Redesigned Health System Rests on Medical Home Concept

Primary care medical homes would be the norm for New Orleans residents under a health system reform plan submitted to CMS Oct. 23 by the Louisiana Health Care Redesign Collaborative.

The plan takes a page from the Future of Family Medicine report, as well as from similar plans promulgated by the American Academy of Pediatrics and American College of Physicians, by establishing a system that relies on a medical home, said FP Richard Streiffer, M.D. Streiffer said is taking time from his position as chair of family and community medicine at Tulane University School of Medicine , New Orleans, to work with the Louisiana Department of Health and Hospitals on the redesign efforts.

"The submission is the starting point of the redesign," said Streiffer. "It is the vision. The process has to go through CMS … and then is subject to the Louisiana legislative action." Although the plan initially will only apply to the New Orleans area, Streiffer noted that eventually the plan is to cover the entire state of Louisiana.

"The first key element of this reform is that the money should follow the patient to give people access to care wherever they choose," said Streiffer. "The second key reform was to build a primary care base, decentralize care and stop relying on hospital care. That was framed within the concept of the medical home system."

The concept relies on a formalized network of providers, similar to those in private health insurance plan provider panels, that provide a medical home, he said. Each member of the network, from primary care office to tertiary subspecialty care to home health and long-term care facilities, would have access to patient information via interoperable electronic health records.

"The medical home forms the foundation for coverage of the uninsured, as well as for the ultimate transformation of the way care is provided in the current Medicaid program," says the collaborative's "Concept Paper for a Redesigned Health Care System for Region 1." (PDF file: 67 pages / 655 KB. More about PDFs.)

Patients enter the health care system via their primary care physician, who "is not a 'gatekeeper (who) restricts patient access to services,' but is rather an entry point who facilitates and coordinates care," according to the plan. Payment for such services "must be at a level that enables the medical home model's success."

In addition to building a primary care foundation, the plan would help expand access to health coverage through a Health Insurance Connector, or HIC, said plan authors.

The HIC would be an information clearinghouse about insurance options and methods of enrolling for people earning a maximum of 300 percent of the federal poverty level. For low-income uninsured workers and Medicaid-eligible people, the HIC would provide "a financial credit sufficient to apply either to the purchase of an individual comprehensive health insurance policy or to the employee cost of participating in a qualified, employer-sponsored group health plan."

As a result, the new system "will push people toward a primary care relationship," said Streiffer. "When people have health coverage, they have access to primary care providers."

Public and private entities, including Medicaid, individuals and employers, would buy coverage from existing health plans.

The plan calls for establishing the Louisiana Health Care Quality Forum, or LHCQF, which would develop clinical quality guidelines and collect, collate and report data on medical home performance. The data collection efforts will help "drive this system based on evidence-based standards," said Streiffer.

The forum "will be the bridge between the concept of quality and its practical implementation," according to the plan. "Rather than working to define and standardize quality metrics, the LHCQF will focus on the application of well-established metrics to facilitate quality improvement through ‘selection’ (valid reporting of comparative performance data) and ‘change’ (lowering barriers to reform of practice patterns and processes by providers)."