Medical Home Takes on Water

Physicians and managed care don't agree on much, but there was finally one area in which they could find common ground—the advanced medical home concept.

Praised by both constituencies as a way to improve patient outcomes and quality while reducing costs, the advanced medical home movement was sailing along calm waters until this month. Now, it is bouncing on the surface and its crew is feeling a little nauseous.

These choppy waters are a result of the American Medical Association/Specialty Society RVS Update Committee (RUC), which recently submitted its medical home recommendations to the Centers for Medicare & Medicaid Services.

The recommendations have been bashed by many who question RUC's predicted physician time commitment to coordinate care and the lacking care management reimbursements.

This kind of opposition is new to the medical home concept. The idea gained steam earlier this year with DMAA: The Care Continuum Alliance's Advancing the Population Health Improvement Model and The Commonwealth Fund's report Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending. Both documents spoke of the potential cost savings and quality improvements involved in a comprehensive, coordinated team approach.

Meanwhile, RUC established its Medical Home Workgroup in February after CMS' request to review the concept. At that time, I wrote an article for my monthly newsletter Disease Management Advisor not about if the medical home was going to catch on, but how disease management could play a key role in its development.

Now, with the release of one document, the concept has come into question. While healthcare officials debate RUC's recommendations, the state of Pennsylvania has moved forward with its own medical home plan, which is part of Gov. Ed Rendell's chronic care model.

Six insurers are involved in a three-year program that will cover 220,000 patients in southeastern Pennsylvania. The insurers will collaborate with more than 150 primary care providers to track patient care and conditions that supporters say will reduce costs for chronic care by improved control and averted emergency room visits and admissions, and improve:

• Access to care
• Patient self-management skills
• Quality of care measured by evidence-based clinical processes
• Outcomes measures

Independence Blue Cross, one of the insurers involved in the project, anticipates making physician payments in the $5 to $6 million-dollar range.

Ruth Stoolman, public relations manager at Independence Blue Cross, says the investment will depend on how many practioners participate and the level of documented transformation their practices achieve through the National Committee for Quality Assurance's Physician Patient Connections—Patient-Centered Medical Home (PPC-PCMH) certification.

Stoolman says the major aspects of the medical home model include:

• Use of a team approach that includes physicians, nurses, case managers, and health educators
• Open access scheduling to enhance patient access to timely care and to allow physicians more time to see sick patients
• Improved patient education and promotion of self-management of chronic conditions
• Improved communications (including e-mail and phone)
• More decision support for patients
• Outside practice coaches to help implement the necessary changes and help guide the practices on how to achieve their goals

Independence Blue Cross' project will offer free technology to participating practices that will allow the health plan and practices to track, monitor, and remind patients about health information, and identify gaps in care.

"It should be emphasized that patient education is a critical component of the PCMH—empowering patients to understand their conditions and take an active role in their care. No matter how successful physicians are in reaching all the stated NCQA goals—unless their patients are actively involved in managing their care, any notable improvements in quality outcomes will be limited," says Stoolman.

Advocates for the Pennsylvania program hope the collaborative will serve as a benchmark in how the model is designed and implemented.

Yet there is another issue for medical home supporters to address. Many people in healthcare simply don't understand how a medical home works or how it can improve healthcare. We conducted an online poll of readers of this site over the past month asking them what they thought about the medical home concept. The results show that many are still unclear about the tenets of a medical home.

In fact, 44% of those who answered the poll could not define an advanced medical home. Twenty-four percent suggested the concept is the future of healthcare, while another 21% predicted there would be some success, but not enough to change healthcare. Only 4% answered that the concept will fail.

As our poll shows, step one in the process should be defining the term "advanced medical home," and properly informing the stakeholders. Once that is achieved, the next step is physician reimbursement and that will be the ultimate challenge that will decide whether the medical home winds up on the rocks or continues toward the horizon.