The Evolution and Importance of the Medical Home

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.

All 280 providers at the Billings Clinic in Montana have re-oriented the practice, making it better for patients and staff. "Culture is important. Physicians need to look at the end of the year to see how they've done for all patients," said F. Douglas Carr, MD, medical director of education and system initiatives at Billings Clinic. "The care is organized by a team, but it has to be done in a 21st century way."

The clinic uses an electronic medical record to reduce variations among different units. While some physicians have issues using the EMR, this is more an indication of a broken process, rather than a problem with the EMR itself. "Our process was flawed on the paper versions as well, but it was less obvious," he said.

Advancing the medical home: government and employers
As assistant secretary & Medicaid director for the North Carolina Department of Health and Human Services from 2005-2007, L. Allen Dobson, Jr., MD, developed Community Care of North Carolina with the goal of improving quality and controlling Medicaid costs.

The program's four objectives were to:

• Improve the care of the Medicaid population while controlling costs
• Develop community networks capable of managing recipient care
• Develop systems to improve the management of chronic illness
• Fully develop the medical home

Now vice president of the Carolinas Healthcare System, Dobson said that the key to the program's success was establishing a medical home. To work, these programs must be community-based to ensure that patients continue to receive care from the same doctors and providers. "Doctors don't mind seeing them, but they don't want it to be more difficult," he said.

Results of the program include fewer hospitalizations and ED visits. "This is important because this is where most of the avoidable money is spent," Dr. Dobson said.

Employers face many similar challenges—members with poorly controlled chronic illnesses—but the approach is different. Terry McInnis, MD, medical director for health management innovations for GlaxoSmithKline, said public and private employers seek coordinated, easy-to-use healthcare for their employees.

"Employers want to provide high-quality healthcare, but instead the system is splintered," she said. A high-quality model needs to help the obese, those with poor health habits and those with a multitude of chronic conditions. Unfortunately, these same consumers get episodic care through a rushed office visit. "Nobody's talking with each other in the system. As payors, we can't afford that cost," she said.

She sees an increase in interest from CEOs who want to impact a company's bottom line as healthcare costs skyrocket. "Employers should remove barriers to preventive care and management of conditions for those patients who take charge of their health. The key words here are 'who take charge of their health'—each of us must take responsibility for our own health. That is 'consumer engagement,'" she said.

Healthcare in the future
The medical home will be successful, but it won't look the same or even have the same name. Today, we have "medical home 1.0. It will be Medical Home 3.0 that emerges with some stickiness. Everybody wants to do the right thing. There's a calling in the healthcare system that's noble," said Paul Keckley, PhD., executive director for the Deloitte Center for Health Solutions.

Keckley believes that by 2017 a number of drivers will push the industry:

• Pressure of policies and politics
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• Connected care anywhere
• More transparency
• Multiple, convergent relationships
• Technology companies delivering suites of solutions for data

The only thing we know for sure is that healthcare will be much different in the future than it is today.

Some changes we expect to see include:

• Reimbursement changes that will transform the role of primary care providers.
• Increased focus on care management strategies.
• Performance-based payment for providers and punitive payment for "never" events.
• New care models using technology and a convergence of healthcare services similar to retail clinics
• New technology adoption after undergoing provider scrutiny.
• Information technology seamlessly combining data and workflow.

"We expect the current model to change and likely include significant advances in and acceptance of technology; new models of provider reimbursement; new and changing roles for healthcare professionals; and other innovations yet to be created," said Rizk.