There is lots of talk about the \”Medical Home.\” It is seen by many as one of the ways to turn around our healthcare system. Yet if you ask most physicians, hospital administrators, and politicians, most probably could not explain to you what it is. In fact, the Happy Hospitalist reports that some in congress believe it involves physicians making house calls.
So here is my attempt to explain the medical home, show who wins, who loses, and why it could really help our ailing system.
Below is a diagram of the traditional model of medicine delivery/reimbursement:
![\"Traditional\"](\"http://distractible.org/wp-content/uploads/2008/04/traditional.jpg\")
Some things to note:
- Insurance companies are the thoroughfare for all transactions except for copays and the percent of care that is not covered.
- The green lines indicate where the money flows. As you see, the insurance companies are at the center.
- Accountability as to the necessity of care and the quality is through billing to the insurance company.
- Businesses are buffered from providers of care through the insurance providers. Any reports they get about the effectiveness of the money they are spending comes through the insurance plan\’s reports to them.
- Care management is done through penalizing physicians and hospitals through withholding payment from unnecessary procedures.
From an information standpoint, the insurance companies are at the center of the universe in this model, despite the fact that:
- Businesses are footing the bill (and to a lesser extent, consumers)
- Patients are getting the care
- Doctors and hospitals are providing the care.
All information about cost and quality is filtered through the insurance industry. This would be fine if they were unbiased, but the fact that they are publicly held companies means that their goal is to maximize their profits for shareholders. This is a huge conflict of interest, kind of like having the fox guard the chicken coop.
As an alternative, the medical home (or at least, my take on it) would look like this:
![\"Home\"](\"http://distractible.org/wp-content/uploads/2008/04/home.jpg\")
In this model there are the following differences:
- Businesses pay physicians directly in exchange for reporting. I will detail this more later.
- The consumer (patient) is also getting a report from the physician.
- Insurance companies lose some of their role as managers.
Reporting
Reporting is one of the main differences in this model. Reports are given to both employers and patients.
Employer reports contain generic information about the overall health of their employees (not on specific employees). These reports contain such data as:
- Preventive care – how are employees using preventive services?
- Disease management – How are patients with diseases such as diabetes, heart disease, etc. doing with their diseases?
- Utilization – The goal of this is to keep the workforce healthy and at work. If preventive services and disease management are done, the utilization of hospitals, specialists, and PCP\’s will be less. I realize some may debate this (since it is not proven), but the assumption is that \”a stitch in time saves nine.\”
- Access – One of the cornerstones of this plan is to give freer access to the PCP through non-traditional means. E-Visits are encouraged because they potentially can decrease employee absences. The patient also has reports and online access (PHR) of chart information.
Patient reports contain specific information about their overall health. It is basically a \”report card\” as to how they are doing and what upcoming care is needed. Ideally this is combined with the idea of a PHR (Personal Health Record) in which the patient has online access to information directly from the PCP and has the ability to assure that this information is accurate and up-to-date.
Winners and losers
Here is how the various players fare in this set-up:
- Primary care physicians – Since they are keepers of the medical home, they are reimbursed with a global fee to manage the care they give. The groups advocating medical home are primary care oriented (AAP, ACP, and AAFP), so it should benefit the PCP financially. Plus, since the money comes directly to the PCP from the business, the \”middle man\” is eliminated.
- Specialists – This model does not effect these physicians as much, as it is more focused on primary care. Some specialists (like endocrinologists, cardiologists, and OB/GYN\’s) are lobbying to be included as caretakers for the medical home.
- Hospitals – The goal of preventive care and disease management is to decrease cost and improve health. Presumably this will decrease ER visits and hospitalizations which may hurt hospitals overall, but that is unclear.
- Employers – They are greatly empowered with information and with tools to maximize their workforce. The ideal end-game here is that they are able to offer medical home plus a high-deductible insurance policy to their employees and so manage the cost of insurance.
- Patients – Most people are blind in their care. With the Medical Home operating in this way, people will know where they stand in terms of prevention and disease management. They also now have much better access to their physicians in ways that are non-traditional. They may be the big winners with this version of the MH.
- Insurance companies – They take the biggest hit here. Some of their \”managed care\” role is taken away (which is a means to control the cash-flow) and in the end they potentially will be transformed back to a more traditional type of insurance (like life or disability, that insure groups based on overall risk but do not manage the day-to-day care). The money flowing through insurance companies is less, so they have less opportunity for profit (which is one of the main point of this idea).
There is no question that information technology is one of the cornerstones of the Medical Home. Practices need to be able to make the reports quickly and accurately which can only happen with a well-executed EMR (and not simply a E/M compliance machine). The ability to communicate securely with patients is also essential.
