I’ve written previously about why we must change the care model. Today, I want to look at medical homes and their potential as part of that transformation.
They go by many different names, including patient-centered medical homes and primary care medical homes. For simplicity’s sake, I will refer to them as medical homes.
What is a medical home?
The National Committee for Quality Assurance (NCQA), which accredits medical homes, defines them as “a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.”
The HIMSS/NCQA Fact Sheet on medical homes says that they are “a model of care where patients have a direct relationship with a provider who coordinates a cooperative team of healthcare professionals, takes collective responsibility for the care provided to the patient and arranges for appropriate care with other qualified providers as needed.”
How is a medical home different from today’s primary care practices?
While medical homes vary widely in how they operate and what features they offer, there are certain recurring themes. The medical home serves as the manager and navigator of the patient’s care in an effort to better and more effectively coordinate care, and typically provides team-based care, incorporating non-physician providers such as nutritionists, physician assistants, nurse practitioners, therapists, social workers, and others who might be able to more fully address the needs of particular patients.
What is the promise for medical homes in achieving accountable care?
Medical homes offer to move us forward in two areas that I have previously discussed as critical characteristics of the new accountable care model: patient-centeredness and team-based care. I plan to write more in the future about patient-centeredness and what that means and looks like.
Medical homes also have the potential to lower costs for primary care, and some already have. They are a great concept, and I wish that I had had the opportunity to work in that kind of setting when I was in practice.
What are some of the limitations?
While some are looking to medical homes as the fix to what is broken with the American health care delivery system, I believe that a different use of the medical home is the solution in the context of a broader accountable care strategy.
Why? To answer this, we need keep in mind the triple aim of accountable care: better health, better care, and lower cost.
First of all, improving the health of patients certainly is a key objective, but that is really the second aim: better care.
In thinking about better health, we have to think about new ways to intervene and improve the health of those who are not yet patients and hopefully prevent, or at least delay, the onset of disease and illness.
I hear many people talk about how to bend the cost curve by changing patient management, and we need to, but it’s short-sighted if we think it will work over the long term to control runaway health care costs. No matter the progress we make in treating patients, if we don’t address who is in the pipeline, health care costs will soar and become even more overwhelming.
Consider the epidemic of childhood obesity we are currently facing. According to the Centers for Disease Control, approximately 17 percent – or 12.5 million – of children and adolescents aged 2 to 19 years are obese. Since 1980, obesity prevalence among children and adolescents has almost tripled.
Over the next two to three decades, we will see alarming rates of increase in the prevalence of hypertension (high blood pressure), hyperlipidemia (high cholesterol and blood fats), diabetes, heart disease, and arthritis that will negate the gains that we make in treating and trying to improve the health of those who are already patients. This is true of cancer as well, since the risk for many types of cancer has now been shown to increase due to obesity.
We must reach these kids and their families and other high-risk individuals before they become ill, to make sure we can improve their health, make sure they receive more frequent screenings, and implement preventative measures to try to delay or prevent the onset of these diseases.
As it is now, until they begin to suffer health consequences, many of these high-risk individuals don’t get primary care services. If we want to reach them, we have to interact with them at home and school, and in work settings. This population management – not patient management – is a big missing piece in many organizations’ plans for the future, and it is why medical homes are not going to solve our health care crisis.
I do believe that medical homes will improve care for many patients, but mostly those patients with chronic diseases. For many of the reasons patients see primary care physicians, a medical home is not likely to offer much added benefit, and in fact could make the overhead costs associated with such a care model unnecessarily more expensive when it comes to sore throats, colds, sports or camp physicals, bladder infections, and other similar ailments. I also think medical homes will be too difficult and too expensive to develop in certain settings.
As we innovate to fix health care, we must make sure that our innovations don’t add unnecessary costs. We can’t afford it. Our strategies must not be one size fits all, and the answers are unlikely to be found in addressing only one aspect of the complicated health care delivery system, in this case, primary care.
We should have learned from the 1990s that a focus entirely on primary care will not control our rising health care costs. Half of federal health care spending is on the care of those with chronic diseases, and I believe that specialists are the best positioned to manage down these costs.
What’s my solution?
One percent of the population accounts for 22 percent of our total health care costs, and 5 percent of the population accounts for half. This is the reason we should target our efforts with laser-sharp focus, employing strategies and tactics that will address this huge opportunity to control costs that have to do with this 5 percent, rather than applying costly solutions to the 95 percent of the population that account for less than half of the health care costs.
My model for medical homes is to include them as part of the solution in an accountable care organization. They should be designed around chronic disease management, not primary care. Team-based, interdisciplinary care would be appropriate for these kinds of complex patients.
We have to change the model in which we manage patients from office visit to office visit to one in which management happens during and between visits. This can be done with home monitoring devices and physician assistants or nurse practitioners in a medical home model that excels at educating patients and their families, increases accessibility so that patients don’t have to go to emergency rooms as frequently, monitors patients’ conditions between visits and makes adjustments to treatment regimens between visits, and that is accountable for the implementation of evidence-based medicine and for the outcomes attained by better medical management and reduced frequency of complications.
Don’t get me wrong. I am a primary care physician. Primary care physicians are critical leaders and partners in our System, our strategy, and our communities. But there are not enough primary care physicians to meet the needs for primary care, let alone the management of complex medical patients with one or more chronic conditions. And it is going to get worse in 2014, when the rolls of the insured increase due to the health care reform law.
Even if we could convert primary care offices into medical homes, with all the attendant extra overhead cost, is a one-size-fits-all approach the right one to a 5 percent problem?
David C. Pate, M.D., J.D., is president and CEO of St. Luke's Health System, based in Boise, Idaho. Dr. Pate joined the System in 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center.