There have been numerous efforts by payers and providers to improve patient access to high-functioning medical homes—an enhanced model of primary care that offers whole-person, comprehensive, ongoing, and coordinated patient- and familycentered care. Public payers, especially Medicaid, have been leaders in these efforts, with the hopes of preventing illness, reducing wasteful fragmentation, and averting the need for costly emergency department visits, hospitalizations, and institutionalizations. With the support of The Commonwealth Fund, the National Academy for State Health Policy (NASHP) has fostered these efforts through the Consortia to Advance Medical Homes for Medicaid and CHIP Participants.

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What is a Patient Centered Medical Home ?
Patient Centered Medical Home (PCMH)
is an approach to providing
comprehensive primary care
to adults, youth and children.
PCMH will broaden access to primary care,
while enhancing care coordination.

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Background Information
• Employers are facing rising medical costs that have now exceeded the
growth of earnings.
 This is a “game over” scenario: it cannot go on anymore.
• There are currently over 46 Million Americans without any form of
Medical Coverage.
• ~ 40% of Americans do not have a Primary Care Provider or a Medical
Home.
 >300,000,000 Americans growing at 1.3%/year
• The median household income in the U.S. is $46,326
• U.S. Health Care System is ranked 37th
by the W.H.O. and we spend the
most per patient.
• U.S. has worst record of the 19 developed economies
in adding years of life using medical interventions.
• The U.S. health care system has to change.

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“Across the globe doctors are miserable because they
feel like hamsters on a treadmill. They must run faster
just to stand still… The result of the wheel going faster is
not only a reduction in the quality of care but also a
reduction in professional satisfaction
and an increase in burnout among doctors.”
Morrison and Smith, BMJ 2000;321:1541
Primary Care: Currently an Impossible Job?

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 Because of inadequate reimbursement, primary care physicians
need excessively large patient panels to keep their practices
viable. The average US primary care patient panel is 2300.
 A primary care physician with a panel of 2500 average patients
would need to spend 7.4 hours per day performing recom-
mended preventive care [YARNALL ET AL. AM J PUBLIC HEALTH 2003;93:635]
 A primary care physician with a panel of 2500 average patients
would need to spend 10.6 hours per day performing recom-
mended chronic care [OSTBYE ET AL. ANNALS OF FAM MED 2005;3:209]
Primary Care: Currently an Impossible Job?

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0
0.5
1
1.5
2
1000 1500 2000 2500 3000 3500 4000
Per Capita Health Care Expenditures
PrimaryCareScore
Primary Care Score vs. Total Expenditures, 1997
Starfield 10/00
00-133
US
NTH
CAN
AUS
SWE
JAP
BEL FR
GER
SP
DK
FIN
UK
Starfield 10/00
IC 1731

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Primary care score vs rank in outcomes
United
States
AUS
BEL
GER
CANFIN
SP SWE
UK
0
1
2
3
4
5
6
7
8
9
10
0 1 2 3 4 5 6 7 8 9 10 11 12
better------Primary care score ranking-------worse
HealthcareOutcomes
Rank*
NTH/DK
*Rank based on patient satisfaction, expenditures per person, 14 health
indicators, and medications per person in Australia, Belgium, Canada, Denmark,
Finland, Germany, Netherlands, Spain, Sweden, United Kingdom, United States

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Total cost of healthcare
vs availability of Primary Care

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Total cost of healthcare
vs availability of Specialists

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Quality Rank
vs availability of Primary Care

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Quality Rank
vs availability of Specialists

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The numbers say:
primary care delivers better health outcomes
 mortality
 morbidity
 medication use
 per capita expenditures
 patient satisfaction
SOURCE: B. Starfield, et al, “The Effects of Specialist Supply on Populations’ Health,”
Health Affairs (March 2005); W5-97

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Patient-Centered Care is:
*Patient Engagement in Care
*Clinical Information Systems supporting QI
*Care Coordination
*Integrated and Comprehensive Team Care
*Routine Patient Feedback to Physicians
*Publicly Available Data on Physician Performance
*Superb Access to Care
SOURCE: Karen Davis, Stephen Schoenbaum, MD, Anne-Marie Audet, MD, “A 2020 Vision of Patient-
Centered Primary Care”, 2006 Commonwealth Fund Annual Report

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Addressing Care Coordination
through the PC-MH
Care coordination is inherent as part of
Primary Care through training, continuity,
and relationships
Critical new focus on Family Medicine and
primary care as a Team Sport –
 Physicians
 Other clinicians and office staff
 ‘Organized’ Referral Networks based on ‘value’
 ‘Organized’ Community Resources

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Principles of the
Patient Centered Medical Home
- Approved by the AAFP, ACP, AAP, and AOA
• Personal Physician
• Team Based Medical Practice
• Whole Person Orientation
• Care is Integrated and/or Coordinated
• Quality and Safety
• Enhanced Access to Care
• Payment Reform

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“ …studies have demonstrated that a primary care–based health care system
has the potential to reduce costs while maintaining quality.
The hospitalization rates for diagnoses
that could be addressed in ambulatory care settings
are higher where access to primary care physicians is more limited.
States with a higher ratio of generalist to population have
lower per-beneficiary Medicare expenditures
and higher scores on 24 common performance measures
than states with fewer generalist physicians and more specialists per capita.”
Primary Care — Will It Survive?
Thomas Bodenheimer, M.D.
Perspective August 31, 2006

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“Fixing primary care requires actions on the part of
primary care practices (microsystem improvement)
and the larger health care system (macrosystem reform).
A covenant is needed between those who pay for health care
and those who deliver primary care:
primary care must promise to improve itself,
and in return, payers must invest in primary care.”
Primary Care — Will It Survive?
Thomas Bodenheimer, M.D.
Perspective August 31, 2006