November 11, 2013 | Anthony Brino, Associate Editor

Patient-centered medical home models being tested in the Military Health System could offer lessons in team-based care for civilian providers, who are similarly challenged by an aging population with complex chronic conditions, according to researchers writing in Health Affairs.

The MHS’s nascent medical homes were created in 2009 in response to a “crisis in patient perception” among the system’s 9.6 million beneficiaries, 47 percent of whom said they were dissatisfied with MHS care, compared to 32 percent of patients at civilian facilities — at the same that military health costs have been rising even faster than the country’s as a whole, accounting for 6.2 percent of the Defense Department’s budget.

Now researchers are waiting for the results of patient-centered medical home models implemented both in civilian healthcare and in the MHS, and one large factor may end up being scope-of-practice, as Benjamin F. Mundell, a US Air Force captain, and colleagues at the Rand Corporation and the Mayo Clinic, wrote in Health Affairs.

Mundell et. al. argue that the MHS PCMH may show viability in part because nurses and physician assistants are used as clinically empowered primary care managers, as a way to use physicians more efficiently, in a health system that has trouble recruiting and retaining staff.

It would also represent a largely single payer health system at work, with the MHS providing some $50 billion worth of health benefits annually to almost 10 million service members, retirees and families under Tricare.

The military directive establishing the medical homes required all patients to be overseen by a primary care manager, with the Army, Navy, and Air Force each given the flexibility to designate the clinician roles. PCMH teams in the Air Force include two primary care managers, a physician and PA or NP, while the Navy’s six-member PCMH teams are mostly physicians. In the Army, the care team consists of three to five MDs, NPs, and PAs, plus a support staff.

The PCMH directive also encouraged MHS clinicians to offer beneficiaries digital services like online scheduling and email, which builds on an earlier innovation military health leaders introduced, online health risk screenings. PAs and NPs will review the questionnaires decide the patients should come in for an appointment — “to some extent, substituting online questionnaires for annual checkups,” Mundell said.

Time and money saving digital health services could go a ways to contributing to one goal of of the MHS’s “Quadruple Aim” to deliver increased readiness, better care, better health, and lower costs in times of both war and peace.

If a chunk of patients are already healthy and can be kept that way, the online questionnaires in tandem with expanded NP and PA roles could help primary care teams expand their patient panels and curb the primary care shortage problem, Mundell said.

And like civilian providers adopting trauma care innovations that the MHS has developed over the past decade, the outcomes of the MHS patient-centered medical homes could inform civilian PCMH practices, and “ingredients of the most successful MHS medical homes could be incorporated into evolving civilian definitions of medical homes.”