Medical home inspection

As more attention and activity gets focused on the “medical home” concept, it’s only natural that critics are now lining up to point out faults in the model.

Medical homes are care and reimbursement approaches that call for such elements as increased patient access to doctors and increased income for primary-care physicians as they receive compensation for time spent coordinating care between specialists and managing chronic conditions. (A separate but related concept, known as shared decisionmaking, also is attracting attention; see story, p. 18).

The medical home approach is attracting a growing number of supporters. Recently launched medical home pilots and initiatives include Seattle’s 615-bed Swedish Health Services opening a new primary-care clinic on March 31 that is “utilizing the medical home model exclusively from day one” at its Swedish Medical Center-Ballard campus. On April 6, IBM Corp. and the University of Oklahoma School of Community Medicine announced they would partner on a medical home pilot in Tulsa with the intent of developing a practice “blueprint” that could be replicated by others. This builds on the initiative the university launched in the last quarter of 2008, which is working to develop medical homes for its Medicaid patients.

Not so fast, some say. Some critics believe that all the attention is causing a potentially dangerous narrowing of focus. “It appears everyone is betting on this one horse and this horse only,” said Laurence Wellikson, CEO of the Society of Hospital Medicine, a physician organization for hospitalists. “It’s a very big bet that primary-care organizations are putting on one plan, and it may only be applicable to a few practices,” Wellikson said. “In an already downtrodden field, if the medical home model is not successful, it may bring primary care down further. If medical homes underperform or underdeliver, it would further demoralize primary care.”

For others, medical homes look to become the next front opened on the process vs. outcome measure debate—especially since there is little evidence that these processes produce the benefits medical home advocates are promising.

The metrics by which a physician practice achieves medical home designation were questioned in a report titled Pay for Innovation or Pay for Standardization that was issued by the Network for Regional Healthcare Improvement in February. “Payers should wait for additional evaluations regarding which specific processes and structures produce better outcomes before establishing or utilizing strict standards for which organizations can serve as medical homes,” according to the report.

The Santa Clara Valley Health and Hospital System, San Jose, Calif., successfully piloted a program using medical home concepts at its Silver Creek Clinic, and hopes to eventually reproduce similar results at the system’s other six clinics. But the person in charge of the project is downplaying the medical home hype.

“ ‘Medical home’ is a new reframing, a jazzy name that people are attaching themselves to,” said Margo Maida, director for primary and community health services at Santa Clara Valley. “It’s just engaging in thoughtful care practices that we should have been doing all along.”

Maida said that the typical method for getting primary-care physicians to move toward the medical home concept has been, “Give people a blueprint and tell them to do it—even if it doesn’t fit their practice.” She said that in Santa Clara, physicians are told where the system wants to go with patients, and the doctors decide the best way of getting there. “We assign a team to a set number of patients and say, ‘You have to take care of these patients 24/7.’ We don’t want to see them in the emergency room or at urgent care and, if we do, figure out why,” she said. “The issue isn’t these nifty little terms.”

Maida said that she realized there has to be some set of medical home standards or regulations for funding purposes, but she thinks the focus needs to stay on outcomes. “The medical home is not a cookie-cutter model.”

There has been a lot of activity on the process side. Late last month the National Partnership for Women & Families, a Washington-based consumer healthcare and workplace advocacy group formerly known as the Women’s Legal Defense Fund, along with more than 20 other organizations developed a set of principles that purport to advance the medical home with the consumer in mind. While the principles don’t differ much from a similar set developed by four primary-care medical societies in 2007, a leader of one of those organizations feels they make a beneficial contribution to the medical home discussion.

“I think the nine principles are totally congruent with our thoughts on a medical home and what are the most important aspects of a medical home in its best expression,” said Douglas Henley, executive vice president and CEO for the American Academy of Family Physicians.

Jeffrey Luther, president of the California chapter of the AAFP, supports state legislation that would create a legal definition of the medical home. “As the medical home becomes a growing concern, more and more parties will be interested in having a hand in what it will look like with various motivations for doing so,” he said.

What do you think?

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