Health outcomes in the U.S. continue to fall behind those of other developed—and some less developed—countries, despite unrivaled spending.¹ Our slippage in general health and longevity relates largely to the fact that we permit large sectors of our population to go without insurance and access to care.² Having a usual source of care, the most essential element of a PCMH, is extremely influential in the care people receive. In fact, having a usual source of care, independent of other factors such as health insurance, is associated with a greater likelihood that people receive care in nearly every setting. People who utilize care but do not have a usual source of care, experience real barriers to getting care when they need it.³ This is true for children and adults. People who have a usual source of care are also more likely to receive preventive care services, independent of having insurance.⁴ For many people, the usual source of care will be a personal physician, and having chosen one’s physician is the single predictor most strongly related to having high overall satisfaction.^5,6

It is well established that having a regular source of care and continuous care with the same physician over time has been associated with better health outcomes and lower total costs.⁷ There is also substantial evidence that increased use of primary care physicians resulted in reduced hospitalizations and reduced spending for other non–primary-care specialist services with improvements in morbidity and mortality rates.^8,9 Unfortunately, continuity has been found to be quite low, particularly for Medicare Beneficiaries many of whom have chronic health conditions that would benefit most from having a personal physician to coordinate their care.

One study of Medicare beneficiaries found that these patients saw a median of two primary care physicians and five specialists working in four different practices. A median of 35% of beneficiaries’ visits each year were with their assigned physicians; for 33% of beneficiaries, the assigned physician changed from one year to another. When the 2006 Commonwealth Fund Health Care Quality study team combined four characteristics of a PCMH in combination, only 27% of working age adults—an estimated 47 million people—had a PCMH. Another 54% of adults have a regular doctor or source of care, but they do not have the enhanced access to care provided by a PCMH.¹⁰ The system will have to address the looming imbalance between the number of chronically ill elderly and available caregivers. If very sick elderly people cannot receive competent and caring day-to-day assistance, then other health care reforms are unlikely to have much impact.¹¹

The Commonwealth Fund Study found that health care settings with features of a PCMH—those that offer patients a regular source of care, enhanced  access to physicians, and timely, well-organized care—have the potential to eliminate disparities in terms of access to quality care among racial and ethnic minorities. This suggests that expanding access to PCMHs could improve quality and increase equity in the health care system.¹²

One of the most unfair ironies of a health care system that now spends $2 trillion per year— nearly $7,000 per citizen on health care is the burden it places on patients to transfer information between their health care providers. The patient is the most vulnerable person in the equation and the one least trained in the complex culture and language of medicine, yet he/she is expected to verbally relate their sequence of care. If they are lucky, it is on bits of paper or the electronic equivalent. It is no wonder that these hand-offs of care are often dangerous for patients. The standards for organizing patient information are still being developed in the US while other developing countries already enjoy interoperable systems. The PCMH should ensure that the health care team pulls together to best serve patient needs in all arenas. In the PCMH, integration will have to be a system-property, with information systems, teams, and organizational linkages promoting integration.¹³

“Other nations ensure the accessibility of care through universal health insurance systems and through better ties between patients and the physician practices that serve as their long-term medical home. It is not surprising, therefore, that the US substantially underperforms other countries on measures of access to care and equity in health care between populations with above-average and below-average incomes.”¹⁴

The rationale for the benefits for PCMH has been found in:

• Greater access to needed services
• Better quality of care
• A greater focus on prevention
• Early management of health problems
• The cumulative effect of the main primary care delivery characteristics
• The role of primary care in reducing unnecessary and potentially harmful specialist care.

Where the [primary care]-team functions as a “navigator” through secondary and tertiary care and other sectors, it can be a strategy for achieving cost-effectiveness.¹⁵

While most Americans utilize primary care doctors as their persona; physicians, the hazards of doing so in the current healthcare environment are well documented. The Future of Family Medicine report concluded in 2004 that, “Unless there are changes in the broader health care system and within the specialty, the position of family medicine in the United States will be untenable in a 10- to 20-year time frame.”¹⁶ Internal medicine has recently reached similar conclusions and is witnessing an unprecedented migration of their young trainees away from primary care.^{17, 18} The PCMH will have to be hospitable to this country’s next generation of physicians if it is to be realized for patients.¹⁹

With health care reform a necessary reality, consumers, payers, and physicians are looking for ways to improve care, improve value, and transform practice. PCMH has attracted support from all three major constituencies, and has inspired both Federal and State legislation. Under Section 204 of the Tax Relief and Health Care Act of 2006, Medicare was directed to support a PCMH Medicare Demonstration Project. This three year project involves care management reimbursement and incentive payments to physicians while evaluating the health and economic benefits of providing targeted, accessible, continuous, and coordinated, family-centered care to high need populations.²⁰

References

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