Patient-centered medical homes and outcomes

Health care reform returned to the national spotlight this week with the unveiling of President Obama’s new federal budget and renewed debate about how best to reduce escalating health care costs and fund expanded coverage for the growing numbers of uninsured Americans. Outside the beltway, the chorus of voices calling for primary care payment reform grew a little louder with the publication of a new report from national health care coalition the Network for Regional Healthcare Improvement (NRHI) titled “Pay for Innovation or Pay for Standardization: How to Best Support the Patient-Centered Medical Home.” The NRHI recommendations sound similar to other primary-care-oriented reform proposals, but with a few different notes that may be music to the ears of those who question the conventional wisdom about how to define, recognize and pay for patient-centered medical homes.

For one, the report recommends that higher payments to primary care practices be based primarily on whether they improve outcomes for their patients rather than whether they meet detailed accreditation standards, such as those established by the National Committee for Quality Assurance patient-centered medical home (PCMH) recognition program. The report emphasizes that additional evaluation is needed to determine which processes and structures produce better outcomes. “While standards such as those developed by NCQA could serve as helpful guidelines to providers in improving their care processes, it is impossible to say that a provider that meets the standards will deliver higher-value care than one that does not,” the report says. It urges that primary care physicians should be able to participate in payment systems designed to support improved care without having to meet “detailed and potentially expensive requirements” without more evidence of their impact on quality and cost-effectiveness.

In a recent post for his FPM blog "Making It," Doug Iliff, MD, calls for PCMH initiatives, including the AAFP's TransforMed national demonstration project, to focus "like a laser beam on Outcomes, both medical and financial," while being "as flexible as silly putty on Inputs," or the methods and practices that produce the outcomes. The NRHI report explains it this way:

“For example, the NCQA standards and many payers have proposed rewarding practices that have electronic health record (EHR) systems. While EHR systems can be very helpful to physician practices in providing quality health care, merely having an EHR does not guarantee quality care. Additionally, many physician practices that do not have EHRs provide high-quality care. If a payment system requires that a physician practice have an EHR in order to participate, it will potentially exclude some practices that provide high-quality care but do not, at least yet, have an EHR. Moreover, it may force physician practices to devote disproportionate time and resources to installing EHRs rather than implementing other types of care improvements that could provide a bigger impact on quality and costs in the short run.”

The report also acknowledges that it might be more difficult for small primary care practices to offer PCMH services than for larger practices. Michael W. Painter, MD, JD, a senior program officer at the Robert Wood Johnson Foundation, which provided funding support for the report, says, “We should encourage and assist small physician practices to participate in medical home initiatives, since that is where the majority of primary care physicians in the nation practice.”

The other key recommendation in the NRHI report advocates replacing fee-for-service payment with a single, severity-adjusted, comprehensive payment that covers all of a person’s outpatient primary care, with a portion of the payment based on outcomes and costs. (Capitation, anyone?) “Payers should phase in changes to payment systems to support the changes in primary care needed to improve quality and cost outcomes, beginning with enhanced fees and moving toward more comprehensive payments,” the report says.

The recommendations were developed by more than 100 health care leaders from across the country who participated in NRHI’s 2008 National Summit on Healthcare Payment Reform. The full set of recommendations from the summit is included in NRHI’s previously released report, “From Volume to Value: Transforming Health Care Payment and Delivery Systems to Improve Quality and Reduce Costs.” NRHI plans to hold another national summit this year and to encourage implementation of its recommendations across the country. 

Posted at 04:14PM Feb 27, 2009 by Leigh Ann Backer  |  Comments[0]