Tuesday, August 11, 2009

The Patient-Centered Medical Home & the Accountable Care Organization: Two Sides of the Coin

The Disease Management Care Blog is happy to welcome Paul Grundy M.D. Dr. Grundy is President of the Patient-Centered Primary Care Collaborative (PCPCC) and IBM’s Director of Healthcare, Technology and Strategic Initiatives for IBM Global Wellbeing Services and Health Benefits.

by Paul Grundy

Increasing access to health care for all Americans is necessary, but not enough for meaningful health reform in this country. We must also re-design our delivery system to achieve accessible, high quality, affordable health care.

Two complementary models of delivery system re-design hold great promise for achieving these goals: the Patient-Centered Medical Home (PCMH) and the Accountable Care Organization (ACO). The PCMH emphasizes primary care that is patient-centered and delivered in practice settings with 21st century infrastructure using evidence-based processes.

The ACO is a larger provider organization that is willing to provide or manage the full continuum of care and be accountable for the overall costs and quality of care for their population. ACOs provide an organizational structure to allow providers to contract with payers to align financial incentives with the goal of improving clinical performance and slowing the growth in spending.

There's a debate about the relationship between PCMH and ACO, and how the two can co-exist. It is my point of view as the president of the Patient Centered Primary Care Collaborative that PCMH and ACO concepts are in effect a different view of the same solution. One does not work without the other. An ACO will not work without a foundation of primary care, and high performing primary care is critical to the success of an ACO.

The PCMH is the view from the doctor/patient relationship, and the ACO is the view from those who pay the bill. The PCMH is the "home," and the ACO is the "house" with supporting plumbing and wiring. The PCMH is what the patient sees, it is their home, centered on their needs, where their care is coordinated and integrated the players are on their team.

Not only are they complementary and mutually-reinforcing: they are part of the same model.

And a PCMH (as we have always said from day one) is only the primary care foundation to build a healthcare system of value. You can, if you wish, call that healthcare system of value an ACO, similar to what exists in Denmark.

When I communicate to my employees, I talk about a PCMH -- access, relationship, a team, safety, and tools like email that are available to them in a place where the doctor and the patients team know their name. When I talk to my CFO, I talk about ACO -- accountable care, a structure that supports the adult supervision we are looking for.

So how does a small practice become and PCMH/ACO? Well, very easily. They need the Internet with the right tools, like a registry or a portal. This can all be done virtually today. The primary care doctor has the relationship with the patient, plus he has is the quarterback, the point where care is integrated and coordinated at the relationship level.

From the view of the patient, all his providers are part of the PCMH team. However, from my point of view, as the payer of the bills, they are all part of an PCMH/ACO if this all works in the way that makes any sense.

Primary care organizations around the country have agreed that the future of primary care is agreed on as the joint principles of the PCMH. But equally important is the fact that an overwhelming coalition of purchasers and payers, and the exemplary integrated delivery systems (Kaiser, Geisinger and others) that recognize the value of primary care in the context of larger organizational structures, have also endorsed the PCMH as an important political paradigm and key element of delivery system reform.

(There's lots more on Accountable Care Organizations here)

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