Locating the “Medical Home”

There’s no doubt that people — especially those with (multiple)
chronic conditions — need a more holistic model for managing their
health needs than what our delivery system currently offers. The PCMH
model is intriguing, but I have worried that many examples of PCMH
deployment thus far have been centered around the physician’s office
(and, to some extent, the physician’s needs).

In contrast, most patients with health problems are living 24/7 with
whatever is affecting their quality of life, and not much of it is
spent in the doctor’s office. Think about it: There are 8,760 hours in
a year, and how many of them are spent in a health care facility?
Unless someone has multiple hospitalizations in a given year, the
answer is probably far less than 1 percent.

I’ve been fascinated for a long time now by the potential of Ix and
Health 2.0 strategies to deliver to us more robust models of truly
patient-centered medical homes than we have seen in most of the
country. Thankfully, other (smarter) people have also been thinking
about this and were able to join us to present in a recent webinar.

Joe Kvedar from Partners’ Center for Connected Health recently wrote with David Kibbe a terrific piece in The Health Care Blog titled, “The Connected Medical Home: Health 2.0 Says ‘Hello’ to the Medical Home Model."
That kind of home could meet the needs of a lot of people:
“…web-comfortable consumers want a ‘participatory medicine’ experience
with their health care professionals that involves modern forms of
communication and coaching. They want to be ‘connected’ online with
their doctors and nurses, and they prefer having their health
information searches guided, if not filtered, by their personal doctors
and medical homes.”

We also had a provocative presentation from Healthwise CEO Don Kemper, who along with Leslie Kelly Hall, recently wrote a white paper on “The Virtual Health Home.”
In their words, “The virtual health home works from the patient’s
perspective, not only to coordinate medical providers but also to
balance health care services with the many other factors that
contribute to improved health.”

Alan Glaseroff, a practicing family physician who helps run Northern California’s Humboldt IPA and also has been living with Type 1 diabetes himself for 25 years,
provided a unique perspective as well. He noted that the advice of his
own patients has been the most valuable information he receives and his
clinical focus over the years has been on self-management and the power
of peers.

A successful medical home needs to take into account all of these
things in order to provide an effective coordination of people’s health
needs. Future PCMH initiatives should consider a variety of virtual and
physical models for centering care and health.

Joshua Seidman is the president of of the Center for Information Therapy
that aims to provide the timely prescription and availability of
evidence-based health information to meet individuals’ specific needs
and support sound decision making.

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3 replies »

  1. The Medical Home is a terrific concept, but the keys to effective, wide spread implementation are well organized primary care physician groups, and appropriately aligned reimbursement systems. As your submission indicates, the main goal of the Medical Home is to provide coordinated services across the continuum in order to better manage chronically ill patients. In fee for service medicine, however, providers are not paid or incentivized to provide care in the gaps that exist as patients are transferred from hospitals, to SNFs, to doctor’s offices, and other care settings. Even in home health Medicare pays for only 60 days of care post discharge, leaving another large gap after that episode is over. In this structure health plans and Medicare carry the risk, yet few insurers have figured out how to effectively fill these gaps.
    Well run and effectively incentivized primary care groups are in the best position to manage chronically ill patients and to deploy the home based monitoring tools that you describe in your submission. PCPs have more information, better patient relationships, and more influence with patients than anyone else in the delivery system. Financially, however, PCPs have limited ability to invest in the infrastructure required to effectively implement the Medical Home concept. These financial issues have led many PCPs to partner with hospital systems, which creates an economic structure that is counter to the idea of caring for people at home and keeping them out of the hospital.
    In order to change this dynamic two things need to happen:
    1. Medicare, Medicare Advantage plans and commercial health plans need to develop reimbursement structures that create Medical Home friendly incentives. Capitation is probably the most obvious structure, but most PCPs are scared of capitation due to poor past experiences and small risk pools. Other potential structures include bundled payments targeted at specific conditions or episodes, or possibly something like the structure proposed by Norbert Goldfield, et al, in his paper Reforming the Primary Care Physician Payment System that has been posted here previously.
    2. Primary care physicians need to organize into sizable, well managed groups that are independent from hospitals and that are prepared to take appropriate levels of responsibility and risk for managing across the gaps described above.
    I work with a group of healthcare executives trying to accomplish the second step. Our goal is to invest in and develop a broad network of New England based PCPs designed to improve service, enhance access, manage chronic disease, and become the work place of choice for Primary Care Providers. Given the current trends in healthcare, it is our view that an organization like this will add tremendous value to the delivery system over the next 20 years by improving quality and lowering utilization of high cost services. I welcome any comments or ideas about our concept and approach.

  2. Michael,
    The adviser and shopper roles are two of the many roles that need to be filled by somebody or something in a future health home. Part of what we’re going to explore at the first-ever “Health 2.0 Meets Information Therapy” conference (http://health2con.com/) in April is how both human and artificial navigational resources can help people find their way through both the health care delivery system and wade through information (see Great Debate #4 in our agenda link).

  3. A few of us have done some collaborative communication of this type with patients on patient support group listservs, as described in its early phase at http://www.aan.com/news/?event=read&article_id=5277. That model is not directly scalable because part of the patient-doctor collaboration was focused around finding genes for several diseases, but it is hugely valued by the patients.
    There is an important role for a health adviser who is independent of one’s doctors, insurance company and employer. Such a person could act as a combination of adviser and personal shopper, but since they have no reason to overspend or underspend they could offer the most reasonable advice.
    The downside of such a plan is that there is some duplication of effort, but it is not so bad to have some extra thought about one’s health. Some of the value added by concierge practices is of this sort, but an adviser would be less expensive and without the economic conflict of interest.
    I’ve seen such a system work in some of the ultraorthodox Jewish communities of New York. The head rabbi of the community and his associates act in this role, and they are very effective in getting top quality medical care with more good sense about what to do and what not to do than one sees with most other patients.

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