The Integrated Patient-Centered Medical Home Model

Posted on April 16, 2021 by Dr. David Edward Marcinko MBA

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By Matias A. Klein

[VP, General Manager, Clinical Quality and Collaboration, Portico Systems]

The patient-centered medical home (PCMH) continues to attract increasing attention from many industry stakeholders. The PCMH model has the potential to enhance the US healthcare system by rejuvenating primary care in a way that improves clinical outcomes, lowers costs, promotes wellness, and increases patient and physician satisfaction.

PCMH Pilot Programs

PCMH pilots are currently being tested in almost all states, including a 3-year Medicare medical home demonstration project overseen by the Centers for Medicare & Medicaid Services. However, few organizations have scaled the PCMH across their entire healthcare network, and the existing implementations appear to remain focused on care management at the expense of patient wellness. The value of focusing equally on promoting wellness (although an underappreciated nuance in the implementation of a PCMH) is a critical factor in effectively leveraging the PCMH model to improve clinical outcomes and the US healthcare system.

Centered on the Patient

The PCMH model, as its name suggests, is centered on the patient. The underlying thought is that if a comprehensive, longitudinal view of a patient is taken throughout a patient’s lifespan, the patient’s health could be better “managed” and better aligned with best medical practices. It is well documented that physicians do not consistently or frequently apply evidence based, recommended care to patients. Therefore, a major goal of the PCMH model is to improve the consistent application of evidence-based guidelines and best practices, by making longitudinal information about the patient available to providers and to patients – including any risks and recommended “intervention opportunities.” And although adherence to best practices in disease management is crucial, the PCMH model also focuses on preventing costly episodes by promoting and incentivizing wellness.

PCPs = Medical Homes

To effectively manage a patient’s health and promote wellness, primary care physicians – designated as medical homes – need to act as health “quarterbacks” or “coaches.” In such a role, these physicians will assist in aggregating a patient’s health information, making best practices transparent, offering health education and counseling, as well as coordinating the provisioning of any healthcare services the patient may need. With physicians spending significant time coaching and making critical clinical decisions, these services will be delivered with the support of care management nurses, who will handle the majority of the information processing and operational activity.

An Innovation in Care

The PCMH model is an important innovation in care delivery and has the potential to reduce medical and administrative costs, while improving the quality of care. However, how to implement the PCMH model within a care-delivery system remains unclear. Providers need the requisite infrastructure and capabilities at their locations to meaningfully participate in a PCMH. Patients must be engaged over long periods of time in proactively managing and improving their health. Outcomes and quality must be objectively measured to optimize the delivery of best possible patient care.

Potential Value

To realize the potential value of the PCMH, three distinct stakeholders – patients, providers, and health plans – must work in a collaborative way. Getting these stakeholders synchronized (i.e., aligned in their goals, using interoperable tools, and collaborating on an operational level) is no small feat but can be accomplished with the smart application of technology. Bringing these three stakeholder groups together on a common, collaborative technology platform results in what some are beginning to call the integrated PCMH. The integrated approach to the PCMH can best ensure that implementing a PCMH model does not create additional administrative burdens to health plans or provider organizations.

An integrated PCMH provides a framework for stakeholders to collaborate in a transparent fashion, and where quality, best practices, and outcomes are incentivized. The integrated PCMH also provides a pathway being awarded a medical home designation.

Vertical Integration Deployment

The key to deploying an integrated PCMH is an end-to-end vertical integration of the care-delivery process – that is, a process in which the provider network management, automation, information exchange, and analytics solutions are tightly integrated with patient and provider information. With so much complexity and so many “moving parts” in the delivery of the PCMH model, this end-to-end vertical integration is a practical solution that enables effective coordination of care and accurate measurement of quality: with such system integration, the provider network (e.g., the health plan) can bring economies of scale to even the smallest provider offices to optimize the quality of care delivery.

The 5 Keys

The five key components for such an integrated PCMH are:

  1. A source-of-truth for mapping medical home – designated providers, patients, as well as  the associated relationships with health plans and other medical professionals; a central medical home fact checking is critical for effectively identifying, managing, and communicating with medical home and their networks.
  2. A set of collaborative workflows that align stakeholders with best practices, incentives, and quality measures reporting; these collaborative workflows help each stakeholder understand where a given patient is in the care-delivery process, potential intervention opportunities, why certain interventions are being emphasized, and what incentives are available for executing specific interventions.
  3. An infrastructure for clinical integration and distribution of intervention opportunities, clinical reference content, education, alerts, and reminders. This infrastructure allows all stakeholders to have access to up-to-date, accurate patient information; it aligns stakeholders and helps reduce or eliminate duplication of procedures and tests.
  4. Interoperable clinical applications and collaboration tools to enable patients and physicians to engage in medical home processes; these tools – which include electronic medical records, e-prescribing, e-labs, secure e-mail, personal health records, and document management and exchange technology – can help manage health information, assist with decision-making, and improve communication between patients, providers, and health plans.
  5. Incentive management and analytics tools for modeling, setting, measuring, and rewarding incentives based on quality measures and outcomes; these tools must span the entire PCMH delivery process and are required for objectively evaluating and optimizing the performance of a medical home.

When considering the multiplicity of stakeholders, information, software systems, and knowledge that has to be coordinated in the context of a PCMH model, implementing a medical home pilot and scaling it to a full-blown network may seem a daunting task. The integrated PCMH offers a real-world solution for deploying a scalable and flexible infrastructure for the management of this emerging care-delivery model.

