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The Rocky Road Toward Universal Health Insurance Coverage in the USA . Fred Ralston, Jr. MD, FACP President, American College of Physicians. The past: How payment for health care has changed over the past 100 years

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the rocky road toward universal health insurance coverage in the usa

The Rocky Road Toward Universal HealthInsurance Coverage in the USA

Fred Ralston, Jr. MD, FACP

President, American College of Physicians


The past: How payment for health care has changed over the past 100 years

The future: Understanding the Patient-Centered Medical Home: What Is It? What Can It Offer Patients, Physicians, and Those Paying for Health Care?

why 100 years
Why 100 years?
  • Abraham Flexner, a research scholar at the Carnegie Foundation for the Advancement of Teaching, undertook an assessment of medical education in North America, visiting all 155 medical schools then in operation in the United States and Canada.
  • His 1910 report, addressed primarily to the public, helped change the face of American medical education.

American Medical Education 100 Years after the Flexner Report N Engl J Med 2006;355:1339-44

flexner report
Flexner Report
  • The power of Flexner’s report derived from his emphasis on the scientific basis of medical practice, the comprehensive nature of his survey, and the appeal of his message to the American public.
  • Although reform in medical education was already under way, Flexner’s report fueled change by criticizing the mediocre quality and profit motive of many schools and teachers, the inadequate curricula and facilities at a number of schools, and the nonscientific approach to preparation for the profession, which contrasted with the university-based system of medical education in Germany.
early 20 th century
Early 20th Century
  • Nearly half of American Medical Schools closed or merged following this report
  • Tremendous scientific advances using a more European model of education and practice
  • With advancing quality come advancing costs – hence the beginnings of talk regarding health insurance to help pay for this higher quality care

After a visit to the Royal College of Physicians in London in 1913, Dr. Heinrich Stern tried to invoke enthusiasm in his colleagues for a similar organization in the United States. But it was two years before Dr. Stern could gather enough physicians—11—that he felt necessary to launch the new organization, the American College of Physicians.

  • From the College's first formal meeting in New York's Astor Hotel on June 25, 1915, the founding members viewed ACP as a way to improve the standards and recognition of internal medicine in this country.

“Americans always want to do the right thing — after they have tried everything else.” 

Winston Churchill

early 20 th century teddy roosevelt
Early 20th century: Teddy Roosevelt
  • In 1906, the American Association of Labor Legislation (AALL) initiated a campaign for national health insurance.
  • 1908: With support of President Roosevelt, Congress enacts first Workman’s Compensation act for civil service employees
  • By 1915 Workman’s Compensation laws had passed in 30 states
  • Health insurance coverage was considered to be the logical next step
theodore roosevelt
Theodore Roosevelt

Roosevelt believed that no country could be strong whose people were sick and poor

1912: Roosevelt campaigned on a platform that called for mandatory health insurance for workers

1910 1920
  • 1910s: Insurance plans started to offer group coverage. Total amount of voluntary HI prior to World War I remained very small, however
  • Into this vacuum, compulsory HI was discussed as part of a broader Social Security movement
american association of labor legislation
American Association of Labor Legislation
  • 1915: Bill to provide health insurance to the working class and all others that earned less than $1200 a year, including dependents
  • Compulsory coverage for services of physicians, nurses, and hospitals
  • Also provided for sick pay, maternity benefits, and death benefit for funeral expenses
  • Costs were to be shared between workers, employers, and the state
aall legislation defeated
AALL Legislation Defeated
    • Supported by the AMA
    • Opposed by Labor
      • Seen as threat to unions, usurping

their role in providing social benefits Samuel Gompers

      • Denounced by AFL leadership as an unnecessary paternalistic reform that would create a system of state supervision over people’s health
  • Opposed by Commercial Insurance Industry
    • Threat to private insurance death benefits
  • Lacked Popular Support
wwi 1929
WWI -1929
  • Compulsory insurance equated with German socialist insurance and Bolshevism
  • Increased resistance from physicians—
    • Viewed as threat to private practice, paternalistic, and “un-American”
    • Viewed as a threat to professionalism itself: mandatory fee schedules, work reviews, organizations outside the doctor-patient relationship over which doctors have no control; and limits on patient choice of physician
  • 1920: AMA House of Delegates opposes compulsory HI
the great depression and fdr
The Great Depression and FDR
  • Social Security Act of 1935 provided grants for states to set up assistance programs for indigents

