AMA Support for Medical Home Principles Is Key Step on Road to Health Care Reform

High expectations, but more than a touch of anxiety -- that's what I felt during the meeting of the AMA House of Delegates last month as delegates debated and prepared to vote whether to support the Joint Principles of the Patient-Centered Medical Home (3-page PDF; About PDFs).

The delegation from the California Medical Association had introduced a resolution asking the AMA to adopt the joint principles as AMA policy. But I wondered if the house of medicine would unify behind the principles developed by AAFP and its primary care partners and vote to support this vision of a health system built around primary care. Would organized medicine instead shatter into fragments over concerns that more pay for primary care doctors might mean less pay for everyone else?

My anxiety transformed to joy when the AMA house finally voted to support the joint principles. When all was said and done, only delegates from the American College of Obstetricians and Gynecologists, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons voted no. (More on that later.) Everyone else -- every other specialty society, every state medical society, every caucus -- voted yes. It was uplifting to see the AMA stand for, instead of against, something. To me, the vote demonstrated that the AMA has a conscience regarding what's good for patients.

The AAFP delegation to the AMA worked hard to convince other delegates of the importance of supporting the principles. AAFP delegates also helped divide the medical home issue into two sections for delegates to consider separately: (1) the joint principles themselves as a stand-alone issue and a vision for the future of the health care system, and (2) the issue of physician payment under the medical home model. Delegates referred the payment issue to the AMA Board of Trustees for further study.

It's not an overstatement to say that the AMA's support for the principles could have a significant impact on the future of health care.

The joint principles already had the support of the four primary care groups who developed them: the AAFP, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association. The principles also had the backing of the Patient-Centered Primary Care Collaborative, a 200-plus-member coalition that includes such heavy hitters as IBM and AARP.

But the AMA's support throws the weight of the house of medicine behind the joint principles, locking them into place as the foundational definition of the patient-centered medical home. Other groups have advanced their own definitions, but the AMA's action effectively takes those definitions off the table in policy discussions.

What will the AAFP do now, given the AMA's landmark support of the joint principles and the possibility of health system reform by the new Congress and the change-oriented Obama administration?

The Academy will push for more medical home pilots and demonstration projects to generate additional data reinforcing the concept. This will further lock in the medical home as the basis for health system reform.

We'll also continue to strongly advocate a "blended" payment model for the medical home. Under the model, a monthly per-patient care management fee would pay for care integration and coordination services. Fee-for-service payments would continue for face-to-face patient visits, and positive incentives would reward quality improvement. Family physicians whose practices qualified as medical homes would finally get paid for all the work they did, and their practice teams would be able to focus on keeping patients healthy, not just treating patients when they're sick.

In addition, the AAFP will keep pressuring CMS for a broad definition of budget neutrality across the entire Medicare program, not just within Medicare Part B. The medical home's care management fee will increase costs in Part B, but the savings generated by the medical home -- resulting from fewer hospitalizations and emergency room visits, less duplicative testing, and better medication management, for example -- will show up in other parts of Medicare. If this broader definition of budget neutrality is adopted, then it shouldn't be necessary to pay other physicians less to pay those whose practices are designated as medical homes more.

What are the "next steps" I'd suggest for you?

Be aware that OB-Gyns and neurological surgeons in your community might not support the medical home concept because their specialty societies didn't support the joint principles in the AMA house. The OB-Gyns were upset because they felt they should have been included in the primary care group that developed the principles. But the truth is, they're not primary care physicians because of their limited scope of practice. The neurological surgeons seemed to be driven by the potential threat to their income if the narrower view of budget neutrality -- within Medicare Part B only -- prevails.

Also be aware that emergency physicians might express concerns about the medical home concept. Although delegates from the American College of Emergency Physicians ultimately voted for the joint principles, comments during the AMA meeting indicated that emergency physicians might feel threatened by what the medical home could do to their patient volume and, thus, their income. They've been talking for years about overcrowded ERs, but they now seem to be reframing their argument. They are no longer citing "too many patients" as the cause of overcrowded ERs and are moving instead to the issue of "boarding" (i.e., keeping patients on gurneys in the ER while they wait for hospital beds to open up) as the chief cause of ER congestion.

Become informed about the medical home model, and begin transforming your practice into a medical home as quickly as you can, if you haven't done so already. As I've traveled across the country as your president, I've come to realize that roughly half of AAFP members are interested in the medical home concept, but the other half don't seem to be paying it any attention whatsoever!

The AAFP offers a great deal of information about the medical home to get you started. Another good place to start is TransforMED, the AAFP-owned limited liability corporation that is dedicated to helping medical practices transform to the medical home model. You can take TransforMED's Medical Home Implementation Quotient self-assessment to see where your practice stands and what changes you need to make to have your practice qualify as a Level II or Level III medical home. These are the two levels that are slated to get a care management fee in the Medicare medical home demonstration project that starts in 2009.

Then, when your practice is ready, apply to the National Committee for Quality Assurance to have your practice recognized as a patient-centered medical home under the Physician Practice Connections -- Patient-Centered Medical Home program. And remember, it is not you who gets designated as a medical home -- it is your practice that gets designated.

I'm convinced there's a bright future for family medicine as the patient-centered medical home model gains traction in the debate about health care reform. The ascendancy of this model gives family physicians the respect we deserve, and the model's care management fee should give us some of the payment relief we need. I hope you'll transform your practice into a medical home so you can reap these benefits for yourself and your practice.