Patient-Centered Medical Homes: Overview, Experience to Date, Success Factors

Thirteen PCMH programs; five started in 2008/2009, others started in 2011 and 2012.
Eight multi-payer: NY, CT, MD, RI, OH, CO, TX, MO 

  • Two single-payer in AZ and TX
  • Chronic care medical home pilot in MO –partnering with BOEING, MONSANTO, GE, and UNITED
  • CMS Comprehensive Primary Care Initiative 

(CPCi) 5 year Demonstration Project in CO, NJ, and OH
A significant and growing level of impact:

  • Membership: 250K+ members impacted
  • Physician Practices: 250+
  • Primary Care Providers: 2000+
  • Participating employer groups: 650+ 


  • Practices need to be ready and willing to change 
  • Need clearly defined, engaged physician and administrative leadership
  • Structure alone does not drive outcomes
  • Processes need to be adopted and sustained to realize clinical and operational efficiency improvements
  • Multi-stakeholder pilots provide the economies for sustainable change 

Early Findings:

  • Dedicated embedded, care manager and coordination is key to success of overall patient population management 
  • Two-way data sharing enables better care management actions
  • Performance payments can affect change in behavior
  • Practice collaboration is key to leveraging best practices
  • This is hard stuff which requires heavy lifting..….if there were easy answers, primary care wouldn’t be in crisis!
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