Medical Homes

People hear "medical home" and they aren't exactly sure what it means. Judith Graham of the Chicago Tribune explains.

It's a new model of primary care that can address a lot of what drives us crazy in U.S. medicine  (at least those of us with doctors and insurance). There isn't yet precise agreement on what a medical home is, or who it should serve, but usually the idea is a way to improve primary care, with particular emphasis on prevention and control of chronic conditions such as asthma or diabetes.

So instead of long waits and rushed visits, Graham writes, imagine this:

There's a scene in the 1996 movie Independence Day where Harvey Fierstein (right), trapped in traffic trying to escape the shadow of an ominous alien ship, calls his doctor's office. Informed that Dr. Katz is not available, Fierstein screams "For $300 an hour, you can put me through to his house in the Hamptons!"

Had Fierstein been a patient with access to Group Health Cooperative's medical homes, his doctor could have called him, reminded him to take his blood pressure medication and scheduled a date for a follow-up visit.

On Wednesday, we began a series of blog posts that will highlight the innovative work being done by members of Health CEOs for Health Reform -- a New America Foundation coalition of industry CEOs and physicians committed to improving our health system.

Today, we'll examine the innovations in primary care made by the Group Health Cooperative -- a consumer-governed, integrated health care system covering over 600,000 individuals and delivering care in one of the largest integrated group practices in the Pacific Northwest. In the video below, Group Health president and CEO, Scott Armstrong, MBA, explains why his organization decided to adopt a medical home model for primary care, how they restructured their system, and the impressive results that followed.

A lot of new terms have entered the health care lexicon—but they don't always mean the same thing to everyone. We have a common vocabulary but not necessarily a common language. We asked Robert Berenson, MD, of the Urban Institute to guest blog on the need for precision.

It's encouraging that so much of the health care conversation in Washington is about delivery system reform, in particular the challenges posed by the intensive and expensive needs of people with multiple chronic diseases. It's also a little disconcerting. We're all talking, but are we talking about the same things?

We need more clarity, more precision.

How are we defining chronic conditions? I have a colleague who says it's like marriage—"It lasts a year or longer. It limits what you can do. It needs care."

Yes, it's funny. But it helps us think about what the definition should be. Under a liberal definition of chronic conditions, by last count I have at least four and fast approaching five, but I would say that I am in excellent health. Is having a certain number of chronic conditions what we're talking about? Or are we talking about those conditions that interfere with our ability to work, to function, to take care of  daily activities? Is it a disease that puts us on a trajectory that will lead to death? Is care management the same thing as care coordination?

Where have all the medical students gone?

No, Pete Seeger has not written the anthem for health reform circa 2009. (Although it's not a bad idea).

It's the headline of a blog post from Bob Doherty of the American College of Physicians, who spends a lot of time peering into the primary care equivalent of a crystal ball, trying to see if anyone's home. (We are mixing our metaphors here but at least it reflects the fragmented nature of our health care system).

Doherty, Senior Vice President of Governmental Affairs and Public Policy for the ACP, accompanied 100 med students and internal medicine residents at a recent ACP leadership day on Capitol Hill. Their goal was to help restore primary care to its rightful place in the American medical universe.

He knows that unless something changes, preferably as part of an overhaul of the whole health system to improve access to preventive care and to improve coordination of care, young doctors are not going to enter primary care in adequate numbers.

Doherty writes:

In a promising sign for health care delivery system reform, a Pennsylvania nonprofit substantially reduced costs and improved outcomes for Medicare patients with chronic illness in a care management study. The success of this trial—and the limited accomplishments of others in this experiment—provides more evidence of the need to involve physicians in any disease management reform.

The February edition of JAMA describes 15 care coordination trials started in 2002 by CMS. The pilots tested the ability of care coordination programs to keep elderly, chronically ill patients out of the hospital, on diet and exercise regimens, and otherwise improve health and lower spending.

The results demonstrate three major points. First, the concept of a patient-centered medical home may not be easy to put into practice, but it can work. The Pennsylvania pilot gave high-utilization patients monthly

Not waiting for action from the federal government, some private companies are searching for ways to drive down health care costs while preserving, or even improving, quality. In today's New York Times, Reed Abelson reports on a pilot medical home program started in Arizona by I.B.M., one of the state's biggest employers, and UnitedHealth Group, its insurer. The pilot will give 26 doctors at seven medical groups more direct responsibility for coordinating the care of 7,000 patients. UnitedHealth will also begin to pay doctors for overall quality of care, not just for the services provided.

Medical homes are a promising way to improve patient care and control health care costs. The medical home model gives patients a "home base," a physician who coordinates the patient's path through surgeries, specialists, and other care. It is seen as a particularly promising tool for managing chronic disease. In North Carolina's Medicaid program, assigning patients to a physician at a community clinic (their "medical home") has saved the state millions since FY2004. Both Senate Finance Committee Chair Max Baucus and the Medicare Payment Advisory Commission are interested in expanding medical homes in Medicare.

Having visited New Orleans and the Gulf Coast 18 months after Katrina, and having seen first-hand the stresses on the hospitals, ERs, clinics, mobile health vans and other health centers, it's heartening to hear even a little bit of good news emanating from that struggling city. Good news is what we heard yesterday about the progress toward building a viable, community-based primary care system in a city that had long been focused on big downtown hospitals, costly specialist care, and very, very busy, crowded ERs. In fact, storm-ravaged, long-suffering, stressed-out (add your favorite cliché here) New Orleans may show the rest of us a thing or two about how to create a patient-centered primary care system.

You wouldn't ask a plumber to build your house. Nor would you expect a dermatologist to manage your heart disease.

The difference is that in the first case, people hire a general contractor to make sure that the job is done by right people at the right price at the right time. In the second case—well that's exactly the problem according to a recent issue brief by Cato's Arnold Kling and Michael Cannon.

Kling and Cannon begin their discussion noting that "credible estimates suggest that one-third of health care spending is wasted." They problem, as they and many others see it, is in the way health care is delivered. As treatments have become more complex, health care has become less coordinated. Patients with multiple chronic diseases see multiple specialists, with no "project manager" in charge of coordinating a patient's care and overall health. The lack of accountability and communication leads to higher costs and worse outcomes. The problem, the authors argue, is perpetuated by fee-for-service payment and exacerbated by state regulations (the Cato authors are libertarian after all...),

The solution lies in creating more integrated systems of care modeled on principles of corporate organization to lower transaction costs; promote cooperation and standardization; and can realign incentives for quality.

We quoted Dr. Elliott Fisher in our recent American Prospect piece but naturally the head Dartmouth Atlas researcher had more smart things to share than we could fit in one magazine article. The Dartmouth team has been telling us for years about the unjustifiable and often inexplicable ways that health care differs from one place to another, and how much of our health care spending doesn't make people healthier. What's exciting now is that more people are listening. So we thought we would share  more of what Dr. Fisher told us about how to create a more sustainable high-quality health care system.

Ok, so may be we don't have a non-fatal strain of the hantavirus... In today's New York Times:

If that headache plaguing you this morning led you first to a Web search and then to the conclusion that you must have a brain tumor, you may instead be suffering from cyberchondria.

On Monday, Microsoft researchers published the results of a study of health-related Web searches on popular search engines as well as a survey of the company’s employees.

The study suggests that self-diagnosis by search engine frequently leads Web searchers to conclude the worst about what ails them.

Further evidence that your Google home page is no subsitute for having a medical home to can help guide you through the complex decisions and treatment options of modern medicine.