Medical Home Movement Reaches a Milestone

Great lakes of metaphorical ink have been used to describe the high hopes that primary-care medical societies, corporations, health plans, and politicians have for the “patient-centered medical home.” A number of plans have mounted pilots to test the PCMH concept, and Medicare is expected to follow suit soon. But Blue Cross Blue Shield of Michigan has gone one step further: It will soon designate about 1,000 physicians in 300 primary-care practices as medical homes, and it promises to pay them 10 percent extra, beginning July 1, for providing the requisite services. This is the largest medical home program in the U.S., and one of the first to go beyond test status.

To be a medical home, a physician must lead a health care team that provides long-term coordination and management of their patients’ health care across all settings. Among the elements of a medical home are 24/7 access to care, ensuring follow-up so that patients get all necessary services, coordinating referrals to specialists, reporting of quality data, and the use of health information technology. Ideally, the practice should have an electronic medical record, and all of the physicians in the Michigan Blues’ PCMH program are at least doing electronic prescribing.

In some ways, the medical home is a kinder, gentler version of the traditional HMO approach, in which primary care doctors act as “gatekeepers” to specialty care. In the new model, which is independent of a patient’s type of insurance, patients consult with their personal doctors, and they jointly decide which specialists the patients should see. But it remains to be seen whether patients will want to do this or will prefer to go directly to specialists. To the extent that patients choose the latter course and don’t regularly visit a primary-care doctor, care coordination will continue to be poor.

What’s unique about the Michigan Blues’ approach is that it has developed it in conjunction with physician-hospital organizations (PHOs) and independent practice associations (IPAs). The company started paving the way for its PCMH program five years ago, around the time that the American Academy of Family Physicians was reviving the idea of the medical home, which had first been proposed by the American Academy of Pediatrics in 1967. The Blues paid the PHOs extra to create disease registries for small practices and to develop the infrastructure that these practices would need to provide medical homes. For example, the registries give the physicians information about which preventive and chronic care services their patients have received, and when the patients will need follow-up visits and tests.

Altogether, Blue Cross Blue Shield of Michigan has spent $100 million on developing this system. And it’s continuing to spend more, as shown by the fact that about 3,800 physicians in its network—including the 1,000 who will be eligible for bonuses– are working on one or more components of a medical home.

What will the Blues get back? The premise is that the use of medical homes will keep patients healthier and prevent unnecessary hospital admissions and ER visits. That would not only be good for patients, but would save the health plan money. According to a 2004 study in Annals of Family Medicine, the medical home approach could cut health costs by 5.6 percent. At today’s national level of health spending, that translates to annual savings of about $134 billion.

But the devil, as always, is in the details. Even if larger organizations support primary-care physicians in providing medical homes, will patients come? Will they realize that a personal physician could keep them healthier than a bunch of unrelated specialists who don’t talk to one another or to their primary-care doctor?

Tune in five years from now and see.