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Specialists/Subspecialists and the Patient-Centered Medical Home FREE TO VIEW

Neil Kirschner, PhD; Michael S. Barr, MD MBA
Author and Funding Information

From the American College of Physicians, Washington, DC.

Correspondence to: Neil Kirschner, PhD, American College of Physicians, 25 Massachusetts Ave NW, Suite 700, Washington, DC 20001; e-mail: nkirschner@acponline.org


For editorial comments see page 8 and 10

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(1):200-204. doi:10.1378/chest.09-0060
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This article provides an overview of the Patient-Centered Medical Home (PCMH) care model. It provides a history and definition of the concept, a discussion of its growing acceptance by the health-care community, and a review of current public and public-private demonstration projects testing the concept. The role of specialty/subspecialty practices within the PCMH model is described, with a focus on the potential for these practices to serve as a PCMH for a subgroup of patients or, alternatively, as a PCMH “neighbor” that interfaces effectively with PCMH practices. The authors conclude that the model for effective connections between the PCMH and specialty/subspecialty practices requires further development, including the cross-specialty establishment of guidelines and processes regarding referrals, information flow, transitions in care, and accountability. The efforts of the American College of Physicians’ Council of Subspecialty Societies PCMH Workgroup to further develop this model are described. The authors encourage involvement from all interested stakeholders to ensure that the issues and challenges identified are addressed through collaboration and consensus based on available evidence.

The concept of the Patient-Centered Medical Home (PCMH) developed in response to a fragmented US health-care system that undervalues primary care services and inadequately addresses the needs of a growing chronically ill population. The roots of the care model stem from the pediatric literature of the 1960s and 1970s, highlighting the importance of a “medical home” to facilitate the coordination of care for special-needs children.1 More recently, the American Academy of Family Physicians (AAFP)2 and the American College of Physicians (ACP)3 expanded the concept to include elements of patient-centered care,4 the Wagner chronic care model,5 and the role of health information technology in facilitating access, communication, and safety.

In March 2007, the AAFP and the ACP collaborated with the American Academy of Pediatrics and the American Osteopathic Association to develop a set of “joint principles” to describe the key attributions of the PCMH.6 These principles promote health-care delivery for all patients throughout all stages of life that is characterized by the following features:

  • Personal physician—each patient has an ongoing relationship with a personal physician trained to provide first contact and continuous and comprehensive care.

  • Physician-directed medical practice—the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

  • Whole-person orientation—the personal physician is responsible for providing for all the patient’s health-care needs or taking responsibility for appropriately arranging care with other qualified professionals.

  • Coordinated and/or integrated care—care is available across all elements of the complex health-care system. Care is facilitated by registries, information technology, health information exchange, and other means to ensure that patients get the indicated care when and where they need and want it, in a culturally and linguistically appropriate manner.

  • Quality and safety—these concepts are hallmarks of the medical home and are promoted through such practices as having patients actively involved in decision making, using evidence-based medicine and clinical decision-support tools to guide decision making, and expecting physicians in the practice to accept accountability for continuous quality improvement.

  • Enhanced access—care is available through systems such as open-access scheduling, expanded hours, and new options for communication (eg, e-consults) between patients, their personal physician, and practice staff.

Bodenheimer7 recently highlighted that these principles define a model of care delivery quite different from that found in most current ambulatory practice settings. The PCMH operates as the central hub of patient information and care coordination. The concept of the care team is expanded. Care delivery places a high priority on patient involvement and recognition of patient needs and preferences. Population management processes that facilitate the delivery of evidence-based disease management and patient self-management services are incorporated into the practice work flow. The practice continuously monitors its progress toward defined clinical and efficiency goals and makes necessary changes based on this information as well as the results of measuring the experience of patients who access the services provided by the practice. The PCMH care model requires substantial practice restructuring that necessitates additional reimbursement to cover the initial and ongoing costs of practice infrastructure, systems, and services not currently recognized.

