Patient Centered Medical Home Essay

Patient Centered Medical Home Essay

As the medical care crisis continues to spiral out of control in the United States, emerging managed healthcare models have been heralded as the “technological bullet” that will solve healthcare reforms. One of these models that have jumped to the forefront of healthcare reform is the patient-centered medical home [PCMH]. According to Helfgott (2012), the PCMH is a model centered on primary health care providers who deliver and organize all-inclusive health care for the patient as well as continuous medical care that is patient-centered and evidence-based. This model strongly supports coordinated care, allowing for more appropriate resource utilization that is oriented toward healthcare and outcomes improvement while minimizing costs (Admson, 2011). Undeniably, this model presents a strategy for cultivating much-needed collaboration among healthcare stakeholders, but the financial burden associated with its implementation has hampered its statewide adoption by healthcare service providers.

Given these considerations, as well as the fact that our country’s current healthcare reforms desperately require such new models, this paper delves deeper into the patient-centered medical home model by examining its managed healthcare quality, cost containment, provider contracting, and payments, effects on Medicare and Medicaid, the emerging role of government regulations, and offers recommendations for quality and cost improvement.

Quality of Managed Health Care

As primary healthcare stakeholders, the patient-centered medical home model has fostered healthcare system-wide improvements as well as supported diverse collections of values for providers, health plans, and patients. In a PCMH structure, for example, the patient is assigned to a physician assistant, social worker, or registered nurse at the level of provider practice, whose primary goal is to care for the patient’s health throughout the healthcare continuum. Furthermore, PCMH, on behalf of the patient, has facilitated the collaboration of specialists, the health plan, lab technicians, pharmacists, and other relevant participants in the formulation of holistic as well as effective medication strategies (Adamson, 2011). This has, on the whole, resulted in a remarkable understanding of the patient’s own needs, more healthcare access through the care coordinator, and a patient who is informed and engaged, giving the patient more potential to act in accordance with the prescribed medication and suggested preventive actions.

PMCH has provided healthcare providers with a transparent reporting environment on progress toward measurable outcomes, which may be the occasion of specific medical home bonus payments and incentives. This is significant because the foundation of the healthcare system is deeply rooted in primary care. As a result, regions with strong primary healthcare have patients who are more satisfied and have better outcomes while also experiencing lower healthcare costs and disparities. Furthermore, members within the PCMH structure have generally reported higher overall satisfaction, which has important implications for healthcare reform because members have the option of switching between healthcare plans.

Unlike traditional gatekeeper models, many PCMH programs use more liberal scheduling programs to organize appointments for patients during peak-demand periods and then schedule doctors to meet patients’ needs. Furthermore, the patient has 24-hour access to a physician who can answer phone calls. According to the American Journal of Managed Care [AJMC] (2014), PCMH has been linked to better care for Medicaid patients, lower costs for Medicaid-enrolled patients, and positive clinician and patient experiences. Recent studies have shown that PCMH components such as pre-visit planning and care coordination have a positive impact on patient outcomes as well as clinician quality of life. et al. (2016), on the other hand, documented that PCMH was significantly associated with unassertive variations in peak utilization measures as well as offered the same quality in comparison to paper and EHRs records in their five-year cohort study focused on establishing the impacts of PCM on health care quality and utilization compared with paper records alone and EHRs alone.

Cost-cutting measures:

The PCMH cost-cutting goal is intended to address a number of deficiencies in today’s healthcare system, particularly uncoordinated care associated with duplication of procedures, adverse drug reactions, unnecessary nursing home placements and hospitalizations, and conflicting treatment. According to NCSL (2016), several studies have shown immediate medical home savings, while others have shown minimal or no overall savings; however, they have also reported other associated benefits such as fewer medical errors, improved healthcare, and improved quality care. In most states where PCMH is required, there has been a reduction in costs associated with pharmacy, outpatient, and emergency room utilization. For example, in the New York community care program, hospital spending was reduced by 27%, and emergency room costs were reduced by 35%. (NCSL, 2016).

Furthermore, NCSL notes that while most PCMH programs have shown reductions in hospital admissions and emergency room use, a number of studies have found little or no evidence of absolute cost reductions in health care. Furthermore, Keckley and Underwood (2008) established no documented return on investment from PCMH programs in their report submitted to the Deloitte Center for Health Solutions. Most studies have focused on the value delivered by the PCMH model, with evaluations pointing to reduced downstream costs, such as those associated with emergency department visits, when compared to improved insurance payments in favor of PCMH, such as through shared savings or per member per month payments (Reid et al., 2010). Magil et al. (2015) established that across practices, the costs varied per full-time equivalent primary care clinician, with an average of US$9,658 in Colorado and US$7,691 in Utah per month in their study comparing the cost of sustaining a PCMH from two states. This resulted in an incremental PCMH cost per encounter of US$36.68 in Colorado and US$32.71 in Utah.

