American College of Physicians: Internal Medicine — Doctors for Adults ®

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ACP's advocacy for patient centered care garners support, concern

From the April ACP Observer, copyright 2007 by the American College of Physicians.

One way to find out if you are being effective is to look at how many people embrace your point of view. The other is to observe how many are beginning to raise concerns. This is happening with the College's advocacy for the patient-centered medical home (PCMH).

As the College envisions it, the PCMH would allow primary and principal physicians to be paid for coordinating care for their patients and for having the practice-level systems in place to help them achieve better outcomes, rather than solely based on the volume of visits or procedures generated by a practice. Patients who voluntarily choose to receive care from such a practice would come to consider it as their "medical home"—a single practice site that would allow them to receive patient-centered and coordinated care to help them achieve better outcomes.

Support for the PCMH has grown over the past several months. In February, the College joined with the American Academy of Family Physicians, the American Academy of Pediatrics and the American Osteopathic Association to release "joint principles" on the PCMH. The four organizations represent a combined organizational membership of more than 300,000 physicians.

At the same time, the College is hearing concerns from some within medicine—especially from surgical specialty societies—about how the PCMH would affect their members.

Health care policy is all about allocation of resources. Health advocacy organizations seek to obtain a greater share of resources to support their own members' or constituencies' goals. The more progress one makes in getting increased funding for a hospital, procedure, research institution or medical specialty, the less money available for everyone else's priorities—and the greater the degree of concern and opposition that will be engendered.

The American College of Surgeons invited ACP to address such concerns at a February "Health Policy Summit" of the top leadership and staff of all the major surgical specialty societies in the U.S. ACP President Lynne Kirk, FACP explained to the surgical societies that the model requires that a personal physician in the practice take on responsibility for providing first contact, and then continuous and comprehensive care for the whole patient. Dr. Kirk noted that in some cases a subspecialist might be the most qualified physician to serve in this role.

She also explained that the PCMH is not a gatekeeper designed to restrict access to specialists, but a facilitator of care. Patients may see a specialist at any time without prior approval. But they are more likely to choose the right specialist for their needs if they have the guidance of a personal physician who knows them best.

The PCMH will help create the systems needed at the practice level to encourage and support the sharing of information among primary care physicians, specialists, nurse-educators and others on the health care team as part of an integrated plan of action centered on the needs of the whole person. Such systems currently are not supported by the payment system.

Redesigning physician payments

Dr. Kirk explained that ACP is proposing a hybrid system of payment for services by the PCMH that would include:

  • bundled, prospective payments for care coordination services,
  • fee-for-services payments for office visits, and
  • performance-based payments based on reporting on evidence-based quality and patient experience measures.

The bundled care coordination fee creates incentives for physicians to coordinate care and acquire the systems needed to manage care effectively, while the fee for service component reduces incentives for physicians to avoid seeing patients face-to-face.

The most contentious issue is how to finance the PCMH in an environment where Congress and private sector employers are not willing to put more money into health care. Instead, the purchasers of health care are looking to the PCMH as a way of achieving savings in total health care spending.

The College believes that the PCMH can be funded largely through expected savings in non-physician expenditures, such as the savings that may occur from reducing avoidable hospital admissions. The dilemma is the anticipated savings may not show up until years after purchasers have been asked to make a commitment of funds to support the PCMH. But without such an upfront financial commitment from purchasers, it will not make business sense for practices to take on the obligations associated with care coordination.

The surgical specialties are concerned that funding for the PCMH will come mainly from redistributing payments among physicians and across specialties—cutting their members' fees to pay more to primary and principal care physicians for care coordination.

The dialogue that the College has established with the surgeons will help clarify areas of potential misunderstanding, such as the perception that the model will lead to gatekeeper controls over access to specialists. It may be possible to agree on a framework to fund the PCMH that would reduce the amount of redistribution among physicians—and the opposition that would inevitably follow—by focusing on its potential to save money in other health care sectors.

It may not be realistic to expect, though, that the PCMH will be funded solely by taking money from other parts of the health care system (such as savings from avoidable hospital admissions). No matter how the dollars are re-allocated, someone stands to lose. Even achieving efficiencies through better care management will mean a certain number of tests, surgeries or hospitalizations won't be needed—hurting the bottom line of those who provide them.

Many critics of the existing physician payment system argue that redistribution of payments among physicians and across specialties should occur, not only to pay for the PCMH but also to address long-standing inequities in payments and earnings.

The growing support within medicine for the PCMH is terrific and welcome news. At the same time, the increased level of concern expressed by others in medicine is in itself a barometer of the College's effectiveness in propelling the medical home concept to the forefront of national health care policy discussions.

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