(Illustration by Gerd Altmann via Pixabay)

MASSACHUSETTS HEALTH CARE, often praised for its excellence, is experiencing systemic strain. Our primary care infrastructure is falling woefully short, with many people unable to access a provider.

One consequence of that is that we have the longest emergency department wait times in the nation. Those ER bottlenecks are bad for everyone – but especially for high-risk elderly patients and individuals with chronic health conditions, who disproportionately wind up in emergency rooms when the care they need is not accessible within the current primary care system.

Nearly 50 years ago, a bold health care model called the patient-centered medical home, or PCMH, was introduced to prevent these very problems. It aimed to provide comprehensive, coordinated primary care to patients with complex needs, minimizing the need for emergency room visits for anything other than truly urgent situations requiring hospital care.

As is typical of many new innovations, the initial version of this model had flaws that limited its effectiveness. But instead of making the changes needed to improve it, the health care industry wound up mostly dismissing it as a promising idea that didn’t pan out. To put it in clinical terms, the treatment was deemed ineffective, but candidly, we only delivered half the necessary dose.

As Massachusetts struggles to address a worsening primary care crisis, it’s time for the Primary Care Task Force the state launched last year and the Legislature to make the PCMH model a priority, spearheading efforts to improve how it operates and, crucially, adopt payment reforms needed to make it financially feasible.

Why the Original Patient-Centered Medical Home Model Failed

First introduced in 1967 by pediatricians to better serve children with complex health conditions, PCMH is a care model designed to understand and treat patients’ complete needs. At its most basic, it promised the kind of sensible, forward-looking care we all would want.

The idea was to ensure the coordination of care across all health care settings, putting an end to the frustrating situation we’ve all encountered where health care providers don’t share information well and end up delivering redundant or disjointed care. It also aimed to prioritize proactive management of chronic diseases to improve health outcomes, reduce hospitalizations, and lower overall costs by addressing health concerns in less expensive care settings before they worsened. In practice, as an example, a pediatrician would coordinate with a neurologist, school nurse, and physical therapist to manage care for a child with cerebral palsy.

PCMH was meant to revolutionize primary care, but it has ultimately failed to meet its clinical and financial objectives. A core part of the problem is that it operates as a 9-to-5, Monday through Friday service. Limited to standard business hours, clinicians are unable to provide continuous, coordinated care when a patient experiences an urgent, unscheduled health event. This forces patients to seek care from emergency services that don’t offer adequate wrap-around support.

Under the current practice of PCMH, when a patient’s health deteriorates during nights, weekends, or holidays, the urgent call goes to an off-hours medical professional who often doesn’t know the patient’s comprehensive medical history or have the ability to get vital signs, conduct a physical examination, perform laboratory tests, or deliver meaningful treatment. To minimize risk, these clinicians frequently direct patients to the emergency department, which then initiates a costly and cascading cycle of medical care.

An emergency department visit typically leads to an inpatient hospital admission, which may necessitate post-acute care in a skilled nursing facility. Once a patient enters this cycle, reversing it and safely transitioning them back to their home environment becomes exceedingly difficult and expensive due to the complex nature of their health care needs.

Introducing PCMH 2.0

It’s easy to see how PCMH cannot deliver on the promise of this model when operating under these limitations. But there is an opportunity to create a new version of PCMH – or PCMH 2.0 – that addresses the shortcomings of the old model by making it a 24-hour, seven-day-a-week service. Combining the best of the days long gone when doctors would make house calls at any hour with today’s cutting-edge technology, PCMH 2.0 allows clinicians to continuously monitor high-risk patients, conduct telehealth appointments, and direct on-the-ground care teams when in-person health visits are needed – all while keeping patients entirely in their homes.

Consider a patient recently discharged from the hospital after being admitted for congestive heart failure. As part of a PCMH 2.0 program, the patient would be outfitted with remote patient monitoring technology, such as medical-grade wearable or implanted devices like pacemakers or defibrillators, and remote therapeutic monitoring technology, or digital tools, where patients can track and record their medication schedules, pain levels, mental well-being, and more.