Currently, there are only limited data available on the estimated cost of PCMH adoption by a practice. These include a cost analysis conducted in preparation of the Medicare Medical Home Demonstration Project (elaborated in another section) and an analysis of the costs associated with selected elements of the medical home conducted by AAFP.8 In light of this limited data set, the ACP, with support from the Commonwealth Fund, has contracted the Urban Institute to study the incremental costs of PCMH implementation. The results of the Urban Institute study,9 as well as those of PCMH demonstration projects, should help answer this cost question.

The AAFP, the ACP, the American Academy of Pediatrics, and the American Osteopathic Association collaborated with the National Committee for Quality Assurance (NCQA) to develop a voluntary, three-tiered recognition process to measure the degree to which practices have services and infrastructure consistent with the PCMH care model. The nine practice elements assessed through this process are access and communication, patient tracking and registry functions, case management, patient self-management support, electronic prescribing, test tracking, referral tracking, performance reporting and improvement, and advanced electronic communication. The tool was released in January 2008, with the primary care groups endorsing its use only within PCMH demonstration projects.10

The PCMH joint principles also outlined a hybrid, risk-adjusted payment system that appropriately recognizes the value of this model of care. The components of this payment system are:

  • a care-coordination fee to cover the additional physician, staff, and infrastructure costs not recognized under the current Medicare Physician Fee Schedule;

  • the current visit-based fee-for-service payment; and

  • a performance-based fee linked to quality, efficiency, and patient experience measures.

The funds to pay for these expanded fees are expected to be obtained over time through anticipated cost savings as a result of the systematic way PCMH practices will increase primary care access, coordinate care, use clinical decision support tools to provide evidence-based medicine, and manage chronic conditions as well as most other health related needs. Substantial data exist reflecting that the increased access to the type of primary care services promoted by the PCMH model is positively and consistently associated with improved outcomes and lower overall costs of care.11 The Commonwealth Fund estimated that $194 billion could be saved over 10 years by assigning each Medicare beneficiary to a medical home.12 Furthermore, North Carolina’s Community Care program, which implements a number of features of the medical home, has realized substantial savings compared with a historic benchmark.13 Despite this evidence for anticipated model savings, a number of medical societies have expressed concerns that the additional funding required for model implementation will be redistributed from their payments.

The concept of the PCMH has received substantial support from multiple health-care stakeholders. The driver of this acceptance is its promise for increased care coordination, improved quality, and efficiency. The joint principles have been endorsed by 18 specialty medical societies (see Appendix) in addition to the four major primary care groups, including the American Medical Association. In May 2007, the Patient-Centered Primary Care Collaborative was formed—a coalition now representing over 600 major employers, consumer groups, professional societies, and other stakeholders dedicated to promoting the elements of the PCMH. Thirty-one states are engaged in efforts to incorporate medical home concepts within their State Children’s Health Insurance and Medicaid programs,14 the federal government plans on implementing a medical home demonstration, and there are multiple private and public-private PCMH demonstration projects being implemented throughout the country.

Despite widespread interest and advocacy for the PCMH model, the literature recently reflected concerns about the model, including possible unrealistic expectations, the potential inability of small practices to successfully implement the model, the problem of obtaining adequate physician reimbursement, and concerns regarding the adequacy of the current NCQA PCMH recognition tool to assess basic aspects of the medical home.1517

The Medicare Medical Home Demonstration Project, authorized in 2006, focuses on beneficiaries with at least one chronic condition. Approximately 50 primary care practices in eight different regions that meet the requirements of a modified, two-tiered NCQA PCMH recognition process, including specialty and subspecialty practices that affirm the delivery of primary care, would be enrolled in the project. The project will use a payment structure consistent with the joint principles, with average monthly care-coordination payments of $40.40 or $51.70 per beneficiary, dependent on the degree of PCMH model implementation. The amount of these fees was determined with the assistance of the American Medical Association’s Relative-Value Update Committee. At this time, the implementation of the Medicare Medical Home demonstration is currently on hold, pending the outcome of health-care reform legislation being considered by Congress that includes a broader and better financed Medicare medical home pilot.

