How to Buy a Medical Home? Policy Options and Practical Questions

Abstract

In this paper, we describe a range of payment options to support the PCMH, identifying their conceptual strengths and weaknesses. These include enhanced FFS payment for office visits to the PCMH; paying additional FFS for "new" PCMH services; variations of traditional FFS combined with new PCMH-oriented per patient per month capitation; and combined capitation payments for traditional primary care medical services as well as new medical home services. In discussing options for PCMH payment reform we consider issues in patient severity adjustment, performance payment, and the role of payments to community service organizations to collaborate with the PCMH. We also highlight some of the practical challenges that can complicate reimbursement reform for primary care and the PCMH. Through this discussion we identify key dimensions to provider payment reform relevant to promoting enhanced primary care through the patient centered medical home. These consist of paying for the basic medical home services, rewarding excellent performance of medical homes, incentivizing medical home connections to other community health care resources, and overcoming implementation challenges to medical home payments. Each of these overarching policy issues invokes a substantial subset of policy relevant research questions that collectively comprise a robust research agenda. We conclude that the conceptual strengths and weaknesses of available payment models for medical home functions invoke a complex array of options with varying levels of real-world feasibility. The different needs of patients and communities, and varying characteristics of practices must also be factors guiding PCMH payment reform. Indeed, it may be that different circumstances will require different payment approaches in various combinations.KEY WORDS: primary care; reimbursement; health care delivery.

The Case for Synergy Between a Usual Source of Care and Health Insurance Coverage

“…19 "Patient-centered medical homes" might help to improve synergistic relationships between the financing and delivery of primary health care, especially if payment mechanisms are transformed to facilitate comprehensive and integrated care. [42][43][44][45][46][47][48][49] Innovators have made headway in defining and demonstrat- Figure 1. Potential and realized access to health care services.…”

Where Americans Get Acute Care: Increasingly, It’s Not At Their Doctor’s Office

“…Additional incentives may be needed. 28 Workforce shortages represent another obstacle to expanding access to primary care. Today's primary care physicians are hard pressed to meet existing levels of demand, much less the pent-up needs of the estimated thirty-two million Americans who will soon acquire health insurance.…”

Context for Understanding the National Demonstration Project and the Patient-Centered Medical Home

“…36,40,41 Some of these projects include various attempts at different ways of paying for primary care for recognized PCMH practices or, on occasion, for particular components of the PCMH. 48 Amidst a measurement/accountability culture and widely perceived need to control costs, a tool developed by National Committee on Quality Assurance (NCQA) 37 has become the de facto standard for recognition as a PCMH, despite concerns about its focus on technical aspects of practice that can be easily measured 49 and the potential for unintended consequences from implicitly devaluing relationship aspects of primary care that are essential but more diffi cult to measure. Project participants conducted research, developed 7 reports, and acted on their recommendations.…”