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43411 Garfield, Suite A  •  Clinton Township, MI 48038 Phone: 586.842.0870 •Fax: 586.649.7583 Email: info@gmpnetwork.org
Patient-Centered Medical Homes (PCMH)

GMP Network would like to inform you of a relatively new program focusing on Patient-Centered Medical Homes (PCMH) developed by Blue Cross Blue Shield of Michigan (BCBSM). PCMH represents a transformational change in the way physicians practice medicine. It is a pro-active approach to guiding patients as they take a more active role in managing their own health. Once certified, your practice can receive increased reimbursement of at least 10 percent for Evaluation and Management Services.

This ongoing initiative was designed to improve the quality of patient care. The program requires each practice to go through our certification process annually. Each year, as the program advances, the certification criteria will also become more advanced. The first round of nominations has already occurred, but look for other opportunities to nominate your office in the future. If you are in Greater Macomb PHO, follow the criteria within the Physician Group Incentive Program (PGIP) to reach nomination. There will also be an opportunity for advanced certification in subsequent years, which will result in greater BCBSM reimbursement.

During the nomination and certification process, GMP Network will send a consultant and clinical integration team out to your practice to help assess your practice and develop an action plan for implementing PCMH criteria.  We will provide you with tools, sample policies, handouts, and helpful information to get your practice on its way to becoming a PCMH.

What is a Patient-Centered Medical Home?

There is a lot of buzz surrounding the PCMH.  What is it and what does it mean for your practice?  With all of the jargon and value-laden descriptions, the discussion can be confusing.  There are dozens of professional societies, business coalitions, consulting firms, accreditation agencies, governments and insurance companies. Each has a slightly different perspective on the PCMH.

GMP Network summarizes all that discussion this way:  The PCMH is the ideal physician practice for primary care, especially preventive care and the management of chronic disease.  The PCMH is about strong patient-physician relationships, engaged patients, increased access to the physician, simple computer technology to track patient care against evidence-based standards and supportive teams who help educate patients about their disease and stay committed to their care plan. The focus of the PCMH is managing care, inside the office and out.

This focus starts with the patient-physician relationship.  It must be strong.  The patient must know who his physician is and must be able to see that physician when necessary.  The physician must be committed to treating the whole patient by coordinating other physicians, hospitals, ancillary providers, social service agencies and the family.  The patient must be informed about and actively engaged in his own care.  The physician’s role is to inform the patient and remain engaged.

We cannot expect physicians to do all of that on their own.  They need help.  This help may include advanced practice nurses and diabetic educators working in the physician’s office to coordinate patient education and after-hours care.  Assistance may also take the form of accessible, problem-focused computer technologies like patient registries and e-prescribing.

It is best not think of the PCMH as a single, exact way of doing things.  Instead, look at all the ideas about the PCMH, and pick one that makes sense to you. Next, work with your staff to design a plan to implement that idea in your practice. Then, measure your success over time and revise your plan to improve your success. When you get that idea nailed down (almost), pick a new idea and start over.

The PCMH requires measuring your performance and continuously working to improve.  In the end, you will feel better about the care you provide to your patients as well as the success of your practice. But to quote Colonel Green from The Bridge Over the River Kwai, “In a job like yours, even when it's finished, there’s always one more thing to do.”

The more you read about the PCMH, the more you realize that there isn’t that much about it that is new or surprising.  Intuitively, it all makes sense.  It’s a nice packaging of ideas that you have heard before, would like to implement in your practice, and that somebody needs to pay for.

The PCMH requires a new way to pay for physician services.  In addition to fee-for-service payments, there needs to be monthly care management fees and incentive payments for performance improvement.  If the PCMH is going to work for the people who pay the bills, it must reallocate expenditures between physicians and other parts of the health care system in order to cut overall medical expenditures. The PCMH is important to all physicians, not just primary care physicians.  If paying for these improvements is reduced to a discussion about how to reallocate RVUs between physician specialties, they will not be implemented sufficiently to help primary care, specialists, hospitals, payers, or worst of all, patients.

What does a Patient-Centered Medical Home look like?

  • There is a written agreement between the physician and patient detailing how they are going to work together to implement a care plan.
  • The patient attends group visits where they get one-on-one time with their own physician (which is reimbursed) as well as time to talk to dieticians and other professionals about the details of their disease and their care plan.
  • Nurse practitioners and physician assistants are used to keep the practice open into the early evening and for half-days on the weekend.
  • Almost all of the time, patients calling in can get a same-day appointment.
  • The physician uses e-prescribing to maintain a comprehensive medication history and to generate error-free prescriptions.
  • The physician and his staff meet daily to review the plan for patients scheduled on that day, using the electronic patient registry to ensure they are on track.  (Markers like which 50+ males need rectal cancer screening or which diabetics are due for an HbA1C test.)
  • The MA enters all lab orders into the patient registry which then reminds staff when to check for results.  When the MA enters lab orders into the registry, it identifies which orders need to be discussed with the physician and which can be sent to the patient through a secure e-mail.
  • The physician has time during the day to review or send secure e-mails. For example, the physician may want to e-mail the orthopedic surgeon about the previous MRI on Mr. Jones’ knee and to reply to Mrs. Smith’s e-mail about the new medication for her heartburn (and be reimbursed).

GMP Network, 2018