My main area of skepticism of this is whether it can actually be pulled off. There are a whole lot of people making a whole lot of money off of the current system that will greatly resist change (using a whole lot of lobbyists and lawyers) or water it down, minimizing the positive impact. The insurance companies will fight to remain the information conduit, which should be avoided for the reasons I gave above. Physicians who refuse to use IT will think it is unfair to favor doctors who do and will try to get a reporting system based on billing data or less rigorous clinical data.
There are also many unanswered issues, such as the uninsured, unemployed, and elderly populations. This model does not in and of itself address these issues.
All in all, however, I at least see this as someone trying to think ahead as to what healthcare should be and an attempt to start shaping it positively.
Your version of the medical home seems to bear little resemblance to the version sponsored by United Health Group.What they proposed certainly does nothing to diminish their role and control and does just the opposite. You might consider calling your plan by some other name.
Your version of the medical home seems to bear little resemblance to the version sponsored by United Health Group.What they proposed certainly does nothing to diminish their role and control and does just the opposite. You might consider calling your plan by some other name.
I am certain the UH did not want the businesses bypassing them and contracting directly with the physicians. They lose control of the pipeline in that situation and are changed to be only insurance companies. Now, their proposal was probably similar, but had them controlling the conduit between physician and business and sending that report card to businesses from the claims data. That is an entirely different beast and should be avoided at all cost (it gives them a bigger pipeline).
I have worked with a number of people on this whole idea and am pretty confident of my interpretation of medical home being correct. It is a system that puts much more control into the hands of the primary care physician and much more information in the hands of the patients and businesses.
I am certain the UH did not want the businesses bypassing them and contracting directly with the physicians. They lose control of the pipeline in that situation and are changed to be only insurance companies. Now, their proposal was probably similar, but had them controlling the conduit between physician and business and sending that report card to businesses from the claims data. That is an entirely different beast and should be avoided at all cost (it gives them a bigger pipeline).
I have worked with a number of people on this whole idea and am pretty confident of my interpretation of medical home being correct. It is a system that puts much more control into the hands of the primary care physician and much more information in the hands of the patients and businesses.
Dr. Rob,
Thank you for your thoughtful presentation of the medical home model, especially its reporting aspects and value to employers, which are rarely emphasized. The Healthcare Intelligence Network has been covering the emergence of the medical home and its impact on primary care for several years now, and I would like to respond to several of your points.
First, there has been much confusion, even in the industry itself, about the term. When we surveyed healthcare execs in 2006, more than half of them had never heard of the concept, or confused it with a physical structure. Thankfully, a similar survey we conducted earlier this year revealed a growing awareness.
Secondly, the key to the medical home model is a coordinated approach to care that is reliant upon an exchange of data among all medical home team members (pharmacies, payors, community organizations, physical therapists, and the patients themselves). In most but not all cases, care will be coordinated by the primary care physician. We cannot talk about the medical home without discussing tandem efforts to redirect consumers who visit the ER with non-emergent health issues to more appropriate health settings such as primary care. The dollars that payors and hospitals spend today to dispense primary care in costly ERs can be redirected to the medical home team. CMS last week announced $50 million in grants to 20 states that have proposed strategies to encourage Medicaid beneficiaries to avoid improper use of costly ERs, and nine of those proposals center around the creation of medical homes for these individuals.
Third, the medical home is a natural haven for the uninsured and the elderly. Several pilots in the medical home model have already been directed toward the uninsured. In North Carolina, doctors with Community Care of North Carolina served as medical homes for their Medicaid patients with diabetes. The ongoing care, information and support that physicians and case workers gave these patients made a huge difference. These patients missed fewer missed doctors’ appointments, made fewer non-urgent trips to the emergency room, and had fewer unnecessary hospitalizations. These changes saved North Carolina taxpayers more than $231 million in 2005 and 2006. North Carolina is planning related pilots for beneficiaries with other chronic illnesses.
And lastly, as we see it, the real key to the medical home’s success is education. Health plans have a huge challenge in marketing the medical home to consumers, who may confuse it with the old HMO “gatekeeper” model of care. PCPs, ER staff and payors need to teach consumers the benefits of the medical home and guidelines for determining when an ER visit is necessary. Primary care doctors need to know when patients are using the ER unnecessarily and address this during patient visits. During its pilot, Community Care equipped its physicians and patients with disease management toolkits and pamphlets on medical home vs. ER use in English and Spanish. Other health plans have found that putting these materials into consumers’ hands does reduce unnecessary ER use. Many payors have placed case managers in ERs as an educational and redirection resource. Education of ER staff and patients on the medical home also figures prominently in many of the CMS grant projects.
