Relationship of the PCMH to Specialty Physicians
The following is information that clarifies the relationship of the Patient-Centered Medical Home (PCMH) model of care to specialty and subspecialty physician practices. The information was developed by the ACP Council of Subspecialty Societies and will be updated in summer 2008.
Learn more about the ACP Council of Subspecialty Societies and the PCMH.
Frequently Asked Questions
How will the PCMH healthcare delivery and payment model affect referrals to specialists and subspecialists? (view answer)
Under what circumstances would specialty or subspecialty practices qualify as a PCMH? (view answer)
How should the decision be made and transition take place when a patient considers changing their PCMH designation from the practice of their primary care physician to the practice of the physician providing principal care?
(view answer)How does the PCMH model affect the flow of information between the referring personal physician and the specialty/subspecialty practice? Who is responsible for what? (view answer)
How are physician payments for the additional services provided under the PCMH care model expected to be funded? (view answer)
Does the College support improved payments for specialty or subspecialty practices that provide patient-centered care coordination services to their patients without becoming a PCMH? (view answer)
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1. How will the PCMH healthcare delivery and payment model affect referrals to specials and subspecialists?
The incentives of the PCMH model are aligned to facilitate improved communication and coordination of care between the personal physician and the referred to specialist or subspecialist. The PCMH personal physician is the patient’s ally in facilitating treatment that is patient-centered, coordinated and of high quality, and in navigating our complex system of care. The PCMH physician should make referrals based upon their clinical judgment, while recognizing the preferences and needs of the patient. It is also expected that the improved physician-patient relationship promoted by the PCMH model will increase the physician’s knowledge of the patient and increase the likelihood that a patient will follow the advice of their personal physician—leading to a higher quality of referral.
The PCMH model provides no incentive to limit appropriate referrals to specialists or subspecialists by a patient’s personal physician. The PCMH practitioner is not a “gatekeeper” who is rewarded based on the degree to which he or she limits access to specialists or subspecialists. The general model does not prohibit the patient from choosing to see a specialist or subspecialist of their choice when they desire.
Physicians practicing within a qualified PCMH setting would be expected to have systems in place to communicate more effectively with their consultant colleagues and thereby improve the efficiency of the referral process.
Since the suggested payment methodology under the PCMH model recognizes the value of quality rather than only volume, PCMH physicians may complete more of the preliminary evaluation of patients whom they previously would have automatically referred for sake of ease and to increase service volume. As a result, while certain low complexity referrals may decrease, specialty colleagues will likely receive more complex referrals with a more robust data base and documentation.
Furthermore, the PCMH model also emphasizes that the practice accept accountability for continuous quality improvement. Thus, it would be expected that the referring PCMH physician would make use of appropriate clinical quality, efficiency and patient experience data in evaluating their referral patterns as such valid data becomes available at the practice level. This refers to the expectation that the PCMH physician would evaluate their own patterns of referring or not referring patients with various conditions and complexities of care, and consider the performance results of specialists and subspecialists when making referrals.
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2. Under what circumstances would specialty or subspecialty practices qualify as a PCMH?
The PCMH healthcare delivery and payment model promotes the delivery of patientcentered, longitudinal, integrated care. It offers the benefits of a personal physician with a whole person orientation who accepts overall responsibility for the first contact, continuous care of the patient and leads a team that provides enhanced access to care, improved coordinated and integrated care, and increased efforts to ensure safety and quality. It is viewed as appropriate for practices providing primary or principal care to their patients that fulfill the following criteria:
- Meets the requirements of an approved third-party PCMH recognition process that ensures that the practice has the structural capability and systems in place to provide care consistent with the PCMH model.
- Affirms the willingness to provide care consistent with the PCMH model as reflected in the statement “Joint Principles of the Patient-Centered Medical Home.”1
The PCMH model would be quite appropriate for patients in specialty or subspecialty practices that are receiving long term, principal care for a condition. Some examples include:
- An endocrinology practice treating patients with Type 1 or Type 2 Diabetes who are on complex insulin regimes, multiple oral medications or display significant complications.
- A gastrointestinal practice treating patients with inflammatory bowel disease or hepatitis.
- An infectious disease practice caring for an HIV positive patient.
- A rheumatology practice caring for patients with rheumatoid arthritis.
- A cardiology practice managing someone with advanced heart failure.
- An oncology practice coordinating care for a person with a malignancy.
In all these situations, the personal physician within the designated PCMH principal care practice would also be expected to be responsible for the more routine first contact, whole person care (e.g., bronchitis, skin infections, urinary tract infections, routine preventive health measures) required by the patient. The presence of a personal physician engaged in a continuous professional relationship with the patient is an important aspect of patient-centered care. Potential models for a specialist or subspecialist who is providing principal care to fulfill this responsibility include:
- A principal care physician with appropriate training in primary care and after discussion with the current primary care physician and patient, directly provides for the routine first contact, whole person care of the patient. Physicians practicing within a PCMH under this arrangement may also benefit from attending the ACP Internal Medicine Update courses.
