Building the medical home
Fam Pract Manag. 2009 Mar-Apr;16(2):8-13.
There is no question that the U.S. health care system is overdue for comprehensive reform. No one understands this better than family physicians who strive to provide high-quality, patient-centered care despite the challenges of working in a dysfunctional system that has never provided equitable reimbursement. In the article “Building the Case for the Patient-Centered Medical Home,” [January/February 2009] Leigh Ann Backer assesses both the promise and challenges of wider acceptance and implementation of the patient-centered medical home (PCMH) in the context of current health care reform proposals.
Unfortunately, the PCMH by itself cannot “cure” health care. The PCMH must be a component of comprehensive reform. Without systemic reform that aligns care and reimbursement around quality, safety, improved patient outcomes and controlled costs, the medical home is not sustainable. The PCMH is an exciting model. It provides a powerful road map for family physicians to enhance the value of the patient-centered primary care we provide by incorporating the systems approach of the chronic care model and integrating information technology. But empowering family physicians and improving the quality and efficiency of the care we provide is not enough. Family physicians and other primary care physicians will ultimately need to think beyond how to reinvent primary care practice and envision how they and the medical home can fit most effectively into a new health care system.
For too long, family physicians have myopically promoted their own interests without also supporting aligned transformation of the rest of the health care system. Rather than reviewing health care proposals through the narrow prism of “what’s good for us,” we need to advocate for the broader changes that are good for our health care system and good for our patients. It is no longer sufficient for family physicians and the AAFP to respond to legislative proposals solely on the basis of their treatment of prevention, primary care, medical home initiatives and our workforce issues. In reality, if family physicians had their “wish lists” fulfilled and the rest of the delivery system remained untouched, our patients and we as their physicians would continue to lose.
Family physicians need to advocate with our patients and for our patients for comprehensive reform that puts patients, quality and safety at the center of health care. We must support reform that moves away from the dysfunctional visit-based reimbursement and toward systems that support and incentivize proactive care management and prevention. Within this framework, patient-centered medical homes could provide an important gateway and coordinating hub for patients to receive the high-quality, cost-effective care they deserve and we want to provide.
It was heartening to read Leigh Ann Backer’s article about the patient-centered medical home. She produced a wonderful summary of where it stands in terms of early demonstrations and policymaking, and offers readers a connection to great resources for evaluating their own practices.
Another helpful resource is the AAFP/Robert Graham Center summary of the medical home model and the evidence that supports it. Thomas C. Rosenthal, MD, of the University of Buffalo also recently published a thorough review in the Journal of the American Board of Family Medicine.
We are concerned about the table “Use of patient-centered medical home components by family physicians” that appeared in your article. The table draws on a 2008 AAFP survey that received a low response rate – low enough that, we believe, it makes the results untrustworthy, especially in light of nationally representative data suggesting a lower rate of electronic medical record (EMR) use. The survey data may be correct for those responding but may not accurately represent what is going on in most family physicians’ offices. We raise this concern because the federal government is considering funding for EMR expansion and having these results in print could underestimate the financial support members need.
Our own examination of the CDC’s National Ambulatory Medical Care Survey (NAMCS) suggests that in 2006 about 33 percent of family physicians used EMRs or some form of electronic record plus paper. (This is substantially lower than the 49.2 percent reported in the table.)
The Office of the National Coordinator for Health Information Technology has funded the development and fielding of a standardized national survey to measure outpatient adoption of EMRs. NAMCS will annually incorporate some of these questions, and the CDC will be monitoring the EMR adoption rate in physician offices and oversampling to include small and rural physician practices. This should be a useful tool for the AAFP to more accurately monitor member needs.
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