Contracting with and paying providers:

Provider contracts under the PCMH model range from extremely complex to extremely simple, such as Karle’s medical group patient contract. Furthermore, a provider’s decision to secure a contract is based on clinicians and patients, which is significant because it ensures that both parties are aware of each other’s expectations (kongstvedt, 2012). PCMH provider payment methodologies are based on opportunities for infrastructure support as well as the alignment of incentives to spur and support practice revolution. The ultimate goal is to align incentives to support and improve the provision of high-value primary and preventive services, as well as to reward improved health outcomes while minimizing or stabilizing total healthcare costs. Although PCMH payment methodologies vary, the majority of them use a combination of fee-for-service, monthly per-enrollee payment, and pay-for-performance.

Many independent teams that investigate best practices in the medical home have strongly supported this blended model (Merrell & Berenson, 2010). The blended provider payment model has three significant elements: a performance-based element that distinguishes the efficiency goal and quality achievements, a monthly care coordination payments element that delivers anticipated practices funding, and a fee-for-service payment element that is an incentive to provide services. A bundled payment is intended to be an all-inclusive payment that covers all expenses but is distributed equitably among all involved providers. Finally, a performance-based component is included for those providers who achieve pre-set safety and quality goals, which is only possible if the health facility is recognized by the National Center for Quality Assurance, whose six standards are ingrained in the PCMH model mission (Klein et al., 2013).

The Impact on Medicare and Medicaid:

Payment qualifications for Medicare and Medicaid have been forced to shift from volume-based to quality- or value-based, in accordance with the PCMH model. This implies that members of Medicare and Medicaid have the option of selecting the most appropriate payment method, and because PCMH is one such payment method, it is highly likely to gain more popularity than the two in terms of utilization of some healthcare services and decreasing health care costs. According to Langston, Undem, and Dorr (2014), Medicare beneficiaries were subjected to a positive patient experience in PCMH, with 73 percent indicating that they desired PCMH-style care and 83 percent who received PCMH care indicating that it improved their health.

This is just one of the many advantages of the PCMH model over Medicaid and Medicare. Furthermore, PCMH reduced the total cost of care for fee-for-service Medicare beneficiaries. Similarly, following the implementation of PCMH, pediatrician participation in Medicaid increased from 20% to 96% across all states in the United States (Friedberg et al., 2014). This clearly demonstrated the negative and positive effects of PCMH on Medicaid and Medicare.

Government Regulation’s Emerging Role:

The PCMH model is not directly subject to any government regulations. Despite this, government regulations and activities that specifically support PCMH include authorizing new state programs, establishing uniform definitions and standards, mandating commercial payer participation in multiplayer programs, and allocating funds for existing and new programs. The Idaho Medical Home Collaborative, for example, was established by Executive Order Number 2010-10, which promoted the implementation of a PCMH model of care to address Idaho’s healthcare system transformation to a PCMH model (PCPCC, 2018).

Similarly, any initiative that wishes to be delegated under this model must adhere to the PCMH principles for primary care as articulated by the primary care medical associations, as well as the NCQA rules. Without the NCQA’s approval, which is regarded as the gold PCMH standard, an initiative cannot be subject to PCMH and thus cannot use the PCMH status to gain access to Medicare and Medicaid customers. To be eligible for the NCQA’s recognition initiatives, applicants must meet the NCQA’s six standards. Enhancing health care access and continuity, planning and managing care, identifying and managing patient populations, providing support for self-care and community resources, tracking and coordinating health care, and performance measurement and improvement are the six standards.

Recommendations:

To make the PCMH model more feasible and to achieve statewide implementation, the financial burden associated with it should be reduced. This is because, while many providers agree that the model is the technological silver bullet that can bring about significant healthcare reforms, the financial burden associated with its implementation can only be afforded by a small number of healthcare service providers. As a result, both the state and federal governments must downsize or support the implementation of this model by providing additional financial incentives to participants who will downsize. According to Coldwell (2016), despite the superior outputs that their patients could potentially achieve, the high initial implementation costs and ongoing annual costs discourage key healthcare service providers from adopting this model.

In the short term, the PCMH model acknowledgment focus should be on a streamlined set of evidence-based transformation impressions or procedures that champion its outcomes, as well as a less organizationally oppressive methodology of recognizing practices that have gotten to grips with the transformation impressions and are thus highly inclined to reflecting the best PCMH mode3l. However, in the long run, the PCMH model should be recognized as a ‘technological bullet’ that demonstrates the achievement of its distinguished outcomes [attributes], ensuring patients’ and their providers’ trust in the healthcare system practice. The model’s outstanding practices should be rewarded with increased participation as well as financial compensation.

