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What Will the ‘Medical Home’ Proposal — A ‘One-Stop Shop’ Model for Health Care — Mean for Neurology?

Supermarkets provide a convenient one-stop shop for life's staples: vegetables, dairy, toiletries, cleaning supplies. Can't find the peanut butter? Chances are an employee will direct you in the right direction. It is also likely that you will shop at the same supermarket for most of your life, or until you move somewhere else. Now what if a similar idea were applied to medical care? The medical home model, a new initiative supported by several medical societies including the AAN, would create a coordinated care system of specialists, therapists, and other health-care providers who would report to a primary care doctor. All paperwork, appointments, and other administrative details would be coordinated by one office.

The American Academy of Pediatrics began developing the concept of the medical home in the mid-1990s, hoping to revive the traditional doctor-patient relationship in which the primary care doctor serves as the guardian of each patient's health. Originally conceived as a way to provide continuity of care for children with chronic diseases, the medical home has evolved into a model that could serve all Americans.

Last November, for example, Senator Richard Durbin (D-IL) introduced The Medical Homes Act of 2007, which authorizes three-year medical home demonstration projects that will provide Medicaid and the state Children's Health Insurance Program to an estimated 500,000 to one-million beneficiaries. When patients are referred to specialists or other health-care providers, the primary care physician would receive a full report and incorporate the findings into the patient's comprehensive health record. Participants in the medical home project would receive a per-member, per-month management fee to subsidize the extra costs associated with this care.

IMPLICATIONS FOR NEUROLOGY

How would neurologists benefit from the medical home model? And would this result in a reduction of income? The answer depends largely on the type of patients seen in practice, said Lily Jung, MD, advocacy editor of AAN.com. Some who manage chronic diseases such as multiple sclerosis (MS), autism, or epilepsy already have a practice that resembles a medical home, she said. They may provide a child with routine immunizations, for example, or treat a case of pneumonia. But neurologists who focus primarily on performing procedures or consulting on specific problems are more likely to perform the services requested, but no more.

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“Some neurologists serve primarily as consultants — they do EMG, give opinions and so on, and for them, the medical home model won't make much sense,” Dr. Jung said. “For those of us who develop a long-term relationship with a patient with a chronic disease such as MS, Alzheimer disease, or Parkinson disease, the medical home model makes a huge amount of sense.”

Dr. Jung, for example, treats MS patients, and sometimes ends up performing the functions of their primary care physician.

“I follow these patients during the course of their lifetime,” she said. “I talk to them about bowel problems, sexual or urinary dysfunction, and other chronic problems. When these become too great for me I may send them to a urologist or surgeon, but those patients consider me their doctor. I'm the one they call up when they're having problems.”

Under the medical home model, neurologists such as Dr. Jung could be reimbursed for these services, for which she currently receives nothing.

But overseeing a patient's entire health care does not appeal to all neurologists.

“Many neurologists, including me, don't feel confident taking care of patients with diabetes, or lipidemia, or urinary tract infections,” said Joel Kaufman, MD, clinical associate professor of clinical neurosciences (neurology) at the Alpert Medical School of Brown University, and chair of the AAN Payment Policy Subcommittee. “The medical home is not just about counseling patients with a chronic disease; it's having the ability to provide one-stop shopping for patients.

“The patient would see the medical home as having the ability not just to provide a referral, but also to ensure that the psychiatrist gets back to the neurologist with recommendations,” Dr. Kaufman said. “A lot of consulting physicians are not set up to do that.”

Despite such challenges, Dr. Kaufman said, the concept of the medical home makes a lot of sense. “It's absolutely something that should be tried to reduce the fragmentation of medical care, and to help patients with chronic illnesses get better care,” he said.

The AAN agrees. In a Mar. 6 letter to the American College of Physicians, AAN President Stephen M. Sergay, MB BCh, said the Academy would like to be included in demonstration projects being conducted by the Centers for Medicare and Medicaid Services and private payers.

And last month the Academy endorsed the “Joint Principles of the Patient-Centered Medical Home,” set forth in 2007 by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association.

