The large and growing cost of healthcare, which amounted to 17.9% of the gross domestic product in 2011,1 will continue to be a burden for all payers in the US healthcare system, not only for states that are struggling to meet Medicaid costs and the federal government’s requirements, but also for private health plans that serve commercial, Medicare Advantage, and Medicaid beneficiaries.2,3 Costs will continue to grow as millions more people become newly insured because of the Patient Protection and Affordable Care Act (ACA).
Primary care that is delivered through patient-centered medical homes (PCMHs) and other coordinated-care models has served as a means to improve care and to reduce costs.4,5 Health plans, therefore, have a strategic opportunity to promote better care at a lower cost by embracing medical homes and encouraging their growth. Using this strategy would enable health plans to play an important role in transforming the US healthcare system, and to be better positioned for long-term corporate success.
Large business groups already have taken note of the potential for primary care and medical homes to reduce their healthcare costs. The National Business Group on Health (NBGH), which has more than 300 large corporate members that provide health insurance for 50 million Americans, has made primary care, and more recently the PCMH model, a priority “for years,” said NBGH Vice President Veronica Goff in an April 18, 2012, telephone interview. Several large employers are conducting PCMH pilot programs, including IBM, Boeing, Whirlpool, Dow Chemical, and Perdue Farms. Some state Medicaid programs and private health plans have also launched efforts to establish medical homes.
In this article, we discuss several examples of organizations that serve a variety of beneficiaries and that have been successful in promoting medical homes and coordinated primary care. We review their results and make recommendations to health plans that are interested in seizing this opportunity.
Defining and Certifying Patient-Centered Medical Homes
The PCMH model has been widely discussed in recent years. In 2007, the 4 major associations representing 333,000 primary care physicians (PCPs) issued joint principles of the PCMH model.6 These principles indicate that a PCMH should include6:
- A personal physician
- A team approach
- A patient-centric focus
- A dedication to quality and safety, including evidence-based medicine and clinical decision support tools
- Coordinated care across settings
- Enhanced access for patients, such as through open scheduling, e-mail, and expanded hours
- Appropriate, enhanced payment.
In 2008, the National Committee for Quality Assurance (NCQA) released its first set of standards and guidelines for PCMH recognition, which were revised and reissued in 2011.7 Practices that were recognized under the 2008 NCQA guidelines have 3 years from the date of recognition to update their practices to match the 2011 guidelines.
“As of January 2013, 5198 sites with a total of 24,544 clinicians had received NCQA recognition,” said Peggy Reineking, NCQA’s Director of Clinical Recognition Programs, in a January 8, 2013, telephone interview. “Practice size varied, but about 50% of those recognized were large sites, likely primary care practices from integrated health systems,” she said.
The NCQA’s 2011 guidelines include 6 standards, each with a number of elements, for practices to meet.7 Within these 6 standards, there are several must-pass elements for which a practice must earn at least 50% of the total possible points. These 6 standards are7:
- Enhance access and continuity
- Identify and manage patient populations
- Plan and manage care
- Provide self-care support and community resources
- Track and coordinate care
- Measure and improve performance.
Based on their point totals in those categories, practices can earn 3 levels of recognition: level 1 (35-59 points), level 2 (60-84 points), and level 3 (85-100 points).8
To achieve the highest levels of PCMH recognition, practices must have electronic health record (EHR) systems for activities such as patient and population management. The NCQA aligned its 2011 standards with the “meaningful use” standards from the Office of the National Coordinator for Health Information, which is part of the US Department of Health and Human Services.
Practices with clinicians demonstrating meaningful use standards will also receive credit from the NCQA. Approximately 21,300 family practice and internal medicine specialists demonstrated meaningful use standards as of April 2012, receiving on average approximately $17,000 per practice from the Centers for Medicare & Medicaid Services (CMS) EHR incentives program.9 In addition, more than 13,800 nurse practitioners have enrolled in the CMS incentives program as of April 2012.9
Challenges to Promoting Medical Homes and Primary Care
PCMHs and PCP practices in general face a number of barriers to growth. Yet, the medical home model will likely become an increasingly important way to curb healthcare costs as millions more people across the country become newly insured as a result of the ACA.
