The Patient Centered Medical Home AN OPPORTUNITY FOR IMPROVEMENT IN CARE AND REVENUE ver the past decade, a new model of primary care called the “Patient Centered Medical Home” (PCMH) has gained increasing acceptance by payors, creating opportunities for increased revenue. We will review its history, requirements for transformation, associated revenue opportunities, and use of claims data. A New Model for Primary Care The concept of a medical home – a primary care practice in which a personal physician provides and coordinates the care that a patient receives within and outside of the practice – was first proposed by the american academy of Pediatrics (aaP) in 1967, and became an element of aaP policy in 1992.1 subsequent work by other primary care specialty societies to envision future models of care resulted in the issuance in 2007 of the “joint statement of Principles of the Patient-Centered medical Home” by the aaP, the american academy of Family Practice, the american College of Physicians, and the american Osteopathic association.2 The joint statement advances seven principles of PCmH: 1. a personal physician has a relationship with a patient to provide continuous and comprehensive care. 2. The personal physician directs a practice team. 3. Care is oriented around a whole person, meeting acute, chronic, preventive, and end-of-life needs. 4. Care is coordinated with other providers, such as specialist physicians, mental health providers, hospitals, nursing facilities, and pharmacies. 5. Quality and safety drive care through quality improvement, use of information technology, evidencebased medicine, etc. 6. Enhanced access is achieved through scheduling and offering alternate methods of providing care. 7. Payment reflects and incentivizes added value. 12 HBma BIllIng • maRCH.aPRIl.2014 since the issuance of the joint statement, the model has been the subject of multiple demonstrations, some showing positive impact on quality and utilization evidenced by primary care preventive and chronic care measures, as well as reduced emergency department visits and hospitalizations.3 Consequently, the concept has been increasingly embraced by commercial and state-based payors and by medicare through funding made available in the affordable Care act of 2010. PCMH Requirements and Transformation PCMH REQUIREMENTS several organizations have PCmH accreditation or recognition programs, including the national Committee for Quality assurance (nCQa), the joint Commission (TjC), and the accreditation association for ambulatory Heath Care (aaaHC) in collaboration with the the utilization Review accreditation Commission (uRaC). all require that practices demonstrate their medical home capabilities and/or activities against specific requirements. Developed first, the nCQa program is the most broadly accepted. The requirements in the current version of the program (2011) are organized within six categories that nCQa classifies as standards: 1. enhance access and continuity 2. Identify and manage patient populations 3. Plan and manage care 4. Provide self-care support and community resources 5. Track and coordinate care 6. measure and improve performance each of the six standards has elements that provide the specific requirements. Figure 1 shows the elements under each standard. Within each element, factor statements assess whether a practice has met requirements. an example is in Figure 2. Documentation is required as supporting evidence. nCQa reviews the By William Rollow, MD, MPH, Deborah Johnson-Ingram, and Julie Peskoe O
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