The Medical Home, Round Two: Building on a Solid Foundation

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Commentary on The Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey on Views on Health Care Delivery System Reform by Martín-J. Sepúlveda, vice president of Well-Being Services & Health Benefits, IBM Corporation.

The medical home is a 40-year-old concept created by pediatricians in response to fragmented information and community resource challenges for children with special needs. More recently, the medical home—a practice-based structure that facilitates the delivery of comprehensive care and promotes strong relationships between patients and their primary-care, physician-led team—has been applied to adults. In the last several years, the medical home concept has been aided by several key developments, along with the continued escalation of health care costs and a growing national chronic disease burden.

First, buyer activism led by IBM and other purchasers of health care has forged novel partnerships with the primary care physician community to capture the attention of government officials, employer coalitions, major health plans, and health care service intermediaries. Second, primary care physician groups have advanced medical home standardization and recruited key stakeholders to initiate the critical work of transforming the medical home from abstract concept into tangible product. For example, the various medical home constructs were incorporated into a unified declaration of Joint Principles of the Patient-Centered Medical Home and, in response, NCQA built a framework for recognizing physician practices as patient-centered medical homes. The third key development is evidence of patient preferences for medical home services and of better health outcomes and lower cost in primary care-based health systems.

What Next? Channeling and focusing this initial momentum presents the next series of challenges. Foremost among these is the need to re-examine the many activities under way in pursuit of the patient-centered medical home to assure that priorities are explicit and investments are aligned to these key objectives; precision exists with regard to interventions and their expected impact on specific outcomes; and lead time for change management and lag time for results are accounted for in experiments and measurement.

Asymmetric investment. There is a glaring imbalance between the human resources and funds devoted to the medical home's plumbing and wiring—technology, processes, certification, measurements, and payments—and the investment in solutions for its critical dependencies. These include the need for a standard inventory of primary care services, an expanded physician skill set, such as leadership and team building, and to strengthen the quality of the relationships between those who will deliver and those who will receive care within the medical home.

Patient surveys of physician quality consistently rank effective communication among the most important attributes influencing their physician rating and satisfaction with care. While much is known about the elements of effective physician–patient communication, current efforts at enhancing communication effectiveness center only on engagement through technology. Skills of non-judgmental inquiry, heedful listening, sharing, comprehension testing, advocacy, and coaching are being neglected, despite their critical importance to meaningful exchange, dialogue, and real behavior change. Who is taking responsibility to assist physicians to acquire these skills?

Small practice conundrum. Most physician practices are in non-institutional environments and are predominantly small practices. Nearly 75 percent of visits to physicians occur in practices of four or fewer physicians and nearly 50 percent of practices have only one or two physicians. The requirements of the medical home increase the number, intensity, and accountability for delivered services as well as the information management needs of practices. Most small practices today lack the people, process and technology infrastructure, space, capital, and purchasing efficiency to meet the full set of medical home requirements.

Meeting medical home requirements may well enhance the pressure on small practices to consolidate or to seek new models for pooling resources to make needed investments in staff and technology; implement process changes; measure, monitor, and improve quality, and create efficiencies to manage unit costs. Large primary care practices may supplant the small cottage-type industry of the profession today. These practice models include large private group practices, primary care practice cooperatives, institution-based primary care, and integrated delivery system-based primary care with or without alliances with health care service extenders. These service extenders such as disease management firms, pharmacy retailers, or prescription benefit management firms, as well as health plans appear interested in exploring and testing such office extender approaches. This interest may be motivated by the medical home's potential to disrupt current purchasing patterns for disease management services, prescription drugs, and the discounted network.

Cost Savings: Value or Values? It is now known that most near-term, direct cost savings from chronic disease management are related to reduced hospitalization and emergency room visits. The medical home is anticipated to deliver similar financial benefit through delivery of the same service. The chronic disease management evidence is not persuasive, however, in demonstrating that the initial magnitude of reduction in facility utilization—and cost reductions—persists over time. Buyers and payers of health care are more interested in changes between current and prior year costs than in comparisons of current versus pre-implementation or baseline-year costs. No data on medical home suggests it will impact other near-term cost categories to sustain this initial effect on cost savings related to facility use.

It is expected that comprehensive care and strengthened patient–physician relationships in the medical home will cause changes in volumes and patterns of specialty referrals and technology use, resulting in lower health care costs. This has been demonstrated in integrated delivery, or closed systems of care, such as the Veterans Administration, environments with cultures, controls, and populations that are not representative of the overall U.S. population. If patient-centered primary care in medical homes cannot replicate this performance, it is unlikely to meet demands for reductions in direct health care expenditures. From a patient-centered perspective, providers in medical homes will be pressed to meet patient needs for autonomy and control and to avoid behavior or associations construed by patients as restricting access to care or "gate keeping."

If buyers and payers expect consistent cost savings from the medical home, how will they respond to failure to realize this end? Is direct health care cost savings the appropriate economic construct for expectations from the medical home? I believe that the medical home is better served by promising value rather than near-term cost savings. Value is the worth that the buyer places on a product or service and includes personal judgment of benefit in relation to cost and to alternatives. This is true for patient, employer, and government buyers who attach importance to the prevention of adverse productivity or the impacts of impairment and restricted access to care on communities. Value also focuses on the benefits perceived by patients. Patients consistently report that they want physicians to spend time with them, to communicate effectively with them in ways that respect their preferences, to receive comprehensive care, to have their care coordinated, and to have all their information at the point of care.

This may not save money, but it is associated with better patient participation in health improvement. These patient requirements for medical home services reflect personal values involving human needs for autonomy, control, safety, security, and trusting relationships. Care that reflects these internal values increases the likelihood that patients will actively participate in decision-making and will undertake the difficult changes in lifestyles and behaviors that lead to risk mitigation and adherence to treatment.

The restructuring of health care delivery to provide for trusting patient–physician relationships and comprehensive care in a medical home is cause for great optimism. The medical home is an attractive operational model for catalyzing both the transformation and reinvestment in primary care. Greater attention to disclosure and remediation of gaps in skills, service capacity, and process are now key priorities. Medical home expectations should be reassessed to assure that the measure of success is appropriate. Finally, the time has come to address the patient values component of the new care delivery model. The success of the medical home is dependent on harmony with personal values since, in the end, home is where the heart is.

The views presented in this commentary are those of the author and should not be attributed to The Commonwealth Fund or its directors, officers, or staff.