- A principal care physician with appropriate training in primary care and after discussion with the current primary care physician and patient, hires a nurse practitioner to provide for the routine first contact, whole person care of the patient.
- A principal care physician working in a multi-specialists practice recognized as a PCMH can team-up with a primary care colleague to provide the necessary routine first contact, whole person care of the patient.
1American Academy of Family Physicians, American Academy of Pediatrics, American College of
Physicians and American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home![[PDF]](/graphics/new/pdf.gif){kind=small}
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March 2007.
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3. How should the decision be made and transition take place when a patient considers changing their PCMH designation from the practice of their primary care physician to the practice of the physician providing principal care?
The answer to this question would be generally the same for any anticipated change in a patient’s PCMH. The PCMH care model emphasizes the importance of the patient’s active participation in all treatment decisions. The choice of which practice to designate as the PCMH should be made by the patient after consultation with both his or her primary care and principal care physicians. Factors that should be considered by the patient when considering to change a PCMH designation include the ability of the practice to provide first contact, whole person, continuous, integrated care; the length of the expected course of treatment provided by the principal care physician; and such personal preferences as convenience and relationship with the physician. If a transition is decided upon by the patient, the current primary care physician should supply the new PCMH home with adequate information so that the new practice can assume the role of providing care consistent with the PCMH care model. As the patient’s clinical condition changes, the issue of the most appropriate PCMH designation can be revisited.
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4. How does the PCMH model affect the flow of information between the referring personal physician and the specialty/subspecialty practice? Who is responsible for what?
The PCMH is the central hub of care—the location that is responsible for the overall coordination of the patient’s care. This function of the PCMH must be recognized by all providers, including specialty and subspecialty physicians, participating in the care of the patient and the patient.
The PCMH practice must have in place the structural capability and systems to effectively assume the role of overall coordinator of care. This includes systems to adequately track patient referrals and treatment provided by the other professionals providing care to the patient; medications; and diagnostic tests and laboratory results. Furthermore, the PCMH practice should have the capability to communicate this tracked information, including un-summarized or uninterpreted “raw” data, to other treatmentparticipating providers when appropriate and to the patient.
The PCMH practice, in assuming the role of overall coordinator of care, is expected to have formal or informal understandings and agreements with each referred to specialty and subspecialty provider regarding this coordination of care. These understandings and agreements should minimally specify the expected form(s) of communication (e.g. faxed written reports, reports sent by secure email, direct transfers from interoperable electronic medical records), frequency or timeliness of communication, and the specific information expected to be reported.
Finally, the patient should be kept informed of communications taking place between the PCMH practice and the referred to specialist or subspecialist.
It is also notable that the College is currently involved in activities to improve the general care coordination and transition between providers and settings. These activities includes participation in the “Stepping Up to the Plate Consortium” organized by the American Board of Internal Medicine (ABIM) Foundation and a recently held “Transitions in Care” conference organized by the College along with the Society of General Internal Medicine (SGIM) and the Society of Hospital Medicine (SHM). Continued development of policy within the PCMH model related to the issue of care coordination and transition between providers and settings will be informed by these and other related activities.
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5. How are physician payments for the additional services provided under the PCMH care model expected to be funded?
The PCMH care model anticipates that most or all of the additional funding required under this model will be funded through system-wide healthcare savings directly related to the provision of the patient-centered, continuous, integrated care consistent with the care model. Sources of these savings include decreases in unnecessary or preventable use of emergency department or hospital use; decreases in unnecessary, duplicative care and testing; and decreased costs from improved overall clinical results resulting from such practices as engaging in population management, following evidence-based guidelines and providing patients with disease self-management education.
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6. Does the College support improved payments for specialty or subspecialty practices that provide patient-centered care coordination services to their patients without becoming a PCMH?
The College, in the recent policy paper “A System in Need of Change: Restructuring
Payment Policies to Support Patient-Centered Care", supported the development of separate payments for services that facilitate patient-centered, longitudinal, coordinated care.
These “a la carte” payment codes would be used by physicians in practices that cannot or choose not to provide all of the attributes necessary to qualify as a PCMH. It is anticipated that the use of these codes would be limited to specific treatment conditions or situations and would require sufficient physician documentation within the medical record to ensure that the defined service was delivered. There is currently precedence within Medicare for the payment of care coordination or similar services that occur primarily outside of the face-to-face visit. These payment codes include:
- Care plan oversight for patients receiving home health care.
- Care plan oversight for patients who have elected hospice coverage.
- Ambulatory blood pressure monitoring
- Continuous glucose monitoring initiation
Examples of possible new codes related to patient-centered, longitudinal, coordinated care include:
- Care plan oversight, for additional specified conditions, which would include communication with other providers offering the patient treatment, on-going review of patient medical status and lab reports, and care plan modifications.
- Physician email and telephonic consultation related to a care plan.
- Disease self management training related to a care plan conducted by the physician or nurse with related follow-up.
What is the Patient Centered Medical Home?
Who Supports the PCMH Care Model?
What is the Business Model for the PCMH?
Where are PCMH Demonstration Projects Happening?
Resources for the PCMH
ACP Advocacy Efforts for the PCMH
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