The ‘Medical Home’: A New Deal for Doctors or Gatekeeper Redux?

Demonstration projects testing the model, including a long anticipated but much delayed Medicare 36 practice project, are scarce. At present, most PC-MH cheerleaders point to Community Care of North Carolina’s (CCNC’s) 15 networks, 3500 PCPs, and 1000 medical homes as a successful prototype. Since 1999, all of North Carolina’s 750,000 Medicaid beneficiaries have a medical home. The state pays PCPs 95% of Medicare reimbursement plus $3 per member per month (PMPM) for case management and $3 PMPM for care/disease management. For fiscal years 2005 and 2006, CCNC saved $231 million.

Nationally, the $6 PMPM seems too low; other states might add $12-$16 to traditional FFS. A hybrid system of FFS plus a bundled medical home payment based on a practice’s providing one of three levels of medical home services seems likely (see sidebar, PC-MH Practice Sophistication).

Overall, the medical home’s proponents are on a roll, but the concept could be derailed in several ways. Conspicuously absent is the AMA’s endorsement. In addition, PCPs are still retiring in droves with few newly minted generalists to take their place. Dr. Hessan emphasized the need for prompt action to retain them: Medical manpower in Maryland is critically short. Reimbursement is generally low for us, and worse for PCPs. These problems will only get worse over time if PCPs aren’t incentivized in the way that the medical home suggests.

Practice Readiness for the Medical Home

Here are the guidelines from the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and the American College of Physicians (ACP) on practice readiness for implementing a Patient-Centered Medical Home:

Standard 1: Access and Communication

1. Written standards for patient access/communication
2. Uses data to meet standard

Standard 2: Patient Tracking Registry

1. System for nonclinical patient information
2. Has and uses clinical data system
3. Paper or electronic charts to organize information
4. Uses data for diagnosis and condition identification
5. Generates patient lists and reminders

Standard 3: Care Management

1. Uses evidence-based medicine for three conditions
2. Uses reminders for physicians to do preventive care
3. Uses nonclinical staff to manage patient care
4. Care management follow-up

Standard 4: Patient Self-Management Support

1. Deals with language barriers
2. Enhances patient self-support

Standard 5: Electronic Prescribing

1. Electronically write prescriptions
2. Electronically check prescriptions
3. Electronic cost control

Standard 6: Tests

1. Tracks tests, gets abnormal results systematically
2. Uses electronic system to order tests and detect duplicates

Standard 7: Referrals

1. Tracks referrals with a paper or electronic system

Standard 8: Performance, QI

1. Measures clinical metrics by physician or across the practice
2. Surveys patients
3. Has goals for QI
4. Generates QI reports
5. Transmits QI reports electronically to outside agencies

Standard 9: Advanced Electronic Communication

1. Interactive Web site
2. Electronic patient identification
3. Electronic care management supports

Source: NCQA PPC-PCMH Content and Scoring, 2007

PC-MH Practice Sophistication

The PC-MH model would reimburse practices based on their implementing medical home elements. Payers would reimburse a medical home at one of three levels, with Level 3 receiving the highest reimbursement. Each element would be graded on a pass/fail basis, with points allocated as follows:

• Access & Communication (9)
• Patient Tracking & Registry Functions (21)
• Care Management (20)
• Patient Self-Management Support (6)
• Electronic prescribing (8)
• Test Tracking (13)
• Referral Tracking (4)
• Performance Reporting & Improvement (15)
• Advanced Electronic Communication (4)

Total Points: 100