American Healthcare is in Crisis: Is Patient Centered Medical Home (PCMH) the Answer?
Too many of us in the states are used to ‘red tape’ healthcare. We make multiple calls to provider offices, rearrange our work schedule to get an appointment slot at a time that isn’t even ideal for us, we check and double-check with our insurance companies to avoid surprise charges, and we get a call that our appointment has been rescheduled–all before we walk in the door. Then the appointment day arrives and we wait to check in, we wait in waiting rooms, then in exam rooms, and we often explain to three or four people along the way our health concerns—often disappointed about how little they seem to know about us, our history and our normal health status.
When we leave, we have questions; we can’t reach our doctor on the phone. We leave voice messages and keep bugging receptionists and nurses to get medications refilled. We think they aren’t calling us about our lab work because it must have “been ok” and then we reflect back on our visit and we wonder if maybe they just forgot about us so we begin another series of calls and messages to verify the results of our lab work. It’s frustrating and we avoid going back until we absolutely have to–until we’re really sick.
So it’s no surprise that the highest percentage (31%) of the U.S. healthcare dollars is spent on hospital care. Americans are hospitalized due to severe illness and rack up thousands of dollars in medical bills. Our healthcare insurance system, originally designed for catastrophic coverage, has become so expensive to cover very ill patients in the United States who require pricey treatment. The high costs of healthcare are primarily attributed to:
- Administrative Costs. Highly complex private insurance systems result in excess dollars spent on marketing and as well as the overhead cost of public insurance, like Medicaid and Medicare. State and Federal insurance require program auditing and tax collection to support expenditures and staff salaries.
- Malpractice Expenses & Protection. Malpractice premiums are rising exponentially. In 2002, more than one-third of U.S. hospitals faced malpractice premium increases of greater than 100%. Furthermore, malpractice lawsuits drive up cost because most physicians (not just the few who may be careless) are forced to practice defensive medicine ordering tests they may not normally see as warranted simply to defend themselves in case something goes wrong.
- Technology Innovation & Prescription Drugs. The United States is the leader in healthcare innovation. We have the newest drugs and cutting-edge diagnostics and treatment plans. People around the world travel here for innovative surgeries and treatment. The drawback for the U.S.: we’re paying for modernization and it is expensive.
- Chronic Disease Management. It is estimated that 75% of national health expenses result from treating chronic conditions such as obesity and diabetes, a dilemma particularly prevalent in the U.S.
- Lack of Meaningful Results Information. Without transparent data to drive performance improvement, physicians lack objective evidence of whether their results are above average or falling short. This prevents healthy, value-based competition. Patients also lack the information they need to make decisions about their care. In today’s world, we have more information available to us about the restaurants we choose or the products we purchase versus our healthcare.
Something’s got to give. Healthcare in the United States has reached a stage of crisis and federally qualified health centers and private offices alike are wondering, what is the solution. And more so, how do we adapt to the new model that is being proposed? Americans want to know, ‘will Medicare even still exist when I need it?’ How will Health Care Reform change my access to the health care I need?
The answer? Well, the Affordable Care Act offers steps towards the solution and while Patient-Centered Medical Home recognition is at this point, just a recommendation, it is rumored to be a significant part of the future of Medicaid and Medicare reimbursement. More importantly, the Patient-Centered Medical Home (PCMH) model could provide a better patient experience, demonstrable performance measures and therefore dramatically affect clinical outcomes.
Steps Toward A Solution
The Medical Home concept dates back to 1967, when the American Academy of Pediatrics envisioned ideal healthcare delivery to children as family-centered, comprehensive, coordinated and continuous. Since then, numerous organizations, like the American College of Physicians & Patient-Centered Primary Care Collaborative have worked together to adapt the concept for all primary care practices. Today, the National Committee for Quality Assurance (NCQA) defines a PCMH as a practice that organizes care around patients, works in teams to coordinate and track care over time and constantly works to measure and improve performance.
Since 2008, the NCQA has created a system to recognize Patient-Centered primary care practices. See, “PCMH Recognition: Understanding the Application, Scoring, and Recognition Process” for a step-by-step guide to begin the application process.
What is Patient-Centered Medical Home Recognition?
To receive Patient-Centered Medical Home recognition, you must meet a percentage of the requirements defined under each of the six major guidelines and standards as well as a must-pass element for each. For a snapshot of the guidelines without downloading the e-publication, click here to access the NCQA brochure.
Each guideline is a major category to ensure healthcare is being organized around the patient and improves their wellbeing in the long-term. They are:
Guideline 1: Enhance Access & Continuity
Patients are able to get in the same day for services, in person and by telephone. They have access to culturally linguistic and appropriate routine/urgent care. The practice provides electronic access and allows patient to choose their personal clinician. A team of medical professionals manages patients. (Nurse, Physician, MA, Therapist, etc.)
Guideline 2: Uses Data for Population Management
The practice collects demographic and clinical data to assess and document patient risk factors. The practice proactively alerts patients when visits are upcoming, diagnostic testing is due, etc.
