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Preparing for the Payment Models of the Future

Published April 20, 2011

President's Column - April 2011 Issue of the Bulletin

Last month I had opportunity to attend the 2011 Medical Home Summit in the town of my birth, Philadelphia. It is also the birthplace of our nation and of medical training in North America. America’s first hospital was founded there in 1751 by Benjamin Franklin and Dr. Thomas Bond.  In addition, the first American medical school was started at Penn by Dr. John Morgan in 1765.  Philadelphia is a classic East Coast city with carved granite edifices and scattered bronze and stone statuary of our nation’s founders and the city’s prominent citizens.  I had a little time for sightseeing at the end of the conference so I strolled down to Independence Park to see the Liberty Bell with its high-tech internal bracing to prevent extension of its famous crack, and a scaffold enshrouded Independence Hall undergoing renovation.

Amidst all that history I reflected on the history and evolution of medicine in the United States.  Though we have the best “rocket science” medicine in the world, with unsurpassed tertiary and quaternary care for the rarest and most intractable of diseases, we are arguably failing in managing the routine care of our communities.  The World Health Organization ranks the United States as only the 37th best overall health care system in the world.   A recent Health Affairs article by Muennig and Glied reported that among the world’s leading industrialized nations, the United States had both the worst 15-year survival rates for middle agers and the most expensive health care.  Collectively as a nation, we pay the most for care that is the worst of our global socio-economic cohort.

I won’t discuss the antecedents that got us here, though many believe it is our Balkanized, siloed, and fiercely defended cottage industry approach to health care.  As a solution, many are proposing a more integrated model, with comprehensive chronic and preventative care, engaged and motivated patients and enhanced and easy access to providers. Further, care that is coordinated across the full continuum, from primary to specialty care, through ambulatory and acute transitions, with all participants, including patients, accountable.  This model has been called the Patient Centered Medical Home (PCMH), and is often described as the nucleus of the Accountable Care Organization (ACO), the structure that the Affordable Care Act, our recent Federal health care reform, is suggesting as the care delivery and reimbursement model of the future.

The PCMH model of patient care has a distinguished history having started five decades ago in pediatrics as a paradigm for fully coordinated care of special needs children.  Over the years the model has expanded to include all patients, young and old.  Multiple primary and specialty care disciplines have endorsed the model including the American Academies of Pediatrics and Family Medicine, American College of Physicians, American Osteopathic Association, as well as the American Medical Association and Academies and Colleges representing chest physicians, hospice and palliative care, neurology, cardiology, geriatrics, addiction medicine, oncology, adolescent medicine, critical care, and infectious diseases.

The PCMH is increasingly being viewed by employers and the government - the real payers in health care – as the best option we have for improving the general quality of care while containing costs.  CMS was at the Philadelphia conference describing their PCMH pilot program and suggesting this would be their preferred care model of the future. Top medical executives were present from IBM and Whirlpool, as well as leadership from the National Business Coalition on Health, a consortium of over 7,000 private sector employers, reporting that increasingly they will be looking for provider networks that offer PCMH.  Dr. Paul Grundy, IBM CMO, indicated that IBM now sites their corporate facilities specifically in states and communities that offer the PCMH model.

Dr. Bruce Sherman, Medical Director for Whirlpool, asserted that employers have expanded the concept of the triple aim of health care - as described in 2008 by Berwick et al, of optimized patient experience, population health, and per capita costs - to include optimized worker productivity.  The employers call this the quadruple aim, and are looking for health care delivery systems or consortiums that will provide it all.
What does this all mean for American medicine?  Do we all need to march lockstep into large multispecialty group practice with affiliated hospitals?  The answer I gleaned from the Philadelphia conference is that while integrated systems offer efficiency advantages to fulfilling the PCMH paradigm of care, many physicians are achieving the PCMH standards in consortiums of independent providers.  Speaker after speaker described groupings of independent practice physicians banding together - in rural Maine, upstate New York, state-wide Pennsylvania, suburban Colorado, inner-city New Jersey - many in solo and small group practice that contract, often with multiple health plans, to provide PCMH model care.

At the end of the conference, in my stroll through Independence Park, as I looked at the technology and renovation being brought to bear on the Liberty Bell and Independence Hall, I reflected on American Medicine’s ability to build on the greatness of our heritage and to renovate and innovate.   For all of us in primary care and for all who receive referrals from primary care, the evolving PCMH paradigm is a model worth understanding.  For more information see www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483, www.medhomeinfo.org, and www.pcpcc.net. Ω