The term “medical home” has become a catchphrase, tossed around by lawmakers, insurers and health policy experts.
Meanwhile, countless medical-home demonstration projects are being launched by public and private payers, employers, clinical and academic centers and consumer advocacy groups across the country.
In response to that as well as some growing criticism of the movement, four prominent physician groups last month released a set of 16 guidelines for patient-centered medical-home demonstration projects.
“The term ‘medical home’ is used pretty widely,” says Shari Erickson, senior associate for practice advocacy and implementation for the American College of Physicians, one of the groups releasing the guidelines. “We want innovation to occur in this area, but we also wanted to put forth guidance and promote consistency across the programs.”
The American Academy of Family Physicians, American Academy of Pediatrics and American Osteopathic Association joined the ACP in issuing the guidelines. The four groups represent nearly 350,000 physicians.
Ted Epperly, M.D., president of the American Academy of Family Physicians, says in a written statement that the guidelines aim to help “avoid contamination by nonmedical home projects, such as disease-management programs.” The guidelines focus on five areas: collaboration and leadership; practice recognition; practice support; reimbursement; and assessing and reporting results. In short, they are geared toward making sure that physicians are adequately involved, supported, paid and evaluated for their participation in medical home projects.
As for payment, the groups support reimbursement models that are broadly consistent with a bundled component covering physician and staff work and expenses; a visit-based fee component; pay-for-performance using evidence-based quality, cost and patient-satisfaction models; and recognition of varying patient-case mix and complexity.
With an emphasis on health information technology, care coordination and improving clinical outcomes, the guidelines are somewhat consistent with those released last June by America’s Health Insurance Plans, the trade group for insurers. AHIP’s guidelines state that pilot testing should be completed and evaluated fully before the concept is broadly implemented. Others are cautioning against moving to a medical-home model too quickly.
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.
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,” says Laurence Wellikson, M.D., 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 says. “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 & 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,” says 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 says 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 says 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,” Maida says. “The issue isn’t these nifty little terms.”
Maida says that she realizes 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. In March, 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,” says Douglas Henley, M.D., executive vice president and CEO for the AAFP.
Jeffrey Luther, M.D., 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 says.
Submit a letter to the Modern Physician Reader Blog. Please include your name, title, company and hometown. Modern Physician reserves the right to edit all submissions.