Assessment

Early evaluations of the PCMH model show promising, albeit inconclusive, outcomes. The integrated PCMH model offers a practical road map for deploying a management system that will enable objective measurement of PCMH performance and outcomes.

Conclusion

Although the jury is still out on the ultimate value of the PCMH, deploying an integrated PCMH system can help position PCMH pilots in a way that enhances their flexibility and scalability to support full-scale network transformation.

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Health Plans and the Three Levers of Innovation for Affordable Care

Posted on December 13, 2011 by Dr. David Edward Marcinko MBA

Unlocking Affordable Care

Number 2 in a Series of 6

By Sam Muppalla – Vice President, McKesson Health Solutions, Network Performance Management (NPM)

Last week, for the ME-P, I wrote about the increasing Pressure to Deliver Affordable, High-Quality Care.

In the face of those pressures, many health plans have begun to explore innovative approaches to product, care model, and reimbursement designs. What are they doing?

In this second installment of our series about unlocking affordable care, I’d like to take look at how some of the pilots in these areas show promise.

Product Innovation

One path health plans are using to achieve affordable care is through the deployment of value-based insurance designs (VBID). At the heart of this approach is the utilization of member incentives to reduce barriers to high value Rx and services. Conversely, it also incorporates disincentives for low value services or Rx. Typical member incentives include premium reduction, co-pay/coinsurance waiver/reduction, and health reimbursement accounts (HRA). Co-pay increase or cost sharing are typical disincentives. Member steerage to high value providers is another typical goal of VBID. The design of the supporting networks is critical to the success of VBID products. The network design has to ensure that the composition, the quality and the value of the participating providers can fulfill the benefit design and match steerage goals of the member incentives. Furthermore, the network level provider reimbursement guidelines should be complimentary to the member incentives.

For example, member incentive for a preventive exam during a Primary Care Physician (PCP) office visit could be matched by a Pay for Performance (P4P) provider incentive (on top of regular capitation) to perform the examination. Without the incentive, the Per Member Per Month (PMPM) capitation might be a disincentive for the PCP to perform the preventative exam.

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Figure 1: Network steerage is a critical component of product innovation.

Care Model Innovation

Innovative care models provide another approach to the delivery of affordable, high-quality health services. Population management-based care model designs, such as Patient Centered Medical Home (PCMH) and Accountable Care Organization (ACO) designs, are an important advancement towards affordable care. These designs deploy a care team-based approach rather than a traditional siloed services approach to ensure a continuity of care.

The PCMH care model results in continuity of care via a physician who leads the medical team that coordinates all aspects of preventive, acute and chronic needs of patients using the best available evidence and appropriate technology. The emphasis for PCMH is about collaboration to manage a population’s health.

Another example of a care model with a team-based approach is the ACO care model. In this care model, the emphasis is on accountability for providing the required healthcare services for a defined population. Health plans are rolling out ACO pilots across the nation.

For example, the Pension System (of the California Public Employees’ Retirement System) formed a partnership with the Blue Shield of California Health Maintenance Organization, Catholic Healthcare West, and Hill Physicians Medical Group with the goal of improving quality of care while reducing costs. Some of the early findings are showing positive results:

  • 17 percent reduction in patient re-admissions since the pilot began
  • Length of stay reduced by one half day
  • Almost a 14 percent drop in the total days patients spend in a facility
  • 50 percent reduction in the number of patients who stay in a hospital 20 or more days

These results show that it is possible to utilize care models to improve the quality of outcomes while reducing the cost of healthcare.

It is worth noting that health plans are not limited to adopting one care design innovation over another. Greater benefits can accrue to both consumer and provider by combining approaches—leveraging both collaborative and accountable care designs.

Adoption of population management is forcing a change from paying for individual providers’ services to paying for health management of a population across a team of providers. Supporting this requires the reimbursement systems to understand the structure of the care team, role of the various providers within the care team and the relationships between the providers in the care team.

In other words, it will need to understand the provider network structure to calculate the reimbursement. Another complexity is that providers participating in PCMH or ACO care models may also be directly contracted with the health plan. Selecting which payment arrangement to use in these scenarios will require an understanding of providers’ relationships with the plan.

Reimbursement Innovation

Along with innovations in product and care model designs, health plans are also innovating in the area of provider reimbursement. These innovation efforts primarily focus on enabling incentives for quality and performance, while controlling the rate of medical cost growth. These objectives reflect the need to move away from a healthcare system that bases provider reimbursement on volume to one that bases provider reimbursement on the value of the outcome. Within this approach, a variety of different models are evolving (see Figure 2). 

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Figure 2: Mixing and matching payment models.

Evolving in parallel with individual models is an understanding that the ability to mix and match different reimbursement designs will deliver greater value than the utilization of just one design. Health plans are mixing and matching different reimbursement methodologies to optimize provider performance. This implies that a provider is likely to have multiple valid payment arrangements at any given time. Picking the appropriate payment arrangement will require the reimbursement engine to understand the role of the provider in the network and the full context of all of the provider’s relationships.

Assessment

Next week, I’ll be discussing why the alignment between products, care models, provider reimbursement, and network design is so important when it comes to scaling these innovative approaches.

If you can’t wait that long for that discussion, you can read the entire Unlocking Affordable Care by Aligning Products white paper now; it’s available on our website.

Conclusion

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