Tip Sheets

What is a ‘medical home’ and why is it important?

Lola Butcher

By Lola Butcher

In the past decade, thousands of U.S. primary care practices have reorganized themselves as patient-centered medical home (PCMH) practices, making medical homes the most widespread type of health care delivery and payment reform so far. The concept likely will become even more popular in the years ahead because the federal government’s Quality Payment Program included some medical home practices in its advanced alternative payment model (APM), making them eligible for incentive payments.

The term “medical home” dates back to the 1960s, but the concept did not gain traction until about a decade ago. A PCMH is a care-delivery and payment model that theoretically can improve the quality of care and the patient experience while controlling the cost of care.

Four influential organizations – the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), the American Academy of Pediatrics, and the American Osteopathic Association – in 2007 laid out their vision for the primary care PCMHs in joint principles. The care model includes:

  • Team-based care led by a physician.

  • Comprehensive care at all stages of life.

  • Proactive efforts to ensure patients get the preventive and well-coordinated specialty care they need.

  • Use of quality improvement processes and evidence-based medicine.

  • Enhanced access to care through extended hours, telehealth or other means.

The payment model in the principles includes:

  • Fee-for-service payments for face-to-face visits.

  • A care management fee for care coordination and other services.

  • The opportunity for shared savings if the PCMH reduces hospital utilization for a population of patients.

Many payers offer PCMH contracts only to practices certified by the Patient-Centered Medical Home Recognition Program of the National Committee for Quality Assurance (NCQA). Indeed, more than 12,000 practices, including more than 60,000 clinicians, have earned NCQA’s imprimatur, making it the most widely used PCMH evaluation program in the country. Other organizations, such as the Accreditation Association for Ambulatory Health Care, The Joint Commission and URAC, also have medical home recognition programs. A practice can describe itself as a PCMH without being anointed by an independent agency.

Although the term patient-center medical home implies a salute to the joint principles, there is wide variation in how PCMH practices operate, how insurers contract with those practices and how success is evaluated. Thus, it is easy to find both studies that show PCMH is delivering on its promise and those that contend it is a failed concept. The truth is that some PCMH practices and contracts work well and others are duds.

Despite naysayers, because so many payers such as Medicare support PCMH the model likely is here to stay. The federal government’s largest PCMH play so far is the five-year Comprehensive Primary Care Plus model (CPC ), which launched January.

To quickly get up to speed on PCMH issues, three good starting places are the Patient-Centered Primary Care Collaborative, the AAFP and the ACP, though keep in mind that these are all advocacy organizations. Of course, Health Affairs is the best source for independent evaluations and analysis.

Specialty medical homes

Increasingly, the term “medical home” is being extended to specialty practices as well as to primary care practices. Under this newer idea, there are no “joint principles” to define a specialty medical home, and every instance of a specialty medical home should be considered a one-off experiment.

Several years ago, the NCQA introduced a Patient-Centered Specialty Practice Recognition Program, but it has not gained the wide acceptance that its primary care program enjoys.

The idea of applying PCMH principles to cancer care began generating enthusiasm a few years ago. NCQA launched an Oncology Medical Home Recognition Program, the American College of Surgeons’ Commission on Cancer initiated an accreditation program, and the Center for Medicare & Medicaid Innovation (CMMI) sponsored an oncology medical home demonstration. Although some experiments continue, private insurers, in general, have been unwilling to support the oncology care model.

More recently, the “medical home” term surfaced for other types of specialty care. Blue Cross and Blue Shield of Illinois uses the term “specialty intensive medical home” to describe its contract with gastroenterology practices that adopted an innovative care delivery and payment model for patients with inflammatory bowel disease.

Some early results suggest the medical home model can improve patient outcomes while controlling costs. The federal Physician-Focused Payment Model Technical Advisory Committee (PTAC) recommended the federal Department of Health and Human Services accept the model as an APM. HHS has not yet announced its decision.

Meanwhile, UPMC in Pittsburgh uses the term “specialty medical home” to describe its Total Care-IBD care model for patients with Crohn’s disease and ulcerative colitis. Those are the same type of patients treated through the Illinois’ Blues “specialty intensive medical home” contracts, but both care delivery and payment are different.

In sum, there is no uniformity among “medical homes” for specialty care.

Lola Butcher (@lolabutcher) is a health care journalist in Springfield, Mo. She writes about health care policy and the business of medicine for a variety of publications, including Hospitals & Health Networks and Managed Care.