The position paper states that a medical home should coordinate all the patient's health needs throughout life, including preventative services, acute care, chronic care, and end-of-life care. It also states that all aspects of a patient's care should be communicated between hospitals and nursing homes, or a specialist and the primary care physician.

Each player on the treatment team would be paid separately, but the primary care physicians would receive reimbursement higher than today's levels so they'd have more time to invest in face-to-face visits, telephone and e-mail consultations with patients, and discussions with others who are involved in a patient's care.

William Schwab, MD, considers reimbursement for phone and e-mail consultations to be vital to the success of the medical home model.

“There's no direct compensation for such activities,” said Dr. Schwab, principal investigator and project director at the National Medical Home Autism Initiative, and a professor in the department of family practice at the University of Wisconsin. “We do it because we feel it's the right care to provide. It's not easy to treat people with autism in 10 to 15 minutes. You have to spend a little more time. If we had a reimbursement system that recognized that, I could have stable compensation and do more of those things in a regular productive day.”

For example, if one of his patients has a seizure disorder, Dr. Schwab will refer the patient to a neurologist who will be reimbursed only for an office visit.

“A neurologist doesn't get paid to talk to me,” he said. “In a true system of care I could call my neurologic partner and consult about the patient, and we'd both be compensated for that. It saves the system money, and it allows the neurologist to save office visits for more complex patients.”

CHANGES TO THE SYSTEM

Despite its appeal, the medical home model would require some basic changes in the American health-care system.

“Two developments that would speed the adoption of medical home are enhanced reimbursement incentives and electronic health records,” said New Hampshire pediatrician W. Carl Cooley, MD, a co-director of the Center for Medical Home Improvement, dedicated to improving the quality of primary care medical homes for children and young adults with special heath-care needs.

Proponents of the medical home model, however, maintain the model would ultimately save money by reducing hospitalization and by heading off complications of diabetes, heart disease, HIV, and other chronic conditions. A 2004 “Report on Financing the New Model of Family Medicine” in the Annals of Family Medicine estimated that the medical home model would reduce health-care costs by 5.6 percent in the United States — a savings of about $67 billion a year — while improving the quality of care.

In the next year some health plans will try medical home reimbursement models with a number of primary care physicians, Dr. Cooley said. “They're going to be looking at their utilization data to see if this keeps patients out of the hospital and emergency room more,” he said.

Dr. Cooley believes the data will demonstrate the superiority of the medical model. “The term medical home is meant to imply a home base or headquarters, but also a place where everyone knows your name so you feel people are familiar with you,” he said.

JOINT PRINCIPLES OF THE PATIENT-CENTERED MEDICAL HOME

  • Each patient has an ongoing relationship with a physician who provides continuous, comprehensive care.
  • The personal physician serves as the leader of a team responsible for a caring for the whole patient rather than a single disease or organ system.
  • The personal physician coordinates all the patient's health needs throughout life, including preventative services, acute care, chronic care, and end-of-life care.
  • All aspects of a patient's care are coordinated and integrated, with health information exchanged efficiently between, for example, hospitals and nursing homes, or a specialist and the primary care physician.
  • Quality and safety are promoted by measuring physician performance, encouraging patients to participate in decision making, practicing evidence-based medicine, and using information technology to promote optimal care.
  • Access to care is promoted through open scheduling, expanded hours, and the use of efficient communication techniques among physicians, patients, and staff.

WEIGH IN ON THE MEDICAL HOME MODEL

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Let us know your views about the proposal for the medical home model. Would it work for your practice? Why? Why not? Your letters — 400 words, maximum — will be considered for publication on our Letters page in the next Neurology Today. Write [email protected]. Be sure to include your name and daytime contact information.

REFERENCES

• Spann SJ, et al., for the Task Force 6 and the Executive Editorial Team. Report on financing the new model of family medicine. Ann Fam Med 2004;2:S1-S21.
    • Public Policy Committee of the American College of Physicians. Achieving a high-performance health care system with universal access: What the United States Can learn from other countries. Ann Intern Med 2008;148(1):55–75.