Medical Homes (PCMH)

The basic premise behind a medical home as a performance based incentive plan is similar to bundled payments, where providers are reimbursed a set amount to manage all aspects of care for a specific condition. However, a recent study (64) over a two year period demonstrated that patients saw a median of two primary care physicians and five specialists working in four different practices. Due to this dispersion of care, a practical barrier to medical home P4P implementation is assigning and rewarding providers for the care of a single patient. This problem has cited a source of incompatibility between P4P and medical homes (82125). Yet, multiple authors (65176319323) argue that medical homes may ultimately be a necessary precondition for effective P4P programs. Champlin (15) however argues that medical homes could help expand the role of primary care physicians.

In the midst of these controversies, The National Committee for Quality Assurance (NCQA, 68) and Bridges to Excellence (128) have provided metrics and plans for assigning patients medical homes. These metrics have yet to be critically analyzed and may provide useful insights for the advancement of medical homes.

 

 

Medical Homes Literature

 

(15) Champlin, Leslie. P4P May Boost Role of Primary Care. American Academy of Family Physicians. 2006: 2(3).

Link: http://www.aafp.org/online/en/home/publications/news/news-now/profession...

Summary:

  • Author hopes P4P will increase primary care workforce and medical homes.

Significance to Literature:

P4P may boost the role of Primary Care physicians and medical homes.

 

 

***Key Article***

(64) Pham H, et al. Care Patterns in Medicare and Their Implications for Pay for Performance. NEJM. 2007: 356(11) 1130-1139.

PMID: 17360991

Summary:

  • Article seeks to answer what the role is for Primary Care Physicians amongst Medicare patients under P4P.
  • 1/3 patients change PCP every year, and many see multiple providers, making it very difficult assign responsibility for patient care.
  • Dispersion of patient care may limit the effectiveness of P4P.

Significance to Literature:

Properly assigning responsibility for patient care will be a limiting factor for the effectiveness of P4P.

 

 

(65) Davis K. Paying for Care Episodes and Care Coordination. NEJM. Editorial. 2007: 356(11) 1166-1168.

PMID: 17360996

Summary:

  • Identifies multiple providers as a barrier to P4P.
  • Suggests awarding providers for patient centered medical homes.
  • “P4P is unlikely to fundamentally alter the incentives in the FFS payment system.”

Significance to Literature:

P4P requires medical homes to function properly.

 

 

(68) Watcher K. Metrics Chart Plan for Medical Home. Family Practice News. 2007: 37(23).

Link: http://www.familypracticenews.com/search/search-single-view/metrics-char...

Summary:

  • The National Committee for Quality Assurance (NCQA) describes metrics that will be used in designating medical homes.

Significance to Literature:

Defining medical homes will be a key issue once P4P reimburses based on medical home.

 

 

(82) Porter S. P4P Study: Dispersion of Care Erodes Physician motivation. AAFP News Now. April 4, 2007.

Link: http://www.aafp.org/online/en/home/publications/news/news-now/practice-m...

Summary:

  • Patients seeing multiple providers will make P4P difficult to implement successfully.
  • Follow up to NEJM “Care Patterns in Medicare and Their Implications for Pay-for-Performance.” (64)

Significance to Literature:

Supports the notion that fragmented care will be a challenge for P4P.

 

 

(125) Glendinning, David. Medicare pay-for-performance dilemma: Who gets the bonus? American Medical News. April 2, 2007.

Link: http://www.ama-assn.org/amednews/2007/04/02/gvsb0402.htm

Summary:

  • Article is a response to NEJM article from March 15, 2007 (64), dispersion of care.
  • A basic question within P4P is who gets paid if the patient sees multiple physicians?
  • Will CMS assign patients to physicians?

Significance to Literature:

Examines the political issues surrounding which physician should receive the P4P bonus when the patient sees multiple physicians in multiple specialties.

 

 

(128) Fuhrmans V. Group Offers Doctor Bonuses for Better Care. The Wall Street Journal. January 28, 2008.

Link: http://online.wsj.com/article/SB120175692402331541.html?mod=googlenews_wsj

Summary:

  • Bridges to Excellence, a national program backed by big employers and health plans designed $125 annual bonuses per patient for clinics for doctors who create medical homes for patients.
  • Article offers brief explanations why this is becoming a relevant issue, including an estimate that medical homes improvements in care coordination can yield $250-300 per patient in healthcare savings within the first year.

Significance to Literature:

Published in the Wall Street Journal, P4P has growing publicity.

 

 

(176) Goldfield N et al. Implementing a New Payment System for Primary Care Physicians: A Response to Schoenbaum et al and Other Feedback. Journal of Ambulatory Care Manage. 2008: 31(2) 154-160.

PMID: 18360177

Summary:

  • Addresses eight concerns authors received in regards to their original contribution in 2008 titled Reforming the Primary Care physician payment system: Eliminating E & M codes and creating the financial incentives for an “Advanced Medical Home.”
  • Concerns include: medical homes, localized adjustment factors, eliminating E & M codes, value-based payment vs. episodes of illness, sharing savings, zero-sum payments to PCPs, ambiguity in PCP assignment, maintaining quality, and reports for physician.
  • Provides a case example of their payment system

Significance to Literature:

Discusses some important infrastructure components of P4P for primary care physicians including medical homes.

 

 

(319) Shortell SM, Bending the Cost Curve: A Critical Component of Health Care Reform. JAMA. Commentary. 302(11) 1223-1224.

PMID: 19755703

Summary:

  • Changing financial incentives and establishing accountability is the key to changing hospital and physician behavior, which is a critical component to health care reform. 
  • Author suggests accountable care organizations and medical homes can play a major role in establishing cost reductions.

Significance to Literature:

 "Some relative reduction and redistribution of revenue and net income must occur--that is what reducing the rate of increased spending or "bending the cost curve" means."

 

 

(323) Rittenhouse DR, Shortell SM, Fisher ES. Primary Care and Accountable Care--Two Essential Elements of Delivery-System Reform. NEJM. Perspective. 2009: 361(24) 2301-2303.

PMID: 19864649

Summary:

  • Authors discuss two delivery-system reform approaches, including the patient centered medical home (PMCH) and the accountable care organization (ACO).
  • Both models could be synergistic, authors point out three mutually reinforcing strategies.
  • Both systems should provide payment mechanisms to strongly weight the importance of primary care.

Significance to Literature:

P4P can play a major role in establishing delivery system reforms, specifically ACO and PMCH.

 

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