AAMC Reporter: March 2008

Medical Home Concept Gains Momentum

A new model of patient care known as the "medical home" is gaining traction nationwide as a viable alternative to the United States health care system's current system of jumbled provider networks.

The medical home model is defined by the AAMC, which has given a preliminary endorsement to the approach, as a concept or model of care delivery that includes an ongoing relationship between a provider and patient, around-the- clock access to medical consultation, respect for a patient's cultural and religious beliefs, and a comprehensive approach to care and coordination of care through providers and community services.

"Currently we are focused on acute care that people only seek out when they have a new problem or have exacerbated an existing problem, and we lose a lot of opportunities for preventive care, coordination, and patient education this way," said Atul Grover, M.D., Ph.D., AAMC assistant vice president, health care affairs. "This is about agreeing that there are core functions that need to be fulfilled. If you're a patient who has cancer, you may have 10 doctors taking care of you if you have chronic conditions on top of that. The system is so unnavigable, that from the patient's perspective they need an advocate and a central resource."

The medical home, or at least its theoretical version, seems to enjoy almost universal support—patients would benefit from a simpler, more personalized health care experience, while doctors and their care teams would have more support for their legwork and more time to focus on their principle interests.

But the devil, as they say, is in the details. Questions exist over funding and defining a medical home and its components. Scores of studies are underway or in the works to determine whether—and how—a medical home gets better, faster, or cheaper results than more traditional methods of care.

"Everyone says they like the idea," said Michael S. Barr, M.D., M.B.A., F.A.C.P., vice president of practice advocacy and improvement with the American College of Physicians (ACP). "But they wonder about the cost. They wonder if they will know a medical home when they see it."

Most advocates agree that primary care physicians would be a patient's first stop and the central hub of the medical home. So if the medical home is to be widely adopted, the primary care specialties, which are currently less popular than other specialties in part because of relatively low pay, long hours, and voluminous paperwork, would need a shot in the arm.

"The fact that we're losing our primary care base is major—we're looking at some real dissatisfaction among that group," said Barr. "You need to have a strong primary care base for the medical home."

If resources increase for the primary care community, there is concern that Medicare funding may decrease proportionately for specialists or surgeons.

The American College of Surgeons, while declining to comment directly for this article, have through previously published reports expressed general support for the medical home concept with the caveat that more studies were needed. Other experts have said that no other specialty need lose reimbursement for the medical home to work.

"We're so used to it being a zero sum game, of robbing Peter to pay Paul," Barr said. "There is a risk of some of that, but people also say that there is plenty of money in the system right now, and that it's just not going to the right places."

The ACP has recommended a restructuring of the physician payment system to establish or increase reimbursement for primary care coordinators, physician payments for meeting quality benchmarks, incentives such as reduced insurance deductibles for patients who select a medical home as their care provider, and a retooled Medicare system that facilitates coordination between primary care physicians and specialists. According to testimony given Feb. 12 before the Senate Committee on Health, Education, Labor, and Pensions by the federal nonpartisan General Accounting Office, a Medicare fee for a 25- to 30-minute office visit in the metropolitan Boston area for an established patient with a complex medical condition is $103.42, while the fee in the same area for a routine colonoscopy, which normally takes about 25-30 minutes, is $449.44.

"In the current system, procedures are often reimbursed by Medicare and private insurers at a much higher level than cognitive services," said Grover. "So, as a theoretical example, if a physician spends 10 minutes intubating a patient in a hospital, that physician may be reimbursed more than a physician who spent twice as much time taking a patient history and creating a treatment plan. The incentives in our current payment system are seen by some as being at odds with efforts to increase our focus on prevention, disease management, and other aspects of patient-centered care."

There are also concerns that medical homes could create a "gatekeeper" role for the primary care physician and lead to an outsized amount of control for that physician and a bottleneck in the continuum of care—a concern that frequently dogged the early HMO models of the 1980s.

"You think about a medical home as a coordinator of care, not as a gatekeeper that authorizes care," Barr said. "We can use the home to make the appropriate referrals using the appropriate information."

As discussion continues, several organizations are coalescing in support of the medical home. The ACP, American Academy of Family Physicians, American Academy of Pediatrics, and American Osteopathic Association, in addition to the AAMC, have endorsed some version of the concept.

But now, the real work must begin.

Government agencies, public and private organizations, insurance companies, and others are testing various aspects of the medical home—and academic health centers are at the forefront of literally putting the ideas into practice. Officials at the University of Minnesota's Smiley Family Practice Clinic have spent the past three years transforming their clinic into a medical home. The clinic now has an electronic medical records system and a searchable patient registry, and reports an 11 percent increase in diabetic patients who received "optimum care," and that 95 percent of asthmatic patients now have their conditions under control.

Duke University Health System established a regional primary care practice network which now covers six counties in North Carolina. It is part of the state's Community Care of North Carolina (CCNC) program, which is creating medical homes for the state's Medicaid patients. To prepare for the program, Duke officials, local medical practices, and human services agencies pinpointed geographic areas that produced the most emergency room visits. Then, they went out and knocked on the doors of Medicaid patients and others in those areas to find out why.

"We got an earful about how the system was so hard to navigate," said J. Lloyd Michener, M.D., chairman of the Duke University School of Medicine Department of Community and Family Medicine. "We realized we had to change what we did in the office. Patients now have a much deeper involvement in the management of their own care. We have health educators out in the community who work with patients who were just diagnosed with a new condition."

North Carolina's Medicaid system is unusual in that it directly pays physician practices for the costs associated with being a care manager, and also pays practice networks for meeting performance standards on costs and health outcomes for at least three specific diseases. CCNC has resulted in 34 percent fewer hospital admissions for enrollees under age 21 and 8 percent fewer emergency room admissions versus a control group. The average episode cost for children enrolled in CCNC was found to be 24 percent lower versus those not enrolled. The University of Michigan Health System (UMHS) faculty group practice recently participated in a project from the Centers for Medicare and Medicaid Services created by to test new approaches similar to those espoused as part of the medical home. (CMS is currently planning a Medicare Medical Home Demonstration project to specifically gauge the efficacy of a medical home. No timeline or other details have yet been announced.) Among other changes, UMHS nurses followed up with all Medicare UMHS hospital patients within 24 hours of discharge. This reduced the rate of readmission within 48 hours of discharge from 19.5 percent to 18.8 percent. Overall, UMHS saved Medicare $3.5 million in the project's first performance year.

"We were managing patients between visits," Spahlinger said. "That's what you think about for the continuity factor of the medical home. The real fundamental building block of the medical home is to say 'this is who I trust with my health care decisions.'"

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