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The Journal of the American Board of Family Medicine 23 (3): 384-392 (2010)
DOI: 10.3122/jabfm.2010.03.090140
© 2010 American Board of Family Medicine
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Health Policy

Policy Challenges in Building the Medical Home: Do We Have a Shared Blueprint?

Robert J. Stenger, MD, MPH and Jennifer E. DeVoe, MD, DPhil

From the Department of Family Medicine, Oregon Health and Science University, Portland

Correspondence: Corresponding author: Jennifer E. DeVoe, MD, DPhil, Department of Family Medicine, Oregon Health and Science University, 3181 Sam Jackson Rd, Portland, OR 97239 (E-mail: devoej{at}ohsu.edu)


   Abstract
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Methods
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 Discussion
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 References
 
Background: The notion of a patient-centered medical home features prominently in policy reform initiatives across the country, with both state and federal legislation focusing on this new model. We sought to understand the views of key stakeholders and to examine the challenging landscape facing policymakers and practitioners as they attempt to translate the medical home concept into widespread practice change.

Methods: We reviewed legislative documents from state legislative sessions in the year 2007 to identify pieces of legislation that included the medical home concept. Concurrently we conducted an in-depth qualitative analysis of de-identified field notes from a purposeful sample of semistructured interviews conducted with key stakeholders in Oregon after the passage of health reform legislation in 2007.

Results: Legislation that further defined and expounded on the medical home concept was introduced in states across the country in 2007, and some federal and state demonstration projects were already underway. However, we identified a number of barriers to widespread implementation of the medical home, most notably lack of a clear operational definition. Key stakeholders had widely disparate views about elements central to the success of medical home demonstrations, including delivery system reform, payment reform, and performance incentives for providers.

Conclusions: Since 2007 the concept of the medical home has gained increasing attention in health care reform debates. Our findings suggest that translating this concept into successful, widespread reform will require that policymakers build further consensus among key stakeholders and require them to address critical barriers to avoid repeating pitfalls of past reform efforts.

Key Words: Health Policy • Health Care Economics • Health Care Systems • Primary Health Care • Medical Home • Patient-Centered Care

The term "medical home" was introduced in the pediatric literature in 1967.1,2 As the concept evolved, the American Academy of Pediatrics issued policy statements specifying the essential features of a medical home and providing some operational definitions.3,4 In 2007, the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association announced a joint set of principles defining the "patient-centered medical home" (Table 1).5 The medical home concept has become a central focus of health care reform advocacy efforts by the primary care community.6,7 However, despite an intense national focus on the medical home, this new buzzword remains unfamiliar to most Americans, including key policymakers and rank-and-file primary care practitioners. In this study we aimed to describe the incorporation of the medical home concept into legislation across the country and to better understand the views held by critical local stakeholders regarding issues key to the successful implementation of medical home concepts.


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  		Table 1. Joint Policy Statement: Patient-Centered Medical Home Principles*

 

   Methods
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We used 2 major study methodologies: (1) a critical review of state and federal legislation referencing the medical home in 2007 and (2) an in-depth case study analysis of secondary qualitative data collected from key informant interviews during Oregon's 2007 legislative session. Our primary goals included (1) to determine how the medical home concept was incorporated into major pieces of health care reform legislation across the United States in 2007; (2) to highlight the political milieu surrounding the medical home; and (3) to better understand likely challenges inherent in the implementation of medical home concepts, primarily the need to find common ground among diverse stakeholders.

National Legislative Document Review
We obtained a summary list of state and federal legislation introduced in 2007 that contained some reference to the medical home (G. Martin, AAFP, personal communication). We then systematically reviewed the complete text of each separate piece of legislation (one Federal and 58 state bills) using a search on the keywords "medical home." Though all pieces were reviewed, we chose not to report on bills that failed to pass, those without detailed language defining the "medical home," and those without information specific to how a new law would shape the creation of medical homes. Table 2 presents the enacted bills that included broader legislative definitions and characterized the breadth and scope of how the medical home concept would be implemented.


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  		Table 2. Summary of Selected State and Federal Enacted Legislation Referencing the Medical Home

 
State Case Study
With the implementation of the Oregon Health Plan in 1993, Oregon has long been a leader in health policy reform.8,9 Like most states, Oregon continues to grapple with health care reform, including the challenge of ensuring access to primary care for its citizens. In 2007, the Oregon Legislative Assembly passed the "Healthy Oregon Act," which called for expanded health insurance coverage and a "medical home" for all public insurance enrollees.10 While serving as an intern at the Oregon Office for Health Policy and Research (OHPR), the first author (RJS) was asked to conduct semistructured interviews with a purposeful sample of key interviewees. This study started with a purposeful sample of 10 key stakeholders identified by policy leaders at OHPR and then used snowball sampling techniques to identify 5 additional interviewees to broaden the range of informant perspectives from primary care clinicians and clinic staff. The interviewees included a state public employee benefits manager, a managed care medical director, health system medical directors, clinic managers and medical directors, directors of state medical professional associations, primary care clinicians and staff at a clinic participating in a medical home demonstration, local health policy experts, state bureaucrats, and additional primary care physicians not participating in demonstrations. To obtain access to and frankness from this diverse group of key informants, interviews were not recorded and all interviewees were guaranteed complete anonymity. Detailed anonymous field notes were collected for the purposes of a policy document prepared for the OHPR.

