In 2006, one of GHC’s clinics was chosen for a complete transformation into a PCMH, including a large investment in primary care, several methods to improve patient engagement, and improved care practices. Reference Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29:835-843.

Twenty-two quality indicators from the Healthcare Effectiveness Data and Information Set were gathered at baseline, 12 months, and 24 months. For these data, the PCMH clinic was compared to 19 control practices in the GHC system. Both the PCMH clinic and the control clinics saw gains in quality, but the gains were greater for the PCMH clinic in the average number of indicators achieved by each patient, the number of patients achieving all indicators, and the number achieving three-quarters of indicators. Patient experience was quantified by the Ambulatory Care Experiences Survey; the PCMH clinic was superior to 2 control clinics (selected for their similarity to the study clinic) on most of the subscales at both 12 and 24 months. Reference Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29:835-843.

Interestingly, patients at the medical home prototype had slightly fewer primary care visits, and used slightly more specialist care, than did patients at the 19 control clinics. However, they used emergency department (ED) and urgent care notably less and had slightly fewer inpatient admissions as well. Costs were higher for both primary and specialty care in the PCMH clinic, which means that costs per primary care visit were higher. Costs for ED and inpatient care, however, were so much lower that total costs were reduced by $10.31 per patient per month by month 21. By month 21, every dollar spent to implement the PCMH prototype had saved $1.50. Reference Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29:835-843.

According to scores on the Maslach Burnout Inventory, staff at the medical home started the experiment with roughly even levels of burnout compared with staff at 2 similar control clinics. After 1 year, however, a marked difference was seen; this difference continued to widen in the second year.1,2 Note to Presenter: The Maslach Burnout Inventory is a standard tool used for measuring workplace stress. Reid RJ, Fishman PA, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009;15:e71-e87. Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29:835-843. References

The Geisinger Health System, a physician-led health system in Pennsylvania, implemented a PCMH model in 2007.1 The model involved expanded primary care capabilities, including patient and family education, team-based care, and use of electronic medical records triggers to optimize preventive and chronic disease care.2 The model also emphasized population management, integrated care systems to keep the patient in the “line of sight,” quality and outcomes tracking, and reimbursement reform.1,2 Arvantes J. Geisinger Health System reports that PCMH model improves quality, lowers costs. AAFP News Now. 2010 May 26. http://www.aafp.org/online/en/home/publications/news/news-now/practice-management/20100526geisinger.html. Accessed June 9, 2010. Davis D, Tomcavage J. ProvenHealth Navigator: a patient-centered primary care model. Geisinger Health System. http://www.allhealth.org/briefingmaterials/davispresentation-1302.ppt. Accessed September 22, 2010. References

As of 2010, the PCMH practices reported fewer overall admissions, significantly fewer 30-day readmissions, and a 7% decrease in overall costs when compared with a control group that did not implement the model. Geisinger’s PCMH model was implemented in 31 practice sites and 5 non-Geisinger practices. Plans are under way to roll out the PCMH model in the remaining Geisinger practices in addition to other practices that Geisinger contracts with. Arvantes J. Geisinger health system reports that PCMH model improves quality, lowers costs. AAFP News Now. 2010 May 26. http://www.aafp.org/online/en/home/publications/news/news-now/practice-management/20100526geisinger.html. Accessed June 9, 2010. Reference

This shows the pilot activity of the Blue Cross Blue Shield system as of early 2010.1 This is emblematic of the large number of pilot programs being implemented around the country. The pilot programs are intended to test different models of the PCMH and explore various means of provider reimbursement. Patients will be educated on the benefits of the PCMH and have the option to receive care through a demonstration PCMH.2 Rogers E. The Patient-Centered Primary Care Collaborative. http://www.pcpcc.net/files/pcpcc_powerpoint_slides_2010.ppt. Accessed September 22, 2010. BCBSA demonstration project [press release]. Patient-Centered Primary Care Collaborative Web site. www.pcpcc.net/node/50. Accessed on September 22, 2010. References

Rittenhouse et al examined data from the National Study of Physician Organizations and the Management of Chronic Illness (NSP02), a survey of practices with more than 20 physicians conducted in 2006 and 2007, to evaluate adoption of components of the PCMH. In general, adoption was low. However, there was a strong association between practice size and adoption of PCMH components. Rittenhouse DR, Casalino LP, Gillies RR, Shortell SM, Lau B. Measuring the medical home infrastructure in large medical groups. Health Aff (Millwood). 2008;27(5):1246-1258. Reference

For this section, we will discuss how healthcare reform is shaping the development and driving interest in PCMH implementation.

The Patient Protection and Affordable Care Act (PPACA) of 2010 has several provisions relevant to the PCMH. Section 2703 allows states to enroll Medicaid beneficiaries with chronic conditions into a “health home”; this is a team of professionals who provide comprehensive medical services and promote comprehensive services including care coordination.1 Section 2706 creates a demonstration project of a pediatric accountable care organization,1 which is a practice that accepts responsibility for patients’ care and costs, and may also be a PCMH.2 Section 3021 establishes the CMI to develop and test innovative payment and delivery arrangements. Importantly, these arrangements can involve benefits that Medicare currently does not provide; funding is available to offset the cost.1 Patient-Centered Primary Care Collaborative. Health care reform and the patient centered medical home. http://www.pcpcc.net/content/health-care-reform-and-patient-centered-medical-home. Accessed September 22, 2010. McCanne D. What is an accountable care organization? Physicians for a National Health Program Web site. http://pnhp.org/blog/2010/07/09/what-is-an-accountable-care-organization. Accessed August 20, 2010. References

The most notable aspect of the 2010 healthcare reform is a multifaceted reinvestment in primary care. Section 5301 provides funds for training programs in family medicine, general internal medicine, general pediatrics, and physician assistants. These funds include grants to the programs themselves and financial assistance to students and faculty. Priority is given to programs that teach team-based approaches to care. Section 5501 provides a 10% Medicare payment bonus for 5 years, starting in 2011, to PCPs and to general surgeons working in underserved areas. Section 1202 requires that Medicaid payments to PCPs for primary care services in 2013 and 2014 be no less than 100% of Medicare payment rates; funding is available to cover the cost to states. Patient-Centered Primary Care Collaborative. Health care reform and the patient centered medical home. http://www.pcpcc.net/content/health-care-reform-and-patient-centered-medical-home. Accessed September 22, 2010. Reference