Monday, August 18, 2008

Do We Need A Medical Home?

The American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and the American Osteopathic Association (AOA) recently issued a statement entitled “Joint Principles of the Patient-Centered Medical Home.” While the concept of a safe “home” in the middle of the storm that is health care these days is attractive, the loosely defined patient-centered medical home (PCMH) could potentially hinder access to high-quality emergency care.

I have several concerns. I would like to see the specifics of this proposal before wide-spread implementation is begun. A “make it up as we go” implementation plan does not work for our already ailing health care system. I would like to make sure that the patient does not become “medically homeless” if they lose their insurance. The plan should truly be patient-centered, with guaranteed access to medical specialists.

The American College of Emergency Physicians has released eight principles about the concept of the patient-centered medical home, paraphrased here. The full statement is available on the ACEP website. (

Principle 1

ACEP supports high-quality, safe, and effective medical care. ACEP supports the use of evidence based medicine and believes there should be accountability for continuous quality improvement and performance measurement. ACEP supports the use of information technology to optimize patient care, communication, and education.

Principle 2

ACEP supports health care payment reforms that ensure all medical care providers are fairly compensated for the care they provide to patients. ACEP believes that it is critical that physicians who provide EMTALA related services be adequately compensated for those services. ACEP supports additional compensation for primary care physicians for the medical home services they provide to patients outside of face-to-face visits.

Principle 3

Enhanced access must be demonstrated. Home is a place you go where they know you. There is a significant shortage of primary care physicians in America. In 2005, 36% of primary care physicians were working in practices with one or two physicians. It is unlikely that such small practices could meet the criteria for becoming an approved medical home. Most physicians' offices are closed on nights, weekends, and holidays and, in some instances, all or part of certain weekdays. Many patients are unable to get an appointment even during regular working hours because their physician's schedule is booked. The medical home model contemplates an ongoing relationship between a patient and a personal physician who understands the patient's health care needs and has a history with the patient. Much benefit of the model will be lost if a patient must see a host of different physicians and midlevel providers in large group practices in which there may be little or no experience with the patient. There should be a demonstrated ability and commitment to provide the continuous care that is central to the medical home concept before additional payments are made to physicians to offer this service.

Principle 4

Once established, the medical home should continue regardless of insurance status or ability to pay. You are always welcome at home. Many Americans go through transitions when they become unemployed or otherwise lose their health insurance coverage. Essential to the improvement of health care for patients using the medical home model is that there be an ongoing relationship in which a physician provides continuous and comprehensive care. The ongoing relationship must not be interrupted based on the presence or absence of the patient's ability to pay for care. While the medical home does not purport to provide health care for the millions of uninsured Americans, there should be a requirement as part of this model that once a person is enrolled in a medical home, the provider must continue to deliver care to those individuals whether they continue to have insurance or not. In a similar vein, health insurance companies must cooperate and not exclude coverage for patients of medical homes when the insurers are making changes in their networks of providers. To truly be patient-centered and most effectively realize the benefits of the medical home approach, the health care needs of patients must be paramount.

Principle 5

Patients must have freedom to switch medical homes, select specialists of their choosing, and access emergency medical care when they feel they need it. Patients should have the right to choose the home they want without restriction. Patients must be allowed to switch providers and choose whom they wish for their medical home. Proponents of the medical home insist that it is not a gatekeeper model. Yet in order for there to be the cost savings touted by proponents, there will undoubtedly be pressure for medical home providers to limit choices and restrict access of patients to certain providers. ACEP strongly opposes any coercive effort to prevent patients from seeing specialists they may choose. Of utmost importance is the ability of all patients to access emergency medical care according to the "prudent layperson" standard whenever they perceive they are experiencing symptoms of an emergency condition, even if later diagnosis determines there was no serious medical problem.

Principle 6

Research must prove the value of the medical home before it is widely adopted. Society must get the home it is paying for. There should be more research to demonstrate the benefits and continuing costs associated with implementation of the full PCMH model. Demonstration projects being conducted by the Centers for Medicare & Medicaid Services must be carefully evaluated. There should be proven value in health care outcomes for patients and reduced costs to the health care system before there is widespread implementation of this model.

Principle 7

Universal health insurance coverage is necessary for the PCMH model to be most effective. There are an estimated 47 million uninsured in America, and that number continues to grow. In addition, there are many millions more who are under-insured. Those without adequate insurance coverage will remain "homeless" under current PCMH models. Without providing adequate insurance coverage to the growing ranks of uninsured and under-insured, the overall health of many Americans will continue to deteriorate and the PCMH model may have the unintended consequence of increasing health care disparities.

Principle 8

The medical home must include the safety net of emergency care. Resources used to test the PCMH model should not undermine or further compromise the crumbling emergency medical care system. Regardless of the anticipated benefits from having a medical home, there will still be many millions of Americans who experience life-threatening illnesses and injuries for which they need emergency medical care. In addition, there is a serious need for increased surge capacity and medical preparedness for natural and man-made disasters. Ongoing research should be conducted to determine the extent to which implementation of the PCMH actually has the benefit proponents contend of reducing patient visits to emergency departments. Ongoing research must also evaluate whether resources utilized for PCMHs have unintended negative effects on the essential community service of emergency medicine.

The emergency department remains the “home away from home”…….and we’ll leave those big red lights on.

1 comment:

Josh F said...

I know that this will be a hot potato with many readers. One thing that I feel is always missing is putting any onus on the patient. Other countries (that provide state sponsored insurance) actually have provisions to DROP patients if they do not seek routine care (time period varies from 6 mos to 1 year depending on health care type, i.e. doctor or dentist). Where is the the patient responsibility in this?
The most frequent relevant reason for no past medical history in the patients that I have experience with is that they choose not to see the doctor. And, this does not only apply to the medically indigent, it applies to those with insurance too "because they were never sick before."
Something big is needed to change this system to tip it toward truly benefitting the patient. I would propose that this idea could be it.
Additionally, until the abnormal english (to borrow a ping pong term) is removed from our "system" (and I use that term loosely) we (doctors) are seriously hobbled. By english I mean that patients have NO responsibility and that doctors can be subject to criminal charges if they decided to accept milk and cookies from a little old lady as payment.
The usual disclaimer belongs here that this is only my personal opining and not that of anyone else.