ACOs and PCMHs: Improving Patient Access to Care

In a 2008 Commonwealth Fund survey, participants were asked a number of questions about their views of the United States Health Care System. Three of four adults surveyed responded that they have difficulty obtaining timely access to a doctor when medical care is needed. Survey responses indicated several access-related "problem areas," including:

  • Difficulty getting a same or next-day doctor's appointment when sick (without visiting the emergency room)
  • Obtaining medical advice from a physician during normal office hours
  • Getting medical care on nights, weekends or holidays (without visiting the emergency room)

By concentrating their efforts on establishing medical homes and a medical neighborhood for patients via advanced care delivery models like the Accountable Care Organization (ACO) and Patient-Centered Medical Home (PCMH), respectively, providers can successfully eliminate these gaps in patient access to timely and necessary medical care. A September 2010 roundtable discussion (co-sponsored by The Patient-Centered Primary Care Collaborative (PCPCC), The Commonwealth Fund and the Dartmouth Institute) aligned with this realization. Industry thought leaders began planning to use ACOs and PCMHs to support increased access to care in six critical areas: after hours access, same/next day appointments, providing patients with a personal clinician, telephone appointments, secure electronic messaging and patient portals, and population management technology.

First, participants highlighted the importance of access to off-hours primary care for patients. One expectation of a medical home is that the facility will provide patients with options for off-hours care, which can result in a sizeable reduction of emergency room visits. One source estimates that 40 to 50 percent of emergency room visits are for non-urgent conditions, resulting in unnecessarily high health care expenditures. Reducing the number of unnecessary emergency room visits directly lowers health care costs and allows providers to ensure better stewardship of the health care dollar, maximizing value. Ideally, providers within an ACO will collaborate to create availability during off hours, improving patient access to care regardless of the time of day.

Participants also addressed access as it relates to the availability of same-day or next-day access to care. In the above-mentioned Commonwealth Fund survey, 30 percent of those surveyed stated that it was "difficult" or "very difficult" to obtain a same-day or next-day doctor's appointment without going to the ER. Proposed suggestions for improving access to same-day or next-day appointments included allowing open access or advanced access to appointments. According to the Health2Resources summary of the PCPCC roundtable, "research suggests this approach can decrease appointment no-shows, improve continuity of care and increase both patient and clinician satisfaction."

Since a true medical home offers patients comfort, convenience, and optimal care, roundtable participants also emphasized the importance of making it possible for patients to have appointments with a personal clinician. Patients having access to (and continuity with) a personal primary care provider has a far-reaching effect on the entire scope of patient care, including higher rates of preventive care screenings and immunizations, reduced emergency room and hospital visits, lower health care costs and an overall increase in patient satisfaction.

To increase accessibility, roundtable participants also proposed that medical home and ACO providers work to increase the number of telephone appointments, when applicable. This convenient method of patient-to-physician communication can be an appropriate substitute for in-person care in many instances, and can also be an effective method of chronic disease care management. Studies indicate that telephone appointments have helped clinicians effectively monitor patients being treated for depression, asthma and urinary tract infections, among others conditions. Telephone appointments also engage patients to proactively address their own health care and ask questions; they also reduce the number of patient office visits and resulting costs. For telephone appointments to serve as an effective access point, attendees concluded that physicians will need to design their schedules to allow time slots in which providers can call patients. According to Karen Davis, Ph.D, president of The Commonwealth Fund, physicians can design a structure that will "make the right thing to do the easy thing to do."

Providers who advocate improving patient access to healthcare via advanced care delivery models like the ACO and PCMH will find health IT to be an invaluable resource. Facilitating electronic patient-provider communication and online access to patient medical records increases patient engagement and encourages the patient to take responsibility for his or her care management. The Group Health Cooperative's "Access Initiative" recommended a number of methods of online patient communication. Secure email, online medical record access, online requests for prescription refills, online appointment scheduling, health promotion information and online discussion groups are just a few strategies that ACO and PCMH providers can leverage to improve access to care for their patients.

Finally, ACO and PCMH providers should consider that increasing patient access to care can help reduce disparities in care across diverse demographics and accommodate the health care needs of more vulnerable patient populations. Providers will need to closely examine medically underserved populations and determine how they can best provide increased access to quality care. Davis supports the idea that a medical home can significantly reduce disparities in care, saying, "I was really shocked at how much the racial and ethnic disparities in access to care, quality of care and preventive care were eliminated if patients were given care in a practice that met the characteristics of the patient-centered medical home." Essentially, when racial and ethnic minorities have access to a medical home, this disparity is nearly eliminated (Abrams, Davis, Lawlor, & Schoenbaum, 2011).

As organizations seek to meet the standards required to become medical homes for their patients, they will establish a solid foundation of primary care for both patients and providers. According to the Health2Resources summary of the PCPCC roundtable, medical home care coordination and care management activities help ACOs to realize cost savings towards which they strive; PCMHs benefit from ACO infrastructure and support (like information technology, data collection and reporting) in order to meet their functional requirements. Health IT is the backbone of these two care delivery models that take a patient-centered approach to realizing their interrelated goals. Health IT can facilitate practical application of access-improving techniques resulting in a mutually beneficial relationship as they continue on their path of providing more advanced delivery of quality care.