A Possible Solution to a Fragmented Health Care System

tt_53.jpgImagine for a moment that you could have a team of medical professionals dedicated to your health and well-being. A group of folks whose primary mission is to keep you from having to go to the hospital by engaging in preventative medicine and chronic disease management, while not sacrificing quality of care and bringing down the cost of health care. Sounds too good to be true right – well it isn’t. The promise of patient centered medical homes (PCMH) is all that and then some!

The PCMH model is often described as a comprehensive medical services delivery method that is centered around the patient and focused on quality of care and patient safety. The overarching objective is to develop a centralized setting that facilitates partnerships between individual patients, and their primary care physicians.

Across the nation the concept of PCMHs are taking hold. Over 9,000 medical practices and 43,000 clinics have earned this designation by the National Committee for Quality Assurance;the nation’s largest credentialing organization. The increasing cost of health care makes health care insurance more difficult for individuals, families, and businesses to afford. These increases in health care costs are attributable in part to inadequate coordination of care among providers, difficulties in accessing primary care, and a lack of engagement between patients and their primary care providers. The PCMH model is designed to enhance care coordination and promote high-quality, cost-effective care through patient-centered medical homes by engaging patients and their primary care providers.

PCMHs focus on the patient well before they come to the doctor’s office for a visit. The medical team’s course of action is to provide preventative care and chronic disease management in order to reduce hospital utilization and better manage the patient’s health outcomes. This relatively new approach to treatment has been augmented by the advent of the Affordable Care Act (ACA), which requires insurers to cover preventative care services to patients at no cost to the patient. Additionally, the ACA provides financial incentives to providers who adopt this model and show a reduction in costs while maintaining high quality standards.

A January 2014 report by funded by the Milbank Memorial Fund showed that PCMHs continue to “demonstrate improvements across a number of metrics in peer-reviewed and industry-generated studies” in the areas of decreasing health care costs, utilization, improvements in population health, improvements in access to care and patient satisfaction. Patients have flocked to this model because it has demonstrated that it can help lower their health care costs, better utilize their benefits, and take some of the complexity out of health care.

Here in New Jersey this concept is beginning to take hold with some positive results. For instance, Horizon Blue Cross/Blue Shield’s partnership with the New Jersey Academy of Family Physicians, which began in 2009, has resulted in positive documented impacts such as: a decrease in health care access disparity, an increase in patient satisfaction, and a reduction in costs. I am committed to seeing all of New Jersey expand on this foundation.

I have authored a proposal, A4039, which calls on the NJ Department of Banking & Insurance to qualify patient-centered medical homes that provide proof of accreditation by a nationally-recognized accrediting organization approved by the commissioner, and that meet any other requirements for qualification that the commissioner may establish by regulation.

The commissioner would additionally oversee, promote, coordinate, and provide guidance concerning the creation and activities of any patient-centered medical homes doing business in New Jersey, and would establish, by regulation, standards concerning: the payment methods used by health benefits plans to pay patient-centered medical homes; the incentives that a health benefits plan may use to pay a patient-centered medical home based on savings attributed to participation in the program; a uniform set of health care quality and performance measures that includes prevention services; and a uniform set of measures related to cost and medical usage.

The participation of a health benefits plan in a PCMH will not be mandatory, but it is my hope that plans will see the enormous benefit associated with developing this type of program and join in. Consistent with federal law, New Jersey’s Medicaid and Family Care Programs would be able to participate as well, thus potentially saving the state significant amount of money that can be freed up for other priorities like property tax relief and increased school aid.

As the practice of medicine evolves so should it's evolution as to how those services are delivered. The PCMH is an innovative and exciting part of this process and we would be wise to foster an environment that allows that to happen. That’s my take. What’s yours?

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