- The patient-centered medical home (PCMH) model challenges primary care providers to raise the bar on care coordination, population health management, clinical analytics, and access to care, but healthcare organizations that undertake these important quality transformations are usually left to foot the bill themselves. In a reimbursement landscape that remains, for the most part, rooted in fee-for-service payment, the incentive to pay out of pocket for these massive and costly changes can be hard to find.
But the PCMH doesn’t ask for investment without promising return, and federal healthcare reform efforts are doing their part to accelerate the possibility of ROI by expanding value-based payment initiatives that align perfectly with the principles of the PCMH.
With the help of regulators, rule makers, vendors, and dedicated primary care providers, the healthcare industry is slowly breaking down the barriers that prevent care delivery models and payment reforms from working together for the greater good.
Marci Nielsen, PhD, MPH, CEO of the Patient-Centered Primary Care Collaborative (PCPCC), contributes to HealthITAnalytics.com’s practice transformation series with a one-on-one Q&A exploring the intersection of the patient-centered medical home with healthcare reform plans, the health IT market, and accountable care efforts that hope to share more savings for all.
How do you view the patient-centered medical home when it comes to larger healthcare reform efforts?
Cost is really at the top of policymakers’ minds when they are thinking about healthcare reform writ large, but we wouldn’t want folks to think that the patient-centered medical home model of care delivery is really just a payment reform model, Although there are payment reform components, of course, that isn’t the singular goal of the patient-centered medical home.
The goal for the PCMH is really is the Triple Aim. The patient experience of care, population health management, and improving health outcomes are really the most important things we’re trying to achieve with this philosophy of care.
The good news is when you provide a better patient experience of care and patients get more engaged in their own care, we believe that you see measurable impacts on health outcomes. And those better outcomes have an influence on costs. So they do all fit together, but cost isn’t all we care about. The patient-centered medical home is so much more.
What are the challenges of defining the costs and savings of the patient-centered medical home?
In our annual reports, we look at evaluations of medical home initiatives that did indeed measure costs or utilization. But the one real challenge that we have – and we say this in the study in a couple of places, is that we aren’t using all the same metrics around utilization or around cost. Some of those studies are in measuring total cost of care changes. Other studies are just looking at overall cost savings or emergency department use changes that result in changes in cost.
So it’s difficult, when you look at the research, to be able to easily quantify just how much money this model of care can save. That will continue to be a challenge, regardless of whether you change the metrics and everybody agrees to a single way to measure. All of these practices are starting from various places. Some practices are just implementing EHRs. They’re going to have a long way to go before they’ve got a full functioning patient-centered medical home, and that means they’re going to appear to be spending more money, if we start a study today, than a provider that joins the same evaluation but is already most of the way there.
How do federal efforts to transition the healthcare industry to value-based reimbursement affect participation in a PCMH?
There are a couple of important things that are happening right now, including the proposal to repeal the sustainable growth rate. In that bill, the patient-centered medical home is listed as one of the alternative payment models providers can use to receive a 5 percent bonus in 2018. We think it was really important to get the PCMH included in that bill.
Just having accountable care organizations that may or may not be adequately sharing cost savings with primary care isn’t enough. Part of the goal of this bill is to change the way we pay for healthcare delivery at the practice level, as well. We have to include practices as part of the beneficiaries of controlling costs. We’re not doing it enough yet, but I think we’ll be able to achieve more savings for everyone if we pass the SGR legislation and follow along those alternative payment methods.
We are hopeful that our ability to demonstrate that the patient-centered medical home provides better care for real patients will insure that investing in primary care and sharing in savings with the primary care practice is the right thing to do.
Is the health IT vendor market hindering or helping the development of the PCMH? What’s your advice to providers who are looking to bulk up their infrastructure?
Right now, we can’t offer providers a technology recipe book, because everyone has such different, unique needs. But we can acknowledge that if you want real population health management, you can’t do it within the confines of an EHR and meaningful use today.
I do think that vendors have been, for many reasons, slow to embrace the changes that we need – those registry tools for example, risk stratification tools, and clinical decision support.
We need vendors to help us come up with creative ways to develop an EHR and the tools necessary for population health management all in one. There’s nothing more frustrating to a provider who is spending all kinds of money on these products to discover that they may help achieve meaningful use, but they’re not going to help do what they really want to do for their patients in terms of delivering this model of care.
The reason, by and large, is that if you’re still almost exclusively practicing in a fee-for-service world, practices really do need EHRs that link to billing. We hope that the vendor community will change quickly when they realize that providers are moving to value-based care arrangements, and documentation and billing that supports fee-for-service is headed out the door.
We’ve got some smart vendors out there that have figured out how to bridge that gap by making products that sit on top of the EHR. But most of the time, the practices that can easily afford those products are often the bigger, better integrated practices. We need to work on that, because we still have most primary care being delivered in small practice settings.
Do you believe CMS and the ONC are doing enough to foster delivery reform initiatives like the patient-centered medical home?
Their goals, I think, are noble. The announcement by Karen DeSalvo that the ONC wants to speed up the interoperability requirements was certainly music to everybody’s ears. I appreciate the flexibility of the administration to recognize what’s doable and not when it comes to meaningful use and some of the timeline changes they’ve made. We like the idea of more patient engagement and enhancing the patient’s ability to see their records, and adding data that is patient generated. All of that is only going to improve the system.
Our concern continues to be about how we’re lining up technology with payment reform with practice readiness, because those three things aren’t in perfect alignment yet. If we’re asking a practice to take all this on without being very mindful of their ability to afford the tools they need, we’re going to have even more frustrated practices. There are so many physicians who are leaving the field of primary care altogether. And it’s not because they don’t love their patients. It’s because it’s not satisfying work if most of your day is spent chasing administrative details instead of working with patients.
Now that CMS and the ONC are really pushing for payment reform, it’ll be interesting to see what we can do to help vendors understand what we need and when we need it.
I think we demonstrated great capacity to get a really big job done when it came to getting the health insurance exchanges up and running. I can’t say that we particularly came out of the gate very strongly, but it was so important that we learned some real lessons about how to build technology quickly to support these exchanges and really took that to heart.
So I’m hoping that the smart people who have learned from that process are going to help share some lessons about how we get up to speed on real payment reform so that the changes we need can happen quickly.