Home sweet medical home
By Jonathan Nelson
On Jan. 8, 2008, the National Committee for Quality Assurance launched a standardized recognition program designed to be a measuring stick for physician practices wishing to qualify as patient-centered medical homes. Primary care organizations like AAFP and TAFP have been quite successful at raising the profile of the concept and inserting it into the national debate. It has a great ring to it. After all, who wouldn’t want a medical home? But what exactly is it and does anyone know if it will work?
As November nears and election-year rhetoric escalates to its fevered pitch, health care reform ranks high on the list of hot debate topics, making up a significant portion of the candidates’ platforms. Among discussions of universal coverage, tax credits for insurance premiums, health savings accounts and transparency, you’re likely to hear candidates tout a concept familiar to family doctors: the medical home. As medical costs and insurance premiums climb and a growing number of employers shift premium costs to employees or bail out of the insurance game altogether, there’s a palpable sense that something has to give.
The United States spends 16 percent of its gross domestic product on health care—$6,400 a year for each person—yet 47 million people are uninsured. The costs associated with practicing medicine for physicians continue to escalate while payment for primary care services remains flat. As AAFP Board Chair Rick Kellerman, M.D., recently told the American Medical Association House of Delegates, medical students are good at math and they’re using their calculators to help them decide which specialties to pursue. The number of students choosing to specialize in family medicine has fallen dramatically over the last decade.
According to the Robert Graham Center, nearly one in five Americans don’t have ready access to a source of primary health care because of a local shortage of primary care physicians. Patients without access to basic care don’t get proper management of their chronic diseases. Once those diseases progress, they are forced to seek care in the most expensive sectors of the health care delivery system.
Even in areas where there is an abundance of physicians, patients often receive fragmented care. They see several different specialists for different problems, few of whom are aware of the full range of treatments their patients are getting. Duplicate services and tests add to the cost of care patients receive and in some cases, this duplication results in poor quality and unsafe care.
AAFP, TAFP and other state and national primary care physician associations proclaim the many benefits of the patient-centered medical home in hopes that this model of care can improve the quality and cost-effectiveness of health care for the nation.
“The idea of a medical home is no surprise to a family physician because that’s what we are to our patients,” says TAFP President Linda Siy, M.D., of Fort Worth. “Successful, efficient health care systems have at their base a good primary care network, where every patient has access to a primary care physician and every patient has a medical home.”
“I think the medical home is what I do,” says TAFP’s immediate past president, Douglas Curran, M.D., of Athens. “It’s more than just taking care of [my patients’] health problems. I get to know them, to spend time with them. I have an idea about what they will do and what they won’t do.”
Most of what his patients need Curran can provide in his clinic but when someone needs a referral, he can guide them to the right physician and give the specialist the patient history and diagnostic results necessary to ensure quality and efficiency through the transition. “To be a good medical home, you have to help people navigate the system.”
R. Russell Thomas Jr., D.O., M.P.H., is a family physician in Eagle Lake. He says maintaining an ongoing relationship with a patient has many advantages that not only lead to better health outcomes but also save money in the health system. In a medical home, physicians can provide continuous and comprehensive care “instead of treating every single episode as if it’s the only time we’re going to see that patient and do the mega-work-up for each little process that they have,” Thomas says. “Knowing the patient also I think helps to develop trust between the patient and the physician, which means that I don’t have to be as defensive in my practice of medicine,” another way the medical home helps cut costs.
Can the patient-centered medical home work?
The American Academy of Pediatrics started using the term “medical home” in 1967 and since then, its meaning has been shaped, expanded and refined by a number of organizations. In the final recommendations of AAFP’s Future of Family Medicine Project, the medical home concept appeared as the foundation of the specialty’s New Model.
“Family medicine will redesign the work and workplaces of family physicians,” according to the report. “This redesign will foster a New Model of Care based on the concept of a relationship-centered personal medical home, which serves as the focal point through which all individuals—regardless of age, gender, race, ethnicity, or socioeconomic status participate in health care.”
