Introduced in 1967 by the American Academy of Pediatrics (AAP), the patient-centered medical home (PCMH) described the concept of designating a central location for archiving a child’s medical record. In the mid 1990s, the PCMH concept re-emerged as a way to re-invigorate the role of primary care in the U.S. Currently, there are hopes it will reduce costs, improve access to care, enhance quality and re-establish the focus on patient-centered care.
Under PCMH principles developed in 2007 by the AAP and other organizations, every person should have a personal physician to provide the first contact for all medical needs and oversee continuous and comprehensive care.
This PCMH model is almost universally viewed as a primary care-driven system. It assumes that internal medicine trained specialists, like cardiologists, pulmonologists, nephrologists, oncologists, rheumatologists and endocrinologists, although capable of being the principal physician in the PCMH would rarely choose the role. Many argue that specialists should not be allowed to serve as the PCMH.
The reality is that because of the increasing complexity of the management of chronic medical conditions, many internal medicine specialists—particularly cardiovascular specialists—are already often serving as the first contact for chronically ill patients and/or are providing the majority of their general care.
While specialist physicians serving as the principal physicians in the PCMH is controversial, cardiovascular care teams must be prepared to serve as the PCMH for a select portion of patients. For example, cardiovascular professionals managing the care of a patient with advanced heart failure should be allowed to serve as the “medical home” if they are willing and able to do so. To this end, the American College of Cardiology (ACC) is developing customized principles for a “cardiovascular PCMH.”
Like the general PCMH, the cardiac PCMH would have a cardiovascular professional leading a care team. However, in this case, the expertise of the cardiovascular physician to optimally manage cardiac care and oversee non-cardiac comprehensive care would allow continuous care for the patients’ major medical problems in the trusted environment of the office in which the patient spends the majority of his/her medical time.
The challenges for the implementation of the PCMH are similar for all practices regardless of specialty. Practice infrastructure would require extensive IT support to mobilize and link patients with the care team and community resources. In a cardiac PCMH scenario, the cardiac care team would manage the referral to other providers, participate in decisions regarding appropriateness and monitor outcomes—all of which would require enhanced interoperability among disparate health IT systems.
The payment models that CMS currently favors include some form of enhanced reimbursement for the PCMH. Most have some form of enhanced payment to the principal physician in the PCMH practice, such as a per-member/per-month payment, in addition to the standard fee for service payment. Others utilize an episode of care payment for services with potential for shared savings if cost and quality targets are achieved. These payment models should be stratified for the complexity of the care needed by the patient.
While the transition to a cardiac PCMH model may involve new technical, personnel and workflow resources, with commensurate new costs, the implementation would permit greater efficiencies of care and potentially allow net financial savings. No doubt new reimbursement systems will be implemented to allow these models to function. Interest in the cardiac PCMH model will expand as reimbursement systems are modified to reward this model of care.
The jury is still out over what the ultimate PCMH will look like, but the ACC is in active discussions with primary care physician groups, policymakers and other specialty societies to discuss the PCMH and other potential models of care delivery.
Dr. May is a member of the ACC’s Patient-Centered Care Committee and chief of staff at the Presbyterian Hospital of Flower Mound, Texas.