Assembling patient-centered medical homes--the promise and price of the infrastructure principles.

(Fam Med 2008;40(1):11-2.) The principles of the patientcentered medical home (PCMH) reflect the type of care we provide to patients and the practice infrastructure that supports our work. The care principles are personal physician, physician-directed medical practice, whole-person orientation, and coordinated care, while the infrastructure principles include coordinated care, quality and safety, enhanced access, and payment for added value. I believe that we have been achieving the care principle of the PCMH at a reasonably acceptable level. We can always improve, but that core part of the PCMH is quite well established. The infrastructure principles are the least well developed and offer the greatest promise but also at the greatest price. The promise that could be realized from enhancing practices to meet the PCMH infrastructure principles is higher reimbursement through a three-part payment structure that as proposed includes (1) per member per month prospective payment component for care coordination, (2) visit-based fee-for-service component, and (3) performancebased component for achievement of quality and efficiency (www.pcpcc. net/node/14). This reimbursement structure is consistent with the PCMH principle of payment for added value: Payment appropriately recognizes the added value provided to patients who have a PCMH. The payment structure should be based on the following framework: (1) It should reflect the value of physician and nonphysician staff patient-centered care management work that falls outside of the faceto-face visit. (2) It should pay for services associated with coordination of care both within a given practice and among consultants, ancillary providers, and community resources. (3) It should support adoption and use of health information technology for quality improvement. (4) It should support provision of enhanced communication access such as secure e-mail and telephone consultation. (5) It should recognize the value of physician work associated with remote monitoring of clinical data using technology. (6) It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits.) (7) It should recognize case mix differences in the patient population being treated within the practice. (8) It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting. (9) It should allow for additional payments for achieving measurable and continuous quality improvements (www.pcpcc.net/node/14). The price of the infrastructure principles is the substantial investment of financial and human capital that practices must take to qualify for the added reimbursement. Fulfilling these principles is far from easy, as we are learning from the TransforMED project (www.transformed.com/):