There are so many issues related to the medical home model that we have launched a Web page called “The Medical Home Monitor” at http://www.hin.com/medicalhome/medicalhome.html where we have posted our survey results and relevant video, podcasts, blog entries. etc on the topic, which will be updated continuously. Thank you for allowing me to respond to the issue here.
Dr. Rob,
Thank you for your thoughtful presentation of the medical home model, especially its reporting aspects and value to employers, which are rarely emphasized. The Healthcare Intelligence Network has been covering the emergence of the medical home and its impact on primary care for several years now, and I would like to respond to several of your points.
First, there has been much confusion, even in the industry itself, about the term. When we surveyed healthcare execs in 2006, more than half of them had never heard of the concept, or confused it with a physical structure. Thankfully, a similar survey we conducted earlier this year revealed a growing awareness.
Secondly, the key to the medical home model is a coordinated approach to care that is reliant upon an exchange of data among all medical home team members (pharmacies, payors, community organizations, physical therapists, and the patients themselves). In most but not all cases, care will be coordinated by the primary care physician. We cannot talk about the medical home without discussing tandem efforts to redirect consumers who visit the ER with non-emergent health issues to more appropriate health settings such as primary care. The dollars that payors and hospitals spend today to dispense primary care in costly ERs can be redirected to the medical home team. CMS last week announced $50 million in grants to 20 states that have proposed strategies to encourage Medicaid beneficiaries to avoid improper use of costly ERs, and nine of those proposals center around the creation of medical homes for these individuals.
Third, the medical home is a natural haven for the uninsured and the elderly. Several pilots in the medical home model have already been directed toward the uninsured. In North Carolina, doctors with Community Care of North Carolina served as medical homes for their Medicaid patients with diabetes. The ongoing care, information and support that physicians and case workers gave these patients made a huge difference. These patients missed fewer missed doctors’ appointments, made fewer non-urgent trips to the emergency room, and had fewer unnecessary hospitalizations. These changes saved North Carolina taxpayers more than $231 million in 2005 and 2006. North Carolina is planning related pilots for beneficiaries with other chronic illnesses.
And lastly, as we see it, the real key to the medical home’s success is education. Health plans have a huge challenge in marketing the medical home to consumers, who may confuse it with the old HMO “gatekeeper” model of care. PCPs, ER staff and payors need to teach consumers the benefits of the medical home and guidelines for determining when an ER visit is necessary. Primary care doctors need to know when patients are using the ER unnecessarily and address this during patient visits. During its pilot, Community Care equipped its physicians and patients with disease management toolkits and pamphlets on medical home vs. ER use in English and Spanish. Other health plans have found that putting these materials into consumers’ hands does reduce unnecessary ER use. Many payors have placed case managers in ERs as an educational and redirection resource. Education of ER staff and patients on the medical home also figures prominently in many of the CMS grant projects.
There are so many issues related to the medical home model that we have launched a Web page called “The Medical Home Monitor” at http://www.hin.com/medicalhome/medicalhome.html where we have posted our survey results and relevant video, podcasts, blog entries. etc on the topic, which will be updated continuously. Thank you for allowing me to respond to the issue here.
[…] posting last week by Dr. Rob of Musings of a Distractible Mind offered an insightful interpretation of the medical home model, complete with a graphical […]
Thanks for this, Dr. Rob, I have been recommending this post to many who need more integrated and comprehensive follow-up–especially ex-preemies and to the pedis who serve them.
Chris and Vic
Thanks for this, Dr. Rob, I have been recommending this post to many who need more integrated and comprehensive follow-up–especially ex-preemies and to the pedis who serve them.
Chris and Vic
Dr. Rob,
You are close, but not quite right.
The Medical Home is indeed a place for better care, coordination of care, and management of data. But in both of your models you have the insurace company as the major player, I read that you did not believe that was the case for the medical home, but graphically it is very similar to the insurance model.
The primary care medical home is an opportunity for providers to take back control of their practice, consumers to have easier, coordinated access to their community of medical services, employers to have access to real-time or near real-time untilization data, and the insurance companies to become more akin to a bank. There is a role for all involved and it is a win win for everyone, even the insurance groups. True they may have less total gross revenue but they will also be reducing their cost of transactions, management of data, and frequncy of use as they will simply raise the deductible on the plan to achieve a better bottom line each year. They will still have contracts with the providers and be moving a great deal of their work onto them.