Primary Care Reimbursement
The first hurdle is that reimbursement for primary care tends to follow the fee-for-service (FFS) model, and often at lower rates than used for specialist care. For example, in a personal interview on May 8, 2012, Sunanda Sindhwani, MD, of Internal Medicine Associates, Reston, VA, said that at her practice, which treats approximately 10,000 patients in Fairfax County, VA (and has one of the highest county median incomes in the nation10), the practice’s reimbursement level has changed by only a small amount in the past 5 years. Practice reimbursement is still almost exclusively based on FFS, with commercial plans paying a slightly higher amount than Medicare.
Notably, as a sign of the recognition of primary care reimbursement as a problem, the ACA required state Medicaid programs to reimburse PCPs at no less than 100% of Medicare’s reimbursement rate in 2013 and 2014.11 The ACA also provides a 10% Medicare incentive payment for primary care services.12
PCMH Certification and Health
The NCQA certification for PCMHs has tremendous value as a uniform, nationally recognized set of standards. Achieving NCQA’s certification, however, is often challenging for PCP practices, which must invest significant amounts of resources and uncompensated staff time to complete the process. Randall Curnow, Jr., MD, MBA, Executive Vice President and Chief Medical Officer of Summit Medical Group in Knoxville, TN, commented in an April 26, 2012, interview that achieving even the 2008 NCQA standards, which are considerably less challenging than the 2011 standards, required as many as 100 hours in addition to the day-to-day patient care.
The technologic requirements for PCMH certification also can be daunting. In a May 1, 2012, telephone interview, Joel C. White, Executive Director of the Health IT Now Coalition, commented that “Stage 1 represents a fairly low bar.” The stage 1 meaningful use measures focus on basic electronic tools, such as e-prescribing, computerized physician order entry, clinical decision support, and recording basic demographic information.
Stage 2 standards, however, are more challenging and require information sharing to allow for care coordination using point-to-point messaging. “Lack of interoperability, for example, between a [PCP] practice and hospitals or with specialists’ practices is a significant problem, although it is not a technology or standards issue,” Mr White indicated.
Dr Sindhwani reinforced the value of interoperability, particularly as a way to avoid redundancy in services, such as duplicate magnetic resonance imaging or laboratory tests. With the majority of PCP practices being relatively small, and particularly for practices in rural health provider shortage areas, the challenges of moving to an accredited meaningful use EHR system may well be significant, and may “disrupt workflow,” he noted.
Effects of the ACA
The ACA’s policies are expected to increase the importance of and the demand for primary care services, particularly for people who are newly enrolled in Medicaid. The Supreme Court’s decision in NFIB v Sebelius gave states a choice of whether to expand Medicaid eligibility up to 138% of the federal poverty level starting in 2014.13
The estimates vary widely for how many new people Medicaid programs will enroll. The Congressional Budget Office’s latest projection, after the Supreme Court’s decision, estimates that 11 million people will become newly insured through Medicaid by 2022, 6 million fewer than it had projected before the Supreme Court’s decision.14 However, of those 6 million, 50% are expected to get coverage through state health insurance exchanges and the other 50% are expected to be uninsured.14 The Kaiser Commission on Medicaid and the Uninsured estimates that 21.3 million people would become newly enrolled in Medicaid if all states choose to expand the program.15
The combination of people who become newly insured, as well as general population growth and aging demographics, will create an additional demand for primary care services. One recent study projected that those factors would increase the number of annual primary care visits from 462 million in 2008 to 565 million in 2025.16
Successful Models to Promote Medical Homes, Improve Quality, and Reduce Costs
Health plans have an opportunity to address each of the challenges described above. This section discusses several proved methods that health plans could use to support medical homes, drawn from health plans and other organizations that serve a variety of beneficiaries.
At first, paying more for primary care seems at odds with the goal of reducing overall healthcare costs. However, the right kinds of PCP incentives and models have proved to reduce the use of expensive medical services and cut costs. We review those models and then discuss their results. We divided the incentive methods into 2 broad categories—enhanced payments for high-quality primary care and care coordination.
Examples of Enhanced Payments for High-Quality Primary Care
The payment incentives we examined involved a few basic models:
- Enhanced FFS payments based on NCQA and meaningful use certifications
- Supplementary payments, frequently on a per-member per-month (PMPM) basis
- Value-based payment methods, or pay-for-performance (P4P) payments
- Gain-sharing payments (which are less frequently used).
