Dr. Bitton: Today we are talking about the patient-centered medical home, a model of primary care that has generated significant interest and enthusiasm in the United States over the past 5 to 6 years. It’s important as a frame of reference to remember that the patient-centered medical home was actually an idea borne out of the pediatric world as a system for organizing care for chronically ill children who have complex, multisystem diseases. The pediatricians have worked on this model for at least 40 years, but it’s only been in the past 10 years or less that the adult medicine and family medicine worlds have really embraced and begun to adopt this model. Currently there are thousands of practices and millions of patients being served by medical homes across the country, and it is incumbent upon us to understand where this model has come from, and where it is going.
So, with that prelude, we have convened today a panel of experts in adult internal medicine who are well versed in the medical home model. I am Asaf Bitton from the Harvard Medical School Center for Primary Care and Brigham and Women’s Hospital. With me are Drs. Joseph Frolkis and Stuart Pollack from the Brigham and Women’s Hospital in Boston, and Dr. Christine Sinsky from the Medical Associates Clinic and Healthplans in Dubuque Iowa.
We’re here to try to understand what the medical home model is, how it’s working across the United States, what are its main challenges, and to forecast where we see the field moving in the future. So, to all of our panelists, I want to start by asking each of you for your definition of what a patient-centered medical home is. I’ll start with Dr. Sinsky.
Dr. Sinsky: I think access and continuity are really the most important pieces of the medical home. Patients need access and continuity with the same provider: to proactively manage chronic conditions, to evaluate acute symptoms in context, and to build trust and a relationship.
Dr. Bitton: Dr. Pollack, what is your definition of what a patient-centered medical home is?
Dr. Pollack: I think it comes back to really good primary care. I like the World Health Organization definition of primary care from the 1970s: access and continuity, as Dr. Sinsky just mentioned, as well as comprehensive and coordinated care. So my definition of the medical home is just really good primary care delivered by a team, with an activated patient as a key member of that team—and there’s definitely a computer thrown in someplace.
Dr. Bitton: Dr. Frolkis?
Dr. Frolkis: I increasingly quote my colleague, Dr. Pollack, and say that the medical home is great medical care delivered by a team. But, I also think it’s critical to point out that these team members are not what used to be called “physician extenders” whose only real function was to increase the physician’s efficiency in order to maximize throughput in a Fee for Service world. In the medical home model that we’re discussing today, these are colleagues who have shared responsibility for the care of the entire panel of patients in the practice.
Dr. Bitton: As a follow-up question, to all of the panelists, how is your definition of a medical home different from just good primary care? Is there a difference or are they one and the same?
Dr. Frolkis: I think that studies have shown that primary care physicians cannot sustain the demands of acute, chronic, and preventive care in the current model of care delivery. Something has to change if we’re going to save this field. Team-based care has the potential to be that 'something.' I would argue that having fully functional teams, and there’s no standardized definition of this yet, which may include social workers, nutritionists, exercise physiologists, advance practice clinicians, licensed practical nurses, nurses’ aides, community resource specialists, community health workers, and population managers, can provide both a depth and a breadth of care not possible in our traditional, “doctor-centric” model.
Dr. Bitton: Drs. Sinsky or Pollack, do you have any thoughts on what’s different or not?
Dr. Pollack: I don’t think the theory has changed. It’s not like 10 years ago we were walking around saying, “I really think care should be uncoordinated,” and then 5 years ago, we said, “Oh, that uncoordinated thing isn’t working out, let’s try coordinated.” What is different is our ability to deliver on the theory. For really good proactive primary care to happen, you actually do not need an electronic health record, but you do need a registry, which is really hard to do without an electronic health record. And reimbursement has to change to pay for the team required to have any chance of getting through the volume of work that needs to be done.
Dr. Sinsky: I would also add that the medical home framework has given a language and a legitimacy for strengthening primary care and it provides a roadmap for how to do so. As Dr. Pollack said, no one started out intent on providing uncoordinated care; the medical home now gives us direction as to how to deliver truly comprehensive and coordinated care.
Dr. Bitton: Dr. Sinsky, could you tell us a little bit about how you got involved in these efforts at your clinic and in the model that you’ve built?
