Medical Home – Patient Centered Care

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The term medical home prompts associations with George Carlin and his comparison of baseball and football.

In baseball the object is to go home! And to be safe! – I hope I’ll be safe at home!

In football, we’re down in enemy territory

Reaching for the end zone

What would George offer as the medical counterpoint to “home”?  End zone might be a bit extreme.  But “homeless” could surely fit.

Can health care reform offer help for the medically homeless?

Safe at home

Medical home demonstration projectts

Shortly after the Patient Protection and Affordable Care Act was passed in March of this year, Mr. Vince Kuraitis, writing for the e-caremangement blog noted that the word “pilot” appears 80 times in the law, and the word “demonstration” is used 312 times

He might have also noticed that the term “medical home” appears 11 times,  exactly the same as “accountable care organization” that I discussed last week.

What is a medical home?

And why does it matter?  And more important – why is the medical home a challenge?

This is not a new concept.  The term has been around since 1967.   It is the concept about primary care that patients should have an access to a patient centered locus of care that is accountable for the long term health outcome of the whole patient.  It is supported by a wide array of  both physician specialty groups and health policy experts.  From the recent issue of Health Affairs

Most providers and patients, however, see the benefits of the patient-centered medical home as obvious. Some of this belief comes from evidence that primary care–oriented health care achieves better health outcomes at lower levels of spending. Some also comes from experimental and observational data showing that improved continuity and coordination of care lead to improved outcomes and reduced use of high-cost services. Finally, some comes from the simple intuitive knowledge that simply having a clinician who knows your name is a better method of providing primary health care.

The concept of medical home is so intuitive that one wonders how we drifted away from the concept.  But it is more than intuitive.  There is ample evidence that our specialty centric system is not producing good outcomes.  Areas of the country with higher primary care physician ratios have lower mortality rates, fewer ER visits, fewer hospital admissions, and lower costs.

And in comparison to Europe where there is much greater orientation to primary care, the United States has twice as many hospital admissions for diabetes and asthma.  And a person with diabetes is twice as likely to undergo an amputation as a diabetic in other developed nations.

That is a disgrace.

What is getting in the way?  Some argue a shortage of primary care physicians.  Some argue lack of an information infrastructure, others that primary care doctors treat too many patients to focus on individual patients.  Some quibble that there is insufficient research to support this or that fix.

My villain – fee for service reimbursement.  Physicians are paid for things they do, not for the results they achieve.  As I wrote last week, individual physician are not accountable for the long term outcome of their patients.  The medical home tries to fix that.

How do you fix it?

The simple answer is to pay primary physicians differently.  Differently includes more.  The pay gap between primary care physicians and specialty physicians is a huge deterrent to recruitment for primary care specialties.

Differently also includes paying for services not typically reimbursed in fee for service medicine – telephone and e-mail consultations, nurse practitioners and physician assistants, and support for information system restructuring.

A payment system that is tied to quality performance and not to specific tasks will encourage physician practices in the right direction.

But there are many barriers to transforming that system.  The current Medicare reimbursement methodology, and it is the dominant force in the market, is a zero sum proposition.  To add to primary care is to take away from specialists care.

But even if Medicare could find a way to change its reimbursement formula, there may not be dominant enough to move the market, especially among those practices that focus on younger populations.

But organizing physician practices around long term patient outcomes is too important a goal to abandon.

Hopefully the PPACA will be able to build some momentum around the patient centered medical home and refocus health care on the patient instead of the payment.