The Medical Home Model is the way many providers operated prior to now, there just was not reimbursement models for the work that they did. We offer that plan at my company, a reimbursement model dedicated to the medical home model, it is a direct to provider payment vehile that gathers all the data at the time of the vists and makes it instantly available for all concerend parties, in addition we train the providers into the best practices of the medical home to help them run a more efficient business.
There is an approach that is tried and true to this model. It is a retail approach. The terms of disease management, primary care, referrals and follow up to name a few are simply good customer service. If we teach providers good customer service skills then these concepts come to them naturally. They become competitive advantages for the provider.
It is important for the industry to not let the insurance players influence this model too much or they will ruin it with their gestapo tactics on confining costs. However they can and will play an equal role in this model. I agree they will become more like traditional insureance plans.
ER overcorwding will stop when a better alternative to the ER exists in the local community, whether it be a medical home style practice or not. The ER is the Wal-Mart of mediciane, open 24hrs a day, has everything you may need in one place, and does not require payment at the time of service in many cases…is it really a wonder why people use it over pre approvals, appointments and requirements of payment that exist in most primary care practices.
As far as e-visits are concerened, we did some research on that with our own facilities and found that we spend a total amount of time per patient of about fifteen minutes in clinic and twenty-three minutes in an electronic enviorment. We found that the electronic enviorment was cumbersome and required a great deal more questioning of the patient. We also found that repeat visits (in clinic after e-consultations) were nearly double that of face to face visits and letting a patient “self-diagnose” was a risky proposal, they were not correct on their diagnosis often and frequently were just requesting medication based on direct to consumer advertising….simply put…it is not better in any way.
So the debate will continue, but you can rest assured that the free market is gearing up to offer a solution to the cost of healthcar…remember healthcare is not that expensive, health insurance is.
Dan Francis, CEO
Medical Homes of America
http://www.equityhealhplan.com (under construction)
http://www.medicalhomes.org
Dr. Rob,
You are close, but not quite right.
The Medical Home is indeed a place for better care, coordination of care, and management of data. But in both of your models you have the insurace company as the major player, I read that you did not believe that was the case for the medical home, but graphically it is very similar to the insurance model.
The primary care medical home is an opportunity for providers to take back control of their practice, consumers to have easier, coordinated access to their community of medical services, employers to have access to real-time or near real-time untilization data, and the insurance companies to become more akin to a bank. There is a role for all involved and it is a win win for everyone, even the insurance groups. True they may have less total gross revenue but they will also be reducing their cost of transactions, management of data, and frequncy of use as they will simply raise the deductible on the plan to achieve a better bottom line each year. They will still have contracts with the providers and be moving a great deal of their work onto them.
The Medical Home Model is the way many providers operated prior to now, there just was not reimbursement models for the work that they did. We offer that plan at my company, a reimbursement model dedicated to the medical home model, it is a direct to provider payment vehile that gathers all the data at the time of the vists and makes it instantly available for all concerend parties, in addition we train the providers into the best practices of the medical home to help them run a more efficient business.
There is an approach that is tried and true to this model. It is a retail approach. The terms of disease management, primary care, referrals and follow up to name a few are simply good customer service. If we teach providers good customer service skills then these concepts come to them naturally. They become competitive advantages for the provider.
It is important for the industry to not let the insurance players influence this model too much or they will ruin it with their gestapo tactics on confining costs. However they can and will play an equal role in this model. I agree they will become more like traditional insureance plans.
ER overcorwding will stop when a better alternative to the ER exists in the local community, whether it be a medical home style practice or not. The ER is the Wal-Mart of mediciane, open 24hrs a day, has everything you may need in one place, and does not require payment at the time of service in many cases…is it really a wonder why people use it over pre approvals, appointments and requirements of payment that exist in most primary care practices.
As far as e-visits are concerened, we did some research on that with our own facilities and found that we spend a total amount of time per patient of about fifteen minutes in clinic and twenty-three minutes in an electronic enviorment. We found that the electronic enviorment was cumbersome and required a great deal more questioning of the patient. We also found that repeat visits (in clinic after e-consultations) were nearly double that of face to face visits and letting a patient “self-diagnose” was a risky proposal, they were not correct on their diagnosis often and frequently were just requesting medication based on direct to consumer advertising….simply put…it is not better in any way.
So the debate will continue, but you can rest assured that the free market is gearing up to offer a solution to the cost of healthcar…remember healthcare is not that expensive, health insurance is.
Dan Francis, CEO
Medical Homes of America
http://www.equityhealhplan.com (under construction)
http://www.medicalhomes.org