A 2010 study of PCMH pilot projects showed that medical homes used a variety of payment models, often mixing multiple kinds of payments.17 For example, typical FFS and PMPM payments were ubiquitous, with 96% of the programs in the study using each of them. Of these programs, 58% had PMPM payments that were adjusted based on the NCQA accreditation level attained and 23% had payments adjusted for risk. The mean annual additional PMPM payment was $22,834 per physician. (This amount represents the mean high and low. The full range of PMPM payments was between $720 and $91,146.17) Such results mirror the mixture of incentive payment methods in the examples we discuss for this article.
Geisinger Health System. Geisinger Health Plan’s medical home model—ProvenHealth Navigator—is “an intensive multidimensional medical home model that addresses care delivery and financing.”18 Janet Tomcavage, RN, MSN, Geisinger’s Health System Chief Clinical Transformation Officer, said in a May 2, 2012, telephone interview that the program follows a “value-based reimbursement model,” which includes FFS and performance-based PMPM payments. Practices can earn up to 3 P4P stars, which are based on quality indicators, such as Healthcare Effectiveness Data and Information Set (HEDIS) measures, emergency department utilization, and medication adherence. The performance-based payments can reach $6 PMPM. Ms Tomcavage illustrated that a 3-star practice with 1000 Geisinger Health Plan members could earn an additional P4P payment of $6000 monthly, or $72,000 annually.
In the same interview, Ms Tomcavage said that Geisinger’s model also includes “quality gated results sharing.” Practices receive a portion of the estimated cost-savings if, compared with the previous 2 years, they meet targets for efficiency and medical expenses. Practices must also show improvement in quality measures, such as better patient outcomes in diabetes and cardiovascular disease, and enhanced patient satisfaction.
BCBS of North Carolina. Blue Cross Blue Shield (BCBS) of North Carolina is another health plan that has been successful in promoting medical homes. Through its Blue Quality Physician Program, it provides an approximately 25% enhancement to fee schedule payments for practices serving as medical homes and for practices making other clinical improvements. During the 3-year pilot project leading up to the Blue Quality program, BCBS of North Carolina paid financial rewards to physicians who achieved NCQA performance measures. A separate BCBS of North Carolina program helps PCPs to develop EHRs and to demonstrate meaningful use standards. Demonstrating meaningful use standards allows PCP practices to receive substantial incentive payments, often approximately $17,000, from CMS.9
Summit Medical Group. An example of a provider group that has embraced the PCMH model and benefited from enhanced quality- and certification-based payments is Summit Medical Group. The group has approximately 220 physicians (almost exclusively PCPs) with level 3 NCQA certification, and is recognized as a top practice in the NCQA’s certifications for diabetes, heart, and stroke care. Dr Curnow believes that the healthcare industry is moving from an FFS model to a “fee-for-value” model, with P4P and gain-sharing. Dr Curnow expects that in the next few years a substantial portion of Summit Medical Group’s revenue will be related to its NCQA accreditations, meaningful use criteria, and its gain-sharing payments.
Summit Medical Group recently sought relationships with commercial insurers who were interested in making value-based FFS payments. Those relationships have led to significantly enhanced FFS payments for its commercial and Medicare Advantage populations as a result of Summit’s verified quality, size, and market power, Dr Curnow noted. The practice also receives payments based on its NCQA and meaningful use certifications.
In addition, the group is seeking gain-sharing programs with some of its commercial insurers. Gain-sharing typically provides practices with savings based on how actual costs compare with the expected risk-adjusted costs of their beneficiary population. Dr Curnow expects gain-sharing to be adjusted, including potential reductions, based on patient satisfaction and quality scores, such as performance on preventive care, care coordination, and selected HEDIS measures.
Care Coordination and Management
In addition to enhanced payments for quality measures, health plans and other organizations have made additional payments to promote care coordination, which is a fundamental component of PCMHs.
In the Geisinger Health Plan model, Ms Tomcavage noted that “case management is embedded in the practices.” Case managers are registered nurses who are Geisinger Health Plan employees and who are physically located in practices with other team members. Geisinger Health System (the parent company of Geisinger Health Plan) also has superb information technology that links health system components, such as practices, hospitals, and laboratories. The system provides substantial and valuable data for the case managers, practices, and physicians who use these data for patient and population management.
CCNC. Community Care of North Carolina (CCNC)’s PCMH is one of the best-known examples of how care coordination can improve outcomes and reduce costs for Medicaid beneficiaries. CCNC consists of 14 locally owned and locally led care networks. As Paul Mahoney, Director of Communications at CCNC, stated in an April 17, 2012, interview and in personal communications, the networks allow CCNC to tailor its services to North Carolina’s diverse geography and populations, and CCNC staff members consider the networks to be an important part of CCNC’s success. Local ownership and control also help to achieve a high level of buy-in from physicians and their practices.
