The Need to Test the Patient-Centered Medical Home

Patients, physicians, nurses, employers, payers, and other players in the health care system are directly affected by the severe limitations of the current US health care delivery and reimbursement system. The future will be worse unless the root causes of this dysfunction are addressed. The symptoms are fairly clear and the data to support a diagnosis as well as potential therapeutic options are available.

Unwarranted variation¹ in the delivery of care contributes to the lack of a relationship between what is spent on health care and the quality of the services delivered.² Other countries that spend far less per capita on health care than the United States deliver care that is more equitable, effective, and efficient and is safer and more patient-centered than is provided in the United States.^{3 - 4} The United States is slipping further behind other countries in areas such as amenable mortality⁵ and ranks poorly compared with several other countries on important attributes such as access and safety.⁴ Research suggests that the presence and support of a robust primary care system is a major characteristic of an efficient and high-quality health care delivery. This has been demonstrated in other countries as well as in the United States.⁶

However, the future of the US primary care system is uncertain at best and is perilously close to collapse at worst. Fewer medical students and residents are choosing primary care specialties, and physicians in practice are leaving internal medicine faster than their other colleagues with a subspecialty.⁷ Recent workforce analyses highlight this trend and the lack of a foreseeable change in the projections for the availability of primary care physicians.⁸ Furthermore, the poor outlook for the supply of physicians with special training in geriatrics is well documented.⁹ Even though reimbursement is not the only driver of the system's dysfunction, payment based almost solely on the volume of care provided—even with a small performance-based component based on measures of quality—will not attract medical students and residents to primary care. In addition, it does not provide the necessary incentives or capital for physicians to invest in practice enhancements, systems of care, or health information technology.

In the past few years, the American Academy of Family Physicians (AAFP) and American College of Physicians (ACP) independently advanced policies to advocate for change in the health care delivery and reimbursement system based on the concept of the medical home, which was originally described in the 1960s by the American Academy of Pediatrics (AAP). However, several large employers (especially IBM Corporation) encouraged the ACP, AAFP, AAP, and American Osteopathic Association (AOA) to synthesize their respective viewpoints^{10 - 11} into a unified concept and subsequently agreed to collectively promote the Joint Principles of the Patient-Centered Medical Home (PCMH) as a model of health care to test through demonstration projects.¹² The principles, originally developed in late 2006, were released publicly in February 2007. They have attracted considerable attention and are now endorsed by several other medical professional societies.¹³

In March 2007, the Patient-Centered Primary Care Collaborative (PCPCC) was formed. This formation was motivated by the health care model as well as by the new collaboration between the medical societies and a group of large US employers. The PCPCC now counts among its supporters more than 160 organizations representing more than 50 million employees/beneficiaries all supportive of the PCMH model and testing of both the practice transformation elements as well as new methods of reimbursement. More importantly, the call for testing of the PCMH is now embedded in legislation (the Medicare Medical Home Demonstration Project authorized in the Tax Relief and Health Care Act of 2006) and forms the basis of several demonstration projects across the United States that include multiple commercial payers, state Medicaid agencies, regional and national employers, business groups, quality improvement programs, and national/regional medical professional societies. Many of these demonstration projects are being developed with input from health services researchers and are designed to effectively measure the effect of the model on quality, cost, patient experience, and satisfaction.

Data suggest that the model will deliver improved quality and reduced costs and prove attractive to patients and their families; many stakeholders are supportive of the PCMH.¹⁴ However, it is imperative to test the model in a credible and transparent way in different environments. A recent conference sponsored by The Commonwealth Fund called together leading researchers to help define the best methodological designs for testing the PCMH in practice. The Commonwealth Fund is also supporting the evaluation of some PCMH demonstration projects. The National Committee for Quality Assurance, in collaboration with the ACP, AAFP, AAP, and AOA, developed a recognition tool to provide both a road map for practice transformation consistent with the PCMH model and as a mechanism for identifying PCMH attributes of medical practices participating in demonstration projects.

In addition to demonstration projects, quality improvement and research efforts are under way or in development based on the PCMH model. These projects will help determine the costs of implementation, the best methods for improving the structure and characteristics of ambulatory care practices and academic medical center faculty practices, and how to transform the education of medical students and residents based on a patient-centered approach to care.¹⁵

Why should patients, employers, public/private payers, federal and state agencies, researchers, physicians, and other health care professionals care whether the PCMH is tested? The simple answer is that the current US health care system is designed to achieve the results documented and no one should be satisfied with the current performance of the health care system. Although change is unsettling and disruptive, without tests of change only more of the same can be expected. Residents of the United States deserve a better quality of care. The current health care system costs are unsustainable and negatively affect individuals, businesses, and the economy. The basic safety of patients is challenged when interacting with the health care system. Physicians and other health care professionals delivering primary care are barely remaining solvent, and the situation is projected to worsen.

The pace of activity and attention the PCMH has received from the public and private sectors speaks to the desire and need to find alternative models of health care delivery and reimbursement that are responsive to the well-documented shortcomings of the US health care system. Those individuals and organizations involved in these efforts understand that the PCMH model needs to be tested in a robust way and continually improved based on lessons learned through the accumulation of data from multiple demonstration projects. However, the PCMH is only one potential method of addressing some of the ills of the US health care system. Even assuming that the demonstration projects will improve quality, reduce cost, and satisfy the needs of patients and families, unless other major policy changes occur, the PCMH cannot significantly improve the plight of the uninsured, reduce pervasive health disparities, or solve the primary care and geriatric workforce issues. However, the PCMH model may provide a pathway for revitalization of primary care and become an essential part of a new approach to health care delivery in the United States.