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The Evolution and Importance of the Medical Home

Jim Hardy and Diana Verrilli, for HealthLeaders Media, January 29, 2009

The uninsured. The underinsured. Employers offering little or no health coverage. Employees unable to pay for health coverage when it is offered. Disparate technologies. Increasing numbers of people with chronic illnesses. These are among the forces that have come together to form healthcare's perfect storm.

Every year, the McKesson Health Solutions Leadership Forum brings together top healthcare experts to share their views of the industry's future. While all have differing viewpoints, at the 2008 forum they agreed that the healthcare system must change to be effective in the future.

The discussion focused on the many factors that impact healthcare:

  • The United States spends $2.5 trillion annually on healthcare, and the total growing every year.
  • Chronic diseases limit the lives of 25 million people in the U.S.
  • In 2006 and 2007, 90 million people were uninsured for some or all of the year.
  • Many businesses that offer healthcare coverage pass increases in premiums on to employees, who sometimes must opt out of coverage so they can afford to pay the rent or mortgage, or purchase food or gas.

Technology is often hailed as a solution. Savvy patients use e-mail, blogging, and social networking to learn and discuss chronic and acute health conditions, but many providers still use pen and paper to write prescriptions and enter information in charts. Providers who do use technology are stymied by software that doesn't "speak their language."

In today's world, patients want healthcare managed instantly and often prefer quick-fix medications or surgery to address problems like obesity or diabetes, rather than getting to the root of these issues through prevention or management.

Healthcare is "held hostage by cultural factors that we don't know how to affect," said Emad Rizk, MD, president of McKesson Health Solutions, at the forum.

Denmark's medical home program
One solution discussed at the forum comes from Denmark. In Denmark, a successful medical home reaches beyond the physician's office and includes the patient's community.

"A strong primary care system is essential to achieving a high performance healthcare system, which leads to better health outcomes. Patients report better coordination among various physicians if there is a medical home," said Melinda Abrams, senior program officer for The Commonwealth Fund.

Danish patients manage their care with 24/7 access to the provider/medical home, personal health records, and more.

Physicians are paid for telephonic advice, and paid more if the patient settles the issue by phone. A report is e-mailed to the patient's primary physician the next day. This has led to country-wide physician cooperatives that provide patients with 24/7 phone support and providers with around-the-clock access to patient medical records.

"We must get the patient's perspective to have a successful medical home. Let's learn from other countries," Abrams said.

Rebuilding the primary care model
Healthcare is currently an "enterprise"—one that has not delivered on the promise of quality and cost efficiency, said Douglas Henley, MD, executive vice president and CEO of the American Academy of Family Physicians. "We need a revolution to make a healthcare system that can and will deliver on this promise. The primary care patient centered medical home is the cornerstone to healthcare system reform."

Practices should be designated as medical homes to ensure that all physicians within the practice buy into the medical home concept and that the patient is the center of the care continuum. The patient-centered medical home is a "framework for organizing systems of care at both the practice and society level," he said. "This is culture change. It is about creating some chaos before improvement."

Higher payments for the primary care physician will be necessary. The existing physician payment system must evolve into one that includes an updated fee-for-service schedule, incentives for quality improvement and performance assessment, and care management fees. The extra money will come from the savings created through better patient care management, including fewer hospitalizations and ED visits, and unnecessary testing.

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