Rebuilding the foundation

Many people would argue today that
there are serious problems in our
health care system. We pay twice as
much as other countries for health care, but
our outcomes are no better and, in many
cases, worse. Other countries utilize the
patient-centered medical home (PCMH)
model of organized, comprehensive, coordinated primary care as the foundation for
their health care system. We can learn a great
deal from the success of other countries.

Rebuilding our delivery systems should be
the same as rebuilding a house; one should
start with the foundation, says Jim Byrne,
M.D., M.S., chief medical officer with Priority

Smart Business asked Byrne about PCMH,
how it affects overall health care and why
employers are moving toward such care.

What is the patient-centered medical home?

A medical home is not so much a place as
it is a relationship, one that involves a patient
and his/her personal physician. That physician leads a team within the PCMH that provides all the preventive and chronic care that
the patient requires. This care will vary
depending on age and gender. This physician
is both knowledgeable and accountable for
all patient care, whether in the office, hospital or elsewhere.

In this relationship, patients take accountability for their own health care. They are
informed and activated to manage their own
health in partnership with the personal
physician. Health care is very complex in the
21st century. As more technology becomes
available, it will be an invaluable asset for
patients to have one knowledgeable human
being who can oversee their care. This
model has significant benefits to health care
such as improved access; organized, comprehensive, high-quality and affordable care;
and focus on the individual patient as a partner in overall health care.

If primary care physicians are providing care
instead of specialists, is there a risk of a
decrease in the level of care?

No one is advocating a return to the era of
requiring primary care physician (PCP)
approval of all referrals. Rather, this model allows the patient and the care team to work
together to make sure the patient gets care in
the right place. This includes, for example,
getting care in the PCP office instead of the
ER, avoidance of duplicative testing, monitoring of all of a patient’s medications to
avoid interaction, duplication, etc.

If patients receive all of the age/gender
care that is appropriate for them based on
the best clinical evidence, it can be described
as optimal care. A study published in 2003
showed that, on average, patients get only
about half the recommended care.

Why are employers supporting the patient-centered medical home?

With the optimal level of care provided and
patients activated to improve the aspects of
health that are manageable through their
own efforts, employers will see fewer lost
workdays, higher productivity and lower
trends in health care costs.

How do employers implement such new care
practices for their employees?

The alignment of the personal physician
with the insurer and the employer provides a
terrific opportunity to drive the improvements that the model promises. One example is the employer selects a benefit design
that asks the enrollees to:


  • Select a personal physician
  • Complete a health risk assessment
  • Set up an appointment with their doctor
    for a physical exam, and make sure that, at
    that visit, they receive all the care that is
    required for their age and gender
  • Agree to seek care on a scheduled basis
    for any chronic condition, and to fulfill their
    part by pursuing a healthy lifestyle


  • The employer can attach economic incentives to these benefit plans that will help promote these behaviors.

    Employers are also positioned, in many
    cases, to support behaviors that promote
    healthy lifestyles and personal accountability
    for health management. Examples: smoke-free environments, smoking cessation programs, health club memberships, etc.

    How does the patient-centered medical
    home affect the future for physicians?

    The number of new physicians going into
    primary care is dwindling rapidly. This
    model, as noted, will improve patient care.
    However, if the change is to be sustainable, it
    must also produce improvements on the
    physician side — namely, in professional satisfaction and by addressing reimbursement

    Such a change will not be easy. To transform from current state to PCMH is a daunting challenge. It will take years and there will
    be significant cost. Physicians need to reorganize the way they deliver care. It will
    require investment in people and technology
    (electronic medical records, portals, e-visits,
    etc.) that will greatly improve care in the
    21st century.

    Primary care would present a much more
    compelling image if practices had the infrastructure and organization required to provide the kind of care that the model dictates
    and if they could be assured of a reasonably
    competitive income as a reward for the
    value that the model provides.

    JIM BYRNE, M.D., M.S., is chief medical officer with Priority Health. Reach him at [email protected] or (616) 464-8362.