In December, when we published the column "No Place Like Home," about the importance of medical homes in primary care, we asked readers to contact us with their thoughts. The response has been tremendous, and we've enjoyed replying to everyone who connected with us and learning from their perspectives and experience. We've selected a few of our readers' e-mails and, with the permission of the authors, are reprinting them below. The e-mails are followed by a brief commentary.
Steve Schoenbaum and Melinda Abrams
We welcome and greatly admire the efforts of the American Academy of Pediatrics (AAP) and others to promote the concept of "medical homes" [highlighted] but we feel it important to clarify one critical point: the medical home model was already in place well over a decade before AAP crafted its definition on paper in 1977.
The actual model has its genesis in the launch of the federal community health centers program in 1965, during the Johnson Administration. The idea then, as it is now more than 40 years later, is that by widening access to an affordable and regular source of care in places where doctors are scarce, we can help break the cycle of disease and poverty.
In recent years, health centers have expanded upon the original concept, adding vital oral health and mental health services to meet the needs of their patients, and thus moving from "medical homes" to become much more comprehensive "health care homes" for their communities.
Health centers deliver high quality primary health care to 16 million low-income Americans today, yet 35 million others lack access to a health care home. Regardless of how and when the model began in the past, our future depends on building many more of them now. When it comes to saving both lives AND money, the best bet for keeping people healthy and out of hospitals is a package of affordable coverage and a committed health care home.
Vice President for Federal, State and Public Affairs
National Association of Community Health Centers
As a primary care physician myself, I fully appreciate the need for a reliable, effective "medical home" relationship for every American, as an important public policy goal over the next decade. This becomes even more necessary as health care in this country is becoming increasingly fragmented and specialized for most patients. I believe most Americans would ideally be served by a medical home under the auspices of a primary care physician in family medicine, internal medicine, or pediatrics. However, we must also acknowledge that many patients with various chronic diseases may be best longitudinally managed by a specialist in endocrinology, neurology, or cardiology, for example.
So, as we develop the medical home concept, we need to allow for a flexible approach that recognizes that some specialists will, of necessity, continue to do a great deal of primary care. More significantly, for patients with diabetes, heart failure, and many other chronic conditions, the respective specialty physician of such individuals may prove to be the most effective and cost-efficient means of providing the continuity and coordination of care that are the foundations of the medical home.
Jack Lewin, M.D.
American College of Cardiology
We at the New York American Academy of Pediatrics saw how even a crude effort could make a difference in New York over a decade ago. Facing a crisis of pediatricians not being able to afford to see children on Medicaid, we had to find a solution. With the New York State Dept of Health and the Medicaid office support, a program was designed that became known as PPAC, for Preferred Provider and Child. Pediatricians and boarded family physicians with hospital privileges could sign up if they met criteria that included assuring 24-hour availability and continuous care. In return, they got special billing codes (fee for service) that in essence tripled their income from these children. The program did not cost Medicaid extra: ER use dropped and private office care is less expensive than either hospital clinic or neighborhood health center care. The pediatricians loved it too—even when we helped the Department of Health monitor doctor compliance.
PPAC got wiped out by the tsunami of mandatory managed Medicaid. However, it reinforced my belief in the value to patients, clinicians, and the general public of the medical home concept. Setting standards with the appropriate stakeholders, aligning incentives and building accountability can help contain cost while assuring access to quality care.
The medical home concept, by itself, can't reform a $2 trillion monster—but it sure can help give folks better, safer care.
Louis Z. Cooper, M.D.
Professor Emeritus of Pediatrics, Columbia University
Former Chair, District II, AAP
Former President, AAP
New York, NY
I read with great excitement your recent Commonwealth Fund piece "No Place Like Home." At the Center for Medical Home Improvement (CMHI) at Crotched Mountain Foundation here in New Hampshire, we have been supporting primary care practices to develop their "medical homeness" for over 12 years. Our efforts have been supported by the U.S. Maternal and Child Health Bureau and include state, regional, and national medical home learning collaborative efforts. The latter was accomplished in a partnership with the National Initiative for Children's Healthcare Quality (NICHQ).
Broad-based support for primary care must include both quality improvement help coupled with resources for the numerous unpaid care processes needed and recommended. A few CMHI tools, lessons learned, and outcomes achieved may be of interest. Our Medical Home Index (MHI) is a nationally validated measurement tool assessing quality from the practice perspective (Ambulatory Pediatrics, Vol. 3, and No. 4. 2003). Using this tool our demonstration efforts have shown practice improvement of 33 percent over baseline in six indicator domains including: organizational capacity, chronic condition management, care coordination, community outreach, data management, and quality improvement.
