by
28 Feb 2010

A medical home is a patient-centered, multifaceted source of personal primary health care. It is based on a relationship primarily between the patient and physician, but also with the other health care team members formed to improve the patient’s health across a continuum of referrals and services. The provision of medical homes allow better access to health care, increase satisfaction with care, improve health, and reduce costs.

Primary care organizations, including the American Board of Family Medicine, have promoted the concept as an answer to government agencies seeking political solutions that make quality health care affordable and accessible to all Americans. Certainly this is a goal of health care reform, is it not?

The concept of the medical home has evolved since its introduction by the American Academy of Pediatrics in 1967, 43 years ago. In 1992 the Academy published a policy statement defining a medical home. In 2002, seven U.S. national family medicine organizations created the Future of Family Medicine project to “transform and renew the specialty of family medicine.” Among the recommendations of the project was that every American should have a “personal medical home” through which to receive his or her acute, chronic, and preventive services. According to Martin, et.al.(2004), the services should be “accessible, accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians.” To me, this sounds like a necessary ingredient to health care reform, especially for elders…a no brainer! 

As of 2004, one study by Dr. Spann in the Annuals of Family Medicine estimated that if the Future of Family Medicine recommendations were followed (including implementation of personal medical homes), “health care costs would likely decrease by 5.6%, resulting in national savings of 67 billion dollars per year, with an improvement in the quality of the health care provided.” A review of the literature published the same year determined that medical homes are “associated with better health… with lower overall costs of care and with reductions in disparities in health.”

In 2007, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association — the leading primary care physician organizations in the United States — released the “Joint Principles of the Patient-Centered Medical Home.” The principles are:

  • Personal physician: “each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.”
  • Physician directed medical practice: “the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.”
  • Whole person orientation: “the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals.”
  • Care is coordinated and/or integrated, for example across specialists, hospitals, home health agencies, and nursing homes.
  • Quality and safety are assured by a care planning process, evidence-based medicine, clinical decision-support tools, performance measurement, active participation of patients in decision-making, information technology, a voluntary recognition process, quality improvement activities, and other measures.
  • Enhanced access to care is available (e.g., via “open scheduling, expanded hours and new options for communication”).
  • Payment must “appropriately recognize the added value provided to patients who have a patient-centered medical home.” For instance, payment should reflect the value of “work that falls outside of the face-to-face visit,” should “support adoption and use of health information technology for quality improvement,” and should “recognize case mix differences in the patient population being treated within the practice.”

Providing a medical home over time reduces utilization and costs. A survey of physicians in Colorado (Fryer, et. al., 2004) demonstrated that in communities with high numbers of specialists or low numbers of generalists, specialists may spend 27% of patient contact time performing primary care services. Just as with anyone practicing outside of their area of comfort, this inevitability raises cost. Additional chart review research of over 20,000 outpatient encounters and 5,000 inpatient encounters demonstrated that specialists practicing outside of their area of expertise order more tests and make more referrals than generalists.

Americans spend less time with a primary care physician than patients in countries with better health outcomes, yet community-level studies indicate that availability of primary care lowers mortality.

In addition, quality care is impacted as well. In a critical review of the literature on continuity, Saultz and Lochner (2005) analyzed 40 studies tracking 81 care outcomes, 41 of which were significantly improved by continuity. Of the 41 cost variables studied, expenditures were significantly lower for 35.

Continuity has generally been shown to achieve quality at a lower cost. Patients attribute health care errors to the breakdown of the doctor–patient relationship 70% of the time.

One notable implementation of medical homes has been Community Care of North Carolina, which was started in the early 1990s for Medicaid, has reported a savings for North Carolina of $60 million in fiscal year 2003 and $161 million in fiscal year 2006.

 As of mid-2009, it was reported that 22 pilot projects involving medical homes were being conducted in 14 states. The projects are evaluating factors such as clinical quality, cost, patient experience/satisfaction, and provider experience/satisfaction. The final results will be coming out this year sometime, but do we really need to wait.

The Nevada Division of Health Care Financing and Policy is finally not waiting. They released a request for information last month for how Nevada could implement a cost effective Medicaid Medical Home and Care Coordination program for high-need and high-cost patients. Clearly we need to move forward on this and implement it statewide. By so doing, we will provide better care, reduce costs, and add life to years!