Medical Home Model Built on Physician Power in Numbers

This week, the History Chanel released its latest installment on DVD, “Mankind, The Story of All of Us,” which follows the highly acclaimed “America, The Story of Us.” Particularly compelling was the description of the plight of mankind during the last Ice Age; beset by unbearable cold, a shortage of food, not to mention packs of hungry wolves, man adapted by forming alliances. To survive, man simply made friends with his enemy, the wolves. Together, the two formed a lasting bond for protection and survival.

It seems the medical profession too has entered an “Ice Age” of sorts. Only a few short years ago, the sun shone brightly and there was food aplenty. Then almost overnight, the world tilted on its axis ever so slightly, and survival became more precarious. The government, once the provider of limitless bounty, has seemingly become hostile and accusatory.  

The formation of alliances would instinctively seem to provide the best chance of survival; but how, and with whom?  Pooling together resources in the formation of practice groups, IPAs, and other integrated models among colleagues would seem the safest bet. Others, frustrated by the endless administrative headaches, have simply sold their practices to become employees of hospitals, with varying degrees of satisfaction.

The government under the Affordable Care Act (ACA) is experimenting with the formation of accountable care organizations (ACOs) with compensation based upon complex “metrics,” which would seem almost farcical, if money weren’t so scarce. Then, there are “medical homes.” There are several provisions in the ACA directed at the establishment and promotion of the Patient-Centered Medical Home (PCMH). The ACA includes the following provision, among others: establishment of a Center for Medicare and Medicaid Innovation that would pilot test broad payment and practice reform in primary care, including consideration of the PCMH.

The concept of the "medical home" has evolved since introduction of the terminology by the American Academy of Pediatrics in 1967. Today, vendors such as Healthy Circles offer pre-packaged platforms for medical home implementation. As of December 31, 2009, there were at least 26 pilot projects involving medical homes with external payment reform being conducted in 18 states.

The “medical home” concept is not without its critics. Some suggest that the medical home mimics the managed care “gatekeeper” models historically employed by HMOs. The American College of Emergency Physicians expresses caution: "a shifting of financial and other resources to support the PCMH model could have adverse effects on sectors of the healthcare system" and "there should be proven value in healthcare outcomes for patients and reduced costs to the healthcare system before there is widespread implementation of this model,"  At the heart of the criticism is the fear that medical homes are simply another means of forcing physicians to care for an increasing number of patients without adequate sustainable compensation.

Proponents point to key differences, arguing in the medical home model the patient has open access to see whatever physician they choose. No referral or permission is required. The personal physician of choice, who has comprehensive knowledge of the patient’s medical conditions, facilitates, and provides information to subspecialists involved in the care of the patient. And of course, that is the selling point. While the gatekeeper model placed more financial risk on the physicians resulting in rewards for less care, the medical home focuses upon the benefit to the patient resulting from a set of physicians who are more familiar with the patient’s history. The medical home model predicts fewer errors, duplication of tests, and thus lower expense.

Regardless of the merits, it is always a risky proposition to be the first to step through the breach, particularly without knowing what lies on the other side. For now, the question remains in an environment of growing scarcity, “What kind of alliance offers the greatest chance for survival?”