The Medical Home: 
Better for Whom?

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Dr. Frolkis: I would reiterate that to the extent that we are in an accountable world, the upstream investment in medical home infrastructure will pay for itself downstream in reduced, unnecessary utilization, emergency room visits, and admissions. I think that there is early but reassuringly consistent data that this is the case.

Dr. Bitton: Dr. Sinsky, the community medicine world is a little bit away from quaternary academic medical centers. What are your impressions on how this model pays for itself in the community environment?

Dr. Sinsky: I would agree with Dr. Frolkis. My own clinic practice has been a rudimentary Accountable Care Organization for about 35 years. The investment in a strong primary care base has had downstream savings for us over time. I think that in any integrated delivery system if you double the investment in primary care, you will gain that all back and more in downstream savings.

Dr. Bitton: Dr. Pollack, if a private practitioner in a small group, primary care practice comes to you and asks if this is a feasible model in the current state of affairs, what do you say to him or her?

Dr. Pollack: I would say that 
you need to find someone to partner with, be it an insurer, a local 
business, or your hospital, because this really does require new resources. But, even in a fee-for-service system, given that hospitals 
are going to be penalized by Medicare for readmissions, medical home makes sense, because just the savings to the hospital should cover the costs of some rudimentary transformation.

Dr. Bitton: A final question before we summarize our discussion is around health information technology. Is it up to par right now for this model? If not, what areas really need to be improved or built out? I know all of you have thoughts on this. So, let’s start with Dr. Sinsky.

Dr. Sinsky: Thank you. Actually, one of my goals for the next five years is to help in some way to bring our technological tools, and some of the regulations around those tools, into alignment with the goals and needs of the medical homes. There’s a lot of potential power is in the Electronic Health Record and depending on your particular vendor and your institution’s implementation policies, you may have more or less realization of that power. But, right now, many physicians and their teams are actually finding their technology is getting in the way of a team-based model of care; that often the electronic health record is based on the presumption that it’s a physician and a computer, and not a team of people who will be interacting with the computer and interacting with the patient.

Dr. Pollack: I agree with Dr. Sinsky. The medical assistant is on my team, and the social worker is on my team, and the patient is on my team, and a bunch of specialists are on my team, but for some reason the computer doesn’t want to join. It’s not very flexible. There are many things that the computer can do much better than people, especially involving databases and population management. But, it just doesn’t do that. All it wants to do is document my notes, frequently not in the way that’s efficient for me and the other staff I’m on a team with. It doesn’t make it easy to get data into structured fields where it can feed directly into registries or be used for predictive modeling, and it’s not nearly as good as it could be in serving as a communication tool, and helping us distribute work among team members and reminding us to get it done.

Dr. Bitton: So, you’re saying that the electronic health record really exists right now around a billing template as opposed to a shared information transfer template for a team.

Dr. Pollack: Electronic health records were built for the fee-for-service systems they were sold to. Medical home and accountable care really is a fundamentally different model and the electronic health records need to catch up with that.

Dr. Frolkis: Information technology has to provide four key functions in this new world: attribution, severity adjustment, registry functionality, and utilization data. No system that I’ve worked with so far has done all four of those in a way that facilitates what we’re trying build.

Dr. Bitton: Sounds like there’s shared agreement there. So, in summary, we have one last set of questions for each of the panelists. We’ll start with Dr. Frolkis. What are your goals for this model in the next five years? What worries you, and also what excites you?

Dr. Frolkis: What worries me is the zero-sum conflict that I referenced earlier in our current model, and the ability of the folks who are excited about this, not just in the primary care workforce, but in the executive suite to sustain the political will to see this change through. That’s what worries me. What excites me are all the things we’ve talked about in the last 35 or 40 minutes: the regenerative energy around this model, the enthusiasm of young people, the promise of revitalizing our profession.

In terms of goals, I think that if we’re going to make this change stick we need to make it scalable. We need to figure out what’s critical and what’s optional about the models we’re building. We need to figure out who really needs to be on the team. Then, finally, I would say that the goal for the next five years should be to continue the momentum on research and evaluation of this model so that we can say we’ve proved the concept. There’s a lot to look at and a lot to report on. That’s very exciting.

Dr. Bitton: Dr. Sinsky, your thoughts on this summative question?

Dr. Sinsky: What excites me is the possibility of more closely aligning physician and team member training with a population’s need for medical care, rather than restricting training along traditional specialty boundaries. If we do this in physician training, for example, patients will have less fragmented care and more points of contact, and thus continuity, with their primary care physician. And primary care physicians will have a better work experience. Without realignment of training to practice there is a risk that primary care will be reduced to simply the triage station of the medical neighborhood. This would be a mistake in my view.
I believe primary care physicians can be trained to manage chronic conditions further along the spectrum of complexity, and also to perform a wide variety of commonly required procedures, such as joint injections, Intrauterine Device placements and wound treatments. Possessing these skills will enable primary care physicians to provide truly comprehensive, longitudinal, coordinated and personalized care to our patients; and thus also to achieve greater joy in work.

Dr. Bitton: Finally, Dr. Pollack, your thoughts?

Dr. Pollack: I think what worries me is the word “panacea.” I worry that businesses, governments, insurers, and health care organizations have too short of an attention span. When I left medical school, angioplasties were just starting to be routinely performed. Maybe they worked two thirds of the time, which is not great for something that only treats symptoms and has some fairly significant risks. In 2012 a drug-eluting stent works 95% of the time. That was a 25-year journey. If somebody had said, “two thirds of the time isn’t good enough, we’re not going to pay for this,” then cardiologists and device manufacturers and pharmaceutical companies wouldn’t have done the amazing work that got interventional cardiology to where it is today.

 

 

Medical home clearly improves quality. They save money. But, the expectation is that we will save huge amounts of money and create huge improvements in quality and solve all disparities in health care while providing the patient with a wonderful experience. Do I think we can do all of that? Yes. Do I think we know how to do all of that today? No. There’s a learning curve.
The odd thing is that if the medical home were a new drug it could barely improve results and significantly drive up costs and it would still be paid for. On the other hand, we are expected to both improve results and lower costs simultaneously. I worry that the standard we’re going to be held to is very high and that if we don’t succeed immediately people will move on to the next panacea that doesn’t exist.

Dr. Bitton: Thank you all for these really thoughtful words on where we are with medical homes and where we could be in the future.

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