The Patient-Centered Medical Home Model
Approved by the ACEP Board of Directors August 2008
The "patient-centered medical home" (PCMH) model envisions a health care delivery system in which patients have an ongoing relationship with a personal physician who provides comprehensive, culturally and linguistically appropriate care. This physician also takes responsibility for coordinating care with other providers. This model is predicated on patients having enhanced access to their personal physician, including expanded hours and same-day scheduling. Central to this model are the practice of evidence-based medicine, quality improvement, performance measurement, the increased use of information technology, and a revised payment system to compensate providers who become a patient's medical home.
"Joint Principles of the Patient-Centered Medical Home" was issued in March 2007 by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and the American Osteopathic Association (AOA). The PCMH model is gaining support as a potential approach to health care reform, and proponents of the model contend that it will improve the health of patients, reduce costs to the health care system, and, among other benefits, reduce crowding in emergency departments.i
The realities of our current dysfunctional health care system stand in stark contrast to the laudable goals of the PCMH. Previous ideas for reform that seemed promising have taught us that caution is essential if we hope to avoid unintended negative consequences. A shifting of financial and other resources to support the PCMH model could have adverse effects on sectors of the health care system that are already experiencing serious challenges. In addition to the broad principles advocated by proponents, important specifics must be addressed before moving forward with widespread adoption of the PCMH model.
Nowhere is caution more important than in the way implementation of the PCMH model might negatively impact the emergency department. Emergency medical care is an essential community service that is the de facto health care safety net for insured patients as well as millions of uninsured. There is every
reason to believe that this will continue to be the case for the foreseeable future. Because of the value society places on the universal availability of emergency care, Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA), which requires the provision of emergency care without regard to a patient's ability to pay. The emergency department is the only place in our country where a patient is guaranteed access to acute evaluation and treatment until their medical problem is stabilized.
The Institute of Medicine, the media, and Congressional testimony have amply documented that emergency departments are under severe stress and that the safety net is in danger of breaking. Hundreds of emergency departments have closed over the past decade, while the number of patient visits has increased by 32%. The most acute problem is the widespread boarding of admitted patients in the emergency department due to a lack of available inpatient beds. The resultant crowding, ambulance diversion, and harm to patients are well documented. A critical lack of on-call specialists in fields other than emergency medicine, increased medical liability burdens, and a serious lack of financial support for emergency care exacerbate and magnify the impact of boarding.
ACEP is concerned that the widespread implementation of a loosely defined PCMH model might negatively impact our nation's continued access to high quality emergency care. The metaphor of a "home" in connection with health care is inviting and is used in this statement to highlight certain elements that should be required as part of any implementation of the PCMH model. We believe that the emergency department is, and will continue to be, every patient's medical "home away from home."
ACEP agrees with the basic tenets of the PCMH model and supports the concept as long as the critical issues enumerated below are addressed. The lack of access to primary care in America is a serious problem. While the Centers for Disease Control and Prevention (CDC) estimates that only 12.1% of visits to emergency departments are for non-urgent reasonsii, many patients present with emergency conditions that might have been prevented or mitigated were it not for the patient's failure or inability to receive primary care. ACEP believes it would improve health care if every person had access to a personal physician with whom they had an ongoing relationship and who could help them navigate the complex health care system.
||ACEP supports high quality, safe, and efficient medical care.
ACEP supports the use of evidence-based medicine and believes there should be accountability for continuous quality improvement and performance measurement. ACEP supports the use of information technology to optimize patient care, communication, and education.
||ACEP supports health care payment reforms that ensure all medical providers are fairly compensated for the care they provide to patients.
ACEP believes it is critical that physicians who provide EMTALA-mandated services be adequately compensated for those services. ACEP supports
additional compensation to primary care physicians for the medical home services they provide to patients outside of face-to-face visits.
||Enhanced access must be demonstrated.