Franklin Delano Roosevelt

  • FDR spoke in favor of a right to medical care, but did not push compulsory HI over fear that it would endanger other high priority reforms:
    • Economic security for workers and aged, unemployment, national economic recovery, WWII
  • Bill after bill introduced to mandate coverage, but none passed the Congress
    • Growing conservative opposition to social programs after 1938
world war ii
World War II
  • 1943: Health insurance and other worker benefits exempt from wage and price controls
  • 1943-49: Children’s Bureau organized a comprehensive program of maternity and infant care for military dependents; 12 million servicemen were eligible for care in hospitals and systems organized by the Armed Forces (model for the VA)
  • By 1944, the War Food Administration was responsible for health centers and clinics in 250 agricultural areas
1945 53 harry truman
1945-53: Harry Truman
  • 1945: Truman proposed a single plan to provide coverage for all age groups financed by 4% rise in Social Security payroll taxes
truman plan fails
Truman Plan Fails
  • Union leaders advocated for insurance to protect workers from rising medical costs
    • But fail to enlist rank and file membership
  • Opposition from GOP-controlled Congress and Southern Democrats
  • National attention on Cold War
  • “Socialized medicine” made a symbolic issue in crusade against Communist influence
  • AMA launched massive public relations and lobbying blitz in opposition
  • 1946: Hill-Burton Act provides funds for hospital construction with obligation to provide free care to uninsured
1950s dwight eisenhower
1950s: Dwight Eisenhower
  • Eisenhower proposed to help private HI through re-insurance, regulation and initial subsidy, but no requirements on private insurance regarding how health services were provided
  • Tax credits for employer sponsored health insurance prompts greater private coverage
  • Unions winning health benefits by collective bargaining reduces their interest in seeking national legislation
1950s eisenhower administration
1950s: Eisenhower Administration
  • Late 1950s: Forand bill proposed hospitalization insurance for retirees through Social Security; bill never went anywhere – opposed by Rep. Wilbur Mills, chair of the Ways and Means Committee
  • 1960: Kerr-Mills Act passed providing grants to states to provide need-based assistance for the elderly poor, but only 28 states participated
  • Federal Employee Health Benefits Program established – model for future proposals
early 1960s john f kennedy
Early 1960s: John F. Kennedy
  • Kennedy campaigned for a comprehensive program of HI coverage for the elderly
  • AMA established AMPAC with goal of electing conservatives to Congress and opposing Medicare
  • AMA won the propaganda war against Medicare; bill was defeated in the Senate and never got out of the House Ways and Means Committee
1960s lyndon b johnson
1960s: Lyndon B. Johnson
  • Assassination of JFK and LBJ’s ascendancy changed everything; LBJ believed in Medicare even more than JFK and knew how to get legislation through Congress
  • 1964 elections: LBJ trounced Goldwater and the Democrats gained a 2-1 majority in Congress
medicare and medicaid enacted
Medicare and Medicaid Enacted
  • 1965 Medicare and Medicaid passed, providing hospital and medical care for the elderly and creating a State/Federal partnership to cover the very poor
enactment of medicare was a triumph of principled pragmatism
Enactment of Medicare was a Triumph of Principled Pragmatism
  • Key pragmatic decisions were made to ensure enactment:
    • Mandated hospital coverage only for the elderly
    • Voluntary coverage for physician services (Medicare Part B)
    • Payments based on “usual and customary charges”
    • Non-interference in practice of medicine promised
    • Goal was to assure the same level of care for elderly, not to attempt to change the status quo
    • Medicare had to pay its own way: no discounts or prospective payments; cost-based pay to hospitals
1970s richard nixon
1970s: Richard Nixon
  • 1972: Medicare expanded to cover disabled
  • Wage and Price controls; beginning of limits on Medicare payments to physicians and hospitals
  • 1974: National Health Planning Act required “certificate of need” for new construction and acquisition of costly technology
1970s nixon and ford
1970s: Nixon and Ford
  • 1970: Sen. Ted Kennedy holds

