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An Understanding of ‘Medical Homes’ April 30, 2008

Posted by Reginald Johnson in Healthcare, Life.
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The term “medical home” has recently become a hot topic, but has been in the lexicon for decades. The American Academy of Pediatrics is credited with coining the term back in 1967, although back then the concept was limited to creating one central location for all of a patient’s medical records.

Today, the concept embraces 21st century technology, melding it with a primary care delivery system, evidence based medicine and reform of primary care compensation.

The American Academy of Pediatrics defines the medical home as a model of delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care.

Deloitte Consulting, in their recently published paper The Medical Home: Disruptive Innovation for a New Primary Care Model, states a Medical Home “is not a house, hospital or other building. Rather, it is a term used to describe a health care model in which individuals use primary care practices as the basis for accessible, continuous, comprehensive and integrated care. The goal of the medical home is to provide a patient with a broad spectrum of care, both preventive and curative, over a period of time and to coordinate all of the care the patient receives.”

The following physician associations have been central advocates of the new Medical Home model:
• American Academy of Pediatrics
• American Academy of Family Practice
• American College of Physicians
• American Osteopathic Association

The Patient Centered Primary Care Collaborative is a coalition of more than 40 major employers, consumer groups, organizations representing primary care physicians, and other stakeholders who have joined to advance the patient-centered “medical home.” Various health plans are members of the coalition.
The Blue Cross Blue Shield Association has launched pilot demonstration medical home projects involving 27 of its member plans.

Bridges to Excellence (www.bridgestoexcellence.org) is a non-profit coalition-based organization created to encourage quality of care by recognizing and rewarding health care providers who demonstrate that they deliver safe, timely, effective, and patient-centered care. BTE works with large employers, health plans, providers and has partnered with organizations including the Leapfrog Group and the National Business Coalition on Health.

Paul Keckley, PhD, Executive Director, and Howard Underwood, MD, Senior Fellow at the Deloitte Center for Health Solutions, in their paper The Medical Home: Disruptive Innovation for a New Primary Care Model, outline the following “Critical Features of the Medical Home”:

• Personal physician
• Physician-directed primary care professional organization
• “Whole person” orientation
• Primary care team is responsible for providing all of the patient’s health care needs.

This includes care for all stages of life:

• Monitored and integrated care using electronic medical records and personal health records
• Measured and managed adherence to evidence-based practices by the care team and the patient
• Evidence-based medicine and clinical decision-support tools guide decision making.
• Physicians in the practice accept accountability for continuous quality improvement
• Patients actively participate in decision-making
• Information technology is used to appropriately support optimal patient care.
• Patients and families participate in quality improvement activities at the practice level.
• Enhanced accessibility: care anywhere, anytime
• Emphasis on physician incentives for improvements in self-care management

The Joint Principles of the Patient-Centered Medical Home, issued by the AAFP, AAP, ACP and AOA state that payment structures should:

• reflect the value of physician and non-physician staff patient-centered care management work.
• pay for services associated with coordination of care both within a given practice.
• support adoption and use of health information technology for quality improvement;
• support provision of enhanced communication access such as secure e-mail;
• recognize the value of physician work associated with remote monitoring of clinical data.
• allow for separate fee-for-service payments for face-to-face visits.
• recognize case mix differences in the patient population being treated within the practice.
• allow physicians to reduce hospitalizations associated with physician-guided care management.
• allow for additional payments for achieving measurable and continuous quality improvements.

Bridges to Excellence has launched the BTE Medical Home Program, which rewards physicians that demonstrate they have adopted really qualifying systems and processes of care, and are using those systems to deliver positive results in the management of their patients – in particular patients with chronic conditions. Doctors can receive an annual bonus payment of $125 for each patient covered by a participating employer, with a suggested maximum yearly incentive of $100,000.

Beyond the historic concept of primary care physician coordinating the needs of member patients that have been promoted by HMOs, the current Medical Home model is much more far-reaching:

• the concept is ideally meant to be applied independent of a particular health plan such as an HMO, instead changing an entire practice.
• Dr. Paul Grundy, IBM’s director of health care technology and strategic initiatives, is quoted in a recent Business Insurance article discussing the new Patient-Centered Primary Care Collaborative that IBM helped found, stating that “the medical home does not serve as a gatekeeper but rather as a gateway to the health care system.”
• There are many more attributes attached to the current Medical Home model, many embracing new technology
• Medical Home initiatives are being advanced in particular with various state Medicaid and Children with Special Needs programs.

In summary – the medical home concept links primary care coordination with centralized electronic medical records and new concepts in evidence based medicine and standards of care. The medical home concept also advocates changes in primary care reimbursement that compensate doctors for care coordination and technology infrastructure, and or quality incentive compensation in addition to standard reimbursement.

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