This issue of the journal is focused on the greatest challenging confronting ambulatory care management: how to document savings from increased coordinated care. There are many competing and overlapping coordinated care flavors of the month: Medical homes and accountable care organizations constitute today's flavors. At the same time, we still have managed care, staff model, health maintenance organizations, and so forth.

In this issue, we focus on medical homes, an effort to keep alive the primary care health profession. Primary care faces 2 challenges. The principal one is that primary care income lags behind other medical specialties. The second is the burden of paperwork confronting primary care leading to decreased job satisfaction.

Leif Solberg, a true physician leader in every respect, the guest editor of this issue of the Journal, admirably highlights many of the knowns and unknowns of medical home efforts to date. His introduction summarizes all the articles that are included in this issue

Unfortunately, the current version of National Committee for Quality Assurance (NCQA) medical home certification worsens the challenge facing primary care. The current approach to NCQA certification adds considerable bureaucracy to the already significant paperwork confronting primary care. There is precious little evidence, some of it summarized in this issue of the Journal, that the NCQA burdens actually improve patient outcomes. They certainly have modest, at best, impact on primary care income. In addition, because the certification is largely process driven, it is unlikely that any modest income addition to primary care professional income can be sustained in the long term. However, I am eternally optimistic and know that many groups and individuals are encouraging NCQA to adopt a more patient-centered perspective. I am certain that it is just a matter of time that the NCQA process becomes significantly streamlined and increasingly incorporates a patient-centered perspective.

What constitutes a "more patient-centered perspective." The approach pioneered by Wasson and colleagues, in their Ideal Practice Design work, is the closest we have to such a point of view. The Journal has highlighted many of their accomplishments in past issues and Wasson has contributed an article to this issue

To be successful in our efforts to increase primary care professional income, we need to focus on outcomes that have a financial bottom line impact on the health care system. These savings can then be realistically distributed to supplement primary care professional incomes. Payment system reforms that create clear financial incentives for primary care professionals to increase efficiency and improve quality outcomes are a necessary step toward achieving greater health care value. There are 5 types of health care encounters or events that are potentially preventable and lead to unnecessary services. The sum of the dollars for these potentially preventable events represents the total dollars that if they are avoided could be used as financial incentives to complement primary care professional income.

POTENTIALLY PREVENTABLE COMPLICATIONS

Potentially preventable complications are harmful events (accidental laceration during a procedure) or negative outcomes (hospital-acquired pneumonia) that may result from the process of care and treatment rather than from a natural progression of underlying disease.

POTENTIALLY PREVENTABLE READMISSIONS

Potentially preventable readmissions are return hospitalizations that may result from deficiencies in the process of care and treatment (readmission for a surgical wound infection) or lack of postdischarge follow-up (prescription not filled) rather than unrelated events that occur postdischarge (broken leg due to trauma). Readmissions may result from actions taken or omitted during the initial hospital stay, such as incomplete treatment or poor care of the underlying problem. In addition, a readmission may reflect poor coordination of services at the time of discharge and afterward such as incomplete discharge planning and/or inadequate access to care after discharge.

POTENTIALLY PREVENTABLE INITIAL ADMISSIONS

Potentially preventable initial admissions (PPAs) are facility admissions that may have resulted from the lack of adequate access to care or ambulatory care coordination. PPAs are ambulatory sensitive conditions (eg, asthma) for which adequate patient monitoring and follow-up (eg, medication management) can often avoid the need for admission. The occurrence of high rates of PPAs represents a failure of the ambulatory care provided to the patient. PPA-based initiatives are readily suited for scaling should health care entities, such as medical homes, with the full responsibility for coordination and preventive services become more commonplace.

POTENTIALLY PREVENTABLE EMERGENCY ROOM VISITS

Potentially preventable emergency room visits are emergency room visits that may result from a lack of adequate access to care or ambulatory care coordination. Potentially preventable emergency room visits are ambulatory sensitive conditions (eg, asthma) that adequate patient monitoring and follow-up (eg, medication management) should be able to reduce or eliminate.

POTENTIALLY PREVENTABLE ANCILLARY SERVICES

Potentially preventable ancillary services are ancillary services (Magnetic resonance imaging) ordered by primary care physicians or specialists, which may not provide useful information for diagnosis and treatment (Magnetic resonance imaging for back pain).

We conclude this issue focused on medical homes with the latest update from the Republic of Texas and the management column from Ron Goodspeed.

-Norbert Goldfield, MD

Editor