Health Maintenance Organizations (HMO’s) and Patient-Centered Medical Homes (PCMH’s) are both important part of healthcare delivery in the United States, and while there are some similarities between the two healthcare delivery methods, there are some important differences as well. This paper seeks to examine the similarities and differences between HMO’s and PCMH’s and to discuss why things like healthcare information technology, workforce development, and payment reform are integral parts of the PCMH.
HMO’s and PCMH’s: Similarities and Differences in the Two Forms of Healthcare Delivery
The HMO is structured to help manage medical costs through control of medical services: in an HMO, the client chooses a primary care practitioner to act as the “gatekeeper” for medical care; these “gatekeepers” are generally family or general practitioners, internists, or, in cases of children, pediatricians (Felt-Link, 1996, p. 98). As the gatekeeper, the PCP has great control over patient’s access to other members of the medical team, such as specialists, although there is a great variation in how strictly each HMO regulates the gate-keeping authority (Felt-Link, 1996, p. 101). Generally speaking, in an HMO, a patient needs a referral from their PCP before they can access a specialist (a cardiologist or a pain management doctor, for example) and the PCP is not allowed to give that referral unless the HMO guidelines allow it (Wikipedia, 2013, p. 3). The point of the HMO is to contain healthcare costs through controlling patient access to healthcare (Felt-Link, 1996, p. 104) but also through the use of preventative services to help avoid chronic and potentially expensive diseases such as diabetes or cancer (Wikipedia, 2013, p. 5).
The PCMH has a similar structure to the HMO in the sense that the physician leads the team of healthcare providers in caring for the patient, and some have likened the role of the PCP in the PCMH model to the “gatekeeper” role which the PCP fulfills for HMO’s (Wikipedia, 2013, p. 9). However, the emphasis is different in the PCMH model, which contains seven elements to its healthcare delivery method: the personal physician (to provide continuous care to the patient rather than act as a “gatekeeper”), the physician-led team (multiple individuals from different disciplines care for the patient), whole-person orientation (a emphasis is placed on holistic patient care), coordinated care (open communication among all members of the team as well as with the patient), quality and safety (evidence-based medical practice with an emphasis on continuing quality improvement), alternative scheduling arrangements (to provide open access to the healthcare team), and payment reform (reimbursement is linked to things like increased care coordination and use of new technologies) (Goetz & Kuzel, 2012, p. 303); the emphasis here, as it is the HMO, is on cost containment; however, PCMH’s try to manage this through better outcomes for the patient (Virginia Healthcare Association, 2013, p. 5). Fowler and Kelly, in their article on the PCMH, describe this best by saying “Cost savings are expected as the result of providing better care for patients, not from withholding needed care. The PCP serves as ….a patient advocate and guide through the healthcare system, rather than a gatekeeper” (Fowler & Kelly, 2010, p. 3).
Need for Information Technology, Workforce Development, and Payment Reform in PCMH’s
One of the essential elements of the PCMH model, as identified by Goetz and Kuzel, is the element of coordinated care (Goetz & Kuzel, 2012, p. 303). This means that there must be open communication between all members of the healthcare team as well as with the patient since this is a multidisciplinary approach to healthcare (Wikipedia, 2013, p. 6). To achieve this coordination, more and more PCMH’s are relying on health information technology (IT) to increase the ease of communication between the team members and one of the core features of the PCMH is the use of technologies like electronic medical records, registries of patient by certain diseases, and community linkages to care (Goetz & Kuzel, 2012, p. 302). This increased coordination of care between disciplines and across the healthcare spectrum such as with hospitals or nursing homes, is dependent upon staff development to incorporate this system: Goetz and Kuzel, in their study, also looked at the provisions made for staff development, teamwork, and morale (Goetz and Kuzel, 2012, p. 303) and in the state of Virginia, the Virginia Community Healthcare Association, which is in the process of developing their Community Health Centers into PCMH’s offers a variety of classes and workshops throughout the year that focus on staff development (Virginia Healthcare Association, 2013, p. 10). Payment reform is also a core component of the PCMH (Goetz & Kuzel, 2012, p. 303) and reimbursement for PCMH providers is often tied to things like increased collaboration among members of the healthcare team, use of new technologies like electronic medical records, and improvement in patient outcomes (Kaye, N. et. al., 2011, p. 9).
In conclusion, important differences exist between the HMO’s and PCMH’s in regards to the philosophy behind their healthcare delivery methods. Both focus in on cost containment, but the approach of the PCMH is to reduce healthcare cost through improved health outcomes for the patient and not through restricted access to medical care. This will hopefully, as more and more states become participants in this method of healthcare delivery, help to create a healthcare system that is both fiscally responsible and humane, and manages costs by helping people to improve and maintain their optimum health.
Felt-Link, Suzanne. How HMO’s Structure Primary Care Delivery. Managed Care Quarterly. 4 (4). 98-106
Fowler, Wanda & Kelly, Ann. State Initiatives in Patient-Centered Medical Homes. The Council of State Governments. Retrieved from: http://knowledgecenter.csg.org/kc/content/state-initiatives-patient-centered-medical-homes
Goetz Goldberg, Debora & Kuzel, Anton. (2012). Elements of Patient-Centered Medical Home in Family Practices in Virginia. Annals of Family Medicine. 7 (4) 301-308
Kaye, N., Bauxbaum, J. & Takach, M. (2011). Building Medical Homes: Lessons from Eight States with Emerging Programs. National Academy for State Health Policy. Retrieved from: www.commonwealthfund.org/…/1569_Kaye_building_medical_homes
Virginia Community Healthcare Association. (2013). Patient-Centered Medical Home. Retrieved from: http://vacommunityhealth.org/pcmh
Wikipedia Online Encyclopedia. (2013). Health Maintenance Organization Retrieved from: http://en.wikipedia.com/healthmaintenaceorganization
Wikipedia Online Encyclopedia. (2013). Patient-Centered Medical Homes. Retrieved from: http://en.wikipedia.com/medicalhome