PCMH: Patient-Centered Medical Home
The Patient-Centered Medical Home (PCMH) is an NCQA-recognised primary care model that coordinates comprehensive, continuous care across six standards — with recognition triggering enhanced payer payments and serving as a prerequisite for some value-based contracts.
What is PCMH?
The Patient-Centered Medical Home (PCMH) is a care delivery model that organises primary care around a patient-centred, comprehensive, team-based, coordinated, accessible, and quality- and safety-focused care approach. The National Committee for Quality Assurance (NCQA) is the primary recognition body, with PCMH recognition granted at the practice level based on documented adherence to six standards.
The Six NCQA PCMH Standards
- Standard 1 — Team-Based Care and Practice Organisation: Documented team roles, care management, patient engagement
- Standard 2 — Knowing and Managing Your Patients: Panel management, risk stratification, comprehensive health assessment
- Standard 3 — Patient-Centred Access and Continuity: Same-day access, after-hours access, care continuity designation
- Standard 4 — Care Management and Support: Identification of complex patients, care planning, self-management support
- Standard 5 — Care Coordination and Care Transitions: Referral tracking, specialist communication, discharge follow-up
- Standard 6 — Performance Measurement and Quality Improvement: Quality measure reporting, patient experience data, improvement activities
Payer Payment Supplements
PCMH recognition frequently triggers enhanced payer payments — PMPM care management fees, quality performance bonuses, or enhanced E&M reimbursement rates. Major commercial payers (BlueCross BlueShield plans, Cigna, Aetna, United) and many state Medicaid programmes pay PCMH-recognised practices a per-member per-month care management fee ranging from $5–$15/PMPM. For a practice with 5,000 managed care patients, a $10 PMPM supplement equals $600,000 in annual incremental revenue.
Analytics Requirements for PCMH
PCMH recognition requires demonstrating operational capabilities through documented evidence — including panel management analytics (disease registries, care gap reports), quality measure performance tracking (HEDIS-aligned measures), care coordination documentation (referral tracking, TCM completion rates), and patient experience measurement. Practices pursuing or maintaining PCMH recognition need analytics infrastructure that can generate the required evidence quickly and accurately.