Each of these above mentioned measurements and other care process tools are available on our Web site (www.medicalhomeimprovement.org).
Co-Director, Center for Medical Home Improvement
Crotched Mountain Foundation
[The article] raises very pertinent issues that relate to health care for older people. With the ageing of societies across the globe there will be increased demand for systems of health care that respond to the actual needs of this large and increasing "user group."
We have undertaken government-funded research in Australia that showed the very significant numbers (up to 79% of emergency presentations and admissions) of older people who would, with earlier pickup and intervention, not require hospital admission. Qualitative research techniques allowed us to analyze the factors that led to otherwise avoidable admissions for this group of patients 75 years and over. Systemic gaps in primary health care provision leading to missed opportunities for early detection and intervention accounted for the significant number of avoidable admissions.
Following directly on from this research we have been able to design and implement a new trial program run by Australia's New South Wales Department of Health (at 3 sites around Sydney and in one rural setting near Canberra). The program, Sub Acute Fast Track Elderly Care (SAFTE Care) has now been running for 10 months.
The program is being formally evaluated by an academic institution (Wollongong University). The interim evaluation has shown significant wins and learnings.
Dr. Tuly Rosenfeld, MBBS, FAAG, FRACP
Senior Specialist Geriatrician
Senior Lecturer University of New South Wales, Australia
Advisor to Health Services Improvement Branch, New South Wales Department of Health
The medical home concept works by improving quality, patient satisfaction, access and outcomes while decreasing overall costs. This has been demonstrated, illustrating the feasibility of the concept and the pitfalls in getting to a stable base of medical homes in America. One of the Robert Wood Johnson Pursuing Perfection grants in Bellingham, Wash. was used to transform a large practice into one where an information system was installed, phone and nurse visits implemented, open access developed, pro-active monitoring of chronic conditions and preventive care done, and staffing increased to enable all of the above.
Outcomes improved, satisfaction improved, overall costs declined. But, this experiment fell apart because insurers would only pay for face-to face visits and income to the site decreased. Success in developing effective medical homes that are more than an office and a night call rotation require increased funds targeted to improve this care. We have seen an 11 percent decrease in primary care revenue over the past decade while hoping for a transformation.
The larger view is that we need to control costs and improve quality. At this time 75 percent of all health costs are incurred by people with chronic conditions. Eighty percent of the care for these people with chronic conditions is done by primary care (best done in fully competent medical homes). For Medicare, the more primary care in a community, the better the outcomes and the lower the cost—much lower. If we value something like primary care, we will need to invest in it—and this is one investment that pays off.
Bob Crittenden, M.D., M.P.H.
Professor, University of Washington School of Medicine
Chief, Family Medicine Service, Harborview Medical Center
How unusual it is to have the nation's family physicians, pediatricians, and internists—the group of physicians that do a slight majority of face to face visits with people each day—all calling for a medical home AT THE SAME TIME! This is an extraordinary situation and a moment to be seized with vigor.
I would add that in addition to revision in the business model and a new approach to financing the medical home, the data standards for the Continuity Care Record and/or the Personal Health Record are poised to be great enablers of deliberate, forceful movement toward having a medical home for everyone. The name of each person's personal physician and their location should become a required field in these data standards to enable integration of care.
A usual source of care, i.e., a "medical home," is firmly established as crucial to people getting the care they need in a highly personalized and efficient manner. Surely a medical home plus health insurance for all should become the battle cry for health policy in the run-up to the 2008 elections.
Larry A. Green, M.D.
Senior Scholar in Residence
The Robert Graham Center
I teach a required course, Legal and Ethical Foundations of Advanced Practice Nursing, at The University of Texas Health Science Center - Houston, School of Nursing. We have a nurse practitioner program with several specialties leading to a master of science in nursing degree and a new program for a doctor of nursing practice degree.
I strongly support and encourage the use of certified nurse practitioners who have prescriptive authority through their respective State Board of Nursing as primary providers in "medical homes." In a patient-centered, primary-care oriented health care system these nurses would be significant in providing continuous, comprehensive and coordinated care. I concur with your statement that reimbursement might be problematic along with other challenges. However, I like the concept of establishing "medical homes," as it seems very appropriate for our future in health care delivery.
Dorothy A. Otto R.N., Ed.D.
