Can We Create a Realistic and Financially Viable Medical Home?

Initially introduced by pediatricians in 1967 to provide care to special needs children, the medical home embodies the expansion of the role of the primary care-physician to include much more coordination of care, enhanced access, improved communication, and a broader effort to help patients manage their health.

The concept re-emerged in 2004 and 2006 due to strong support by both the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) as well as more than 19 other medical associations.

The recent promotion and test programs of the new Patient-Centered Medical Home (PCMH) model are in part a professional and economic reaction to the reduction in the type of activities that were integral to primary care in the past. While it is only a small part of the changes in medicine today, it attempts to give primary care back its role as the “hub” from which care is coordinated and delivered.

Below the surface, the medical home model has always appeared to me as another way for physicians to make the case for much-deserved higher reimbursement for the services that are not directly related to the encounter. The problem with the model is economics. Who pays for it? How can we deliver that kind of care in today’s economy? In addition, some patients do not need this level of service; and while optimal for some patients, there are no proven cost savings.

The topic has certainly generated a lot of discussion and debate of late. Academic physicians, politicians, and others argue that this type of construct would not only improve care, but it would be cost efficient.

But it’s a hard model to make work in the real world. The cost of true PCMH programs is beyond what any private plan or government program can pay on a large scale, over the long run. This is because it is primarily an investment in patient health, paying more now for some anticipated cost savings in the future.

In fact, I believe the model is in direct conflict with the general direction of healthcare today. The PCMH model promotes:

• Spending more time with patients. That would reduce volume and increase cost, something that is contrary to a system moving to large and more streamlined care.

• Promoting a single physician and less of a team approach to care. Again something that is contrary to many planners and strategists approach for today.

• Encouraging more testing before a health problem surfaces, which “raises a flag” for segments of the industry claiming to want to reduce “unnecessary tests.”

The industry has tried to adjust the model to meet the realities of healthcare today. Many involved in pilot programs note that one big change is that it is not the physician who coordinates and manages care, it is a non-physician care coordinator and the use of care extenders. Yes, this works economically - but it does take physicians out of the picture - at least to some degree.

However, the effort to try a watered-down approach to PCMH is understandable. Some who are currently involved in medical homes say that it is impossible to accomplish the goals of a true PCMH model given the low levels of compensation. What’s more, the primary goal of some of the test programs seems to be cost savings when I believe that there may be little to no such savings. And more importantly, at its essence, that’s never been what this model is about.

Patients and physicians alike generally appreciate the concept of the medical home. From the day I heard about PCMH programs, I was intrigued by the similarities in goals between it and concierge medicine. And then it struck me; concierge medicine, especially the hybrid model, is a truly viable path to a medical home model.

The difference is that in hybrid concierge, it is patient driven, that is, it is paid for by the individual who perceives of the need for the additional services. Payment is at a sufficient amount, per patient, to enable the physician to deliver on the promise of enhancing the relationship and adding convenience, while encouraging prevention, wellness and true care coordination led by a single physician.

Is there a cost savings to the system for this type of care? I’ve got my doubts, but I do know it increases quality and patient satisfaction and for those reasons alone, exploration of viable ways to achieve the medical home goal are important.

Those are my thoughts; what has been your experience with medical home projects?