The Medical Home: The Bottom-up Problem

There is no consensus definition of the term “patient-centered medical home…in 2007 the AAFP, the AAP, the American College of Physicians, and American Osteopathic Association issued principles defining their vision of a patient-centered medical home. The core features include a physician-directed medical practice; a personal physician for every patient; the capacity to coordinate high-quality accessible care, and payments that recognize a medical home’s value for patients.

John K. Iglehart, National Correspondent for New England Journal of Medicine, September 18, New England Journal of Medicine, pages 1200 to 1201

America is an overwhelming bottom-up society.

John Naisbitt, author of Mindset! and Megatrends, in Mindset!, Collins, Imprint of Harper-Collins Publishers, 2006

When the New England Journal of Medicine publishes three articles in one issue on Medical Homes and related physician payment reforms, you know you’re witnessing a top-down medical trend, in this case articulated by a professor of health economics and policy at Harvard; the Journal’s national correspondent, a dependable Washington-watcher; and a professor of medicine and policy guru at Dartmouth.

But what about the professionals at the bottom – the primary care physicians - the family physicians, the general internists, the pediatricians – the doctors in the neighborhood trenches.

What do they think?

Before I address the primary care mindset, let’s see what the top-down people are saying.

• The Medicare Payment Commission, created by Congress to advice Congress says, Medicare costs will be unsustainable unless something is done, “a fundamental change in the organization and delivery of health care is needed and urges Congress to pursue three initiatives “expeditiously” – medical home demonstration programs, bundled Medicare payments for hospitals and their medical staffs, and accountable care organizations that look like multispecialty groups.

• Medicare, the top sheriff and payer of the system, is saying it
is making a big financial bet that Medical Home reform will lead to great savings by reducing avoidable ER visits and hospitalizations with reduced overall spending.

• The AAFP, the CAP, the Academy of Pediatrics, and the American Osteopathic Associations, the societies sitting atop the primary care heaps, have issued guiding joint principles for medical homes.

• Fortune 100 companies, that purchase care for their employees, have joined an array of other organizations, have been instrumental in forming the Patient-Centered Primary Care Collaborative, and are pressuring health plans to make changes to support the medical home concept.

• Health plans are making token gestures to help practices implement medical homes.

• The states are mobilizing to support medical homes. A total of 108 bills in 26 states have been introduced that mention “medical homes,: and 20 bills in 10 states define the concept and provide for demonstration projects.


• Organizations as diverse as HealthPartners, the Comprehensive Primary Care Payments and the Massachusetts Coalition for Primary Care Reform , Promethesus, the Geisinger Health System, the Medicare Physician Group Practice Demonstration, and Alabama Medicaid have developed or are developing payment reforms compatible with the Medical Home concept.

• Even most primary care physicians, to whom I have spoken and who have expressed opinions in Sermo.com and medical publications, agree that theoretically medical homes are a fine idea.

The Problem

But as the astronauts returning in a crippled space craft from the moon once said, “There’s a problem, Houston.”

The problem, as shown by a recent national survey of all primary care physicians conducted by the Physicians’ Foundation for Health System Excellence, representing the nation’s state and local medical societies, is this:

Primary care physicians have deep morale, cash, adn time problems and are ill-equipped to deal with the extra burden of implementing medical homes. These physicians are struggling to survive economically, are in short supply, face an uncertain future, and are swamped with patients, rules, regulations, and demands to adopt electronic medical records.

Given the low morale of primary care physicians, their dwindling numbers, and their marginal economic circumstances, it is unreasonable to think they will flock to the medical home concept or are, indeed, capable of taking on the medical home’s extra economic, training, and implementation burdens.

Eligibility Criteria and Capacities Needed for Medical Homes

Consider the eligibility criteria and capacities necessary to participate in medical home programs. In descending order or priorities, those selected for medical home status, will be granted based on these points as defined by the National Committee for Quality Assurance.

1) 50 points – Use of data systems – Use data for nonclinical and clinical information to track patients diagnoses, and clinical status and to generate reminders. Track referrals and laboratory results systematically. Use electronic system to order, retrieve, and flag tests, write prescriptions, and check their safety and costs and improve safety and communication

2) 15 points – Care Management and Coordination – Adopt and implement evidence-based guidelines and use reminders for preventive services. Coordinate care with other providers and use nonphysician staff to managed patient care.

3) 15 points – Performance Reporting and Improvement - Measure and report performance to physician sin the practice using standardized measures. Report performance externally. Survey patients about their experiences and take action to improve.

4) 11 points – Improved Access and Performance – Have written standards for key components of access and communication and sue data to document how standards are met. Assess language preference and communication barriers.


5) 9 points – Support for Patient Care - Develop individualized patient care plans, which assess progress and address barriers to achieving plan goals. Actively support patient self-care.

Real-World Barriers

Or consider these real-world barriers to making medical homes a reality.

• Lack of time, money, energy, and personnel to fill out the forms, make the plans, and install the systems make Medical Homes go. Keep in mind only 10% or so of primary care physicians now have fully functioning EMRs,

• Lack of confidence that the proposed payment scheme – a mix of capitation, fee-for-service, and pay-for performance – will cover expenses of participating.

• Lack of certainty that hospitals and specialists will collaborate or alter the status quo.

• Lack of integrated information systems among hospitals, specialists, laboratories, pharmacies, and free-standing surgery, diagnostic, and imaging centers that would make data-tracking feasible.

• Lack of certainty that patients would embrace medical homes; after all, patients rejected managed care gatekeepers and most feel they have the smarts and should enjoy the freedom of selecting the specialist of their own choice.

• Lack of certainty that specialists would play ball if medical homes threatened their own income.

• Lack of broad accountability for enforcing population-based care.

A Bottom-Up Problem

It’s a bottom-up problem. You can proclaim from the top-down rooftops of payers, businesses, government, and from medical societies, and health plans – what you want to happen and what you think should happen. But the central players – primary care physicians – in making medical homes happen, may be unable or unwilling to make it happen, and the whole idea may never get off the ground. Furthermore, many primary care physicians may regard medical homes as bureaucratic or electronic prisons, as another nail in their autonomy coffin, and they may choose other options, such as concierge care, cash only practices,locum tenens, refusal to accept Medicare or health plan patients, careers outside of direct patient care, or retirement.



References

M.B. Rosenthal, “Beyond Pay for Performance – Emerging Models of Provider-Payment Reform,” J.K. Inglehart, “No Place Like Home – Testing a New Model of Care Delivery,” and E.S. Fisher, “ Building a Medical Neighborhood for the Medical Home, “ New England Journal of Medicine, pages 11197-2005, September 18, 2008