Multiple private and public-private tests of the PCMH model are under development throughout the country, and several have already moved into the recruitment and implementation phase. These projects typically include multiple payers, are focused on primary care practices, cover a broad range of patients (eg, are not limited to the chronically ill), offer monthly care-coordination payments from $3 to $9 per patient, and employ the NCQA PCMH recognition process to determine practice eligibility. These monthly payments are substantially below those determined as part of the Medicare Medical Home Demonstration Project and have been typically based on short-term savings anticipated by the payers with some recognition of direct practice costs. There are concerns that these low payments will not be sufficient to encourage adoption and effective PCMH implementation and that the time periods projected to accrue savings are too short. Areas in which large, multistakeholder PCMH projects are currently rolling out include Colorado, southwest Ohio, New York, Pennsylvania, Maine, New Hampshire, and Rhode Island. The Commonwealth Fund and the Robert Wood Johnson Foundation are assisting in several of these projects. More complete information regarding PCMH demonstration projects is available at http://pcpcc.net/pilot-guide.

The Council of Subspecialty Societies (CSS) of the ACP established a workgroup in 2007 to specifically address the perceived relationship between the PCMH care model and specialty/subspecialty practices. The workgroup has released a clarification document to respond to a number of frequently asked questions regarding this relationship.18 Two of the most common questions addressed are:

  • 1. How will the PCMH health-care delivery and payment model affect referrals to specialists and subspecialists?

The PCMH model provides no incentive to limit appropriate referrals to specialists or subspecialists by a patient’s personal physician; it is not a “gatekeeper.” The general model does not prohibit patients from choosing to see a specialist or subspecialist of their choice when they desire. The incentives of the PCMH model are aligned to facilitate improved communication and coordination of care between the personal physician and the referred-to specialist or subspecialist.

  • 2. Under what circumstances would specialty or subspecialty practices qualify as a PCMH?

The PCMH care model, while most compatible with primary care practices, is neutral as to the specialty of the physicians providing the care as long as the practice meets all of the criteria described below.

The practice:

  • provides primary or principal care to its patients. Principal care refers to care provided by a specialist or subspecialist that focuses on complex health-care needs requiring the specialist or subspecialist’s expertise, but also meets most of the patient’s general health-care needs.19,20

  • meets the requirements of an approved third-party PCMH recognition process (eg, NCQA PPC-PCMH recognition) that ensures that the practice has the structural capability and systems in place to provide care consistent with the PCMH model.

  • affirms the willingness to provide care consistent with the joint principles, including the delivery of first-contact, comprehensive care.

The PCMH model would appear to be appropriate for the subset of patients in specialty or subspecialty practices who are receiving long-term, principal care for a condition by physicians in that practice. The practice is seeing the patient frequently over a relatively long period of time, and it is most convenient for the patient that the practice serves as the central hub of care. Consistent with the “patient-centric” nature of the care model, the choice of practice to be designated as the PCMH should be made by the patient after consultation with the treating physicians. Some examples of appropriate specialty or subspecialty PCMH practice designations include:

  • a pulmonology practice that cares for patients with complex asthma, cystic fibrosis, pulmonary arterial hypertension, or other chronic lung diseases; and

  • an endocrinology practice treating patients with type 1 or type 2 diabetes who are on complex insulin regimes, are on multiple oral medications, or display significant complications.

In all these situations, the designated PCMH specialty/subspecialty practice would also be expected to be responsible for the first-contact, whole-person care (eg, for bronchitis, skin infections, urinary tract infections, routine preventive health measures) required for the patient. The available clinical literature reflects that specialty and subspecialty physicians are already addressing at least some of the primary care needs for a substantial number of patients, although the quality of this care remains an unanswered research question.21,22 The number and type of specialty practices willing and capable of handling the difficult role of providing both the principal and primary care of these patients is currently unknown.

