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Report Identifies Obstacles to Establishing 'Medical Homes'

By John Reichard, CQ HealthBeat Editor

DECEMBER 12, 2008 -- A new report by a Washington research firm shows that policy makers face many challenges revamping health care by ensuring individuals have "medical homes"—a single physician practice that gives individuals ready access to doctors who oversee their overall treatment to boost its efficiency, including by keeping them healthier through better preventive care.

Released this week by the Center on Studying Health System Change, the report aims to fill a gap in research on how to put the medical home concept into practice. It lists four big challenges in that regard: how to certify the status of a physician practice as a medical home; how to find patients the right medical home; getting patients and doctors to work together to ensure the right care is delivered in the right place at the right time; and how best to pay practices to function as true medical homes.

The report notes that many of the components of the health care system operate independently, a feature of the U.S. system promoted by fee-for-service payments that pay individual doctors per procedure, giving them a financial incentive to prescribe many appointments, tests, and procedures in order to increase their incomes. While there may be benefits to having so many independent operators in the system, including greater choice of provider, "the flip side of independence is fragmentation—across care sites, providers, and in clinical decision making for patients," the report says.

The medical home concept aims to limit care to its essential components by encouraging teamwork both among doctors and other caregivers and between patients and providers. But "qualification tools" that can be used to qualify a practice as a medical home in the eyes of insurers can pose problems, by overemphasizing information technology, underemphasizing primary care, or through an overwhelming application process to qualify as a home, the report suggests.

The right tool helps a practice focus on the most important things to do to improve care. But the early version of a tool developed by the National Committee for Quality Assurance required 80 to 100 hours to complete, according to several physician practices cited by the report.

"Given that practices with five or fewer physicians constitute 95 percent of office-based medical practices, such time and resource considerations could pose significant barriers to participation among the very practices medical home initiatives are targeting," the report says.

A newer version of the tool takes 40 to 80 hours to complete, the report notes, but suggests further improvements are in order. The documentation burden could be lightened by decreasing the number of information technology items, particularly those not proven to be effective, the report advises.

Effective payment for medical home services requires some form of "capitation," or fixed per-patient payment, the report counsels. And it might be better to initially avoid "budget-neutrality" approaches that fund payment for medical home services by reducing payments to specialists, it adds. "Paying for medical home services without immediate expectation of budget neutrality might begin to correct the imperfections of the fee-for-service system in a way that would minimize opposition" from specialists, it says.

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