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A Fork in the Road

by Caroline Smart, CloudView Editor

Welcome back to Population Health(ier), a recurring series featuring athenahealth and The Atlantic’s best storytelling on America’s population health revolution. To catch up on our series, you can find last week’s story here. Today, we explore how community-based and patient-centered medical homes can help to strengthen the communities they serve.

Primary-care medicine is in crisis. Fifty years ago, half of all doctors in America provided primary care to patients. Today, less than one in three do, and 60 million Americans lack adequate access to the first line of healthcare. But now, new healthcare legislation—a bipartisan effort with support from the American College of Physicians, American Association of Family Physicians, and others—is working to fix it.

In an ongoing effort to improve delivery of care while containing the costs of primary care, the law brings doctors to a fork in the road where they must choose between two futures.

The default option doesn’t much change the way a practice operates and “is more aligned with the existing … fee-for-service model,” writes Whitney McKnight in Family Practice News, “but with a twist”: The doctors take on the risk. If a practice outperforms its peers (based on Medicare quality measures), it can earn bonuses on its reimbursements.  If it doesn’t, it might not get reimbursed in full.

On the other hand, doctors can follow a path that represents a move toward true transformation with alternative payment models. Among these models, the patient-centered medical home—team-based healthcare, led and coordinated by primary-care physicians—has achieved favored status. Instead of being on the hook for financial risk, practices that make the transition to a Patient-Centered Medical Home (PCMH) are rewarded with a five-percent automatic bonus on their Medicare payments, with the potential for more down the road.

Following the PCMH path involves redefining the provider-patient relationship and is undoubtedly harder work for a practice to adopt than simply taking on risk. So why does the new legislation encourage doctors to choose it? In recent years, the PCMH has emerged as a proven model for achieving healthcare’s “triple aim”: improving the patient experience, improving quality, and lowering costs, while also giving more patients access to primary care.

Patients report higher satisfaction at PCMHs, which are required to offer patient portals for more on-demand scheduling of appointments and more transparent access to their health data. Meanwhile, the hands-on care from a PCMH team improves healthcare outcomes: Studies have shown 11-percent drops in outpatient emergency room visits from Medicare patients treated at a PCMH. And despite the increased investment and high-touch care, 60 percent of PCMH clinicians report lower healthcare costs. These figures come alongside a 66 percent increase in staff satisfaction, 14 percent growth in clinician salaries, and 11 percent more revenue for their practices.

While the prospect of transitioning to a PCMH is empowering, it’s also more demanding. For physicians to unlock all those benefits—both cost- and care-related—they have to upend the way they currently deliver primary care.

A PCMH requires an investment in technology to track and share patient data with providers, payers, and the patients themselves. But that model requires going beyond the standard electronic health records (EHR) and requires practices to become, to some extent, data analysts. Using EHRs in combination with population-health management tools, practices can analyze every detail of their patient pool—from demographics to missed appointments to how conditions change over time. That facilitates the deployment of resources and attention to the patients and patient groups that need it most.

The technology also works to empower patients. While providers see their patients in ever higher definition, becoming a PCMH requires that they give patients 24/7 access to care for both routine and urgent medical needs via email, text, or other media.  The PCMH has the potential to change the interaction between patients and physicians, turning patients into active participants in managing their health.

There are six key elements a practice must adopt to get certified as a PCMH by the NCQA. Collectively they include 27 measurable features, each of them weighted with a specific value. As a practice implements more and more of these features, it accrues a higher total score that must pass a certain threshold for certification as a Level 1 PCMH (the lowest level) and potentially up to Level 3.

If it sounds complicated, that’s because it is. But practices aren’t typically left to go it alone.

At athenahealth, we’re working to streamline the process. We work with the NCQA and other certification organizations to get our services pre-approved to check off certain boxes, giving our clients a head start on PCMH certification. By providing automatic credits to any practice that signs up to use athenahealth, we work on behalf of practices to make it easier to participate and succeed as a PCMH.

Between incentives offered by the new healthcare legislation and population-management tools from the private sector, more than 6,700 PCMHs and 35,000 clinicians can attest to how the alternative payment model empowers practices to implement changes that benefit patients, practices, and even the healthcare system overall.

As Robert Doherty of the American College of Physicians said to doctors earlier this year, “If you are not in a patient-centered medical home now, you should be thinking about one.” And with 400 percent growth in the number of PCMHs in the country over the last five years, it’s clear that more and more of them are doing just that.

To experience an interactive feature along with access to the full Population Healthier series, visit The Atlantic.


Caroline Smart is a Senior PR Associate and CloudView Editor.

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