Home is a place you can go where they know you. There is a significant shortage of primary care physicians in America. In 2005, 36% of primary care physicians were working in practices of one or two physicians.iii It is unlikely that such small practices could meet the criteria for becoming an approved medical home. Most physicians' offices are closed on nights, weekends, and holidays and, in some instances, all or part of certain weekdays. Many patients are unable to get an appointment even during regular working hours because their physician's schedule is booked. The medical home model contemplates an ongoing relationship between a patient and a personal physician who understands the patient's health care needs and has a history with the patient. Much benefit of the model will be lost if a patient must see a host of different physicians and midlevel providers in large group practices in which there may be little or no experience with the patient. There should be demonstrated ability and commitment to provide the continuous care that is central to the PCMH concept before additional payments are made to physicians to offer this service.
||Once established, the medical home should continue regardless of insurance status or ability to pay.
You are always welcome at home. Many Americans go through transitions when they become unemployed or otherwise lose their health insurance coverage. Essential to the improvement of health care for patients using the PCMH model is an ongoing relationship in which a physician provides continuous and comprehensive care. The ongoing relationship must not be interrupted based on the presence or absence of the patient's ability to pay for care. While the medical home does not purport to provide health care for the millions of uninsured Americans, there should be a requirement as part of this model that once a person is enrolled in a PCMH, the provider must continue to deliver care to those individuals whether they continue to have insurance or not. In a similar vein, health insurance companies must cooperate and not exclude coverage for patients of medical homes when the insurers are making changes in their networks of providers. To truly be patient-centered and most effectively
realize the benefits of the PCMH approach, the health care needs of patients must be paramount.
||Patients must have freedom to switch medical homes, select specialists of their choosing, and access emergency medical care when they feel they need it.
Patients should have the right to choose the home they want without restriction. Patients must be allowed to switch providers and choose whom they wish for their medical home. Proponents of the PCMH insist that it is not a gatekeeper model. Yet in order for there to be the cost savings touted by proponents, there will undoubtedly be pressure for medical home providers to limit choices and restrict access of patients to certain providers. ACEP strongly opposes any
coercive effort to prevent patients from seeing specialists they may choose. Of utmost importance is the ability of all patients to access emergency medical care according to the "prudent layperson" standard whenever they perceive they are experiencing symptoms of an emergency condition, even if later diagnosis determines there was no serious medical problem.
||Research must prove the value of the medical home before it is widely adopted.
Society must get the home it is paying for. There should be more research to demonstrate the benefits and continuing costs associated with implementation of the full PCMH model. Demonstration projects being conducted by the Centers for Medicare & Medicaid Services must be carefully evaluated. There should be proven value in health care outcomes for patients and reduced costs to the health care system before there is widespread implementation of this model.
||Universal health insurance coverage is necessary for the PCMH model to be most effective.
There are an estimated 47 million uninsured in America, and that number continues to grow. In addition, there are many millions more who are under-insured. Those without adequate insurance coverage will remain "homeless" under current PCMH models. Without providing adequate insurance coverage to the growing ranks of uninsured and under-insured, the overall health of many Americans will continue to deteriorate and the PCMH model may have the unintended consequence of increasing health care disparities.
||The medical home must include the safety net of emergency care.
Resources used to test the PCMH model should not undermine or further compromise the crumbling emergency medical care system. Regardless of the anticipated benefits from having a medical home, there will still be many millions of Americans who experience life-threatening illnesses and injuries for which they need emergency medical care. In addition, there is a serious need for increased surge capacity and medical preparedness for natural and man-made disasters. Ongoing research should be conducted to determine the extent to which implementation of the PCMH actually has the benefit proponents
contend of reducing patient visits to emergency departments. Ongoing research must also evaluate whether resources utilized for PCMHs have unintended negative effects on the essential community service of emergency medicine.
- Grumbach K, Bodenheimer T. A primary care home for Americans: putting the house in order. JAMA 2002;288:889-893.
- The Centers for Disease Control & Prevention survey, "National Hospital Ambulatory Medical Care Survey: 2006 ED Summary, August 6, 2008; http://www.cdc.gov/nchs/data/nhsr/nhsr007.pdf
- Liebhaber A, Grossman JM. Physicians moving to mid-sized, single specialty practices. Tracking report no. 18. Washington, DC: Center for Studying Health System Change, August 2007.