The state Medicaid program pays primary care practices 95% of Medicare’s reimbursement rates and makes PMPM payments of $2.50 for beneficiaries who are women and children and $5 for beneficiaries who are elderly, blind, and disabled. North Carolina also gives CCNC networks a variable PMPM payment of between $3 and $11, depending on the populations enrolled. These payments fund care coordination, care management, and quality improvement. CCNC has 600 care managers who are embedded in medical practices and hospitals, and sometimes in emergency departments, according to Mr Mahoney.
Pharmacists are also important participants in CCNC networks, because they support medical practices through medication management and reconciliation. CCNC pharmacists combine patient feedback and clinical data with prescription and claim data to produce comprehensive patient drug profiles. The profiles improve medication adherence and give clinicians a more complete view of their patients’ progress.
CCNC now has interventions that identify and focus on the highest-need and highest-cost Medicaid beneficiaries, which include approximately 1% of women and children and 3% to 4% of elderly, blind, and disabled beneficiaries, according to Mr Mahoney. PMPM payments to Medicaid providers and CCNC networks allow for concerted efforts to reduce major cost-drivers, such as preventable readmissions, psychiatric readmissions, inpatient costs, and the overall cost of the elderly, blind, and disabled population. CCNC also focuses on patients with behavioral and chronic conditions, who may need extra support and for whom care is often expensive.
Vermont Blueprint for Health. An example of a statewide multi-insurer PCMH program is Vermont Blueprint for Health. In addition to its primary care network, it employs additional, locally based community provider teams, including nurse coordinators, behavioral health providers, and social workers who support multiple practices.4 Those providers know the local resources and connections, and can therefore help to integrate community agencies or other resources into the patients’ care.
MDVIP. The final coordinated care model considered in this review is the MDVIP program, a national “concierge” program. MDVIP members pay an annual fee of $1500 and are paired with PCPs in the MDVIP program who give enhanced personalized care, develop wellness plans, and help to manage chronic or acute conditions. Keith W. Michl, MD, FACP, a physician in Manchester Center, VT, with 30 years in practice, said in an April 26, 2012, telephone interview that he had considered leaving clinical medicine or moving to an area where primary care reimbursement was better. Instead, he chose to join MDVIP and reduced his practice size from 2000 patients to 500 patients. His patients now include self-employed people, some of whom have foregone health insurance in the past because of its cost, as well as wealthy retirees and teachers. Dr Michl receives approximately $1000 of each patient’s annual MDVIP fee. Having an MDVIP practice, he said, allows him to spend more time with his patients, to communicate with them via e-mail and phone, as well as after hours, and also to do more disease management, such as nutrition and lifestyle counseling.
Results of PCMH Models
Data from PCMH models demonstrate the clinical and cost benefits of the PCMH model for members with commercial, Medicaid, or Medicare coverage.
As shown in Figure 1, CCNC has generated substantial estimated savings for the North Carolina Medicaid program.5 In addition, CCNC is generating savings from an intensive patient-centric focus on high-cost beneficiaries and savings of approximately 15% per beneficiary 6 months after their enrollment in CCNC, according to Mr Mahoney.
With 4 million members in 39 states receiving care in primary care medical homes, BCBS has been a leader in the move to the PCMH model.4 In one of the BCBS of North Carolina programs—Blue Quality Physician Program—patients who belonged to NCQA-recognized PCMHs had 52% fewer visits to specialists and 70% fewer emergency department visits.4
For Horizon BCBS of New Jersey’s PCMH, the PMPM costs were reduced by 10%, and 26% fewer emergency department visits and 21% fewer inpatient admissions were reported in 2012.4 Similarly, BCBS of Nebraska’s PCMH had 27% fewer emergency department visits and 10% fewer hospitalizations in 2012.4
Other programs have shown similar results for Medicare Advantage, traditional Medicare, and commercial insurance beneficiaries. For example, Geisinger Health Plan’s ProvenHealth Navigator medical home model significantly reduced the use of costly hospital-related services for the program’s patients (Figure 2).19 Acute admissions were reduced by 28% for Medicare members in the ProvenHealth Navigator medical home compared with those not in the medical home. Similarly, a 38% reduction was seen among commercial members in the ProvenHealth Navigator medical home versus those who were not (Figure 2).