This monitoring technology allows the patient’s physicians and care teams to track their vital signs, activity levels, oxygen saturation, and adherence to their medication plans. Clinicians can also use this information to recommend lifestyle changes that improve diet, exercise, and treatment adherence.

Allowing care teams to continuously monitor the health of patients remotely, PCMH 2.0 effectively transforms primary care into an uninterrupted service that can identify patient health events and initiate clinical interventions before the need for an emergency response. It also empowers a patient’s care team to move beyond reactive care and toward proactive, data-driven intervention that adjusts a patient’s treatment plan based upon their lifestyle.

Emergency Level Care in the Home for High-Risk Patients

In instances where the remote monitoring system detects a subtle shift in a patient’s medical baseline that indicates an impending decline in health, the information is immediately communicated to the patient’s expanded primary care team, which includes a paramedic unit. This approach, known as Mobile Integrated Health, brings the PCMH 2.0 model to life by combining outpatient and emergency resources to deliver sophisticated in-person care in patients’ homes.

Under the remote supervision of an emergency physician, Mobile Integrated Health paramedics can perform physical exams and laboratory tests, manage medical equipment, like catheters and gastrostomy tubes, place IVs, and deliver medications. The clinical team also coordinates with a patient’s primary care provider to seamlessly manage acute and chronic conditions.

At UMass Memorial Health, we’ve witnessed the meaningful results that Mobile Integrated Health programs deliver as part of PCMH 2.0. For the past three years, UMass Memorial has deployed Mobile Integrated Health services to care for more than 1,200 patients, allowing for greater home-based management of health conditions. In a study published earlier this year, among recently hospitalized high-risk patients, MIH reduced emergency department visits by about 40 percent and hospital readmissions by 55 percent.

The Administrative and Funding Obstacles

To ensure PCMH 2.0 is administratively and financially feasible, the Healey administration and Legislature have several opportunities to pass meaningful reforms that reduce the administrative burden placed on primary care providers and require insurers to pay for Mobile Integrated Health visits.

Primary care teams need the time to respond to changes detected by remote monitoring signals. Studies have shown that primary care teams spend 20 to 25 percent of their time managing insurance pre-authorizations and filling out paperwork, which adds enormous administrative costs to primary practices, delays patient care, and exacerbates physician burnout. Thankfully, the Massachusetts Division of Insurance, after a two-year review of prior authorization practices, has issued draft regulations to limit the scope of prior authorizations, expedite approvals, and improve transparency. These steps would increase capacity for primary care teams to more quickly address patient needs generated by remote monitoring signals.

Changes also need to be made to ensure that insurers cover innovative programs that move the needle on reducing health care costs. Right now, Mobile Integrated Health isn’t considered a billable service in Massachusetts. Since its establishment, our Mobile Integrated Health program has been self-funded by UMass Memorial Health and provided to patients for free. Insurance companies and government payers are willing to pay $3,000 for an ambulance ride and $5,000 for an emergency department visit, but are unwilling to pay for an MIH visit that could have prevented those outcomes simply because insurers argue it costs too much upfront.

Massachusetts lawmakers can pass legislation that defines MIH as a covered benefit, mandating funding for these services. This would make MIH programs financially sustainable and available to patients throughout the Commonwealth.

To reduce downstream health care costs, we must institute payment practices that financially sustain programs proven to prevent illness, versus only reimbursing services that treat illness. The PCMH 2.0 model fundamentally supports prevention, which is an area that has long been under-reimbursed, just like primary care.

Health care in Massachusetts isn’t living up to its full potential – and it’s leaving patients behind. As the state task force on primary care explores how to stabilize preventive medicine, PCMH 2.0 offers insights into how, with innovation and investment, the health care industry can improve outcomes, reduce emergency department visits, and lower health care costs while caring for high-utilization, high-need patients with dignity and comfort. PCMH 2.0 is just one piece of the puzzle, but by advancing its success, we can begin to unlock the lifesaving impact of a bolstered, technologically innovative primary care system.

Eric Dickson, MD, is president and CEO of UMass Memorial Health in Worcester and a professor of emergency medicine at UMass Chan Medical School.