The Medical Home: A solution to simplifying and improving health care?

The term "medical home has recently become a hot topic, but has been with us for some time. The American Academy of Pediatrics is credited with coining the term back in 1967, although back then the concept was limited to creating one central location for all of a patient's medical records. What does a Medical Home mean today?

Deloitte Consulting, in their recently published paper The Medical Home: Disruptive Innovation for a New Primary Care Model, states a Medical Home "is not a house, hospital or other building. Rather, it is a term used to describe a health care model in which individuals use primary care practices as the basis for accessible, continuous, comprehensive and integrated care. The goal of the medical home is to provide a patient with a broad spectrum of care, both preventive and curative, over a period of time and to coordinate all of the care the patient receives."

So how is that different than the concept of primary care physician coordinating the needs of member patients that HMOs have adopted for decades? Dr. Paul Grundy, IBM’s director of health care technology and strategic initiatives, is quoted in a recent Business Insurance article discussing the new Patient-Centered Primary Care Collaborative that IBM helped found, stating that "the medical home does not serve as a gatekeeper but rather as a gateway to the health care system." Another issue is that as HMOs have de-emphasized various control features of managed care during this decade, the emphasis on primary care has been somewhat diminished as well. Many plans no longer require specialist referrals. Primary care physicians are no longer compensated through capitation reimbursement in a majority of programs.

But that distinction doesn't really tell the whole story. The Medical Home concept is meant to be applied independent of a particular health plan such as an HMO, instead changing an entire practice. This means Medical Homes would deliver the primary care coordinated model for all types of patients. Secondly, there are many more attributes attached to the current Medical Home model, many embracing new technology.

Paul Keckley, PhD, Executive Director, and Howard Underwood, MD, Senior Fellow at the Deloitte Center for Health Solutions, their paper The Medical Home: Disruptive Innovation for a New Primary Care Model, outline the following "Critical Features of the Medical Home":\

• Personal physician – Each patient has an ongoing relationship with a Primary Care Physician (PCP), as well as clinician health coaches
• Physician-directed primary care professional organization – A physician leads a team of health coaches who collectively take responsibility for the ongoing care of patients. The day-to-day operation of the practice is focused on managing population-based outcomes and maximizing individual patient adherence to a distinct, customized self-care management program that leverages information technology. 
• “Whole person” orientation toward adherence, not compliance, incorporating holistic methods with conventional allopathic interventions
• The primary care team is responsible for providing all of the patient’s health care needs and appropriately arranging care with other qualified professionals.
• This includes care for all stages of life: acute care, chronic care, preventive services, and end-of-life care, with strong consideration for the individual’s value system, personal preferences and level of engagement in decision making. 
• Monitored, coordinated and integrated care using electronic medical records and personal health records – Sharing information among medical homes and other providers in the local and regional care system is indicative of an advanced medical home model.
• Measured and managed adherence to evidence-based practices by the care team and the patient 
• Evidence-based medicine and clinical decision-support tools guide decision making. 
• Physicians in the practice accept accountability for continuous quality improvement by voluntarily engaging in performance measurement and improvement.
• Patients actively participate in decision-making, and feedback is sought to ensure patients’ expectations are being met.
• Information technology is used to appropriately support optimal patient care, performance measurement, patient education, and enhanced communication.
• Patients and families participate in quality improvement activities at the practice level.
• Enhanced accessibility: care anywhere, anytime – Care is available via open scheduling, expanded hours and new communications options
• Emphasis on physician incentives for improvements in self-care management – Physician reimbursements appropriately recognize the added value provided to patients who have a patient-centered medical home. 

Keckly and Underwood elaborate on the reimbursement issue. They advocate that the payment structure should: "reflect the value of patient-centered care management work that falls outside of the face-to-face visit; Pay for services associated with care coordination within a given practice and among consultants, ancillary providers, and community resources; Support adoption and use of health information technology for quality improvement; Support enhanced communication access such as secure e-mail and telephone consultation; Recognize the value of technology-based physician work associated with remote monitoring of clinical data; Allow for separate fee-for-service payments for face-to-face visits; Recognize case mix differences in the patient population being treated within the practice; Allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting; and Allow additional payments for achieving measurable and continuous quality improvements.

In the previously mentioned Business Insurance article, primary care reimbursement is also emphasized. They quote Dr. Bruce Bagley, medical director for quality improvement at the American Academy of Family Physicians, discussing the shortage of primary care doctors. “Fewer doctors are going into it. This is a way to reshape the payment environment to get a greater proportion of health care dollars to flow to family physicians for these services.” The article also highlights a new Medical Home Program from Bridges to Excellence (a national coalition of employers and other stakeholders regarding various quality of care and related initiatives). designed to " reward physicians who demonstrate they have adopted good systems and processes of care and are using those systems to deliver positive results in the management of their patients"  Francois De Brantes, CEO of Bridges to Excellence is quoted: "'These doctors will be compensated differently. We believe very strongly…that these practices deserve somewhere around $125 per patient per year in some form of additional incentive. How that incentive is distributed is up to each plan or employer. Some plans are focusing more on fee schedule increases; others are paying a basic capitation fee for care coordination.”

So in summary - the medical home concept links primary care coordination with centralized electronic medical records and new concepts in evidence based medicine and standards of care. The medical home concept also advocates changes in primary care reimbursement that compensate doctors for care coordination and technology infrastructure

Primary care physicians, before HMOs became mainstream, held that fee for service reimbursement typically was weighted towards specialty care, and under-compensated their services. HMO capitation was designed in part, to address that, but was been abandoned in most parts of the country due to managed care backlash over abuses and financial issues. The new Medical Home concept involves patient management and quality incentive compensation in addition to standard reimbursement.

How does any of this simplify health care? If adoption of the new Medical Home model means more care is coordinated through a primary care doctor for each person, with centralized information, then the potential for a simpler system is there.