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

Robert J. Stenger; Jennifer E. DeVoe

doi:10.3122/jabfm.2010.03.090140

Article Figures & Data

Tables

View popup

Table 1.

Joint Policy Statement: Patient-Centered Medical Home Principles*

Personal physician	Patients have an ongoing relationship with a personal physician First contact, continuous and comprehensive care
Physician-directed medical practice	Personal physician leads a team of individuals at the practice level Collective responsibility for the ongoing care of patients
Whole-person orientation	Medical home provides for all the patient's health care needs or appropriately arranges care with other qualified professionals Care for all stages of life: acute care, chronic care, preventive services, and end-of-life care
Care is coordinated and/or integrated	Coordination of care across the health care system and patient's community Care is facilitated by registries, information technology, health information exchange, use of interpreters, and other means
Quality and safety	Quality and safety improvement are hallmarks of the medical home Specific activities could include individualized care plans, evidence-based decision support tools, collection and reporting of quality improvement data, use of information technology, and voluntary certification of practices as medical homes
Enhanced access	Patients can easily access health care via their medical home Specific improvements could include open access scheduling, expanded hours, and enhanced phone or e-mail communication
Payment	Increased payments support the added level of service and value provided to patients who receive care from a medical home

* Issued jointly by the American Academy of Family Physicians, American College of Physicians, the American Academy of Pediatrics, and the American Osteopathic Association.

View popup

Table 2.

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

Entity	Medical Home Definition and Attributes	Impact of Legislation
US Congress PL 109–432 (12/20/2006)	Care planning and coordination Use of health information technology Personal physician within a medical home practice Individual health assessment and management plans Prospective care management fee	3-year medical home demonstration for “high need” Medicare beneficiaries Demonstration to run in 8 states with mix of practice types and locations Requires CMS to create care management fee codes and provide a prospective fee for care management
California SL Ch. 483 (10/112007)	Defines medical home as “a single provider or facility that maintains all of an individual's medical information. The ···provider shall be a provider from which the enrollee can access primary and preventive care.”	Establishes the availability of medical homes as one of 10 criteria to judge local government proposals for insurance coverage expansion under an existing Medicaid waiver demonstration project
Idaho H 168 (7/1/2007)	Defines medical home as a primary care case manager	Requires all Medicaid applicants to receive information about primary care case management Allows the state HHS Director to require Medicaid enrollees to designate a primary care case manager
Louisiana Act 243 (8/15/2007)	Defines medical home “system of care” that includes: PCP-directed, patient-centered care Coordination of preventive and primary care Integrated system of PCPs, specialists and hospitals PCPs must have EMR	Requires the state department of health to develop, implement, and evaluate a medical home system of care for Medicaid and low-income uninsured Requires the state department of health to develop an “enhanced Medicaid reimbursement methodology” for participating providers
Minnesota H 1078, SL 147 (7/1/2007)	Primary care medical homes must include the following attributes: Comprehensive care, including chronic disease management Coordination of care Longitudinal care 24-hour access (via phone) Systematic process for quality improvement	Requires the state human services commissioner to develop at least 4 primary care medical home pilot projects for Medicaid-enrolled children or adults with complex medical needs Requires an evaluation of the pilot projects Appropriation of about $1.7 million over 2 years (2009 and 2010)
Vermont Act 0071 (6/5/2007)	Defines medical home as a primary care practice that provides access to personal health information, individualized health assessments, and training for office staff in care management. Medical home PCPs shall provide: Care coordination, integration and oversight Point-of-care EBM and decision support tools Use of health information technology Patient self-management tools	Funds a medical home demonstration project for Medicaid, Catamount Health, and State Employee Health Plan enrollees Requires the state DHS to develop a care management fee schedule and performance-based incentive payment structure for demonstration sites Establishes community-based care coordination teams that will work with medical home practices to coordinate care and promote the medical home
Washington PL Ch 259 (7/22/2007)	Defines medical home as “a site of care that provides comprehensive preventive and coordinated care centered on the patient's needs and assures high-quality, accessible, and efficient care”	Requires the state department of health to develop a 5-year plan to provide a medical home to all enrollees of state health plans Requires the state DOH to design and implement medical homes for aging, blind, and disabled clients Payment reform emphasized, with the goal of allowing primary care providers to remain in practice and better coordinate chronic disease care.

CMS, Centers for Medicare and Medicaid Services; HHS, Health and Human Services; DOH, Department of Health; PCP, primary care provider; EMR, electronic medical record; EBM, evidence-based medicine; DHS, Department of Human Services.

View popup

Table 3.

Summary of Key Stakeholder Perspectives on Medical Home Principles

	Primary Care Providers	Clinic and Health System Administrators	Insurers and Payers	Policymakers
Personal physician	Familiar concept Highly valued	Familiar concept Not highly valued	Familiar concept Not highly valued	Familiar concept Somewhat valued
Physician-directed medical practice	Foreign concept May be reluctant to participate in team-based care	Good understanding of team dynamics and differing roles of primary care team members	Very limited understanding of team-based primary care	Very limited understanding of primary care teams and roles
Whole-person orientation	Familiar concept Important core value of primary care	Limited understanding of concept Not highly valued	Limited understanding of concept Not highly valued	Some understanding of concept Somewhat valued
Care is coordinated and/or integrated	Limited understanding of care coordination strategies (patient-level focus) Sometimes part of current practice Variable understanding	Limited understanding of care coordination strategies (systems-level focus) Some understanding	Some understanding of concept May not link care coordination to the medical home (caved out services) Highly valued	Some understanding of concept Limited understanding of quality improvement Not valued
Quality and safety	Variable desire to participate in new projects Skeptical of new requirements/oversight	Importance driven by regulatory and licensure requirements	Favor tighter regulation and oversight of primary care to improve quality and safety	Highly valued (regulatory mindset)
Enhanced access	Well understood Limited support because of overwork of providers in current system	Well understood Customer-service mentality	Well understood (emphasis on customer service and costs) May not link to medical home	Well understood Somewhat valued
Payment	Very highly valued, of critical importance Skeptical of pay-for-performance	Very highly valued, of critical importance Skeptical of new payment methodologies	Very sensitive to rising health care costs Likely to demand proof of value/cost savings	Extremely sensitive to overall system costs and impact on health care budgets Supportive of demonstrations