hearings and proposes single-payer plan

  • Sen. Long and Rep. Mills also offer plans
  • 1971: Nixon responds with a plan that all large employers offer catastrophic HI coverage
  • Nixon under threat of impeachment -- bills fail
  • Ford supports National HI in 1974 but later withdraws support as inflation rises
  • Scandal forces Rep. Mills to leave; coalitions for reform weakened, efforts again fail
jimmy carter
Jimmy Carter
  • 1976: Carter campaigns for catastrophic plan
  • After election priority shifts to controlling health care costs; but he proposes a plan
  • Sen. Kennedy offers new legislation for mandatory employer HI, government subsidies for poor, competition among private plans, and negotiated fees
  • Bills fail due to economic recession, rising health costs, Congressional committee restructuring, and failure of advocates for comprehensive coverage to compromise
1980s reagan bush
1980s: Reagan/Bush
  • Reagan favored repeal or overhaul of many of the regulatory laws passed in the previous decade (e.g., National Health Planning Act and PSRO program)
  • Market-based “pro-competition” approach and tax credits favored for expanding HI
  • Medicare catastrophic and prescription drug coverage enacted, but repealed as seniors objected to paying for it
  • Growth in federal budget deficits led to new methods of paying doctors and hospitals
1990s bill clinton
1990s: Bill Clinton
  • Rising health care costs and

46 million uninsured increased

popular support for HI reform

  • Clinton administration became the first since Truman to pursue a comprehensive plan to provide universal coverage
  • Health Security Act called for mandated employer and individual coverage, managed competition, purchasing alliances, and global budgets
  • Plan fails to pass congressional committees
late 1990s clinton administration
Late 1990s: Clinton Administration
  • Following defeat of Clinton plan, more modest goals were set for expanding coverage (e.g. 1997 Children’s Health Insurance Program for low-income children)
  • GOP take-over of Congress led to enactment of Balanced Budget Act of 1997, which mandated cuts in payments to hospitals, physicians, other providers and new “Medicare+Choice” program—first step toward goal of privatizing Medicare
  • In 1998, Congress replaced the VPS with the Sustainable Growth Rate (SGR).
2001 2009 george w bush
2001-2009: George W. Bush
  • Prevailing conservative political view was to use “market competition” and the “purchasing power” of the federal government to reduce costs and improve quality
  • Key elements included: “transparency’ in pricing of services, measurement of performance, public reporting of quality and cost data to “empower” consumers, basing compensation on performance (P4P), and providing incentives for individuals to save for their own care (HSAs) with protection against catastrophic costs
2001 2009 george w bush33
2001-2009: George W. Bush
  • Ironically, Republican Congress passed and President George W. Bush sign into law the largest expansion of federal entitlements since 1965: Medicare Prescription Drug Program (Part D)
    • Decision to run the program through private insurers and PBMs put a conservative “stamp” on expansion of entitlements
2001 2009 george w bush34
2001-2009: George W. Bush
  • Democrats re-gained control of both the House and Senate in 2006 mid-term elections, representing a shift away from prevailing “conservative” trend
    • But the country, and the U.S. Senate, remained closely divided
  • Reauthorization fight over CHIP (2007-2008) marked by extreme partisanship
2009 obama administration
2009 – Obama Administration
  • Obama campaigned for universal health care coverage
  • 2008 elections returned the Democrats to the White House and solidified control over Congress
2010 affordable health care act passed
2010 Affordable Health Care Act Passed
  • Pragmatic Approach: Builds on private insurance and existing government programs
  • Effort made to gain support of public and interest groups
  • President worked with Congress
  • Support from labor, medicine, & business
  • Minimized opposition of insurers, hospitals,

and drug companies

  • Provisions implemented gradually 2010-20
  • Obama and Congressional leaders persevered

The present – an unsustainable health care delivery system that overvalues procedures and undervalues prevention and primary care

Is there a way to align incentives in a way where patients, physicians and insurers want the right treatment at the right time for everyone?