University of Texas Health Science Center-Houston
School of Nursing
Comments from the authors:
Several themes emerged as we sorted through the responses to our column, including the evolution of elements of the medical home; the types of providers who best offer these services; special populations to whom the concept could be applied; the reimbursement quandary; and the role of infrastructure such as information technology. Below, we'll address some of the points raised in each of the selected letters:
Dan Hawkins, of the National Association of Community Health Centers, points out that the concept of providing the services that are embodied in medical homes began long before the term was coined. Medical homes are supposed to provide care that is accessible, patient- and family-centered, comprehensive and continuous, coordinated, equitable, and culturally sensitive. Indeed, not only might community health centers be one early model for medical homes, but also staff and group model HMOs, such as Kaiser Permanente. Nonetheless, the existing practices and practice models that embody some of the elements of medical homes could provide more of, or better execute, this kind of care. In addition, as Mr. Hawkins points out, we believe that the country needs many more practices that incorporate these medical home elements.
Dr. Lewin discusses whether primary care needs to be provided by—or is best offered by—generalist physicians. And Dr. Otto raises the issue of advanced practice nurses providing medical home services. Our understanding is that the evidence shows that primary care services are associated with better outcomes and lower costs regardless of who delivers those services. If specialists, advanced practice nurses, or generalist physicians are going to provide a medical home for patients or to certain groups of patients, they will need to assure that they are providing comprehensive primary care for those patients. This is an important reason why we raised in the original article the need to be able to specify, measure, and possibly certify or accredit practices delivering primary care services and highlighted some of the promising work being done in this area.
Ms. McAllister's e-mail introduced us to the Center for Medical Home Improvement at Crotched Mountain Foundation in New Hampshire. It developed out of the classic definition of medical homes for children with special needs. Interestingly, Ms. McAllister and her co-director, Dr. Cooley, have developed a practice-level measure of the implementation of the medical home model.1 They also have been running collaboratives for improving care in medical homes, with significant success.
Dr. Rosenfeld, in Australia, and others who wrote to us are applying or would like to apply the medical home concept to geriatric patients, which makes perfect sense.
Drs. Crittenden and Otto note the problems in maintaining the medical home concept in the face of current reimbursement practices. Without question this is a major challenge. It is unlikely that medical homes will proliferate without a change in reimbursement. The last Congress, in year-end legislation, required the Centers for Medicare and Medicaid Services to perform a demonstration project on medical homes that would include changes in reimbursement. It remains to be seen whether a demonstration started now could lead to broad change soon. The American College of Physicians has recently advocated for more widespread demonstration.2 We believe that much more thinking needs to be done about new ways to compensate primary care and medical home services. A new paper on this subject is now available on the Web to subscribers to the Journal of General Internal Medicine, and with luck, interest, and action, compensation for primary care and medical homes will increase soon enough to attract more into the field.3
Dr. Green observes that in addition to new ways of financing, we need to think about supporting medical homes with an information infrastructure—a subject in which he is an expert. Again, we agree. One of us spent many years at Harvard Community Health Plan (HCHP) when it was a primary-care oriented staff model HMO. HCHP implemented an automated medical record system in 1971. Even the technology in that pre-Windows era permitted some forms of decision-support, such as reminders and prompts, that do not exist in the majority of primary care practices in the U.S. today.4,5
Finally, Dr. Green exhorts us to support the concepts of medical homes plus health insurance for all. These priorities are consistent with the framework for a U.S. health system for the 21st century that has been developed by The Commonwealth Fund Commission on a High Performance Health System.6
Again, we thank you for your responses to the column and look forward to continuing this conversation.
Steve Schoenbaum, M.D., M.P.H.
Melinda Abrams, M.S.
1W. C. Cooley, J. W. McAllister, K. Sherrieb, R. E. Clark, The Medical Home Index: Development and Validation of a New Practice-Level Measure of Implementation of the Medical Home Model. Ambulatory Pediatrics 2003;3:173-180.
2American College of Physicians, A System in Need of Change: Restructuring Payment Policies to Support Patient-Centered Care. Philadelphia: American College of Physicians; 2006: Position Paper.
3A. H. Goroll, R. A. Berenson, S. C. Schoenbaum et al., "Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care." Journal of General Internal Medicine; published online: 9 January 2007, available to members at: http://dx.doi.org/10.1007/s11606-006-0083-2
4S. C. Schoenbaum and G. O. Barnett, Automated Ambulatory Medical Records Systems: An Orphan Technology. International Journal of Technology Assessment in Health Care 1992;8(4):598-609.
5C. Schoen, R. Osborn, P. Trang Huynh, M. Doty, J. Peugh, K. Zapert, On The Front Lines of Care: Primary Care Doctors' Office Systems, Experiences, and Views in Seven Countries, Health Affairs Web Exclusive (Nov. 2, 2006):w555–w571.
6The Commonwealth Fund Commission on a High Performance Health System, Framework for a High Performance Health System for the United States, The Commonwealth Fund, August 2006.