Dr. Sinsky: Sure, I’m happy to. We formally went through the process of medical home recognition in 2008 when we were recognized as a level III clinic by the National Committee on Quality Assurance (NCQA). In fact, we were the sixteenth clinic in the nation to have medical home recognition. But, it was really during the previous 20 years that we gradually built systems so we could manage the three domains of primary care Dr. Frolkis identified: acute care, prevention, and chronic illness care, with planned care appointments, with pre-visit laboratories, and with an after-hours nurse call line for our patients. We built stable care teams, initially with a 2 to 1 ratio of nurses to physicians. Now, we’re piloting three nurses per physician. So, our medical home model has been gradually evolving over a 20-year period.
Dr. Bitton: What are the biggest changes that you’ve seen in your day-to-day work of primary care, Dr. Sinsky?
Dr. Sinsky: Over time patient care has become more complex. Fifteen years ago a patient with a blood pressure of 146/85, cholesterol 235, fingerstick blood sugar of 134 and a creatinine of 1.5 may have been considered to be doing fine and might have been advised to come back in a year. Now, that very same patient may be diagnosed with four chronic diseases and in need of more intense management. We now need better systems and infrastructures that’ll allow us to manage this increased complexity in our patient population.
Dr. Bitton: Dr. Pollack, can you tell us a little bit about your journey into the world of medical homes and how it arose in your context?
Dr. Pollack: I spent most of my career practicing in what we would now call an accountable care organization, a multispecialty group integrated with a hospital and a single payer. I ended up as Chair of Medicine about 10 years ago. About 3 months after I started, the group decided to change to a fee-for-service multi-payer group, which now sort of sounds crazy, but 10 years ago it was what people were doing.
So, I actually got to help transform a group of physicians into a fee-for-service model. On paper, we did very well. Relative value units (RVUs) per physician went up by 50% in 2 years, the budget looked good, and people were productive. But when you sat back and talked to the patients and to the nurses and to the doctors, people really weren’t happy. In addition, it got to the point where we literally could not recruit young primary care physicians. And when you love what you do, it’s depressing to realize that young docs don’t want to do it anymore.
I think we did a really good job of optimizing a model that was fundamentally flawed. I woke up one morning and realized that it was just not working. It wasn’t the people in the model; it was the model itself that was broken. I wanted to get way outside the box and create a primary care innovation site. That was just when medical home was really hitting peoples’ consciousness. I discovered that if I talked about medical home, organizations would respond to me. It’s been a wonderful journey ever since.
Dr. Bitton: Dr. Frolkis, tell us about your network’s effort to promote the model, and especially why or how it might fit into an academic medical center context.
Dr. Frolkis: I think it’s important to remember that academic medical centers are still fundamentally just “hospitals,” but with the added complexity and incremental missions of teaching and research. So, the critical importance of a strong primary care base is every bit as relevant to the fiscal health of the academic medical center, to their market share, and to their community mission, as it is in a community hospital. In fact, whether we remain in a fee-for-service world or end up in a fully accountable care world or in what is our current quite uncomfortable transitional space, primary care physicians still generate the referrals that “feed the beast” of subspecialty care, which is where the margins are for hospitals now. By doing so, they drive the clinical enterprise, but also, by definition, the educational enterprise and the teaching mission. We supply the cases that become the great teaching opportunities that medical students and residents in all the specialties learn from.
I would add that in this new world toward which we’re heading, however uncertainly, academic medical centers will be wise to invest in patient-centered medical home growth to deliver on the metrics that are going to become very important to them, such as population management, quality, access, and cost outcomes. Finally, for this point, I would say that it’s also a wise investment for academic medical centers because the transformation of primary care and the creation and spread of patients in medical homes is an increasingly potent draw for medical students and residents who are interested in being part of this movement of care redesign and health system reform.
Dr. Bitton: The next question I’d like each of you to answer in sequence starting with Dr. Sinsky. What are your thoughts about the trajectory of the medical home movement or transformation across primary care in the United States? Specifically, is this a panacea for primary care, a temporary flash in the pan, or something in between?
Dr. Sinsky: I’m really optimistic about the trajectory that the patient-centered medical home might take primary care on, if you will. While it is not yet certain that patient-centered medical home will strengthen primary care, I think it’s very plausible.
I’m concerned that we’re at a tipping point and that we now have to pay attention not only to the patient in the patient-centered medical home, but also to what it is like to live in the medical home as a physician, a nurse, a medical assistant. Can we make this work joyful, manageable and rewarding? Some practices found that when they first implemented the patient-centered medical home they did it on the backs of the providers and actually decreased work-life satisfaction. So, we have to make sure that we pay attention to joy in practice.