The Medical Home Gains Momentum: Could a team-based model work for otolaryngology?

The patient-centered medical home’s star appears to be rising. Thirty-eight states are testing this model of care in some way, according to the National Academy for State Health Policy. The federal health system reform law, passed this spring, includes several provisions encouraging the concept.

So what is a patient-centered medical home (PCMH), and what does it mean for otolaryngologists?

Redefining the Concept

The American College of Physicians (ACP) defines the PCMH as a team-based model of care led by a personal physician who provides continuous, coordinated care throughout a patient’s lifetime to maximize health outcomes. The practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified professionals.

The PCMH model was developed by primary care physician groups, which agreed on unified principles in 2007. The focus is on primary care practices using the model to improve patients’ health.

The challenge will be to distinguish medical homes from the strict health maintenance organization (HMO) model of the 1990s, which proved unpopular with both patients and specialists because it made primary care doctors gatekeepers of referrals, said Mark C. Weissler, MD, FACS, an otolaryngologist and member of the American College of Surgeons Board of Regents, speaking on his own behalf. If public or private payers decide to capitate medical home payments, the incentive could be to limit referrals, he explained.

Under the PCMH model, primary care doctors are not gatekeepers, said Roland A. Goertz, MD, MBA, president of the American Academy of Family Physicians (AAFP). The concept’s focus on care coordination and quality improvement should result in better communication and stronger relationships between primary care doctors and specialists, he said. “The public should demand it,” he added.

Others worry that any extra pay to compensate primary care physicians for medical home costs, such as the effort involved in coordinating care, might be taken from funds that would otherwise go to specialists. Sixteen surgical societies, including the American Academy of Otolaryngology-Head and Neck Surgery, argued against this notion in their 2009 agenda for Medicare payment reform.

Primary care organizations do not advocate for extra medical home payments to come from other doctors’ pay, noted Dr. Goertz. Likewise, a Medicare payment bump for pediatric medical homes at the expense of pediatric subspecialists would be a move in the wrong direction, said an American Academy of Pediatrics (AAP) spokesperson.

An article in Chest noted that funds to pay for expanded fees for medical homes could be obtained over time through cost savings resulting from the way the PCMH model increases primary care access, coordinates care, provides evidence-based medicine and manages chronic illnesses (2010;137(1):200-204). A December 2007 Commonwealth Fund report estimated that $194 billion could be saved over 10 years by assigning each Medicare fee-for-service beneficiary a medical home.

The 2009 surgical specialty society agenda also stated that specialists should be able to run medical homes. The medical home principles adopted by the primary care associations are specialty neutral.

The new health reform law includes provisions that call on the Department of Health and Human Services to issue grants or enter contracts to foster establishment of medical homes. The act defines the medical home as a mode of care that includes personal physicians but does not elaborate on what a personal physician is.

Practical Implications

Do specialists want to redesign their practices as medical homes? In a survey of 373 single-specialty cardiology, endocrinology and pulmonology practice leaders, 81 percent of respondents said their physicians serve as primary care doctors for 10 percent or fewer of their patients. Just 2.7 percent said doctors in their practice fill that role for more than 50 percent of their patients, wrote the researchers who conducted the survey, which was reported in The New England Journal of Medicine (2010;362:1555-1558).

“Specialist-based medical homes should be required to meet the same standards as primary care-based medical homes, including the requirements for providing first-contact, continuous and comprehensive care, and for using systematic processes to improve the health of the practice’s patients,” the authors stated.

PCMH criteria can be expensive and difficult to meet, an evaluation of the two-year AAFP pilot project showed. “Transforming from a physician-centric practice to a team-based, patient-centered model is challenging for physicians who are accustomed to being responsible for the entire patient encounter,” the evaluation team noted. “Developing care teams requires substantial cross-training efforts, as well as developing a shared vision among front- and back-office staff of how care teams affect the patient experience. Most practices will need additional financial and human resources to achieve full medical home transformation.”

Any non-primary care specialty practice that wants to meet the criteria could become a medical home, Dr. Goertz said, but he suspects that most would not want to, because providing primary care isn’t their goal. Dr. Weissler agreed. “I don’t think it’s realistic that otolaryngologists are going to want to manage conditions like diabetes or chronic obstructive pulmonary disease.”

It’s more likely that specialists would opt to work with primary care PCMHs to coordinate care, Dr. Goertz said. The AAP spokesperson said that good relationships with pediatric subspecialists are essential for the success of pediatric medical homes.

Medical homes, if structured properly, could strengthen communication and care coordination between specialists and primary care doctors, said Dr. Weissler. “That’s the dream, but right now it’s sort of just a dream.”