Intermountain Healthcare, an integrated health system in Utah, has a medical home model called “Care Management Plus.” For Care Management Plus patients, the odds of dying in the first and second years of participating in the program were significantly less for all patients, with greater benefits for patients with diabetes (at 1 year 6.2% vs 10.6% for all patients with diabetes in the control group, at 2 years 21.0% vs 24.2% for patients with diabetes in the control group).20,21 The odds of admission for any cause were reduced by 27% to 40%.20
A Call to Action
Healthcare plans covering the gamut of patient populations have an opportunity to improve care and to reduce costs for their beneficiaries by taking steps to support the growth and the evolution of PCP practices and PCMHs. Based on our review of the plans discussed in this article, we recommend the following 6 actions that health plans can take to achieve these goals.
Get Feedback from PCPs
Managed care organization executives involved with network management should have frank and open conversations with PCPs representing a variety of practices with varying sizes and locations to learn from their experiences. Doing so will help health plans to craft policies that strengthen networks by retaining PCPs, who are vital to improving care and to reducing costs.
Create Value-Based PCP Reimbursement
Enhanced and value-based reimbursement policies for PCPs, particularly those in PCMHs, are vital to improving care and to reducing costs. We recommend that:
- Commercial insurer and Medicare Advantage FFS payments for primary care services are roughly 10% higher than Medicare payments; the ACA requires state Medicaid programs to reimburse PCPs at no less than 100% of Medicare’s reimbursement rate in 2013 and 2014
- Enhanced PMPM payments to practices that meet higher levels of NCQA accreditation and CMS meaningful use standards, or for smaller or rural practices or older physicians, other medical home models, HEDIS scores, use of nonphysician providers, health information technology infrastructure, and expanded patient access
- Gain-sharing or bonuses when cost-savings are demonstrated, which can be actuarially imputed or otherwise estimated
- Substantial total increased payments, representing as much as a 20% increase in payment.
Encourage Biannual Visits with High-Risk Patients
Pay practices an enhanced FFS payment, of roughly $125 to $150, for biannual visits for patients whom practices or plans identify as being at a moderate or an increased risk based on their health status.
Fund Case Managers for High-Risk Patients
Assist PCPs in identifying the 2% to 5% of patients who have the highest morbidity and costs. Then identify a provider who can be an overall case manager for the care of those patients and help to identify or to provide resources for patient and practice assistance.
Consider Medicaid Coordinated-Care Models
With the dramatic expansion of Medicaid under the ACA, it will be particularly important to consider models, such as CCNC, that have reduced costs.5
Promote ACA Provisions that Support Primary Care
Health plans should advocate that the components of the ACA that support primary care are brought forward and funded, whether as ACA components or as separate bills.22
The cost of healthcare in the United States presents a tremendous burden to all stakeholders, including federal and state governments, employers, commercial payers, and individuals. With millions of new health insurance beneficiaries expected in 2014 as a result of the ACA, there will most likely be an increased demand for healthcare. Primary care is the front line for delivering preventive care and the care for chronic conditions, such as diabetes, hypertension, and hyperlipidemia, which are the major drivers of morbidity, mortality, and costs. Robust primary care models, such as the PCMH model, have shown to improve outcomes; reduce the use of higher-cost resources, such as hospital admissions and emergency department visits; and lower the total costs of care. Payers’ support of primary care (eg, via enhanced payment and support for the PCMH model) is key in transforming the US healthcare system to improve healthcare quality and outcomes and to reduce the current unsustainable trajectory of growth in healthcare costs. n
Author Disclosure Statement
Dr Owens is a consultant to Allergan, Biogen Idec, Boston Scientific, CardioDx, Crescendo Biosciences, Eli Lilly, Genzyme, Iroko, Johnson & Johnson, and Novocure. Ms Collins has nothing to disclose. Mr Piper has no conflicts of interest to report.
Ms Collins is President, America’s Health, Oak Hill, VA; Mr Piper is President, Health Results Group, Washington, DC; and Dr Owens is President, Gary Owens and Associates, Glen Mills, PA.
- Centers for Medicare & Medicaid Services. National Health Expenditure Projections 2011-2021. www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Proj2011PDF.pdf. Accessed January 15, 2013.
- Kaiser Family Foundation and Health Research and Educational Trust. Employer Health Benefits 2012 Summary of Findings. http://ehbs.kff.org/pdf/2012/8346.pdf. Accessed January 15, 2013.
