Principles Establish Basis for Health System Reform

The AAFP and three other primary care organizations on March 5 released a definition of the personal medical home that forms the foundation on which health system reform can be built.

The definition, "Joint Principles of the Patient-Centered Medical Home," (PDF file: 3 pages / 36.8 KB. More about PDFs.) was developed by the AAFP, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association.

"The importance of these principles is that all primary care specialists in the country have agreed on what a medical home is," said AAFP Board Chair Larry Fields, M.D., of Flatwoods, Ky. "The majority of physicians who will be providing a medical home are on record as agreeing to what a medical home actually is. That’s the first step for building a primary care-based health care system that will give us the ability to cover everyone in a cost-efficient, high-quality manner."

The definition encompasses the physician-patient relationship, the quality of health care, the infrastructure and the payment system that will result in ongoing, comprehensive, cost-efficient and effective health services.

"This is not a gate of any kind," said Fields of the medical home. "It's not a hurdle that somebody has to cross to get medical care. It's a portal to medical care. That's far different from the way things were in the '90s."

American Academy of Pediatrics President Jay Berkelhamer, M.D., agreed. “By its very definition, a medical home is a quality improvement approach that promotes a partnership between the child, the family and the physician care team,” he said in a March 5 news release accompanying the announcement of the principles. “This partnership not only optimizes quality care, but also minimizes patient risk because the medical home forges a safe bond and quality connection between the care delivered and the specific needs of the child and the family.”

According to the principles, key to the personal medical home are

Vital to the success of personal medical homes is appropriate payment that enables the physician to provide crucial behind-the-scenes services, said Fields. To that end, the principles will undergird communications with large employers, insurance companies, Congress and administration officials.

"It will show them what we mean when we talk about the medical home and how it would work to increase health of employees or government beneficiaries," said Fields.

The principles call for a system that, in addition to paying for office visits, reflects the value of care management that "falls outside of the face-to-face visit," such as coordinating internally and with outside practices, ancillary services and community resources. The system also should support adoption and use of health information technology and pay for the doctors' time and expertise when they monitor patients remotely or communicate with patients via secure e-mail.

The payment system "should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting," say the principles.

That element, said Ray Stowers, D.O., a member of the American Osteopathic Association Board of Trustees, is key to the success of the medical home.

"There is an investment that must be made in medical homes to keep people out of the hospital," he said. "Under medical homes, if they're done correctly, we will see an increase in services in (Medicare) Part B. For example, physicians might provide more breathing treatments to keep a patient out of the hospital. But there should be offsetting decrease in services in Part A.

"Part of that savings has to leave Part A and go to Part B to compensate for management. Unless savings shifted between Part A and Part B, it would be difficult because it would need new money."

Stowers emphasized the flow of funds between Part A and Part B would not impinge on payment for services provided by hospitals.

"This is not an issue of hospitals getting paid less," he said. "We're looking for volume savings. We're not asking hospitals to get paid less for taking care of diabetic patients when they do go to the hospital. But the volume of hospital stays will go down, and that’s a savings to Part A. If Medicare has x-number fewer hospital stays and it's saving $1 billion under medical homes, then there should be some flexibility to shift those funds back for rewarding the physician."