In order to foster recognition, the guiding principles of PCMH should be aligned with the outcomes of the ideal PCMH model in terms of effective communication. Clarifying the language surrounding the model’s recognition, such as certification and accreditation (Coleman et al., 2012), as well as acknowledging that the model comes first before ACO, as well as other structured, primary care teams, and integrated health systems should be involved in sharing PCMH’s financial incentives and models.

Conclusion:

One of these models that have jumped to the forefront of healthcare reform is the patient-centered medical home [PCMH]. This model strongly supports coordinated care, allowing for more appropriate resource utilization that is oriented toward healthcare and outcomes improvement while minimizing costs. Undeniably, this model presents a strategy for cultivating much-needed collaboration among healthcare stakeholders, but the financial burden associated with its implementation has hampered its statewide adoption by healthcare service providers.

For it to be successful, both the state and federal governments must downsize or support the implementation of this model by providing additional financial incentives to participants who will downsize. Furthermore, in the short term, the PCMH model recognition focus should be on a streamlined set of evidence-based transformation impressions or procedures that champion its outcomes, and the PCMH guiding principles should be aligned with the outcomes of the best PCMH model to foster its recognition.

References

Adamson, M. (2011). The patient-centered medical home: An essential destination on the road to reform. American Health & Drug Benefits, 4(2):122–124. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106584/

American Journal of Managed Care [AJMC]. (2014). Patient-centered medical home and quality measurement in small practices. https://www.pcpcc.org/resource/patient-centered- medical-home-and-quality-measurement-small-practices

Coleman, K., Reid, R., Phillips, K., Sugarman, J.R. (2012). Guiding transformation: How medical practices can become patient-centered medical homes. The Commonwealth Fund.

Friedberg, M.W., Schneider, E.C., Rosenthal, M.B., Volpp, K.G., Werner, R.M. (2014).

Association between participation in a multiplayer medical home intervention and changes in quality, utilization, and costs of care. Journal of the American Medical Association, 311(8):815-25. doi: 10.1001/jama.2014.353.

Helfgott, A.W. (2012). The patient-centered medical home and accountable care organizations: an overview. Current Opinion in Obstetrics & Gynecology, 24(6):458-464. doi: 10.1097/GCO.0b013e32835998ae

Keckley, P.H., & Underwood, H.R. (2008). The medical home: disruptive innovation for a new primary care model. Deloitte Center for Health Solutions Report. http://www.dhcs.ca.gov/provgovpart/Documents/Deloitte%20-20Financial%20Model %20for%20Medical%20Home.pdf.

Kern, L.M., Edwards, A., & Kaushal, R. (2016). The patient-centered medical home and associations with health care quality and utilization. Annals of Internal Medicine, 164(6):395-405. http://dx.doi.org/10.7326/M14-2633

Klein, D. B., Laugesen, M. J., & Liu, N. (2013). The Patient-Centered Medical Home: A Future Standard for American Health Care? Public Administration Review, 73S82. doi:10.1111/puar.12082

Kongstvedt, P. R. (2012). Essentials of managed health care (6th ed.). Sudbury, MA: Jones and Bartlett Publishers

Magill, M. K., Ehrenberger, D., Scammon, D. L., Day, & et al. (2015). The cost of sustaining a patient-centered medical home: experience from 2 States. Annals of Family Medicine, 13(5), 429–435. http://doi.org/10.1370/afm.1851

NCSL. (2016). Medical homes-health cost containment and efficiencies. http://www.ncsl.org/research/health/medical-homes-health-cost-containment.aspx

Reid, R.J., Coleman, K., Johnson, E.A., et al. (2010). The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Affairs (Millwood), 29(5):835–843. doi:10.1377/hlthaff.2010.0158

PCPCC (2018). State legislation: PCMH and advanced primary care. https://www.pcpcc.org/legislation

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Jimmy, ten years old, was admitted to the pediatric intensive care unit after a fall from the second-story townhome were sustained a fractured left femur and mild head injury. Currently, Jimmy is two days post open reduction internal fixation of the left femur. Orders were updated to transfer Jimmy out of Intensive Care Unit (ICU) after being cleared by the neurologist. He has a long leg cast, indwelling foley catheter and will require neuro checks every two hours.

• What are two priority nursing diagnoses for this child?
• What are the priority nursing interventions for this patient after being transferred from the ICU?
• What are the risks of foley catheter placement?
• Does the patient still require an indwelling foley catheter? Provide a rationale to support your answer.