PCMH and Healthcare Reform: Avoiding Drowning in an Ocean of Opportunity

This article appears in the April 2010 issue of Medical Home News.

First, the good news: There are a lot of pilot and demonstration projects potentially involving the Patient Centered Medical Home (PCMH) in newly enacted Federal health care reform legislation – the Patient Protection and Affordable Care Act (PPACA).

Then, the bad news: There are a lot of pilot and demonstration projects potentially involving the PCMH in the PPACA.

…so many that the PCMH risks being drowned in an ocean of opportunity.

I’d like to make a few simple points in this essay:

1. The number of authorized pilots and demos in the PPACA is staggering
2. This creates both opportunities and challenges
3. PCMH focus will be required to navigate the ocean

1) The number of pilot and demo projects is staggering

How many? Nailing down an exact number today isn’t possible since there is a fair amount of discretion given to CMS (the Centers for Medicare and Medicaid Services) in structuring the projects.

By my count, the PPACA requires at least 5 pilots and 30 different demos (not necessarily specific to the PCMH, but covering many issues. Click here for more details).

On top of that, Section 3021 of the enabling legislation also establishes the Center for Medicare and Medicaid Innovation within CMS. According to the Democratic Policy Committee:

The purpose of the Center will be to research, develop, test, and expand innovative payment and delivery arrangements to improve the quality and reduce the cost of care provided to patients in each program. Dedicated funding is provided to allow for testing of models that require benefits not currently covered by Medicare. Successful models can be expanded nationally.

Eighteen different models are listed for possible testing; the PCMH is explicitly mentioned in several and could be embedded in many others.
On top of that are two other recently authorized but yet-to-be-implemented Medicare demos specifically relating to the medical home:

• The Multi-Payer Advanced Primary Care Practice (MAPCI) demo – which replaces the shelved Medicare Medical Home Demonstration
• The Federally Qualified Health Centers Advanced Primary Care Practice (FQHCAPC) demo

MAPCI was created in 2009, and FQHCAPC was created in 2010 by HHS Secretary Sebelius.

On top of that are over two dozen PCMH demonstration projects being conducted by private health plans and/or States.
Feeling a bit overwhelmed yet?

2) Opportunities and Challenges

The opportunities are obvious: the PCMH is going to get a lot of visibility and a lot of road testing. But beware of the challenges, too:

• The PCMH could become quagmired in a plethora of pilots and demos authorized by the PPACA
• The PCMH should be included in many other related pilots and demos. For example, several of the pilots and demos are labeled as testing “Accountable Care Organizations” (ACOs) and don’t use language specific to the “medical home”. However, the PCMH can and should be embedded in an ACO testing project.
• Resources and talent around PCMH implementation and evaluation will be spread thin

3) PCMH Focus Will be Required

First, the PCMH community should focus resources on pilot projects. What’s the distinction between a pilot and a demonstration? In short, the Secretary of Health and Human Services (HHS) will have the authority to expand pilot programs and put them into practice without requiring Congressional approval.

Thus, emphasizing pilot projects promises easier physician recruitment, easier expansion beyond pilot stage, and generally far more bang-for-the-buck.

Second, let’s focus on answering the primary questions on CMS’s mind about the PCMH. Speaking at the recent Medical Home Summit conference, Linda Magno, Director of CMS Demonstrations, listed two “Primary Evaluation Questions” around the PCMH:

• How do the health care quality and outcomes of beneficiaries treated in medical homes compare to those of beneficiaries treated in other practices?
• How do the costs and utilization of beneficiaries in medical homes compare to those of beneficiaries in other practices?

Quality and outcomes. Costs and utilization. Let’s remember Steven Covey’s advice on prioritization in his book “First Things First”:

The Main Thing Is To Keep The Main Thing The Main Thing