American College of Physicians: Internal Medicine — Doctors for Adults ®

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Can the 'medical home' model solve health care's woes?

From the November ACP Observer, copyright © 2005 by the American College of Physicians.

By Robert B. Doherty

As fans of the movie classic "The Wizard of Oz" already know, sometimes the solution to life's troubles is rediscovering that "there's no place like home." Could a "medical home" likewise solve the problems facing the health care system—and the specialty of internal medicine?

A growing number of health policy experts think so. Within the College, there is also a great deal of interest in exploring the medical home concept as a way to improve patient and physician satisfaction and revitalize internal medicine.

A model for better care

The premise behind the model is that care will be improved if patients have direct access to one physician ("my personal physician") who accepts responsibility for their care and practices in a system organized to support better care. On the surface, the medical home model sounds like a return to the way medicine used to be practiced in pre-managed care days, when most patients had a primary care doctor they called their own who was always there when needed.

But the medical home is much more than a nostalgic return to the past. Medical home practices would employ cutting-edge innovations centered on patients' needs.

Practice innovations would place a high premium on patients' time and convenience to ensure an overall positive experience. A medical home practice might, for instance, use open scheduling as well as Web-based patient-directed scheduling software to minimize "wait" time and maximize face-to-face time between the patient and physician. E-mail and telephone consultations might be available outside regular office hours to reduce the need for patients to come into the office for non-urgent care.

Home practices would make arrangements with teams of additional health professionals to provide services outside the practice's expertise. They would use evidence-based guidelines and decision support tools at the point of care. And they would be accountable for participating in continuous quality improvement programs that would include measuring and reporting quality data based on evidence-based care measures.

The medical home would, in other words, offer the best elements of what is known as "retainer" or "boutique" practices—without the accompanying inequities. Like the medical home concept, retainer practices appeal to growing numbers of patients and physicians because they offer patients the promise of timely access to a personal physician.

But boutique practices typically require patients to pay a larger retainer fee not covered by insurance, making such practices more suitable to wealthier patients. The medical home model would be financed by insurance coverage so it would not be limited to patients with higher incomes. And unlike boutique practices, medical homes would be publicly accountable for the quality and efficiency of care they provide.

Benefits for internists

The College believes the medical home concept may be a key component in revitalizing internal medicine.

The concept offers internists the potential of practicing medicine in a way that is more satisfying to them and to their patients. Internists could spend more time with patients--and have systems in place to relieve many of the administrative and scheduling burdens that both they and their patients find so frustrating. Doctors could practice knowing that the care they were providing met the highest standards of clinical performance.

The benefits of the medical home aren't limited to internists. The model can encompass physicians in a variety of specialties, as well as patients with many different health needs.

An internal medicine subspecialty practice might be the best suited to serve as medical home for patients with conditions that fall within that subspecialty's expertise. A family medicine or pediatric practice might be well qualified to serve as the medical home for many other patients.

And internal medicine specialists in a general medical practice would be particularly well suited, by virtue of training and experience, to serve as the medical-home physicians for a large number of adult and elderly patients with multiple chronic diseases. As such, the model should especially appeal to young internists who want to realize the joy and satisfaction that comes from providing comprehensive, coordinated care to adult patients with complex conditions. The concept should also appeal to established internists who wish to rediscover the connections many feel have been lost in today's fragmented, hurried and over-specialized health care system.

Getting there

If the concept of a medical home has so much potential, why isn't it already in place? The answer is: because fundamental changes in financing, coverage, reimbursement and workforce policies are needed to make it viable. Here are changes that need to be made:

  • Medicare, Medicaid and private payers have to be persuaded that they must become the principal financing sources for the medical home. Financing must be sufficient to support the investment of resources needed for a practice to qualify.

  • Insurance coverage will have to include services typically not reimbursable under traditional payment methodologies, such as e-mail consultations and physician work associated with care coordination that falls outside of a face-to-face visit.

  • Reimbursement methodologies will have to move away from paying physicians based on the volume of episodic services (with per visit and per procedure codes) to one that creates incentives for care management, team-based care and practice redesign.

  • Workforce policies will have to be reformed to make sure enough physicians are trained to serve as medical home physicians for adult and elderly patients with multiple chronic conditions. This will require reversing the precipitous decline in the number of physicians now in training to provide general internal medicine.

Over the next several months, ACP will develop a series of policy papers to make the case for the medical home model and for the changes needed in financing, coverage, reimbursement and workforce policies to make it work.

For America's health care system, going home will be a bit more difficult than Dorothy finding her way back to Kansas with just a fervent wish and a few clicks of her heels. Even so, physicians and patients should find the journey to the medical home well worth taking, notwithstanding the many challenges they will face along the way.

Robert B. Doherty is ACP's Senior Vice President for Governmental Affairs and Public Policy.

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