- State Budget Crisis Task Force. Report of the State Budget Crisis Task Force. Revised July 31, 2012. www.statebudgetcrisis.org/wpcms/wp-content/images/Report-of-the-State-Budget-Crisis-Task-Force-Full.pdf. Acessed January 15, 2013.
- Nielsen M, Langner B, Zema C, et al. Patient-Centered Primary Care Collaborative. Benefits of implementing the primary care patient-centered medical home: a review of cost and quality results, 2012. www.pcpcc.net/files/benefits_of_implementing_the_primary_care_pcmh_0.pdf. Accessed January 15, 2013.
- Cosway R, Girod C, Abbott B. Analysis of Community Care of North Carolina Cost Savings. Milliman, Inc. December 15, 2011. www.communitycarenc.org/elements/ media/files/milliman-executive-summary.pdf. Accessed April 26, 2012.
- American Academy of Family Physicians, American Association of Pediatrics, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. March 2007. www.aap.org/en-us/professional-resources/practice-support/quality-improvement/Documents/Joint-Principles-Patient-Centered-Medical-Home.pdf. Accessed January 22, 2013.
- NCQA’s Patient-Centered Medical Home (PCMH) 2011. November 21, 2011. www.ncqa.org/Portals/0/PCMH2011%20withCAHPSInsert.pdf. Accessed January 22, 2013.
- NCQA’s Patient-Centered Medical Home (PCMH) 2011 January 31, 2011. http://ncqa.org/Portals/0/Programs/Recognition/PCMH_2011_Overview_5.2.pdf. Accessed January 25, 2013.
- Centers for Medicare & Medicaid Services. April 2012 EHR Incentive Program Active Registrations. www.cms.gov/Regulations-and-Guidance/Legislation/EHR IncentivePrograms/downloads/Monthly_Payment_Registration_Report_Updated.pdf. Accessed January 22, 2013.
- Vardi N. America’s richest counties. Forbes.com. April 11, 2011. www.forbes.com/2011/04/11/americas-richest-counties-business-washington.html. Accessed January 15, 2013.
- Centers for Medicare & Medicaid Services. Affordable Care Act Timeline. www.medicaid.gov/AffordableCareAct/Timeline/Timeline.html. Accessed January 15, 2013.
- Centers for Medicare & Medicaid Services. MLN Matters. August 8, 2012. www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMatters Articles/downloads/mm7060.pdf. Accessed January 15, 2013.
- Implementing the ACA’s Medicaid-Related Health Reform Provisions After the Supreme Court’s Decision. Kaiser Family Foundation Focus on Health Reform. August 2012. www.kff.org/healthreform/upload/8348.pdf. Accessed January 15, 2013.
- Congressional Budget Office. Estimates for the insurance coverage provisions of the Affordable Care Act updated for the recent Supreme Court decision. July 2012. www.cbo.gov/images/cbofiles/attachments/43472-07-24-2012-Coverage Estimates.pdf. Accessed January 23, 2013.
- Holahan J, Buettgens M, Carroll C, Dorn S. The cost and coverage implications of the ACA Medicaid expansion: national and state-by-state analysis. The Urban Institute and the Kaiser Commission on Medicaid and the Uninsured. November 2012. www.kff.org/medicaid/upload/8384.pdf. Accessed January 23, 2013.
- Petterson SM, Liaw WR, Phillips RL Jr, et al. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med. 2012;10:503-509.
- Bitton A, Martin C, Landon BE. A nationwide survey of patient centered medical home demonstration projects. J Gen Intern Med. 2010;25:584-592.
- Gilfillan R, Tomcavage J, Rosenthal MB, et al. Value and the medical home: effects of transformed primary care. Am J Manag Care. 2010;16:607-614.
- Steele GD, Haynes JA, Davis DE, et al. How Geisinger’s advanced medical home model argues the case for rapid-cycle innovation. Health Aff (Millwood). 2010;29: 2047-2053.
- Dorr DA, Brunker CP. Building the Medical Home: The Role of Care Management Plus. http://caremanagementplus.org/publications/FinalCM+CenteronAgingFeb232011Brunker.pdf. Accessed January 23, 2013.
- Dorr DA, Wilcox AB, Brunker C, et al. The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors. J Am Geriatr Soc. 2008;56:2195-2202.
- Collins S. Primary care shortages: strengthening this sector is urgently needed, now and in preparation for healthcare reform. Am Health Drug Benefits. 2012;5:40-47.