Health Care

The Medical Home: Not Rocket Science

by Tim Foley

category: Primary Care

Published March 29, 2009 @ 07:13PM PT

There are some practices in the delivery of health care that make intuitive sense, but are practiced with shocking infrequency:  having a primary care doctor who’s your partner in care;  getting regular reminders of when you need to come in;  training on how to take your medicine or take care of yourself;  and coordination between your health care providers when you have one or more chronic conditions.  It’s not rocket science – it’s the “medical home” model, and its show tremendous potential to reduce costs and improve quality.

We spent some time on this blog reviewing how doctors get paid – largely fee-for-service – and how this consciously and unconsciously tilts the care we receive towards doing a lot of procedures, regardless of their cost or quality.  One of the underappreciated resources in our health care system is primary care and preventative care.  We know that it saves quality and reduces costs by catching ailments early, where they’re easier and cheaper to treat – and yet primary care doctors in private practice have trouble making ends meet.  They get paid for the 15 minute office visit only, and not for spending time teaching you about your condition, training you on how to take your medicine, coordinating with any specialists you may be seeing, etc.  The other underappreciated resource is that last part – coordination and teamwork, which adds value to the quality of care but is uncompensated.  As a result, we’re not getting the care we need as a country. According to the RAND Corporation, Americans get the primary care we need about half of the time.  According to the Commonwealth Fund, only 65% of Americans under 65 even have a personal doctor.

The best sources of care in the country, from the Mayo Clinic to the VA Hospitals and Clinics, stress integrated, coordinated care with all providers working together as a team, sharing information on the patient electronically and, not to get all touchy feely, treating “the whole body.”  The medical home model would makes these features the cornerstone for care.  As always, the hardest nut to crack is paying for quality.  Most implementations of the medical home maintain the fee-for-service prices, but then pay the personal primary care physician a per patient cost on a yearly or monthly basis.  Now some people may remember this “capitated payment” system (a lump sum per patient) as the basis for the HMOs, and subsequently the financial arrangement that led to denying care so the practice or insurance company could keep more of that payment as profit.  For the medical home, the capitated payment comes with strings attached – the practice that’s using the medical home model has to prove that it’s offering coordinated care through establishing clear guidelines and backing that up with hard data, preferably through electronic medical records.  It has to focus on evidence-based results (or prove that it’s using best practice treatments), that it’s providing enhanced access (not just 9 to 5, Monday through Friday but real 24-hour coverage), that it’s truly tracking the referrals for the patient when specialists are involved, that it’s providing instruction on self-management for its patients, and that it’s reporting the results of its physicians.  In short, it’s extra payment for demonstrated quality, not just quantity.

And what do you know? The damn thing works.  It makes sense that it would work for better quality and less cost for those with chronic diseases, as coordination between the various doctors involved, with one doctor -- or physician’s assistant or even just a designated project manager -- having responsibility for coordination has an obvious benefit.  For one thing, it cuts down on duplicate tests or treatments and errors resulting from incomplete records (something I’ve always had to deal with when seeing a specialist, and I don’t even have a chronic condition) or conflicting medications.  For another, it turns out having one person build a relationship with a patient, training them how to self-observe and self-manage their condition, and sending reminders, makes all the difference in the world (as it did when Medicare recently ran trials of coordinated care models).  To give just one example, the rate of men who get screened for prostate cancer who received a reminder from a medical home and got their screening (70%) is double the rate of those who didn’t get a reminder (37%).

So how can you sign up for this fine medical model, you ask?  It sure sounds better than seeing a number of different doctors who don’t coordinate, and paying for doctors completely blind to whether they’re following best practices, right?  This is one area of health care reform that’s going take a long time to accomplish.  The best instigators for developing the medical home are not insurance companies (United Health has launched a program in Arizona, but they had to have a figurative gun to their heads to do so), or at least nor companies that only handle insurance.  Companies who have their own providers on salary, like Kaiser Permanente or Group Health Cooperative in Seattle have found this coordinated care model great for costs and quality.  But the most intriguing implementations so far comes from the public and non-profit world.  The labor union UNITE-HERE has a successful medical home clinic in New York City.  The publicly administered Healthy San Francisco plan runs entirely on the medical home model.  Similarly, the “Sustinet” proposal in Connecticut proposes a publicly administered plan run entirely on the medical home.  Public coverage is very interested in the medical home – private insurance without other incentive, not so much.

The reason why is obvious:  you can’t throw a bunch of providers together, make each one in charge of a set of patients, and call it a medical home.  You need to invest in electronic records, in training, in a coordinator who can have a real relationship with the patient and not just be an impersonal call center, and you have to, have to have physicians who buy into the system and want to make it work.  Without any of these elements, the home falls apart.  It’s work, and it’s not easy.  But the same can be said about any transformational change.

If we really achieve health care reform, it won’t be enough to cover everyone – whether it’s the Obama plan or single-payer, the systemic change offered by the medical home model is crucial to controlling costs and improving quality.  Proponents of the medical home call it “patient-centered.”  Doesn’t “patient-centered” translate to “what medicine should be doing in the first place?”  It’s not rocket science, but it’s a path to restoring the central role of primary and preventative care and, with it, our health outcomes as a nation.

(Photo credit:  jcbonbon on Flickr.)