Relationship of the PCMH to Specialty Physicians
The following information attempts to answer a number of questions regarding the relationship of the Patient-Centered Medical Home (PCMH) care model to specialist and subspecialist practices. The PCMH care model, while receiving strong interest from providers, payers, and patients, still requires substantial development and testing. Much of this effort is taking place in demonstration projects throughout the country. One particular area that requires further development and testing is the integration of the care model with services provided by specialty and subspecialty practices. This model development is being addressed by the Council of Specialty Societies (CSS) PCMH Workgroup, and through collaborative initiatives between ACP and various specialty and subspecialty societies.
Learn more about the ACP Council of Subspecialty Societies and the PCMH.
Frequently Asked Questions
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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 specialists and subspecialists?
The proposed 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 is not intended to limit appropriate referrals to specialists or subspecialists by a patient’s personal physician. The PCMH practitioner is not a “gatekeeper” and there is no incentive tied to limiting 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 and care co-management 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. This will both decrease the likelihood of inappropriate, unnecessary referrals and provide a more robust data base and documentation to accompany referrals that are made. The model continues to recognize the importance of specialist and subspecialist active participation in the evaluation, diagnosis and treatment of the more complex medical conditions. In addition, a number of specialty and subspecialty societies are in the process of developing or updating evidence-based best practice protocols to assist the PCMH personal physician in deciding under what conditions to refer, and how best to treat if a referral is not necessary.
Furthermore, the PCMH model also emphasizes that the participating PCMH 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.
.2. Under what circumstances would specialty or subspecialty practices qualify as a PCMH?
The PCMH healthcare delivery and payment model promotes the delivery of patient-centered, 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 (e.g. the NCQA PPC-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 appropriate for the subgroup of 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 severe 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 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. The principal care physician will, however, still be medically responsible for the overall care of the patient, and thus should remain up-to-date on important clinical aspects of primary care medicine.
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.
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 their principal care physician. Factors that should be considered by the patient when considering changing 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 model. As the patient’s clinical condition changes, the issue of the most appropriate PCMH designation can be revisited.
.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 participating healthcare teams 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 or care co-managing 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.
Specialists and subspecialists who choose not to become a PCMH should determine appropriate practice management strategies to manage an increase in communication (phone, e-mail, and fax) between PCMHs and their office. These strategies may include:
Setting time requirements between PCMH and specialist/subspecialist to communicate referral, consultant or treatment progress letters.
Setting time requirements between PCMH and specialist/subspecialist for follow-up on lab and test results
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 American College of Physicians (ACP) has been 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 the “Transitions in Care” conference organized by the ACP in collaboration with the Society of General Internal Medicine (SGIM), the Society of Hospital Medicine, the American Geriatrics Society (AGS), the American College of Emergency Physicians and the Society of Academic Emergency Medicine. Furthermore, guidelines or best practices regarding such issues as transition procedures, information flow and responsibility protocols specifically related to the PCMH-specialist/subspecialist interface are currently being developed within the CSS PCMH Workgroup, and through direct discussions between the College and various specialty and subspecialty groups.
.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. These savings directly relate to the provision of the patient-centered, continuous, integrated care that is consistent with the PCMH care model. Sources of savings include decreases in unnecessary or preventable use of emergency departments or hospitals; decreases in unnecessary, duplicative care and testing; and decreases in costs from improvements in overall clinical outcomes resulting from such practices as population management, adhering to evidence-based guidelines and providing patients with disease self-management education. This assumption will be tested in both the Medicare Medical Home demonstration project scheduled for implementation in 2009 and a number of additional private or public-private multi-payer PCMH demonstration projects being implemented throughout the country.
.6. Does the American College of Physicians support improved payments for specialty or subspecialty practices that provide expanded patient-centered care coordination services to their patients without becoming a PCMH?
The American College of Physicians (ACP), in a 2007 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.
In addition, several subspecialty societies have suggested the development of the concept of a “PCMH Neighbor” recognition process. It would reflect many of the elements of the NCQA PPC-PCMH recognition tool currently being used in most of the PCMH demonstration projects to identify PCMH practices. Required elements for recognition would include the practice’s ability to provide high levels of care access, patient communication, focused care coordination, evidence based care and efforts towards quality improvement. An important aspect of this recognition would be validating practice’s ability to communicate effectively with the patient’s PCMH. This form of recognition would also not require the subspecialty practice to assume the first contact, whole person, primary care responsibilities or be the major communication hub for the patient’s treatment. The College is working with NCQA and several payers to explore the possibility of establishing this type of recognition that would provide subspecialty practices with increased funding for this expanded level of service.
1 American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. March 2007.
Page updated: 03-18-09
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