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Delivered by Publishing Technology to: Naval Medical Center, San Diego IP: 159.71.254.248 on: Sun, 26 May 2013 21:26:15
Copyright (c) Association of Military Surgeons of the U.S. All rights reserved.
IMPACT OF PATIENT-CENTERED MEDICAL HOMES
MILITARY MEDICINE, 178, 2:126, 2013
The Patient-Centered Medical Home in the Transformation
From Healthcare to Health
VADM Matthew L. Nathan, MC USN
Our nation’s health and wellness trajectory continues in the
wrong direction. Nearly 68% of Americans are overweight or
obese. Chronic diseases that account for 75% of all direct
health care costs are also on the rise; 45% of the U.S. popula-
tion has at least one chronic medical condition, and of those, at
least half have multiple chronic conditions. If current trends
continue, by the year 2030, these numbers will skyrocket.
As a nation, we are on an unsustainable cost trajectory. By
2020, U.S. health care costs are estimated to account for 20%
of our gross domestic product. Some of the causes for this are
unavoidable, such as aging baby boomers. However, we are
not doing enough to combat the entirely preventable causes,
namely the trifecta of unhealthy behaviors, including inactiv-
ity, poor diet, and tobacco/alcohol use. In addition, there is an
increasing tendency for our health care system to prioritize
and incentivize taking care of the sick rather than keeping
people healthy.
Since becoming the Surgeon General of the Navy in
November 2011, my priority has been to strategically align
Navy Medicine with the priorities of the Secretary of the
Navy, Chief of Naval Operations, and Commandant of the
Marine Corps. Navy Medicine is fully engaged in executing
the operational missions and core capabilities of the Navy
and Marine Corps. We do this by maintaining warfighter
health readiness, deploying forward, and delivering a contin-
uum of care from the battlefield to the bedside, while also
protecting the health of all those entrusted to our care. To
ensure the fulfillment of our mission, I have outlined 3 stra-
tegic goals for the Navy Medicine enterprise: readiness,
value, and jointness.
Transforming our societal focus from health care (a pound
of cure) to health (an ounce of prevention) is a strategic
imperative. The implications on military readiness are pro-
found. Approximately 30% of potential military candidates
ages 17 to 24 do not qualify for military duty because they are
overweight; but to sustain our fighting force and successfully
execute our missions, our naval forces must be armed with fit,
healthy, and ready Sailors and Marines.
Fortunately, we have a way to address this crisis—the
Patient-Centered Medical Home (PCMH) model launched at
Naval Hospital Pensacola and Walter Reed National Military
Medical Center, Bethesda, Maryland (formerly the National
Naval Medical Center) in 2008. It is now being implemented
throughout the Military Health System (MHS) and carries
great promise. It provides the clinical framework we need to
meet our strategic objectives in terms of quality of care,
impact on costs, population health, and readiness.
One of the most significant benefits of the team-based,
collaborative approach is that it allows us to embed within a
primary care environment the psychologists, nutritionists,
tobacco cessation specialists, mind-body medicine therapists,
and health educators our patients need in order to develop
and maintain mindful, healthy behaviors—along with the
“mental armor,” our active duty military personnel need to
increase their operational effectiveness and their resiliency in
bouncing back from stressful situations. As we move ahead
with this more comprehensive approach to health, we can
begin to better address so many of our patients for whom we
can find no specific reason for pain and discomfort.
The PCMH model also provides a positive impact on
our costs. Early data reporting from the PCMH clinics
at Bethesda show reduced visits to the emergency room,
lowered pharmacy costs, and significant per beneficiary per
year savings and improved Healthcare Effectiveness Data
and Information Set metrics, access, and patient satisfaction
and trust. These positive impacts on the bottom line can be
applied directly to improved costs or toward the reallocation
of resources from reimbursing those who are sick to the
population health-based programs that can make and keep
our patients healthy.
More significant, however, the PCMH environment allows
us to go beyond mere collaboration and to a much more
proactive approach to managing our patient populations. It is
within the context of the medical home that we can begin to
surround our patients with the tools and resources they need
to move them from health care to health. To lead vibrant,
Surgeon General of the U.S. Navy
Chief, Bureau of Medicine and Surgery, Falls Church, VA.
doi: 10.7205/MILMED-D-12-00467
MILITARY MEDICINE, Vol. 178, February 2013126

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Delivered by Publishing Technology to: Naval Medical Center, San Diego IP: 159.71.254.248 on: Sun, 26 May 2013 21:26:15
Copyright (c) Association of Military Surgeons of the U.S. All rights reserved.
healthy lives, our patients will need health risk assessments,
personal plans for health, live and virtual coaching, and
access to a broad array of online and mobile applications,
including wireless biometric monitoring devices for our
sickest patients. We will also need to link our patients to the
social networks and community resources that will reinforce
their healthy behaviors.
None of these objectives come easy. Workforce redevel-
opment will play a critical role in our efforts to be successful.
Some patients and providers hold on to the comfort of the
personal visit for any and all things; however, the reality of
our health crisis is that the workflow of the future will be very
different. Because our populations are so unhealthy, there
will be fewer personal encounters between patients and their
providers in favor of phone, e-mail, or web-based visits by
nurses, nutritionists, psychologists, coaches, and others who
help address the underlying causes of poor health. Our criti-
cal reliance on information technology tools is not just out of
desire but necessity. Provider appointments will be reserved
for only those patients who truly need a provider to hear,
see, or touch directly the patient concern. Fortunately, our
patients themselves are yearning for a more “plugged-in/
wireless” way to connect to their health providers.
There are challenges in implementing the PCMH model.
Change is never easy. Conflicting issues over staff roles on a
medical home team, competing objectives between teams
and leadership, and institutional inertia in the face of innova-
tion can all present issues that must be worked through and
resolved if the transformation from health care to health is to
be successful. Because the PCMH concept is different from
the primary care we all grew up with, its unique culture must
be fostered, nurtured, and championed, and the lessons
learned from its implementation shared MHS wide.
The MHS and its population of 9.6 million beneficiaries
are positioned uniquely, I believe, to serve as a place where
we can pioneer national health care reform efforts. The
MHS has the essential ingredients to make this work: an
insured population, electronic medical records, potential
rewards for health vice health care, and a vertically inte-
grated system that “owns” almost all aspects of care. As a
closed system that closely mirrors the U.S. population in
general, the MHS can allow health care experts and U.S.
policymakers to study the effects of the PCMH model; and
our population health efforts as tools for a broader, more
concerted, national dialogue on how to improve the health
of not just a few, but all, Americans.
And, I might add, with a sense of urgency. Our choices of
unhealthy behaviors as a nation are rapidly closing in not only
on our fiscal solvency, but also on our ability to thrive as a
healthy nation. Health and access to health care are essential
pillars for the well-being of our nation as well. The military
engagements that have occupied our efforts for so long may be
turning the corner, and our first responsibility will always be to
the combat zone; but make no mistake, we must all now deploy
to the health care zone. We have no other choice. We need to
be healthy, and when danger, disaster, or disease arises, ready.
MILITARY MEDICINE, Vol. 178, February 2013 127
Guest Editorial