Independent Medical Reviews
July 05, 2017
“Patient-centered” is a widely used term in health care discussions, but what does it really mean? The patient-centered medical home (PCMH) provides an instructive example. A PCMH embodies an approach to the primary care practice (PCP), one in which care is coordinated, accountable and comprehensive, as well as inclusive of wellness, preventive, acute and chronic treatments for both physical and mental health conditions.
Name aside, the typical PCMH is more a set of practices than an actual location, meaning that it can be implemented within many existing health care settings such as clinics and community centers. As such, it is a practical response to several overlapping challenges within the current health environment.
Inconsistent utilization of care at PCPs
According to a study by researchers at Harvard Medical School and the David Geffen School of Medicine at UCLA, patients with common afflictions such as headaches and infections who sought treatment at hospital-based PCPs were likelier to receive treatments with relatively low diagnostic and therapeutic value, than ones who received care at PCPs situated in community clinics. The prevalence of fee-for-service (FFS) systems, as opposed to value-based reimbursement (VBR) paradigms, at the overwhelming majority of medical providers is one difference that can encourage unnecessary treatment.
Reliance on PCPs by patients with chronic conditions
Compared to other patients, individuals with high-cost chronic conditions such as hypertension are much more reliant on PCPs. A study published in the Journal of the American Board of Family Medicine found that these patients had a 69 percent likelihood of seeing a primary care physician, versus only a 24 percent chance for a specialist. Seventy percent of U.S. doctors have subspecialty training for treating patients with specific diseases; much of their care is delivered in the PCP and, if delivered in line with clinical guidelines, would require upward of 10 hours per chronically ill patient per day.
The high costs of chronic conditions and their treatments
The Centers for Disease Control and Prevention has estimated that in 2010, 86 percent of all health-related spending was for patients with one or more chronic conditions. Similarly, the Health Cost and Utilization Project (HCUP) revealed that the most expensive hospital care condition billed to private insurance in 2013 was osteoarthritis, while cardiovascular diseases accounted for 4 of the top 20 slots. Notably, mood disorders were among the most costly conditions billed to both private health plans and Medicaid that year, demonstrating the centrality of mental health treatment in modern PCPs.
There are five unique features that distinguish PCMHs style of care from most other PCPs:
In addition to shorter waiting times for urgent conditions, a PCMH may also offer after-hours access via options like online portals or around-the-clock phone help lines. The PCMH is ultimately responsive to the patient’s preferences for access to care. The National Committee for Quality Assurance (NCQA), which oversees a large PCMH certification program, has identified easy access as an important means for reducing hospital admissions and emergency room visits.
A PCMH makes full use of the expertise of medical personnel and professionals in other fields such as social work and nutrition. Diverse teams enable comprehensive care that can address a broad spectrum of conditions. They are especially helpful when addressing the risky and expensive conditions – both physical and mental – that HCUP highlighted in its aforementioned lists of the most billed inpatient treatments for private insurance and Medicaid. Patients can thus avoid the risk of disjointed care across multiple siloed providers.
3. High-quality and coordinated
In the PCMH, patients gain a primary care environment that is closely aligned to their specific needs, plus providers get an opportunity to transition away from traditional FFS to models that prioritize quality. Accordingly, teams working in PCMHs are likely to draw upon practices such as population health management, shared decision-making and patient satisfaction assessments to improve the quality of the care they deliver. Since quality is at the forefront and reinforced by models such as VBR, there is greater incentive to integrate sources of clinical, financial and operational data when making key decisions.
The NCQA has documented the success of PCMHs in reducing claims to private and public (i.e., Medicaid and Medicare) insurers while preserving quality. For example, a study compared approximately 31,000 privately insured patients in PCMHs to over 350,000 non-PCMH patients in New York City. It revealed that the former used 11 percent fewer emergency department services, had 12 percent fewer hospitalizations and averaged $409 per member per month (PMPM) in costs, compared to $484 PMPM for patients not in PCMHs.
As the name suggests, a PCMH offers care that is individualized for every patient. To return to the question we opened with, the National Academy of Medicine has defined “patient-centered” practice as “care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.” PCMHs are uniquely positioned to deliver on these promises, due to their concentrated focus and coordination.
PCMHs are just one route that health providers can take to make sure that everyone has access to high-quality care. Healthcare is fundamentally an industry devoted to problem solving, with each player possessing a very specific expertise for finding those solutions. Technology and innovations in medicine, as well as novel healthcare delivery models aim to encourage collaboration between experts so patients can get the comprehensive care they need. Many of these improvements would not be possible, however, without a clear idea of the current state of health care utilization- that’s where utilization management (UM) and utilization review (UR) enter.
UM and UR are tools used by providers to assess the necessity and appropriateness of treatment in the context of a patient’s history. At Advanced Medical Reviews, an independent medical review company, the company belief that “every patient should receive quality healthcare” carries through in their utilization review services. As Megan Kaufman, General Manager of AMR, notes, “the healthcare industry is evolving very quickly, and we are keeping an eye on new care delivery models that aim to address overutilization and high costs while maintaining quality. Patient-centered medical homes are one great example, among many, of healthcare innovators collaborating and experimenting with new reimbursement models to address patients’ needs more specifically. We’re excited about the innovations and our partnerships with these leading payers and providers.”
The five unique benefits of PCMHs offer a practical glimpse at how to address many current challenges in healthcare. As regulations and the insurance landscape continue to change, these models will surely adapt to ensure providers are supported while patients’ needs are met.
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