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Home Calls

A new idea is being touted as the next cure-all for the ills of the health care system. But it's not clear yet what a 'medical home' is.


Penelope Lemov

Penelope Lemov is a GOVERNING correspondent. She was GOVERNING's health columnist and was senior editor for several award-winning features.

If you were thinking of the doctor from the old television show, "Marcus Welby, M.D.," you would be wrong. A "medical home" -- the latest buzzword to hit health care circles -- is not about returning to the days of the warm and fuzzy family doc, the one who makes house calls and holds your hand through everything from an infected splinter to a life-threatening disease.

If the medical home is not a step back in time, however, it's not exactly a giant leap forward, either. The idea isn't a bolt-out-of-the-blue innovation. Rather, it builds on key evolutionary reforms in health care delivery, such as managed care, case management and wellness. I've heard the medical home described as everything from "an enhanced version of primary care" to "paying doctors to do what they ought to be doing in the first place."

Even the experts touting this concept are tripping over the definition. When Health Affairs, the prestigious health care journal, led off its September/October issue with "Building the Medical Home," the editors admitted in their introduction that "it's hard to pin down exactly what 'medical home' means." Robert Berenson, one of the article's authors, gave it a try: "A medical home in broad terms," he wrote, "is a physician-directed practice that provides care that is 'accessible, continuous, comprehensive and coordinated, and delivered in the context of family and community.'" To amplify that definition, Berenson noted that the interest in medical homes stems from a growing recognition "that even patients with insurance coverage might not have an established source of access to basic primary care services and that care fragmentation affects the quality and cost of care."

Now we're getting somewhere. We all know how it feels when we have to switch from one primary doctor to another -- our employer changes its health insurance plan and the physician covered under Plan A is no longer available to us under Plan B. Or how vulnerable we feel when one doctor prescribes a medication that's at war with a pill another physician put us on. And how foolish we feel when we get home and realize that we don't quite understand the doctor's instructions.

The reason I'm going to such pains to come up with a definition is that so many health care experts, academics, theorists and policy makers see the medical home as a cure-all for whatever ails the health care delivery system.

Essentially, what a medical home promises is to make sure that all patients receive a full panoply of preventive care -- in a way that makes the patient an active participant. Should patients become sick -- whether from an acute episode or a chronic illness -- their care isn't fragmented: There's a physician (or group of physicians) in charge to oversee that care. They'll suggest specialists, or call on a nutritionist, social worker, nurse practitioner or other health provider to work with the patient and his or her family in what the advocates call "a culturally appropriate manner."

One tool a medical home relies on is the electronic health record. That's so all the medical facilities and providers the patient visits have full access to that person's medical history. The Geisinger Health System in Pennsylvania, which runs one of the few large and comprehensive medical-home programs, also taps into electronic records to notify both the physician and patient when a patient is due for a flu shot, mammogram or other primary-care measure. Geisinger is beginning to reap some rewards from its pilot program -- thanks in part to a realignment of incentives to pay doctors for outcomes rather than services rendered. In its first year, the program reduced hospital admissions by 20 percent and saved 7 percent in total medical costs -- without any reduction in the quality of care offered to its patients.

This isn't just a private-sector movement. Several community clinics and Medicaid programs are beginning to incorporate medical-home principles into their health care delivery systems. North Carolina's Medicaid program, for instance, has tapped into a medical-home program for its elderly patients.

There is a big danger for medical homes, however. As Arnold Milstein, medical director for Pacific Business Group on Health, wrote in a recent Health Affairs blog, employer-, union- and government-sponsored medical homes need "to be a 'medical home run.'" That is, the innovation in care delivery has to deliver lower health care spending and higher quality of care. Such great expectations on a fledgling movement could be just enough to sink it.

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