IN PURSUIT OF A TRANSFORMED HEALTH CARE SYSTEM: FROM PATIENT CENTERED MEDICAL HOMES TO ACCOUNTABLE CARE ORGANIZATIONS AND BEYOND

Well before the federal Affordable Care Act legislation, the concept of a “Patient Centered Medical Home” (PCMH) was promoted within academic and clinical family medicine as the foundation for health care delivery transformation. Yet the PCMH is not sufficient in itself—it must be part of integrated health care delivery systems that span the continuum of care that a patient receives. As a result, new federal efforts through the Center for Medicare and Medicaid Services (CMS) to develop Accountable Care Organizations (ACOs) have arisen. Efforts to transform health care for communities and large populations will undoubtedly continue to push forward, regardless of nomenclature and regulatory definitions. Although formal definitions and regulations are emanating from CMS, the commercial world may actually be more influential in the long run, as businesses demand health care that is less expensive and that results in a healthier, more productive workforce.

The Association of Departments of Family Medicine, as part of a collective effort by the Council of Academic Family Medicine (CAFM) recently provided feedback to CMS on its proposed ACO regulations; 3 key points are worth emphasis:

I. Practice transformation on the level of the patient centered medical home is a critical first step to improving care of the patient and putting our own house in order—but it is just a first step

Features of the PCMH, where accountability for prevention, acute and chronic disease care, and coordination of care that patients receive outside of the primary care office is provided primarily within interdisciplinary practice teams, are fundamental to health care delivery. The PCMH alone, however, does not address the care of a community or a population size that is more than that of typical primary care panels. Partnerships beyond the PCMH are necessary for larger system improvement.

Additionally, the future of the PCMH is at risk if reimbursement for care does not align with the model. In the context of numerous demonstration projects, grant funding has established interdisciplinary, inter-professional teams that have proven the model to be effective and lower costs, but the PCMH will not adequately spread nor be self-sustaining without significant payment reform.

II. We need to be concerned with the other parts of the health care system—the medical neighborhood, the ACO, or a regional or national integrated, comprehensive, accessible system

The payment structure proposed through ACOs may be more sustainable in the long-term: it combines fee-for-service with annual shared savings and performance bonuses tied to specified quality performance standards. Joint accountability for care by all providers in an ACO is fundamental—the providers within a PCMH form a critical foundation for this type of delivery system transformation. Blended payment systems are essential for the most effective health system reform, and therefore must be supported in the ACO and other value based reimbursement structures that evolve. One of the main challenges for any ACO is to modify physicians’ behaviors; immediate reinforcement in the form of payment for services provided both directly in the office, and the plethora of outside-the-office care that occurs in primary care settings (telephone and e-mail follow-up, review of diagnostic tests and coordination with specialists, time spent studying registry results to identify and contact patients in need of services, and completion of insurance and prior authorization forms) as well as a per-patient/per-month care management fee are viable mechanisms to accomplish this.

III. The ACO model as proposed by CMS is clearly flawed but we need to be both open to new ideas and to generate models with shared savings

Unless, or until, CMS is able to pay ACOs (and, in turn, facilitate ACOs paying their participants) in a manner more consistent with the desired outcomes (ie, through a blend of fee-for-service, partial capitation, etc), the Medicare ACO program may never succeed. From the experience of many state Medicaid programs, such as those in North Carolina and Illinois, we know that blended payment systems that include both prospective care coordination payments and fee-for-service payments lead to impressive health care cost savings and improvement in quality indicators—the value proposition that our health care system so desperately needs.

The proposed ACO model from CMS creates significant practical challenges; in particular, the quality reporting requirements are onerous and would prevent most primary care practices from engaging in this endeavor. A much more focused set of high priority quality reporting measures that have the greatest likelihood of major impact on health care quality and costs would attract more family physicians. With time, more measures might be added as participating systems establish a more robust reporting infrastructure, and as health services research defines additional effective quality reporting metrics.

The conversation about improved health care delivery for the health of the public has never been more important. We must continue to be actively engaged and open to new possibilities on the horizon.

• © Annals of Family Medicine, Inc.