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Have you noticed the lack of primary care physicians in your community? Or had the challenge of identifying a primary physician for a Medicare or Medicaid patient? Are you often asked to take care of all the needs of your patients, beyond their hematologic/oncologic issues?
These questions illustrate a disturbing transformation in medicine in the United States. Several factors are driving these changes. Many wonderful advances in the science of our practice have made specialty care attractive to young physicians. Reimbursement schemes (both government and private payers) have emphasized the value of procedures and de-valued cognitive services. The poor reimbursement of cognitive services has had a disproportionate negative effect on primary care physicians. Thus, young physicians are choosing specialty care over primary care, and established primary care physicians are leaving the field earlier than projected. These forces (and its likely you can name others) are impacting all the primary care specialties. As primary care decreases in this country, our practices exist in silos that provide care in our area of focus, often failing to integrate the total care of a patient. Transition between silos is associated with duplicative testing, repetitive visits, and often lost information. Patients are frustrated and clamor for change. Equally dissatisfied are physicians and payers.
Many argue that the future of medicine will be in integrated systems of care. Classically these systems are highly structured, with all (or most) of the physicians belonging to a single multispecialty clinic or group. Associated hospitals are owned or operated by the same group. Within these systems, patients have a primary physician who coordinates evidence-based care, and is involved in all aspects of the patient's care as a partner with the patient. Ideally, transitions of care are seamless and all relevant data is available to physicians caring for the patient. The difficulty (or lesson) is that these systems are integrated financially and structurally. To remake the health care system in this country to mimic these models will require tremendous structural change.
Can integration of care be achieved without changing the entire delivery structure? One idea that seeks to do that is the concept of a patient-centered medical home (PCMH). The American Academy of Family Physicians, the American Academy of Pediatrics, the American Osteopathic Association, and the American College of Physicians have partnered to develop this model. Key to the concept is the central role of the primary care physician. The model requires that the primary physician is the touch point for the patient in coordinating the care he or she needs. This physician is supported by a team that adopts principles of a system of care. These principles include a commitment to evidence-based practice, to structures of information systems that collect and share patient data, and to facilitate communication and coordination of needed specialty care. Payers reward the PCMH with a premium payment for this enhanced care. The goal is to reward a practice that integrates a patient's care to provide value to the patient and the payer.
There are multiple pilot programs underway across the country testing the feasibility of this model. These pilots differ from one another in many respects, but at the core they aim to adhere to the founding principles (See sidebar information). Many of the pilots involve cooperation by multiple payers in a locale. Such agreement by payers on principles of care and reimbursement is a very powerful lever in changing practice (See sidebar for link to current pilots). Lastly, Medicare, with the support of Congress, is creating a pilot program to test the concept.
Where will oncology specialty care fit in with this care model? In the PCMH model, the primary physician is responsible for coordinating and augmenting communication among the specialists attending a patient. With complex specialty care, such a role may be difficult or even distractive from the needs of the patient. There may be instances where specialty practices become the PCMH for a given patient. The current proposed criteria for becoming a PCMH are clearly skewed to a primary care setting (proposed by National Committee for Quality Assurance – see sidebar). There is a need to recognize the role of specialty practices in fulfilling the PCMH model of care. Recognizing the potential tensions present, the American College of Physicians (ACP) has convened a committee to examine the interface of the PCMH with specialty care.
Questions abound. How will transitions occur? Who will be responsible for what? Who will determine the flow of the funds? Is this a move back to the gatekeeper system of the 1980s? Concerning this last question, all the involved organizations agree that the PCMH will not be a gatekeeper for specialty services. The emphasis of the model is on patient-centered principles, the underpinning of which is choice. Under any model of care coordination, evidence-based medicine will be a key guiding principle to determine best care.
The American Society of Clinical Oncology (ASCO) is an active participant in discussions of the PCMH model. ASCO supports the central role of the primary care physician as a key driver to a healthy care delivery system and supports the need for unfettered access of cancer patients to oncology specialties.
PCMH is an approach to providing comprehensive primary care for children, youths, and adults. The PCMH is a health care setting that facilitates partnerships between individual patients and their personal physicians, and when appropriate, the patient's family.
The American Academy of Pediatrics (AAP) introduced the medical home concept in 1967, initially referring to a central location for archiving a child's medical record. In its 2002 policy statement, the AAP expanded the medical home concept to include these operational characteristics: accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective care.
The American Academy of Family Physicians (AAFP) and ACP have since developed their own models for improving patient care called the “medical home” (AAFP, 2004) or “advanced medical home” (ACP, 2006). All of the organizations came together in 2007 and developed the Joint Principles of the Patient-Centered Medical Home.
Joint Principles of the Patient-Centered Medical Home: http://www.medicalhomeinfo.org/Joint%20Statement.pdf
American Academy of Family Physicians: http://www.futurefamilymed.org
American Academy of Pediatrics: http://aappolicy.aappublications.org/policy_statement/index.dtl#M
American College of Physicians: http://www.acponline.org/advocacy/?hp
American Osteopathic Association: http://www.osteopathic.org
For an update on proposed NCQA scoring criteria for PCMH: http://www.ncqa.org/tabid/631/Default.aspx
For an update on ongoing PCMH Pilots: http://www.pcpcc.net/