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PCMH Model Soaring, Despite Funding Challenges

January 20, 2016

Also, in a traditional primary care setting, a patient who does not follow her treatment plan is labeled as non-compliant and blamed by clinicians for not getting better. In a PCMH, Cotton says, the patient is at the center of the planning process and receives more support to be successful.

"With a PCMH, they ask the patient why the plan didn't work for them. Perhaps it was too costly or too difficult to maintain. [The team] tries to figure out another care plan that is going to work better for what is going on in the patient's life. It's a conversation now, and that kind of personal approach is getting better results," he says.


Margaret O'Kane

Funding the Transformation
While PCMHs are demonstrating success in lowering costs and improving patients' health, they are typically not being funded by payers at a high enough level to be sustainable in the long run, NCQA president Margaret O'Kane said during the Google Hangout.

Citing a study that was published recently in the Annals of Family Medicine, O'Kane said the most common reimbursement model is a per-member-per-month payment from payers, but that most are typically below the roughly $5 PMPM it costs a primary care practice to operate a PCMH.

"Practices are often not given the money that they need to implement the model fully. PCMH is a delivery model that really is quite different from regular primary care in that it takes the responsibility for managing a panel of patients for population health," O'Kane said.

The care management being done by PCMHs creates a lot of additional work and cost as compared to the traditional model of primary care, O'Kane says, because practices need to hire more support staff, implement electronic health records systems and data tools, and expand access to care.

One way for providers to negotiate a higher PMPM from payers, Cotton says, is to show them the 2015 NCQA PCMH Evidence Report that indicates the positive impact of the PCMH model. NCQA has also conducted several studies that show PCMHs reduce emergency department utilization and lower the total cost of care for patients in a PCMH program.

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