'Medical home' gaining traction, but at what cost?

Washington-The concept of the primary care "medical home" is everywhere in the health care reform debate; it's hard to find a discussion on reform without a focus on the concept. But it's an idea that's getting some pushback from specialists.

The medical home concept calls for a team led by a physician-usually a primary care physician-to be paid extra to handle personalized coordination of a patient's care across the health care system, including arranging for care with other providers. It includes elements such as use of registries listing patient conditions for an overview of the practice's population, patient outreach, and management beyond the acute care episode to ensure that patients receive needed care.

"Urology is a surgical specialty and may be the most appropriate medical home for patients with certain chronic urologic conditions, such as prostate cancer or bladder control problems," he said.

Whatever form the medical home takes in health care reform, and regardless of whether it includes specialties, the concept has gained a lot of backing in a short time. The current push was initiated about 3 years ago by large employers, including IBM and medical groups, which cited research indicating that nations that emphasize primary care spend less on care and have better outcomes on average.

A number of ongoing demonstrations are currently testing the medical home in different areas of the nation. There are also over 400 groups, including large employers, insurers, and medical professional groups, in the "Patient-Centered Primary Care Collaborative" (PCPCC), established in 2006 to work for expansion of medical homes. The basic medical home principles were written by four primary care societies: the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association.

According to the PCPCC, 13 specialty societies, including the American Academy of Neurology, the American College of Cardiology, and the American Society of Clinical Oncology, have endorsed the principles. AUA has not. In addition, the National Committee for Quality Assurance (NCQA) has set accreditation standards for three levels of medical homes.

At present, much attention is centered on the large, 3-year Medicare medical home demonstration getting under way this year that is expected to include approximately 400 practices in eight states. According to a Medicare fact sheet, practices eligible for the trial include family practice, internal medicine, geriatrics, general practice, specialty and subspecialty practices, except where specifically excluded. The excluded specialties and subspecialties include radiology, pathology, anesthesiology, dermatology, ophthalmology, emergency medicine, chiropractic, psychiatry, and surgery.

Regarding urology's eligibility, Donald E. McLeod, a CMS spokesperson said, "It is unlikely that a urology practice... will want to coordinate all of the patient's health care with other providers the patient sees. That said, if a urology practice wanted to participate and could qualify as a medical home according to the criteria developed for CMS by NCQA, they could probably participate."

At the recent hearing of the Senate Health, Education, Labor and Pensions Committee where Dr. Schlossberg testified, Sen. Sherrod Brown (D-OH), who chaired the hearing, said, "While there is widespread agreement that the concept of a medical home is a good one, there are some concerns about how best to meet the patients' needs. Some have argued that it might not make sense for a primary care physician to always serve as the medical home coordinator." Brown also cited concerns about any requirements for physician referral to specialty care.

"To foster collaboration, Congress should not divide medicine and strive to strengthen primary care at the expense of specialty care," said Dr. Schlossberg, who testified on behalf of the Alliance of Specialty Medicine.

"Rather than having government decide which providers are most appropriate, let individual physicians, in consultation with their patients, together decide if they want to participate; many may not."

The Alliance asks that Congress analyze the outcomes of the Medicare medical home demonstration before enacting the medical home as a permanent model, Dr. Schlossberg said. He noted the demonstration will not be implemented in practices until January 2010.