Fisher15 recently observed that the effectiveness of the PCMH care model to promote integrated, coordinated care throughout the health-care system depends on the availability of a “hospitable and high-performing medical neighborhood.” More specifically, this would require reforms in other provider entities (eg, hospitals, specialty and subspecialty practices) to align with the critical elements of the PCMH. Fisher further highlighted that such alignment is important to improve quality and generate the anticipated savings attributable to the PCMH model. Toward this goal, members of the CSS PCMH workgroup have suggested the possible development of the concept of a PCMH “neighbor”—a specialty or subspecialty practice that effectively works in conjunction with PCMH practices to enhance coordination of care, improve consultations and comanagement, and create seamless transitions for patients moving through different components of the health-care system. A PCMH neighbor would also reflect many of the other elements of the NCQA PPC-PCMH recognition tool, including the practice’s ability to provide improved levels of access to care, facilitate patient communication, follow evidence-based treatment recommendations, and increase efforts toward quality improvement and safety. This form of recognition would not require the specialty/subspecialty practice to assume the first-contact, whole-person, primary care responsibilities or to be the major communication hub for the patient’s treatment, which are the essential roles of the patient’s medical home. The ACP is currently in discussion with the NCQA, several subspecialty societies, and potential payers to explore the possibility of establishing this type of recognition, which could provide specialty/subspecialty practices with increased funding for this expanded level of service.

The PCMH care-delivery model has generated substantial interest and support over a relatively short period of time. Many critical questions remain, including which of the model’s elements are most crucial to ensure improved clinical quality and efficiency, and how to effectively provide incentive for practices to deliver this form of care. Answers to these and many other questions will be addressed in the PCMH demonstration projects being planned and implemented across the nation. The issue of the interface between the PCMH and specialty/subspecialty practices clearly requires further definition and development. Guidelines and processes need to be established regarding such issues as referrals, information flow, and accountability. While the ACP has initiated this discussion with the CSS PCMH workgroup, the college has been and continues to request input from all interested stakeholders to ensure that the issues and challenges identified are addressed through collaboration and consensus based on available evidence. Materials related to the relationship between the PCMH and specialty physicians, including the minutes and products of the workgroup, are available for review on a special area of the ACP PCMH Web site, at http://www.acponline.org/running_practice/pcmh/understanding/specialty_physicians.htm.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Drs Kirschner and Barr provide frequent presentations on the PCMH as representatives of the American College of Physicians. Dr Barr has received a grant from the Commonwealth Fund to research cost issues related to the PCMH and grants from Pfizer (unrestricted) and the Physician’s Foundation for Health Systems Excellence to promote practice improvements.

Appendix

Societies that have formally endorsed the “Joint Principles” are: American Academy of Family Physicians, American Academy of Hospice and Palliative Medicine, American Academy of Neurology, American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American College of Osteopathic Family Physicians, American College of Osteopathic Internists, American College of Physicians, American Geriatrics Society, American Medical Association, American Medical Directors Association, American Osteopathic Association, American Society of Addiction Medicine, American Society of Clinical Oncology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Clerkship Directors in Internal Medicine, Infectious Disease Society of America, Society of Adolescent Medicine, Society of Critical Care Medicine, and the Society of General Internal Medicine.

Sia C, Tonniges TF, Osterhus E, Tuba S. History of the medical home concept. Pediatrics. 2004;1135:1473-1478. [PubMed]
 
Future of Family Medicine Project Leadership Committee The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2Suppl 1:S3-32. [CrossRef] [PubMed]
 
American College of Physicians The advanced medical home: a patient-centered, physician-guided model of health care. http://www.acponline.org/hpp/adv_med.pdf. Accessed July 12 2006.
 
Institute of Medicine Envisioning the National Healthcare Quality Report. 2001; http://books.nap.edu/openbook.php?record_id=10073&page=41. Accessed March 2, 2009.
 
Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Boroni A. Improving chronic illness care: translating evidence to action. Health Aff. 2001;206:64-78. [CrossRef]
 
American Academy of Family PhysiciansAmerican Academy of Family PhysiciansAmerican Academy of PediatricsAmerican College of Physiciansthe American Osteopathic Association Joint principles of the patient-centered medical home. 2007; March http://www.acponline.org/advocacy/where_we_stand/medical_home/approve_jp.pdf. Accessed December 18, 2008.
 
