The next big idea in health finance reform may be the "medical home."
The definition of the term medical home is still evolving, but policymakers now apply it to efforts to have a patient's primary care doctor do more than give the patient checkups and care for bad colds. The primary care doctor who runs a modern medical home is also supposed to maintain detailed electronic health records for a patient; ensure that the patient gets help with managing any health conditions, such as diabetes, depression or substance abuse; and manage and coordinate the patient's use of specialty care and hospital care.
Congress included funding for a Medicare patient-centered medical home demonstration project in Section 3502 of the new Patient Protection and Affordable Care Act and dozens of other pilot projects are either under way or in the planning stages.
CIGNA Corp., Philadelphia, has teamed with Dartmouth-Hitchcock Healthcare System to launch a medical pilot that serves 17,000 plan members in New Hampshire. CIGNA also has newer, smaller medical home pilots in other markets. Other carriers with high-profile medical home pilots include UnitedHealth Group Inc., Minnetonka, Minn., and several of the Blues, such as Blue Cross and Blue Shield of Detroit, Michigan and CareFirst Inc., Owings Mills, Md.
America's Health Insurance Plans, Washington, has issued a statement of principles supporting efforts to develop and test the medical home concept. A successful medical home system "would replace episodic care with a sustained relationship between patient and physician," providing patients with "more personalized and coordinated health care," AHIP says.
"Certainly, not all of the answers are there," says Warren Skea, a health care consultant in the Dallas office of PricewaterhouseCoopers L.L.P. "But this is not just dipping our toe in here. We're definitely going to move in this direction."
The medical home effort "is high priority," says Jordan Bazinsky, a vice president at Verisk Health Inc., Waltham, Mass., a health data analysis firm. "It's really front and center…. It will be meaningful in the lives of everyday people."
Although the term "medical home" has been around since the 1960s, "there are still some questions about what a medical home would look like, and what structures within the medical home work best," Bazinsky says.
The National Committee for Quality Assurance, Washington, the most visible health plan quality grader, has developed a set of medical home recognition requirements to create a standardized definition of "medical home."
When the NCQA evaluates whether an organization really is a medical home, it looks at factors such as patient communication and access; patient tracking; care management; patient self-management support; electronic prescribing; test tracking; referral tracking; and electronic communications systems, according to an NCQA fact sheet.
Ensuring that the primary care practice is in charge is another key factor, says Melinda Abrams, an assistant vice president at the Commonwealth Fund, New York.
Many health insurers, wellness vendors, disease management vendors and others offer care-management services.
Abrams argues that primary care physicians and their staffs are the best care coordinators; that counselors who at least occasionally see patients face to face, in a physician's office, are probably more effective than counselors who communicate with patients only over the telephone; and that the physician-run system is easier on the physicians.
If several large insurers each send a care manager to a group practice each week to perform comparable services, but using different procedures, the group practice will have to spend time and money to help the care coordinators. Physicians will feel as if they are running separate health care kiosks for each carrier, Abrams says.
Years ago, family doctors had the time to know their patients and look after their care from cradle to grave. But today, even the best family doctors lack the electronic health record systems, data analysis tools and on-staff care counselors and coordinators to identify patients who need extra attention in a systematic fashion and to provide that attention where needed, Abrams says.
Other big new health finance ideas have come and gone over the decades. In the 1990s, for example, health maintenance organizations persuaded many primary care doctors to accept a flat fee, or capitation payment, for each patient served.