For this study, we conducted a secondary analysis of these de-identified field notes using qualitative research techniques. Both authors independently read all comments, met together on several occasions to discuss and reach consensus agreement on the 4 stakeholder categories. Then a common codebook of themes was discussed and decided upon using a standard iterative process that was guided by the joint set of principles defining the "patient-centered medical home" described in Table 1. Individual reviews were repeated with codebook guidance and we then met to conduct a series of immersion/crystallization cycles.11 During these subsequent meetings, specific comments were grouped into more general categories. We then developed a weighted compilation of themes most important to each stakeholder group. The final summaries reflect consensus reached after reconciling the differing interpretations of both authors. Complete results of our legislative review are available upon request to the corresponding author (JED).


   Results
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State and Federal Medical Home Legislation
The medical home concept has been adopted by policymakers at multiple levels, and several medical home demonstration projects—both public and private—are already planned or underway, including the Centers for Medicare and Medicaid Services's 3-year demonstration project mandated by the Tax Relief and Health Care Act of 2006.12–14 At the state level, the phrase "medical home" appeared in at least 58 bills from 22 states during 2007 legislative sessions. Among all 58 bills, only 17 contained a substantive definition of the term "medical home" whereas 41 did not offer legislative definitions. Thirty-three bills failed and 25 were enacted, including 6 that offered substantive definitions of the medical home. Of those 6 bills only 4 explicitly discussed delivery system or payment reform. The 6 State bills plus the Federal bill are presented in Table 2 as examples of how the medical home concept was discussed in 2007 legislative health care reform efforts.15–20

The Oregon Case Study
We catalogued stakeholders into 4 key groups: primary care providers, clinic and health system administrators, insurers/payers, and policymakers. A summary of stakeholder perspectives on medical home principles is presented in Table 3.


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  		Table 3. Summary of Key Stakeholder Perspectives on Medical Home Principles

 
Primary Care Providers
Rank-and-file primary care clinicians viewed the medical home concept as ambiguous and lacking evidence. As a group they feared the increased costs associated with a medical home and believed that successful implementation hinged on achieving significant payment reform. One provider commented that the medical home would essentially provide "better payment for what we've always done." Primary care providers identified most strongly with the medical home principles of personal and longitudinal relationships with patients, whole-person orientation, and care coordination. This group viewed the medical home as a means to strengthen the traditional role and values of primary care. Providers focused less on the medical home principles that represent significant departures from the current delivery system. Interviewees expressed confusion and doubt about how to operationalize team-based care, primary care case management, enhanced access to care, quality improvement, and patient safety. The 2 providers participating in ongoing medical home demonstrations also noted the many unexpected challenges associated with developing primary care teams, implementing electronic medical records, and a number of other aspects related to transforming their current practices.

Health System Administrators and Clinic Managers
Health system administrators and clinic managers identified most strongly with the systems aspects of the medical home model. They focused most on the medical home principles of safety and quality improvement, team-based care, and technology issues, such as the implementation of electronic health records. As a group they talked about the medical home in terms of coordinating systems of care, new staffing models for primary care teams, and improving workflows. Most administrators recognized that significant change would be required to transition to a medical home model of care. Administrators tended to agree with providers about the importance of payment reform as a means to achieve lasting change. They also worried about additional "unfunded mandates" by insurers and public payers who were portrayed by this group as eager to use the medical home concept to reduce costs. Respondents from this stakeholder group wondered how their clinics or health systems would pay for systems changes or cope with alterations in the current fee-for-service payment model. Compared with primary care providers, administrators and managers were less likely to speak about the importance of a personal physician, continuity of care, and whole-person care.

