Patient Centered Medical Home

Colorado Medical Home Pilot Project
From Theory to Reality

By Jeffrey J. Cain, MD

DRUM ROLL, please…. The much talked about patient centered medical home is taking a giant step forward in Colorado, moving us from concept to reality. Intense planning has been under way for six months, selection and preparation of practices that will achieve medical home designation will begin this summer, and an actual pilot, including enhanced payment, is slated to begin in January. This is The Real Deal.

The genesis for the medical home stems to a large degree from physician leadership of the primary care societies, including strong engagement from AAFP, to take a proactive step toward addressing some of the major issues of our broken health care system. Instead of being victims, physician leaders have come forward with a solution based on the documented evidence that when patients are managed by primary care physicians, health outcomes are improved and costs are lower. That is the key premise behind the medical home concept – putting primary care back in as the quarterback of patient care to provide comprehensive, continuous, and coordinated care.

The published work of Barbara Starfield, MD, MPH, shows this model improves quality and decreases costs. The evidence is strong enough that businesses and payers are willing to put significant financial resources on the table to find out if it can really work.

Two basic components make the medical home different from our current system: delivery system redesign and realignment of financial incentives. System redesign means moving care delivery from acute, episodic, and reactive care with responsibility solely on the provider, to planned proactive care delivered by a health care team, using data and performance measures to guide care decision and process redesign. Information support in the form of registry functionality, either as a part of an electronic medical record or a stand-alone registry, is essential. It is critical that patients have alternative access to the practices and that there be more efficient and reliable coordination of care among physicians providing care for patients. Realignment of financial incentives moves from acute episodic transaction based fees to include compensation for care management and extra incentives for demonstrating improved health outcomes.

Colorado has been selected to be one of several states to participate in a patient centered medical home pilot project. The Colorado pilot is being referred to as a “Multi-payer, Multi-state Pilot” to test the concept that a patient centered medical home (as defined by National Committee for Quality Assurance and supported by enhanced payment) does improve care and lower costs. At this point six payers (see inset) have agreed to provide support for the pilot in the form of enhanced payment for between ten and 15 practices that among them provide care to 30,000 patients covered by the six payers. Practices will be assisted in meeting NCQA Level 1 Medical Home designation. Enhanced payment will be in the form of combining a care management fee, RBRVS (resource-based relative value scale) fee for service, and a pay-for-performance arrangement for practices meeting or exceeding quality benchmarks.

To make the concept of a medical home sustainable over time and to spread it beyond the pilot, primary care needs to redesign the way we deliver care to be able to achieve the goals of improved health outcomes and reduced costs. In many cases this will require practice transformation to put the systems and processes in place to be able to efficiently and effectively manage a population of patients. We will need to be able to monitor our patients’ care according to evidence based guidelines and to be able to demonstrate with objective measures that the care that is being delivered is good quality care; i.e. at least 60 percent of my diabetics have good control of their Hemoglobin A1C ( less than 7)

Times are changing. The CAFP will be working with members to help them prepare to deliver on the expectations of the medical home and to be able to participate in the rewards. CCGC (www.coloradoguidelines.org) can offer grant funded in-office coaching and software support to help practices make some of the transformation that is necessary through its IPIP program. Now is the time to prepare, so Family Medicine will be ready.

Colorado Medical Home Pilot:

Follows the AAFP’s Joint Principles of the Patient Centered Medical Home
Utilizes the NCQA–Patient Centered Medical Home measurement tool
Denver Metro, with ability to spread along the Front Range
25,000-30,000 lives / 10-15 Physician Practices
Measurement of outcomes:
Technical assistance to pilot practices to reach “Medical Homeness”
Enhanced payment in the form of
Participating Payers to date :
Aetna, Anthem-Wellpoint, CIGNA, Humana, Rocky Mountain Health Plan, United Healthcare