Guideline 3: Plan & Manage Care
The practice identifies patients with high-risk conditions and complex care needs to emphasize pre-visit planning, to regularly assess patient progress, to address barriers to achieving treatment goals as well as reconciling medication lists. The practice uses e prescribing.
Guideline 4: Self-Care, Support & Community Resources
The practice assesses the patient (and family) ability to self-manage their care. They also develop self-care plan for the patient to include community resources, behavioral health counseling and mental health/substance treatment when warranted.
Guideline 5: Track & Coordinate Care
The practice is the hub of the patients’ healthcare needs. If the patient is referred to outside specialists or hospitals, the practice follows-up and manages care transitions.
Guideline 6: Performance Improvement
The practice continuously measures and tracks clinical and operational performance measures to improve the patients’ experience. The practice follows the rate of hospitalizations and ER visits and identifies vulnerable populations. The practice demonstrates improved performance publicly.
Patient-Centered care makes sense, right? The principles are clear and Coleman Associates has taught and coached them for over 15 years: it takes a care team, focused on prevention, setting up processes so that patients don’t fall through the cracks, and an approach that treats every patient holistically. So it’s exciting that a recognition process exists to incentivize the very same principles.
The Patient-Centered Medical Home concept was developed around the intent to put the patient experience first. Then, a set of measures was created to quantify that experience. Unfortunately, the recognition system is still inherently bureaucratic. You can become a recognized PCMH as many practices are recognized by the NCQA as Patient-Centered Medical Homes. However, a quick survey of patients and some honest staff will tell you that the system is still not patient-centered.
A surveyor can award a practice PCMH recognition without ever setting foot in the health center. In fact, some data shows that only 5% of health centers applying receive an audit in addition to the off-site application. PCMH recognition is based solely on the documentation and written processes to verify an office is meeting the six guidelines listed above.
Many of us have had this feeling—like cramming for an exam—right before a Joint Commission (JCAHO) survey. Meetings, trainings, handouts all intended to make us well-versed on advance directives, fire safety or some other process that we supposedly know everyday–not just the days and weeks before/after the audit.
Documentation can be tweaked and look correct, but documentation will never tell you how it FEELS to be a patient visiting your practice. In short, it has a variable bearing on the patient experience.
Too often in modern health care organizations, we pay lip service to the accrediting bodies that decide whether we are adequately equipped to serve patients. Coleman Associates principles align with the six guidelines of PCMH because they are patient-centered. Our job is to teach practices how to live up to the very essence of Patient-Centered Medical Home. We do that in our Dramatic Performance Improvement (DPI) trainings by working shoulder to shoulder with staff, coaching a model that centers work around the patient, their care and focuses on results. (See the description for our Rapid DPI program.)
A True Transformation
Studies show that practices and Health Plans who have adopted the recognized PCMH model have reduced hospital admissions by 24%. Overall costs of providing care to patients under the Patient-Centered model have been shown to decrease costs by $640 per patient, per year! But the concepts are new and the sample size is still small. These preliminary results indicate that focusing on a delivery model that benefits the patient will likely reduce hospitalizations; lower overall healthcare costs and most significantly, improve the health of the patient.
Imagine a health center where you call this week and get in this week at the time of your choosing. You receive a text message reminder.
Imagine being able to reach a member of your care team whenever you need quick advice on something by sending an email. Imagine walking in for your appointment and there isn’t even a “waiting room” full of bored, impatient, irritable people because all visits run on time and you can receive quality care in about 30 minutes. Imagine leaving a visit where the doctor and her/his assistant seemed to know you and your history and you walk out the door with a summary of the care you received including the medical jargon you will want to research later online and share with your family.
This is my Patient-Centered Medical Home; a place where waits are minimal, where my a team of dedicated medical professionals wants to fix me, and where I don’t have to jump through hoops to get answers about the most important thing in my life, my health.
True patient-centeredness doesn’t come from a certification or recognition process; it comes from a culture change within an organization. Culture transformation happens when you remove the “red tape” and the overhead and concentrate on one thing: tending to the patient in front of you and their needs. It is that simple.
Revolutionizing healthcare delivery in the United States starts with a group of healthcare professionals who want to provide the very best for every patient they encounter. Accomplish this and the getting the recognition is the icing on the cake. To positively impact the patient experience means you have worked in a way in which patients feel supported and encourage to come back for their preventative care, to ask questions, to engage and received active reminders about to know why their engagement is important.
Now, let’s do more than just do the checklist to get PCMH recognition and instead let’s truly transform our clinic cultures and processes to be patient-centered.
Health Policy Explained. Adara Beamsderfer & Usha Ranji. February 2012. Kaiser Health. May 8, 2012.
“Getting the most for our health care dollars. Administrative costs of health care coverage.” American Medical Association. May 8, 2012.
Kevin Grumbach, MD & Paul Grundy, MD, MPH. “Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the United States.” Patient Centered Primary Care Collaborative. November 2010. Accessed May 8, 2012.
Redefining Healthcare: Creating Value-Based Competition on Results. By Michael Porter & Elizabeth Olmstead Teisberg. Harvard Business School Press, 2006.
Written by Amanda Laramie, Coleman Associates