Bodenheimer T. Transforming practice. N Engl J Med. 2008;35920:2086-2089. [CrossRef] [PubMed]
 
American Academy of Family Physicians Task force report 6: report on financing the new model of family medicine. Annals of Family Medicine. 2004;2Suppl. 3:S1-S23. [CrossRef] [PubMed]
 
Zuckerman S, Merrill K, Berenson R, et al. Incremental cost estimates for the patient-centered medical home. Commonwealth Fund. 2009; Octoberhttp://www.commonwealthfund.org//media/Files/Publications/Fund%20Report/2009/Oct/1325_Zuckerman_Incremental_Cost_1019.pdf. Accessed November 9, 2009.
 
NCQA NCQA program to evaluate patient centered medical homes [press release]. http://www.ncqa.org/tabid/641/Default.aspx. Accessed December 18, 2008.
 
American College of Physicians How is the shortage of primary care affecting the quality and cost of medical care? http://www.acponline.org/advocacy/where_we_stand/policy/primary_shortage.pdf. Accessed March 2, 2008.
 
Schoen C, Guterman S, Shih A, et al. Bending the curve: options for achieving savings and improving value in US health spending. http://www.commonwealthfund.org/usr_doc/Schoen_bendingthecurve_1080.pdf?section=4039. Accessed December 18, 2008.
 
External evaluations requested by Community Care of North Carolina: Mercer Group. 2007; http://www.communitycarenc.com/PDFDocs/Mercer%20SFY05_06.pdf. Accessed March 2, 2009.
 
National Academy of State Health Policy (NASHP) Results of state medical home scan. http://www.nashp.org/_docdisp_page.cfm?LID=980882B8-1085-4B10-B72C136F53C90DFB. Accessed December 22, 2008.
 
Fisher ES. Building a medical neighborhood for the medical home. N Engl J Med. 2008;35912:1202-1205. [CrossRef] [PubMed]
 
Berenson R. A house is not a home: keeping patients at the center of practice design. Health Aff. 2008;275:1219-1230. [CrossRef]
 
O’Malley AS, Peikes D, Ginsburg PB. Qualifying a physician practice as a medical home. Center for Studying Health System Change—policy perspective. http://www.hschange.com/CONTENT/1030/. Accessed March 4, 2009.
 
American College of Physicians Relationship of the PCMH to specialty physicians. http://www.acponline.org/running_practice/pcmh/understanding/specialty_physicians.htm. Accessed December 18, 2008.
 
Langdon L, Toskes P, Kimball H. Future roles and training of internal medicine subspecialists: The American Board of Internal Medicine Task Force on Subspecialty Internal Medicine. Ann Int Med. 1996;1247:686-691. [PubMed]
 
Vaselow NE. Primary care and the subspecialist. JAMA. 1998;27917:1394-1395. [CrossRef] [PubMed]
 
Fryer G Jr, Consoli R, Miyoshi T, Phillips Dovey S Jr, Green L. Specialist physicians providing primary care services in Colorado. J Am Board Fam Pract. 2004;172:81-90. [CrossRef] [PubMed]
 
Weingarten SR, Lloyd L, Chiou C-F, Braunstein GD. Do subspecialists working outside of their specialty provide less efficient and lower-quality care to hospitalized patients than do primary care physicians? Arch Intern Med. 2002;1625:527-532. [CrossRef] [PubMed]
 

Figures

Tables

References

Sia C, Tonniges TF, Osterhus E, Tuba S. History of the medical home concept. Pediatrics. 2004;1135:1473-1478. [PubMed]
 
Future of Family Medicine Project Leadership Committee The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2Suppl 1:S3-32. [CrossRef] [PubMed]
 
American College of Physicians The advanced medical home: a patient-centered, physician-guided model of health care. http://www.acponline.org/hpp/adv_med.pdf. Accessed July 12 2006.
 
