The concept of patient centered medical homes (PCMH) has been evolving since it was first presented by 4 primary care medical societies, (AAFP, AAP, ACP & AOA), in March 2007.  Since then, the PCMH concept has been endorsed by many other medical societies and interest in PCMHs has grown.  Some of the significant steps forward have included:

• The National Committee for Quality Assurance (NCQA) created specific requirements and a certification procedure for PCMHs
• Several states are moving forward with PCMH pilot projects
• Congress passed a law for Medicare Demonstration projects and the Department of Health and Human Services created draft guidelines for these projects – however, these guidelines haven’t been finalized although the demonstrations were scheduled to start in 2010

Steps Sideways
Along with all the interest and activity related to medical homes, there has been a blurring of the definition about what constitutes a medical home.  For example, the definitions of a medical home in the Medicare Demonstration’s draft materials are somewhat different than the NCQA’s criteria. And in various venues others have presented their modifications on what a patient center medical home needs to – or should – look like.  And most recently, HHS announced an initiative “that will allow Medicare to join Medicaid, and private insurers in state-based efforts” using the “Advanced Primary Care model (APC), also known as the patient-centered medical home.”

This new initiative is interesting for at least two reasons: It may be giving PCMHs a new name, and it will not replace the previously unstarted Medicare Demonstration which, according to a healthreform.gov fact sheet about the initiative, will move forward on its own. [FYI – CMS’s website for that demonstration hasn’t been updated since April and doesn’t reflect the APC initiative.]  Whatever the connection between the two demonstration projects, I hope that the powers that be at CMS avail themselves of the groundwork already laid in the draft materials for the original Medicare only PCHM demonstration, since the HHS press release states that, for the new APC concept demonstration, “The Centers for Medicare & Medicaid Services will develop application materials later this fall with the expectation that the demonstration programs begin next year.”

With Greater Interest (and Funding) Comes Pressures to Bend
This entire time-line – from the 4 Medical Societies agreeing to the “Joint Principles of the Patient-Centered Medical Home,” to the current initiative which seems to rename PCMHs as Advanced Primary Care – reflects the morphing of medical homes because of economic and political interests from outside groups that hope to benefit from new medical home based funding.  The blurring of the definition of medical homes may enable some groups to be eligible for those funds with a minimum amount of effort.  The policy counter argument will be that by having many different types of medical homes  in demonstration projects will provide the best evaluation of what works best.

The shapes and sources of those pressures for “diversity” of definitions, and how they have led to changes and delays in different programs, are often hard to tell, but their effects will likely be seen in the demonstration programs’ final forms…. if they ever get started.  And looking forward, the next point of attack for these pressures will likely be the demonstration programs’ data collection and evaluation processes, since similar vested interested will want to show how various features of APC practices (or PCMHs) are important for improving quality and reducing costs – or not.