Insurers and Payers
Payers and insurers placed the most emphasis on cost containment. They expressed concern about how to quantify the value of care coordination and were ambivalent about the idea of increasing compensation for quality and safety. They questioned whether these types of improvements should warrant increased payment. Payers did differentiate between the medical home and the current "status quo" primary care system, which is not organized effectively to optimize delivery of preventive care.21 Most payers expressed hesitation to assume the financial risk for medical home demonstrations. One payer, however, embraced the medical home concept and had already started funding innovative models. All of them discussed the need to make payment reform contingent on performance improvements and/or cost savings. Payers rarely addressed the medical home principles involving patient care at the individual level, including the personal physician, whole-person care, and enhanced access to care. Though payers were clearly supportive of these aspects, there was no consensus about whether to provide and finance services such as chronic disease management, case management, and access to 24-hour nurse/physician care through the medical home.

Policymakers
As a group, elected and appointed policymakers had the most diverse perspectives about the medical home. Most were supportive of the need to deliver health care at the individual level, including the importance of a personal physician. They also shared concerns about the rising cost of health care and the importance of improving patient safety and quality. Unique to this group was the heightened awareness of the need for efficient and responsible use of public funds. Thus, their discussions about medical home initiatives tended to focus on how to achieve rigorous evaluation of potential models and to demonstrate successful results before widespread adoption and implementation. This group had a wide range of familiarity with medical home concepts, especially in the way it was described by medical professional organizations. Though one policymaker had significant expertise about the details, the others made few distinctions between a medical home and status quo primary care. Different from the other 3 groups, the policymakers did not discuss the details of building medical homes and expressed no fears or hesitation about the delivery system changes that might be needed to move toward a comprehensive network of medical homes.


   Discussion
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Our legislative review indicates that across the country in 2007 there was widespread interest among policymakers in the medical home concept. The Oregon case study highlights a number of key potential challenges to implementation at the local and state levels. In this section we will further discuss these challenges, many of which proved to be insurmountable barriers to health reform efforts in the past. Although our case study applies directly to the local Oregon environment, we believe it has national relevance because many issues raised here have broad applicability to those that will need to be addressed in national discussions as the medical home concepts are further developed.

Lessons from the Past: the Legacy of Managed Care
It is difficult to discuss the medical home without drawing a parallel to a prior health reform effort that aimed, in part, to build a stronger primary care base within the health care system. At the outset of the managed care boom, many viewed the growth of managed care as a potential boon to primary care. A 1988 American Medical Association/AAFP report published in the Journal of the American Medical Association concluded that managed care "offers new opportunities for providers of primary care" and that "...this orientation in health care delivery is likely to provide an attractive spectrum of opportunities for present and future primary care physicians."22 Though the theory behind managed care appealed to many primary care providers, its focus on cost containment, control of utilization, and the use of providers as gatekeepers led to widespread disappointment.23 Many of the same pressures that contributed to the downfall of managed care still exist and will create similar challenges as states work to develop and implement medical home models.

Potential for the Future: The Patient-Centered Medical Home?
Health care costs have risen substantially since the 1990s. Meanwhile, a robust literature has emerged demonstrating the importance of a strong foundation of primary care in the delivery of efficient, patient-centered care in health systems across the globe.24,25 Quality improvement and patient safety have also evolved as central themes in health care reform.21,26,27 Finally, one area of consensus among key informants in this study was that payment mechanisms for primary care are broken and unsustainable. In summary, the time is ripe for reform, yet many still question whether the patient-centered medical home will flourish or suffer the same fate as managed care.28 This study provides further insight about key stakeholder conflicts that will probably present many challenges in the years ahead.

Challenges Ahead: Key Stakeholder Conflicts
The absence of detailed medical home language in roughly 75% of state bills enacted in 2007 suggests that the details of the medical home will probably be developed by bureaucrats, administrators, and other stakeholders with little legislative guidance. In this context, it will be critical for those shaping the reforms to understand divergent stakeholder views. Based on our secondary review of qualitative interviews, we identified 3 key challenges to reaching consensus among Oregon medical home stakeholders: payment reform, performance incentives, and delivery system reform.

Payment Reform
Payment reform is perhaps the top policy concern of primary care physicians. Primary care clinics face increasing costs and flat or declining reimbursement. Physicians are not likely to support medical home proposals unless they include—up front—reorganized payment schemes and increased payment to support a higher level of care delivered under the medical home model. Primary care physicians working "on the ground" project that the medical home will cost more money in the short term and demand that payers must agree to up-front investment, which should lead to cost savings and better population health in the long term. Public and private payers, however, are under extreme pressure to control costs now. Provider demand for more money, coupled with unrealistic expectations of short-term cost-savings on the part of payers, could threaten the success of medical home demonstrations.