Institute of Medicine Envisioning the National Healthcare Quality Report. 2001; http://books.nap.edu/openbook.php?record_id=10073&page=41. Accessed March 2, 2009.
 
Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Boroni A. Improving chronic illness care: translating evidence to action. Health Aff. 2001;206:64-78. [CrossRef]
 
American Academy of Family PhysiciansAmerican Academy of Family PhysiciansAmerican Academy of PediatricsAmerican College of Physiciansthe American Osteopathic Association Joint principles of the patient-centered medical home. 2007; March http://www.acponline.org/advocacy/where_we_stand/medical_home/approve_jp.pdf. Accessed December 18, 2008.
 
Bodenheimer T. Transforming practice. N Engl J Med. 2008;35920:2086-2089. [CrossRef] [PubMed]
 
American Academy of Family Physicians Task force report 6: report on financing the new model of family medicine. Annals of Family Medicine. 2004;2Suppl. 3:S1-S23. [CrossRef] [PubMed]
 
Zuckerman S, Merrill K, Berenson R, et al. Incremental cost estimates for the patient-centered medical home. Commonwealth Fund. 2009; Octoberhttp://www.commonwealthfund.org//media/Files/Publications/Fund%20Report/2009/Oct/1325_Zuckerman_Incremental_Cost_1019.pdf. Accessed November 9, 2009.
 
NCQA NCQA program to evaluate patient centered medical homes [press release]. http://www.ncqa.org/tabid/641/Default.aspx. Accessed December 18, 2008.
 
American College of Physicians How is the shortage of primary care affecting the quality and cost of medical care? http://www.acponline.org/advocacy/where_we_stand/policy/primary_shortage.pdf. Accessed March 2, 2008.
 
Schoen C, Guterman S, Shih A, et al. Bending the curve: options for achieving savings and improving value in US health spending. http://www.commonwealthfund.org/usr_doc/Schoen_bendingthecurve_1080.pdf?section=4039. Accessed December 18, 2008.
 
External evaluations requested by Community Care of North Carolina: Mercer Group. 2007; http://www.communitycarenc.com/PDFDocs/Mercer%20SFY05_06.pdf. Accessed March 2, 2009.
 
National Academy of State Health Policy (NASHP) Results of state medical home scan. http://www.nashp.org/_docdisp_page.cfm?LID=980882B8-1085-4B10-B72C136F53C90DFB. Accessed December 22, 2008.
 
Fisher ES. Building a medical neighborhood for the medical home. N Engl J Med. 2008;35912:1202-1205. [CrossRef] [PubMed]
 
Berenson R. A house is not a home: keeping patients at the center of practice design. Health Aff. 2008;275:1219-1230. [CrossRef]
 
O’Malley AS, Peikes D, Ginsburg PB. Qualifying a physician practice as a medical home. Center for Studying Health System Change—policy perspective. http://www.hschange.com/CONTENT/1030/. Accessed March 4, 2009.
 
American College of Physicians Relationship of the PCMH to specialty physicians. http://www.acponline.org/running_practice/pcmh/understanding/specialty_physicians.htm. Accessed December 18, 2008.
 
Langdon L, Toskes P, Kimball H. Future roles and training of internal medicine subspecialists: The American Board of Internal Medicine Task Force on Subspecialty Internal Medicine. Ann Int Med. 1996;1247:686-691. [PubMed]
 
Vaselow NE. Primary care and the subspecialist. JAMA. 1998;27917:1394-1395. [CrossRef] [PubMed]
 
Fryer G Jr, Consoli R, Miyoshi T, Phillips Dovey S Jr, Green L. Specialist physicians providing primary care services in Colorado. J Am Board Fam Pract. 2004;172:81-90. [CrossRef] [PubMed]
 
Weingarten SR, Lloyd L, Chiou C-F, Braunstein GD. Do subspecialists working outside of their specialty provide less efficient and lower-quality care to hospitalized patients than do primary care physicians? Arch Intern Med. 2002;1625:527-532. [CrossRef] [PubMed]
 
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