American College of Physicians: Internal Medicine — Doctors for Adults ®

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ACP's vision for the patient-centered medical home

From the June ACP Observer, copyright © 2007 by the American College of Physicians.

Internal Medicine 2007 hosted many discussions about the concept of a patient-centered medical home (PCMH), a vision for patient-centered, physician-guided and comprehensive health care that emphasizes the importance of everyone having a long-term and personal relationship with a caring, well-trained physician.

The idea of patient-centered care coordinated by a caring personal physician isn't new. In 1927, in his now-famous essay "The Care of the Patient," Dr. Francis Peabody advised us to see our patients as individuals, not cases or examples of diseases. Dr. Peabody encouraged physicians to engage deeply with our patients, to make home visits, to see the sorrows of severe illness, the hardships and resources of the family, and the circumstances of our patients' lives.

He continued, "Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is the interest in humanity, for the secret of care of the patient is caring for the patient."

Much has changed since this essay was written, but the importance and appreciation of having or being a good personal physician has not. The PCMH revisits and reinforces this concept. Functionally, it brings the ideals of Dr. Peabody into the modern era.

Organize for better health

A central concept of the PCMH is that the physician should organize care to focus on what is best for the patient. If you are in good health, your personal physician provides preventive services, cares for acute illnesses and is available to give medical advice whenever it is needed. If you have specific health problems, your personal physician—a generalist or a specialist—advises on the best tests and treatments for your problems of greatest concern and coordinates other services as needed. If you have multiple and chronic health problems, your personal physician coordinates and integrates care between multiple specialists and helps with interpreting tests and treatment recommendations.

The PCMH recognizes that today medical care is delivered in many ways beyond the traditional office or home visit. We serve our patients by phone, e-mail and the Internet and through coordination of care whenever the need arises. Also, the personal physician communicates in a manner that is culturally sensitive, understandable and informed by patient preferences.

We serve patients through contact with pharmacies and pharmacy-benefit managers and through referrals and advice for consultations and procedures. We coordinate with visiting nurses services, home health services, medical supply services, referral agencies for disability and rehabilitation, insurance companies, employers, and other agencies. We also supply information to drug safety organizations, researchers, certifying agencies, laboratories and accrediting bodies. We are responsible for more and more elaborate systems for medical record keeping and security, monitoring the offices and staff for compliance with HIPPA procedures, maintaining and overseeing occupational and safety standards, and the ensuring the security of office supplies and medications.

Overcoming hassles

These and many other rules and regulations are the "hassle factor" of practicing medicine today. Most of us will acknowledge the importance of all of these activities, but in aggregate, they make it harder and harder to succeed as an office-based personal physician. Surveys show that physicians are increasingly frustrated by the hassles of practice, which consume their energies and funds. The data are very convincing that hassle factors and unreimbursed services are key reasons for established physicians leaving office-based internal medicine practices and for new physicians choosing not to specialize in primary care.

To overcome these hassles, the ACP's concept of the PCMH involves organizing the doctor's office as a physician-directed medical practice that integrates other health providers and assistants and coordinates all the services the patients need. The College has proposed an enhanced reimbursement model that accounts for the costs of coordinating care and adopting technology and for the value of such services to the patient, payer and purchaser. This prospective remuneration would be in addition to the typical visit-based fee-for-service. It is important to determine the staffing and overall costs for serving populations using the principles of the PCMH. Therefore, ACP is engaged in several collaborative efforts to test this model in a variety of settings.

ACP supported legislation authorizing the Medicare Medical Home Demonstration Project included in the 109th Congress' Tax Relief and Health Care Act of 2006. This demonstration project will help determine whether the PCMH can reduce hospitalization through better management of complex and chronic illnesses. State and private organizations also are beginning to examine and test the practicality and cost of operating a PCMH in diverse locales and circumstances. At its April 2007 meeting, the Board of Regents accelerated work on planning and testing the PCMH concept, including support to develop the payment methodology based on ACP policy.

The PCMH is a way for ACP to address the need for better healthcare for all and to restate and reinforce the best traditions of our profession. It is also a way for internal medicine to endure and to be passed onto a new generation of internists. I hope you will join me in embracing the ideals and possibilities of the patient-centered medical home. Our specialty has a wonderful heritage stemming from words and practices of leaders like Dr. Francis Peabody. The PCMH is a return to these ideals.

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