Re: The Patient-Centered Medical Home Movement—Promise and Peril for Family Medicine

To the Editor: As a recent participant in TransforMed, I read the recent Journal of the American Board of Family Medicine article, “The Patient Centered Medical Home Movement—Promise and Peril for Family Medicine,”¹ with great interest. My thanks goes to the author, Dr John Rogers, for articulating so completely and with such deep insight what I came to realize after 2 intensely transformative years.

During that time my typical 1 doctor, 1 nurse practitioner private family practice office transformed itself into a 2.5 doctor, 1.25 nurse practitioner medical home complete with open access scheduling, an advanced electronic medical record (EMR), and a recently submitted application to the National Committee for Quality Assurance (NCQA) for a level 3 Physician Practice Connections –Patient Centered Medical Home certification.

I’ve addressed below in outline form those points which I found most compelling from your article and most consistent with my own beliefs about the patient-centered medical home (PCMH) concept and its future impact on restoring and reimbursing the value contributed to this country's health care system by its primary care physicians. Readers interested in reviewing the “Principals of the Patient-Centered Medical Home” can do so by going to www.aafp.org/online/en/home/policy.html.

1. “Care principals” and “Infrastructure principals” do not mutually insure each other. You are correct in your assertion that relationship-centered practices were like that from the beginning. I suspect practices that are already patient-centered will have a somewhat easier transition to the PCMH as they attempt to incorporate the “infrastructure principals” into their daily office routines.

2. Time, money, commitment, and superior leadership are necessary ingredients to survive the disharmony and change fatigue produced by the transformation experience. Try to imagine the strain on staff and physicians produced after months, not weeks, of the varied systematic changes operationally and technologically that are needed to go from a typical harried inefficient 20th-century primary care office poorly reimbursed on volume to the medical home practice of the 21st century whose reimbursements are based on the value of the documented quality of continuous coordinated care.

3. NCQA or some other independent objective organization will be necessary to distinguish a true medical home from those practices that want to take a shortcut and bypass the rigors required by the transformative process. Many family practices and perhaps certain other specialties will declare their practices to be medical homes. However, without a clear demonstration of in-place functioning systems and processes that verify the existence of the PCMH's fundamental principals, these declarations will be insufficient to qualify for the enhanced reimbursements designed to sustain this redesigned delivery of primary health care.

4. The financial rewards for attaining a medical home status must be substantial. A per member per month management stipend comprising the blended components required of a medical home which is then annually adjusted for inflation is a good start. The initial amounts announced by the Center for Medicare & Medicaid Services (CMS) and the commercial plans seem reasonable. However, incremental savings to CMS and the commercial plans must be transparent and shared fairly with the medical home offices that produced them. CMS, commercial plans, and medical homes must work together to closely monitor hospital and ER utilization rates and the resultant savings. This arbitrage must then be divided equitably. Confidence and trust must reemerge in the relationship between the providers of health care and those who pay for it. It is the only way to sustain the concept.

5. All certified medical homes should be exempt from preauthorization and precertification requirements. After all, evidence-based practices and clinical decision tools are integral parts of the PCMH which have already been shown to be cost-effective. This makes precertification and preauthorization unnecessary exercises and further reduces their burdensome administrative costs to patient care.

6. Lastly, the specialty must assiduously guard our ownership of the medical home. It was the centrality of the patient–doctor relationship and the coordination of continuing comprehensive medical care within the context of the family and community that defined our specialty in the first place and attracted so many of us decades ago. The basic tenets of family medicine when combined with the infrastructure principals described in your article become the medical home concept. So although the high-tech documentation of care may be new, the basic concept of the medical home is not.