A look at the medical home concept for primary care physicians

The idea is getting emphasis from state Medicaid and State Children's Health Insurance Program plans, health plans, large employers, and Medicare. Payers and others are also getting trials underway to test the potential.

"I don't think that anybody is really surprised that this has happened. In the recent years here, primary care certainly has had its amount of problems," said William DeMarco, head of the consulting firm DeMarco and Associates, in a recent Web summit sponsored by information company MCOL.

Keckley noted that the health costs situation is "facing meltdown," citing a June Congressional Budget Office report stating they will bankrupt the federal budget. He warned, "Under any scenario of any new administration, there have to be mechanisms to slow the escalating costs of care. And that is not good news if you are a physician."

Outlining the concept

In the forefront of the medical home push is the Patient-Centered Primary Care Collaborative (PCPCC), formed about two years ago. It now has over 160 members, including companies such as Proctor & Gamble and IBM.

In countries where there is more focus on primary care, "People live longer, populations are healthier, patients are more satisfied with their care and everyone pays less," PCPCC asserts. "These 'primary care providers' do more preventive health counseling, perform more screenings and immunizations, and provide care advocacy and coordination."

In addition, the Medicare Payment Advisory Commission devoted a portion of its report on reform for Congress this June to the medical home, calling it a promising intervention.

Where it came from

The medical home idea in this country evolved from the American Academy of Pediatrics' (AAP) concept of continuous care for children with special needs. But a cornerstone of the current effort is a set of principles adopted last year by the AAP, the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association.

Those principles state that each patient should have a personal physician who leads a team at the practice level. The care should be coordinated or integrated across the system, and it should be facilitated by registries, information technology, and health information exchange. Evidenced-based medicine and clinical decision support tools should guide decision-making. Practices should go through a voluntary recognition process by a non-governmental entity for this type of service.

As DeMarco explains, "We are not going to be doing this for too long without somebody raising their hand and saying, 'Well, what about quality, what about safety? Why is this practice better than another practice?'"

The principles also say payment should recognize the value of this management work outside the face-to-face visit. Payment should also support health information technology, and use of secure e-mail, telephone consultation, and technology to monitor clinical data.

DeMarco suggested providers perform a feasibility study, using recent National Committee for Quality Assurance (NCQA) requirements. He noted that the clinical information system is key: "We've had so many people falling through the cracks, so many pieces of the data that are useful that never make it through the report process, they are trying to really broaden this whole clinical information requirement."