty, MD

The previously unfamiliar term “Patient Centered Medical Home” (PCMH) made its way into conversations about the health care system over the course of the last year.  Since January 2008, the National Committee on Quality Assurance (NCQA), one of the nation’s arbiters of health care quality, has certified primary care practices that seek to be designated as a PCMH.  The total number to apply for or receive the designation is still small, but the number of applications is growing.  In some states, including the state of Pennsylvania, the PCMH designation translates into higher reimbursement rates for primary care services.  The link between designation and reimbursement has led to a rush of education offerings by medical societies and the continuing medical education industry to clinicians and practices that may wish to apply for NCQA designation. 

There are numerous indicators of widespread interest and activity.  Legislation is under consideration in 20 states to stimulate the establishment of patient centered medical homes.  The Center for Medicare and Medicaid Services (CMS) has made available a demonstration program funded through federally qualified community health centers.  Think tanks, policy groups, and business trade organizations have published histories, analyses, and interpretations on PCMH for their constituents.  The New England Journal of Medicine and Health Affairs, both journals with a wide reach, have recently published thoughtful commentaries on this subject.    

          A bit of history is helpful.  The concept of the patient centered medical home was first utilized in the 1980s by academic pediatricians who focused on building a “medical home” for children with special needs.  A decade later, the Future of Family Medicine project was organized by the American Academy of Family Practice (AAFP) to rejuvenate family medicine at a time when managed care was the cause of rising fragmentation and disruption of established networks of care.  The AAFP project focused on the “personal medical home,” which was intended to reflect the key principles of primary care such as point of first contact, comprehensive care, continuity and coordination.  The new term implied a reincarnation of these well-established principles that were defined in the 1960s and '70s but were not accompanied by a solid evidence base until later and perhaps never had sufficient public relations to be heard over the blare of excitement about specialty medicine.  A few years later, the American College of Physicians brought elements of Ed Wagner’s chronic care model into its parallel formulation called the “advanced” medical home. 

The “patient centered” half of the new term emerged onto the landscape when the Institute of Medicine, in its popular publication Crossing the Quality Chasm (IOM), held that “the system of care should revolve around the patient, respect patient preference and put the patient in control.”  The patient centered focus has been growing in prominence ever since,  associated with research on self management to address chronic disease and the growing awareness of the need for “practice re-engineering” of the health delivery system to achieve a more efficient and less fragmented system that is better at generating meaningful health care outcomes. 

The Commonwealth Fund together with the American College of Physicians co-sponsored a project to evaluate the cost of building the medical home.  Subsequently, health systems began to sponsor demonstration programs.  Examples include the Emblem Health project, the Mid-Hudson Valley pilot, and the Improving Performance in Practice (IPIP) initiative developed and initiated in several states funded by the Robert Wood Johnson and American Board of Medical Specialty Society Foundations

          The PCMH morphed from a theoretical idea to a reality with the establishment of a primary care collaborative of the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association.  These primary care professional organizations with heightened awareness of the importance of primary care services assembled for the purpose of building consensus among payers and reformers of the health system about the importance of primary care services and the pivotal significance of reimbursement rates that actually pay for those services.  The organizations aimed to ensure that payers provide payment for the functions that are integral to the success of primary care.

          Two factors added a sense of urgency to this work.  The first is the “crisis” in primary care services that was declared by the American College of Physicians a couple of years ago when it was noted that there was a dramatic fall-off in the choice of a primary care careers by graduating medical students and medical residents.  The fall-off was a present-day indicator of a dramatic change in the future landscape.  The second factor was the snag that developed in the efforts to achieve universal access to care at the state level through state health reform efforts.  Experiences like that of the state of Massachusetts pointed up with startling clarity that even access through insurance coverage could not guarantee medical care if there were no clinicians to provide it.  A shortage of primary care providers in Massachusetts hampered efforts to get newly insured individuals the care they anticipated.   

          Decades of development and the urgency produced by the brewing crisis led to consensus of the four prominent primary care societies. A collaborative of these societies issued a statement that defined the essential characteristics of a patient centered primary care medical home.  The definition included: 1. a personal physician; 2. a whole person orientation; 3. coordinated and integrated care; 4. safe and high-quality care (evidence-based, appropriate use of health information technology, continuous quality improvement); 5. enhanced access to care; and  6. payment that recognizes the added value that is provided to patients who  have a patient-centered medical home.  The American Medical Association and 11 other major medical societies or associations formally endorsed these concepts.  The NCQA criteria involves measurement of these characteristics and adds a few others.  Specifically, NCQA adds requirements for measurement of population based characteristics and use of strategies demonstrated by the chronic care model like care management and self management.    

          Activity over the last year occurring around the PCMH concept such as meetings, publications, demonstration programs and certifying agencies, etc. typically reflects lasting change.  However, it is hard to predict the future of the patient centered medical home concept, especially its impact on the delivery of primary care services or the health delivery system in general.  For many years, the health care system has only grown in complexity and fragmentation.  Whether the patient centered medical home will strengthen primary care services or reimbursement on a grand scale or have any larger impact on the delivery system remains to be seen.  Stay tuned.