Synopsis
The patient-centered medical home seeks to expand patients’ access to primary care, promote prevention, and ensure that care is well coordinated. National survey data show that the number of medical home initiatives and the number of patients they serve have grown significantly since 2009. Current initiatives tend to be larger and have no specified end dates, while per-member per-month fees are higher. These findings suggest that stakeholders recognize the importance of investing in primary care and the substantial time and effort required to change practice patterns and provider behavior.
The Issue
Strengthening primary care is a key thrust of health care delivery reform efforts in the United States and the patient-centered medical home model is often a core component. Medical homes, whether organized by health plans, state Medicaid programs, or other entities, rely on multidisciplinary care teams, care managers, patient registries, and other tools to expand access, promote prevention, and coordinate patient care. To understand the prevalence and nature of these initiatives, Commonwealth Fund–supported researchers fielded a nationwide survey of patient-centered medical homes in 2013 and compared the results with a similar survey fielded in 2009.
Key Findings
- In 2013, there were 119 medical home initiatives in the U.S. that featured payment reform, 114 of which responded to the survey. In 2009, there were only 26.
- Medical home initiatives in 2013 ranged from small pilot programs with only a few participating practices to large programs covering nearly all patients in a region or state, with these larger initiatives dominating. The number of enrolled patients increased from about 5 million in 2009 to about 21 million in 2013.
- In 2013, 69 percent of the initiatives required participating practices to achieve official recognition as patient-centered medical homes based on established standards, either set by the National Commission for Quality Assurance or internally developed.
- While most medical home initiatives in 2009 had set end dates (77%), in 2013 only 20 percent had designated end dates.
- The dominant payment model for medical home providers has remained fee-for-service, supplemented by per-member per-month payments and pay-for-performance bonuses. The use of shared-savings models (under which both payer and provider typically share the cost savings achieved through better patient care) had become more common, however, and per-member per-month fees were higher in 2013 than in 2009.
The Big Picture
"The longer-term, more open-ended nature of the current patient-centered medical home initiatives suggests a recognition of the importance of sustained investment in the primary care infrastructure."
Based on substantial growth in the number of medical homes and payers’ commitment to the model over the long term, there appears to be a recognition that reforming primary care will require considerable time and resources. Evaluations of early medical home initiatives have found mixed results regarding their ability to improve care and control costs, but today’s initiatives are learning from past experiences and providing greater incentives to control the total costs of care.
About the Study
As in the 2009 survey, the researchers surveyed all patient-centered medical homes that featured external payment incentives to participating providers. They identified medical homes through public databases, literature review, web searches, and expert consultation. The survey included questions about the process used to select participating practices, medical home recognition standards, payment methodologies, use of consultants, involvement in learning collaboratives, and planned evaluations. Of the 172 patient-centered medical home initiatives the researchers identified, 119 incorporated payment reform in their model and thus met inclusion criteria. Of these, 114 (96%) responded to the survey. Collectively, the initiatives included 63,011 providers caring for 20,764,676 patients.
The Bottom Line
Between 2009 and 2013 there was a fourfold increase in both the number of patient-centered medical home initiatives and the number of patients enrolled in them. Current initiatives tend to be large, open-ended, and varied in respect to payment and delivery reform approaches.