A wealth of information has come to light over the past several years to support the theory that patients with ready access to primary care receive higher quality care with better health outcomes for less cost. The Center for Evaluative Clinical Sciences at Dartmouth has found that U.S. states relying more on primary care report better health outcomes, scoring higher on quality rankings and recording fewer ICU deaths. They also have lower Medicare spending and lower health care utilization rates.
Barbara Starfield, M.D., M.P.H., of Johns Hopkins University has published numerous studies showing that primary care is associated with lower health costs while achieving lower mortality and morbidity rates. Her research also suggests that a health system based on primary care reduces socio-economic health disparities. This finding was recently bolstered by a report from the Commonwealth Fund that shows medical homes can reduce or even eliminate racial and ethnic disparities in health care access and quality for people with health insurance.
AAFP reports that a study of diabetes care in North Dakota by Blue Cross Blue Shield and Harvard Medical School found that services provided in medical homes improved results for comprehensive diabetes care and improved patient satisfaction while netting a savings of $232,923, or $1,213 per patient, in 2006. “Likewise, the Community Care of North Carolina program for Medicaid patients showed improved outcomes and a $231-million savings for fiscal years 2005 and 2006 as a result of implementing physician-led networks based on the medical home concept,” according to an AAFP news release.
Lawmakers are beginning to get the message. The term “medical home” is showing up in legislation both state and federal, and at a conference in November 2007, the Council of State Governments approved a resolution urging its members to implement and fund pilot medical home programs. “More and more employers and insurers—and now lawmakers—are recognizing that America’s health care system must rest on a foundation of primary care that’s provided in a setting where patients can develop long-term relationships with their physicians and where physicians can provide comprehensive and preventive care,” said AAFP President James King, M.D., in a release after the conference.
Sen. Richard Durbin of Illinois and Sen. Richard Burr of North Carolina have co-sponsored legislation that would establish a medical home demonstration project for some patients enrolled in Medicaid and SCHIP. In TAFP’s new advocacy video, “Academy in Action: The Patient-centered Medical Home,” Sen. Durbin says that in today’s health care system, a medical home is a luxury that doesn’t exist for many patients. “When you consider the growing cost of medical care across America, there are certain common-sense approaches that we should be turning to. Medical homes would be one of those, to make sure that primary care physicians can be in direct touch with families on a regular basis to provide them the best and most economical health care,” Durbin says in the video, which can be viewed on the Advocacy pages of TAFP’s Web site at www.tafp.org/advocacy.
In a letter to Sens. Durbin and Burr, AAFP’s Kellerman praises the intent of the bill but raises an important concern. The bill doesn’t specify that there be one definition of a medical home, meaning physicians could find themselves trying to meet the requirements of several different definitions put forth by organizations and regulatory bodies that may not hold the health of the patient as the top priority.
Defining and certifying the patient-centered medical home
While most family physicians would argue that they already provide a medical home for their patients, if insurers and employers are to agree that they should pay more for those services, they will certainly require that there be a standard definition against which they can measure practices. AAFP has worked to ensure family physicians are instrumental in setting that definition.
In February 2007, AAFP along with the American Academy of Pediatrics, the American Osteopathic Association and the American College of Physicians published seven joint principals of the patient-centered medical home. Larry Fields, M.D., who was serving as AAFP Board Chair at the time, described the importance of the proposed reforms. “These principles define and articulate the health care environment our patients need and want—where patients have a relationship with a doctor who knows them, their medical history and their family, where doctors and other health care professionals provide comprehensive and continuous care in an environment that nurtures patient/physician collaboration, improves quality and is cost-effective.”
The seven principles are detailed in a three-page document entitled, “Joint Principles of the Patient-centered Medical Home,” which is available on AAFP’s Web site. In short, they are:
- Personal physician – each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
- Physician-directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
- Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for 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.
