Transforming Specialty Practice — The Patient-Centered Medical Neighborhood

The patient-centered medical home (PCMH) is a well accepted primary care delivery vehicle in the United States. The National Committee for Quality Assurance (NCQA) has recognized nearly 27,000 clinicians at more than 5000 sites throughout the country in its PCMH program. State and private payers have their own certification criteria. As PCMH efforts have spread and met with mixed success, some observers have noted that refurbishing primary care is probably necessary but not sufficient for addressing the fragmentation of care and underlying cost growth. Primary care services themselves account for only 6% of total health care spending. Moreover, attempts to make primary care solely accountable for global costs raise the specter of gatekeeping.

The term “medical neighborhood” has been coined to capture an expanded notion of patient-centered care, in which the PCMH is located (virtually or otherwise) centrally and is surrounded by specialty clinics, ancillary service providers, and hospitals. The concept of the medical neighborhood, however, has been based almost entirely on the notion of primary care practices as integrators of downstream specialty care. Despite widespread reform of primary care practice, specialty practices have remained largely unchanged.

Many PCMH initiatives have wrestled with building effective partnerships with specialty practices that lack the capabilities and orientation to support care collaboration. In a patient-centered medical neighborhood, specialty practices risk being relegated to the periphery, with patients' access to them restricted by primary care providers, if the specialists do not embrace a more population-based approach and provide better value. The success of the medical neighborhood rests on alignment between the medical home and its neighbors in their long-term goals for their shared patient population. One possible blueprint is the specialty analogue and complement to the PCMH concept: the patient-centered specialty practice (PCSP).