The Patient-Centered Medical Home: What Is It? What Can It Offer Patients, Physicians, and Those Paying for Health Care?

two kinds of talks
Two kinds of talks
  • Emotional – from the heart but without the data to back it up
  • Data filled slides that put everyone to sleep and while evidence-based are met with skepticism by those who feel they may not be relevant to those practicing in “the real world” – whether community or academia
  • I hope to show you why as a practicing internist I am so excited about the medical home and also that we have the data to back this up
from the heart
From the heart
  • Internal medicine – both general and subspecialty is a highly rewarding professional career – I would argue among the highest callings possible
  • General internal medicine and many subspecialties face tremendous threats to survival without improved payment
  • Those subspecialists who like the current payment system need to know that it is unsustainable and will melt down if the cost curve is not bent
from a self professed health policy wonk
From a self-professed health policy wonk
  • I am convinced that there is no way possible under the current payment model to rebalance primary care through modifications to the RBRVS alone
  • There is no traction to pleas asking for higher payments for primary care using the current delivery model
  • There will be continued unfunded or semi-funded mandates or expectations involving but not limited to quality improvement and reporting
from a self professed health policy wonk in private practice
From a self-professed health policy wonk in private practice
  • I am sympathetic to internists who say that the patient-centered medical home is what they have been doing for twenty years
  • Many practices are close but require documentation and others have further to go
  • With current trends in workforce and practice overhead, if there is no fundamental change in payment private practice of general internal medicine will only exist in subsidized environments
subsidized environments
Subsidized environments?
  • Hospital ownership of practices
  • Integrated groups pulling in revenue from ancillaries and other specialties
  • Those offering an insurance product or gain sharing with insurers
  • Concierge medicine
unintended consequences
Unintended Consequences
  • Smaller practices with seasoned veterans may close before they can attract new physicians to provide care
  • It would be wise to bring a new generation to learn the art of medicine from those who have decades of experience
  • Time is short
  • We need to increase the pipeline for primary care before these potential mentors leave practice
alignment of incentives
Alignment of incentives
  • Hospitals, unless the process changes from previous efforts, are not well suited to be nimble in running medical practices
  • Some of the first savings to be gained from improved medical practice is savings from hospital admissions – that runs counter to financial pressures on hospitals
  • If general internal medicine (and other primary care) is reimbursed according to its true worth rather than as a loss leader it allows us to test various models of practice organization
from someone in private practice gim since 1983
From someone in private practice GIM since 1983
  • Revenue is flat
  • Less free time and more hassles
  • Expenses rise relentlessly
  • Over the years experts have regularly presented a new idea which didn’t work to save or enhance primary care
initial response to medical home
Initial response to medical home
  • I don’t have the time to set one up
  • I don’t have the money and resources to set up a medical home
  • It’s just another idea that will end up not working
  • Notice the I (or even we referring to my physician partners)
why have i changed my mind and started to set one up
Why have I changed my mind and started to set one up?
  • I have been hearing great things from practices large and small who have started this process
  • Someone else is paying much of the start-up costs
  • There is a full time employee (not paid out of our limited revenue) to help us transform our practice
  • The patient-centered medical home will provide a platform to deal with some ongoing issues related to continuous quality improvement
preliminary results indicate these trends
Preliminary Results Indicate These Trends
  • Happier patients
  • Happier staff
  • Happier doctors
  • Lower cost
  • Higher quality
  • Helps practices do many of the things we are expected to do now but become easier in a team based approach with the proper resources
why isn t this just another passing fad
Why isn’t this just another passing fad?
  • Aligns incentives toward improved care
  • While the payment levels are not yet finalized initial levels for general internal medicine are much higher than current practice revenues allow
  • Best hope to provide attractive practice opportunity for new doctors
  • Provides proper resources to free up physicians for direct patient care and builds in CQI
  • Team based approach provides opportunity to use scarce health professionals in evidence-based ways to provide cost-effective care
why is primary care important
Why is Primary Care Important?
  • States with higher ratios of primary care physicians to population have better health outcomes*
  • Supply of primary care physicians associated with an increase in life span & reduced low birth-weight rates*
  • In both England and the US, each additional primary care physician per 10,000 population (a 12-20% increase) is associated with a decrease in mortality of 3-10%, depending on the cause of death**

*Starfield, B., et al: The Milbank Quarterly 2005; 83:457-502

**Gulliford, J Public Health Med 2002; 24:252-4

primary care associated with decreased costs
Primary Care Associated with Decreased Costs
  • According to the Center for Evaluative Clinical Sciences at Dartmouth, for patients with severe chronic diseases, those who live U.S. states that relied more on primary care have:
    • Lower Medicare spending (inpatient reimbursements and Part B payments)
    • Lower resource inputs (hospital beds, ICU beds, total physician labor, primary care labor, and medical specialist labor)
    • Lower utilization rates (physician visits, days in ICUs, days in the hospital, and fewer patients seeing 10 or more physicians)
    • Better quality of care (fewer ICU deaths and a higher composite quality score

Dartmouth Atlas of Health Care, Variation among States in the Management of Severe Chronic Illness, 2006

how connected are you to your primary care physician
How Connected Are You to Your Primary Care Physician

“Not surprisingly, those patients with the strongest relationships to specific primary care physicians were more likely to receive recommended tests and preventive care. In fact, this sense of connection with a single doctor had a greater influence on the kind of preventive care received than the patient’s age, sex,

race or ethnicity.”

How Connected Are You to Your Doctor?

Patient–Physician Connectedness and Quality

of Primary Care

Steven J. Atlas, MD, MPH; Richard W. Grant, MD, MPH;

Timothy G. Ferris, MD; Yuchiao Chang, PhD; and

Michael J. Barry, MD 3 March 2009 | Volume 150 Issue 5 | Pages 325-335

The PCMH concept advocates enhanced access to comprehensive, coordinated, evidence-based, interdisciplinary care

Medical Home Care

Today’s Care

My patients are those who make appointments to see me

Our patients are those who are registered in our medical home

Care is determined by today’s problem and time available today

Care is determined by a proactive plan to meet health needs, with or without visits

Care varies by scheduled time and memory or skill of the doctor

Care is standardized according to evidence-based guidelines

I know I deliver high quality care because I’m well trained

We measure our quality and make rapid changes to improve it

Patients are responsible for coordinating their own care

A prepared team of professionals coordinates all patients’ care

It’s up to the patient to tell us what happened to them

We track tests and consultations, and follow-up after ED and hospital

Clinic operations center on meeting the doctor’s needs

An interdisciplinary team works at the top of our licenses to serve patients

Source: Adapted with permission by IBM from Daniel F. Duffy, M.D.

The Patient-Centered Primary Care Collaborative:Examples of broad stakeholder support and participation

Providers 333,000 primary care

Purchasers –

Most of the Fortune 500

  • IBM
  • General Motors
  • ACP
  • AAP
  • FedEx
  • General Electric
  • AAFP
  • AOA
  • Pfizer
  • Merck
  • ABIM
  • ACC
  • Business Coalitions
  • ACOI
  • AHI
  • Wal-Mart

80 Million lives


Patient-Centered Medical Home



  • NCQA
  • Aetna
  • National Partnership for Women and Families
  • Humana
  • United
  • HCSC
  • MVP
  • Foundation for Informed Decision Making
  • WellPoint
  • Kaiser
  • SEIU
why the patient centered medical home
Why the Patient-Centered Medical Home?
  • The Patient Centered Medical Home creates a framework for change
  • The Patient Centered Medical Home creates a common language for change
  • The Patient Centered Medical Home creates an opportunityfor change
  • The Patient Centered Medical Home aligns

paymentwith the added valve and therapeutic



Pilots: BCBS North Dakota, Marillac Clinic (Chicago)

  • 6% decrease in hospital admissions
  • 24 % decrease emergency room
  • $500 per member per year savings

Marillac’s Integrated Care Patients (PCMH)

results clinical process metric improvement
Results: Clinical Process Metric Improvement

HbA1c Testing

January 2007


Permission from Horizon Blue Cross Blue Shield and Partners in Care, Corp.

pilot with best overall data
Pilot with best overall data

Group Health’s experience in a prototype clinic suggests that primary care enhancements, in the form of the medical home, hold promise for

  • Controlling costs
  • Improving quality
  • Better meeting the needs of patients and care teams.
health affairs may 2010 group health
Health Affairs May 2010 – Group Health

Paper examines the effects of the medical home prototype at twenty-one to twenty-four months after implementation on

  • Patients’ experiences
  • Quality
  • Burnout of clinicians
  • Total costs
health affairs may 2010 group health61
Health Affairs May 2010 – Group Health

Results show improvements in patients’ experiences, quality, and clinician burnout through two years.

  • Patients’ experiences
  • Quality
  • Burnout of clinicians
  • Total costs
health affairs may 2010 group health62
Health Affairs May 2010 – Group Health

Patients in the medical home experienced

  • 29 percent fewer emergency visits
  • 6 percent fewer hospitalizations.
  • Estimated total savings of $10.30 per patient per month twenty-one months into the pilot
what is the patient centered medical home
What is the Patient-Centered Medical Home?
  • …a vision of health care as it should be
  • …a framework for organizing systems of care at both the micro (practice) and macro (society) level
  • …a model to test, improve, and validate
  • …part of the health care reform agenda
pcmh is a term
“PCMH” is a Term…
  • …to describe a pathway to excellent health care
  • …to re-claim a role as advocates for our patients (with our patients & their families)
  • …to encourage team-based care
  • …to create educational opportunities
  • …to attract medical students and residents to primary care
the joint principles of the pcmh
The Joint Principles of the PCMH

Team-based care:



Medical Assistant

Office Staff

Care Coordinator



Behavioral Health

Case Manager

Social Worker

Community resources

Other clinical specialists

DM companies


  • Personal physician
  • Physician directed medical practice
  • Whole person orientation
  • Care is coordinated and/or integrated
  • Quality and safety
  • Enhanced access to care
  • Payment to support the PCMH
gaps in care coordination
Gaps in Care Coordination
  • Primary care and specialists:
    • No information sent to Peds specialist 49% of time; no feedback to primary care 55% of time
    • Dissatisfaction with quality of referrals (28% of primary care; 43% of specialists rating information from the other)
  • Emergency Department
    • 30% of adults indicated regular physician not informed about visit
  • Hospital
    • 33% of adults with chronic condition did not have follow-up plans post hospital discharge
    • 3% of primary care physicians discussed discharge plans with hospital physicians
    • 66% of time primary care follow-up post discharge was done without a hospital discharge summary

Bodenheimer, T: Coordinating Care – A Perilous Journey through the Health Care System. NEJM 2008;358:10

collaborative care
Collaborative Care
  • Collaboration includes ongoing interdisciplinary communication regarding the care of individuals and populations of patients in order to promote quality and cost-effective care
    • Critical to ensuring that all patients receive the highest possible quality of care
important questions
Important Questions
  • How do you recognize a PCMH?
  • How is care different?
  • Will physicians & their teams want to build the medical home?
  • How do we prepare physicians, students & residents?
ncqa physician practice connections pcmh
NCQA: Physician Practice Connections/PCMH
  • Access & Communication
  • Patient Tracking & Registry Functions
  • Care Management
  • Patient Self-Management Support
  • Electronic Prescribing
  • Test Tracking
  • Referral Tracking
  • Performance Reporting & Improvement
  • Advanced Electronic Communication
the process
The Process
  • Gap analysis – take the “pre-test.”
  • Analyze your results.
  • Implement changes necessary
  • Retake the “pre-test.”
  • If ready submit application to NCQA.

Cost: Readiness assessment = $80

NCQA application fee: varies by size of practice from $450 for 1 physician to $2,700 for 6+

acp resource to prepare your practice
ACP Resource to Prepare Your Practice
  • ACP Medical Home Builder Kit
  • Nominal cost - $85 for my 8 physician practice total value of the deal for about 2 years
  • Practice biopsy
  • Links to tools for areas needing improvement
Demonstrates timely access and communication processes

Organizes charts (paper or electronic) to facilitate team-based care and tracking age-appropriate and condition-specific interventions

Identifies key clinical conditions among population served & follows evidence-based guidelines

Encourages and provides support for patient/family self-management

Addresses health literacy issues

Tracks tests & referrals to assure completion

Collects and reports on quality & satisfaction data to practice

Level 1: 25-49 Points

key points for level 1 pcmh
Key Points for Level 1 PCMH
  • Does not require electronic health record
  • Will require registry & tracking functions
  • Emphasis is on providing better care through:
    • Access to care
    • Organization of office structure & processes
    • Enhancing patient self-management; addressing health literacy issues
    • Introduction of evidence-based guidelines, measurement & quality improvement
level 2 level 3
Level 2 → Level 3
  • Advanced access options for patients
  • Electronic health record
  • More, and more complex care coordination and patient support
  • Robust population management
  • Advanced reporting and quality improvement initiatives
  • Additional technology solutions
are you blurry eyed yet
Are you blurry eyed yet?
  • Remember this is a team effort
  • You don’t have to do it all and most of the process activities should be handled by others
  • Need outside help with start-up costs
  • Need outside help with practice transformation
  • Need support structures facilitating conversation and co-operation with those in similar practices
  • May lead to shared services or groups without walls
more features of a pcmh practice
More Features of a PCMH Practice
  • Each team member practices to highest capability (and no lower)
  • Supports cultural competency training
  • Understands health literacy
  • Establishes connections to the community
  • Provides extensive self-management support
  • Engages a Patient/Family Advisory Group
more features of a pcmh practice77
More Features of a PCMH Practice
  • Provides individualized written care plans and monitors adherence to plan with patient/family
  • Assesses barriers to adherence and initiates plans to overcome them
  • Collaborates with other physicians & institutions to insure timely access to health care and health care information
  • Manages transitions of care seamlessly
specialty care connections
Specialty Care Connections


  • PCMH is NOT a gatekeeper system
  • Jointly develop/identify referral guidelines
  • Emphasis on transitions in care & continuity
    • Referral agreements
    • Care transitions programs
  • Some subspecialists may want to qualify as PCMH
  • ACP in discussions with several groups regarding the PCMH model and primary care/specialty care interface (sharing care – medical neighborhood)
practice implications
Practice Implications
  • Challenges of transformation
  • Initial capital and restructuring costs
  • Ongoing support & maintenance
  • Reporting on quality, cost and satisfaction
  • Implementation of HIT coincident with PCMH
  • Patient-centered model
  • Encourages evidence-based medicine
  • Could improve quality
  • Could bend the curve on costs
  • Payment models decrease incentive for volume and encourage investment in practice changes to promote quality
  • Requires considerable change in practice
  • Data pending on practicality
  • Unknown return on investment
  • May disenfranchise small practices
  • Workforce projections for primary care
  • Uncertain impact on access – will panel sizes decrease?
  • Demonstration projects including public & private payers
  • Inter-professional collaboration
  • Health information technology
  • Modeling of different payment models and organizational structures
  • Perception that this is a zero-$um game
  • Primary care workforce
  • Physicians overwhelmed
  • Fear of change
  • Consumers may not understand/accept the model (or name)
  • Unintended consequences
growing interest in the pcmh
Growing Interest in the PCMH
  • Patient-Centered Primary Care Collaborative
    • 300+ organizations; represent 50+ million people
  • Articles in NEJM, JAMA, Health Affairs, Annals of Internal Medicine
  • Trade & Lay Press
  • Legislation
  • Commercial payer demos
  • Public payer demos
the need for education support
The Need for Education & Support
  • Team-based care
    • Everyone practices to the level of his/her license, skill, and ability – and no lower
  • Patient-centered care
  • Communication skills
  • Use of technology
  • Quality improvement & measurement skills
a commitment to excellence
A Commitment to Excellence
  • Patient-centered communication
  • Shared decision making
  • Timely access to care
  • Electronic health records
  • Use of comparative effectiveness research & evidence-based guidelines
  • Measure, improve, measure
  • Transparency & accountability
  • Safety
thinking about becoming a medical home
Thinking about becoming a medical home?
  • Look at ACP Medical Home Builder Kit – nominal cost (About $85 for our 8 MD’s total)
  • Look for initiatives that are in place for start-up funds
  • Perhaps talk with insurers about becoming more involved in PCMH
  • Look at practice size – large and small can work but likely a critical mass needed (Consider virtual groups with other like-minded small groups)
questions or comments
Questions or comments?

Fred Ralston, Jr. MD FACP

Private Practice General Internal Medicine

Fayetteville Medical Associates

207 South Elk Avenue

Fayetteville, Tennessee 37334


American College of Physicians