- Care is coordinated and/or integrated across all elements of the complex health care system and the patient’s community. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
- Quality and safety are hallmarks of the medical home.
- Enhanced access using open-access scheduling, extended business hours and methods of asynchronous communication, such as e-mail, voice mail and interactive Web sites.
- Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home.
The document contains extended explanations of both the quality and safety principle, and the appropriate payment principle, laying out the framework for a new method of paying for primary care. Many physicians and primary care advocates believe that for patient-centered medical homes to be viable, payment from public and private entities must account for the coordination of patient care, work done outside the bounds of the face-to-face visit.
With the help of these physician organizations, the National Committee for Quality Assurance launched a new practice recognition program designed to determine which physician practices meet the standards of the patient-centered medical home. The program, “Physician Practice Connections—Patient-centered Medical Home,” is based on the Joint Principles of the Patient-centered Medical Home and has three levels of recognition.
The process consists of a Web-accessible survey tool physicians use to perform a practice evaluation, and a more intensive application process that includes submission of documentation to support the assessment. Practices that meet the standards will receive the recognition for three years, after which they will have to renew the certification. The survey tool costs $80 and physicians can purchase a license to use it without committing to the full application, which is priced according to the number of physicians in each candidate practice.
“It’s really a tool like a roadmap for a practice,” says Mina Harkins, NCQA Vice President of Physician Recognition Programs. Practices can use the survey to see how they measure against the standards, then take as long as they need to implement changes necessary to win recognition.
Once a practice receives the recognition, NCQA publishes the news on their Web site, www.ncqa.org, and it submits the names of the physicians and their practice to health plans receiving its monthly quality report. “Health plans love to turn around and tell their patients and employers that they have physicians who meet these standards,” Harkins says, referring to the organization’s other physician recognition programs.
Harkins says the hope is that the recognition will make physicians eligible to receive financial bonuses through pay-for-performance programs where they are offered. “The primary care physician is so important to health care and if we can find a way to substantiate paying them a better level of reimbursement, then everybody benefits.”
While NCQA reports receiving several inquiries about the program, it’s too new for any practice to have completed the process. Perhaps the more important aspect of the program’s launch is that this process can now be used as a standard for medical home pilot projects. Harkins says at least three health plans have signed up to do demonstration projects based on the NCQA medical home recognition. She expects the plans to announce these projects publicly in the next couple of months.
“This is what was intended to [happen] first, to have some practices go through this program and get this recognition as a medical home and then the health plans want to measure whether these practices in fact coordinate care better,” she says.
Several other pilot projects are in development across the country to measure the effectiveness of various payment models for medical homes as well as their ability to deliver on the promise of better health outcomes and cost savings. The largest of these may be the long-expected, three-year Medicare Medical Home Demonstration, scheduled to begin in 2009 across eight states. Texas is not among the states chosen to participate.
With all the attention placed on the concept of a patient-centered medical home, all eyes are on primary care specialties, and perhaps most intently focused on family medicine. AAFP Board Director and TAFP Past President Roland Goertz, M.D., of Waco, is optimistic about the prospects of the medical home and the specialty. “For the first time in the history of family medicine as a discipline, we have data, information, scientific studies that show the value of a personal medical home beyond the shadow of a doubt,” he says. “Legislators will listen to information like that, and they’re listening more and more. They want us to help put the personal medical home in place for all the people in Texas.”
The Robert Graham Center recently published a comprehensive report entitled, “The Patient-centered Medical Home: History, Seven Core Features, Evidence and Transformational Change.” In its final paragraph, the report gives voice to the urgency and importance of the task of proving the benefits of the medical home to employers and insurers. It states that the physician workforce most suited to provide the medical home to patients is “under siege,” so undervalued in the current payment system that fewer medical students choose to join it each year. “The patient-centered medical home,” the report concludes, “may be a model without a workforce if efforts to develop it are delayed much longer.”