The 21st century has begun with some very exciting changes for primary care and specifically for Family Medicine. In this chapter we will discuss why a new model of primary care is essential; describe past, current, and future efforts for redesigning primary care with a focus on the Patient-Centered Medical Home (PCMH); and conclude with a discussion of how to transform both medical practices and the nation’s health care delivery system to take full advantage of the PCMH’s potential to improve the quality of, and access to affordable care that enhances the well-being of everyone in this country.

The objective of any system of health care should be to improve the lives of the patients it serves, both in the quality and the length of those lives, to create an environment in which people feel better, avoid preventable medical problems, ameliorate the effects of existing disease, and enjoy the lives they have as fully as possible.

Currently in the United States of America we have too many people who do not have adequate access to care, receive care that is of less than optimal quality, get care that costs too much and has significant disparities in its provision (Institute of Medicine, 2001). We need to do things differently because we know there is a better way; a way that is based on solid scientific fact, which builds on the good of our current system and that is fair to all, a truly American way.

We must change from rewarding doing things to people, and create incentives to do things for people, from paying to do a task to paying for thinking about the task. Is a given procedure the most appropriate one for this individual at this particular time, if ever?

Past Attempts

Managed Care

In the early 1990s the idea of “managed care” was introduced into the United States, primarily as a way to increase profits and control costs by the insurance industry. This was popularly known as the “Gatekeeper” system. Patients were required to visit a primary care provider who was approved by their insurance carrier to provide services under a particular plan as an entry point for any further access to the Healthcare System. Payment was made to the physician on a capitated basis. That is, a fixed amount was paid to the physician for each member of that insurance plan who designated that doctor as his or her primary care physician. The payment was the same each month regardless of whether the patient had been seen in a particular month or not. Additionally, a preauthorization was required for most services provided outside the physician’s office. Testing and procedures done in the physician’s office were generally not compensated beyond the amount of capitation. Understandably, both patients and physicians generally despised this idea.

It deprived the patient of freedom of choice, while increasing the inconvenience of obtaining a referral, test, or most any other service. Physicians were in the unfamiliar and uncomfortable situation of being a patient adversary rather than a patient advocate. Payments were generally slow in coming and many times did not come at all, making it difficult, if not impossible, for practices to maintain financial margins sufficient to remain viable. This system was further flawed in that the physicians were selected to be the “gatekeepers” solely on the condition that he or she have a pulse, and not by specialty or any other criteria that might indicate the doctor’s ability to improve quality and control cost.

Case Management

Next, insurance companies and other third parties tried to charge employers and other providers of insurance (such as state and federal governments) to provide chronic disease management services on the theory that managing the disease, and not the whole patient (without direct contact with the patient, by the way), would somehow improve the patient’s health and long-term prognosis. The only tangible results of this idea were to increase duplication of testing and increase the cost of providing insurance with no tangible benefit to anyone except the companies providing such services.

Present and Future

The Patient-Centered Medical Home

The term “medical home” originated in the 1960s with the American Academy of Pediatrics (AAP) who proposed that this entity be a repository for all medical information on certain patient populations. Since that time, the meaning and application of the concept of medical home has varied and now, at the beginning of the 21st century, the concept has evolved to the Patient-Centered Medical Home (PCMH) which is the leading framework for transforming primary care in the United States.

Prior to the PCMH, much progress had already been made toward conceptualizing a new model of chronic illness care and how to change the current health system to improve clinical outcomes. The resulting model was the chronic care model (CCM) developed by Wagner and his colleagues at the MacColl Institute (Wagner, 1998; see Figure 64-1) which was an important influence on the Future of Family Medicine (FFM) project (discussed below) and the evolution of the PCMH.

At the core of the CCM is a shift in focus from a reactive approach to chronic illness care to a proactive approach that results in improved outcomes through productive interactions between an informed and activated patient and a prepared and proactive practice team (ICIC, 2008). It is beyond the scope of this chapter to provide a detailed description of the model, but in brief the model shows that to improve the current health care system and promote high-quality chronic illness care, the system must be reorganized to include six essential elements (see Figure 64-1). These elements include a Health System that promotes safe, high quality care by supporting effective and patient centered Delivery System Design, Decision Support, and Self-Management Support strategies and Clinical Information Systems as well as collaboration with The Community to mobilize community resources to meet the needs of patients (IHI, 2008).

Since the inception of the CCM, there have been numerous intervention studies conducted that incorporate one or more elements of the CCM and there is extensive evidence to support the positive effects of CCM based interventions on both clinical processes and patient outcomes (Glasgow et al., 2001; Ouwens et al., 2005; Tsai et al., 2005; & Piatt et al., 2006) and cost-effectiveness (Bodenheimer, Wagner, & Grumbach, 2002). Each individual element of the CCM is important and can lead to improved outcomes and while no single element appears to be more effective than the other, the more CCM elements implemented the better the outcomes (Tsai et al, 2005).

Although the CCM was originally developed as a model for improving chronic illness care, most components are also applicable to the necessary redesign of primary care; hence the model serves as the foundation of the new model of primary care that has been adopted by the American Academy of Family Physicians (AAFP, 2004), it is also endorsed by The National Committee on Quality Assurance and The Joint Commission (ICIC, 2008), and is one of the most important influences on the development of the PCMH (Robert Graham Center, 2007) which builds upon CCM elements to address the needs of patients and families in the medical home. The CCM and PCMH complement each other with the CCM focusing more heavily on health care system change while the overall PCMH philosophy focuses on the patient and family to determine the best ways to support them through system change as well as other strategies.

In the year 2000, leaders in Family Medicine began an assessment of that specialty’s future role. Known as the “Future of Family Medicine Project (FFM),” this effort, along with similar projects by the AAP and the American College of Physicians (ACP), ultimately became the second major step in the development of the medical home.

During this period much independent research, both here and abroad, demonstrated that primary care was associated with higher quality care delivered at lower cost and with increased patient satisfaction. Simultaneously, IBM, aware of this research and it’s own experiential data from countries with primary care–based health systems, began to search for the same value in healthcare in the United States.

In the spring of 2006, having become aware of the now completed FFM project and it’s conclusion that the country’s family doctors needed a “new model” of practice, representatives of IBM approached leaders of the American Academy of Family Physicians (AAFP) at the World Health Care Congress held in Washington, DC, about collaboration on the issue.

Subsequently, the ACP and AAFP along with IBM convened a summit to educate and involve more businesses, insurance companies and physician groups such as the American Osteopathic Association (AOA) in the development and propagation of what came to be termed the “Patient-Centered Medical Home” (PCMH).

These groups developed and refined the principals on which the medical home would be based, formed the “Patient Centered Primary Care Collaborative (PCPCC)” with headquarters in the Nation’s Capitol to promote and disseminate the medical home idea to businesses, the public, physicians, and insurance companies as well as to federal and state governments. Currently the PCPCC has over 700 member organizations representing 333,000 primary care physicians, several Fortune 500 companies and their millions of employees, major health insurance companies, other physician groups and organizations representing patients.

In the span of just three short years the PCMH has gone from a glimmering of an idea to becoming the most important idea for health system change in the past 50 years. It can be the vehicle that finally provides quality, affordable, accessible health care for everyone in the United States.

Pcmh Evidence