The Oregon example shows that some payers may be willing to shoulder start-up costs for medical home demonstrations. However, until cost savings are well established, short-term successes may require that payment reform be taken off the table initially, with medical home demonstrations funded by grants or one-time expenditures. Once proof of concept can be established, policymakers might have more success in reforming the funding mechanisms for medical homes over the longer term. There are many potential models for payment reform that hold promise; for example, the AAFP supports a mixed-payment model that preserves fee-for-service payments and incorporates new prospective payments to support care management and other medical home functions.29 Others have proposed broader reform models, such as comprehensive prospective payments for primary care.30 The particular payment mechanism may not be as important to primary care groups as the reassurance that payments will be stable and sustainable. New payment methodologies must both encourage behavior change among providers and avoid creating unnecessary burdens.

Performance Incentives
Although the central focus of providers is increased payment, payers and policymakers are equally focused on ensuring that an investment in primary care will yield tangible results in terms of cost savings and patient outcomes. Payers will establish new requirements for primary care practices that seek increased payment as medical homes. Providers, on the other hand, are skeptical of performance incentive schemes, especially "pay-for-performance." As noted above, they prefer to hold out for long-term gains in population health, which exceed waiting times agreeable to most payers. Managing this conflict between payers and providers will be a critical challenge for policymakers. The collaborative development of operational medical home definitions, such as medical home standards by the National Committee for Quality Assurance is a potential first step in this process.31 However, the current National Committee for Quality Assurance standards have generated some criticism and may not have widespread support among primary care providers.32–34 The most effective initial approach may be one of "pay-for-process," where providers are rewarded for implementing small, incremental changes to the delivery system. If early performance incentives are too onerous, payers run the risk of creating the same discontent with medical home projects that primary care providers felt toward managed care in the 1990s.23

Delivery System Reform
Delivery system reform is an underappreciated challenge in moving from the current primary care system to the medical home model. Medical home proposals call for significant changes in the routine operations of primary care clinics, such as the adoption of electronic medical records, creation of team-based staffing models, development of systems for prospective patient management, collection and reporting of quality improvement measures, and enhanced patient access to care.

Interestingly, this study reveals that policymakers who are responsible for legislating reform may not acknowledge the complexity of making changes in the delivery system nor realize the controversies that may arise between providers, administrators, and payers with differing interpretations about how to achieve change. Preliminary findings from early medical home demonstrations already suggest that these basic delivery system changes are difficult, even within willing and motivated primary care clinics, and cannot be accomplished quickly.34 Demonstration projects have just begun the critical work of showing that delivery system reform is possible, and they will yield valuable lessons about how policymakers can manage and facilitate broader changes to the delivery system.

Limitations
We recognize that there are significant limitations to our current study. We conducted stakeholder interviews in a single state and limited our consideration of the medical home concept strictly to primary care. Though all groups are also patients within the system, we did not have an explicit patient/consumer group within our sample. In addition, significant developments have occurred since 2007; the medical home concept continues to be a topic of intense policy debate. Given these limitations, however, we feel that our results bear relevance to current and future policy and practice discussions by many who seek to further refine and advance the medical home concept.


   Conclusions
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 Abstract
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References
 
Our review of legislation and key informant interviews does suggest that a number of proposed strategies may be well received by receptive local stakeholders willing to collaborate on testing reform ideas, including innovative financing models, small grants for practice infrastructure improvement, development of learning collaboratives, and financial or educational support for retraining of staff. It is too soon to know, however, whether it will be possible to translate this pioneering work into widespread and sustainable reform because the difficulties encountered by motivated pioneers will only be magnified across the general population. Without stakeholder consensus around a clear operational definition of the medical home, the success and sustainability of medical home projects will be jeopardized.

Because the medical home concept is not being consistently legislated, demonstrations across the country will probably implement very different experiments all bearing the name "medical home." In the best-case scenario, this diversity of effort will lead to broad experimentation and development of best practices that can be replicated. If successful, these leading experiments will drive changes in the health care system both within and outside of primary care. In the worst case, however, early adopters of modest, short-reaching, or overly restrictive "medical home" models will divide key stakeholders, fail to demonstrate short-term results, and discourage others from considering this new model as a viable strategy for health reform. Policy makers must continue to engage all stakeholders, including primary care organizations, and work toward achieving consensus to provide the best opportunity for success of early medical home projects.


   Acknowledgments
 
Drs. DeVoe and Stenger have both worked collaboratively with researchers and policymakers in the Office for Oregon Health Policy and Research. We are grateful for the generous mentoring of many individuals from this office throughout this project.


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This article was externally peer reviewed.

Funding: This project was partially supported by grant numbers 5-F32-HS014645 and 1-K08-HS16181 from the Agency for Healthcare Research and Quality (JED) and by the Oregon Health and Science University Department of Family Medicine.

Conflict of interest: none declared.

Received for publication June 3, 2009. Revision received August 19, 2009. Accepted for publication August 24, 2009.


   References
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HOME HELP CONTACT US SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS