You are close, but not quite right.

The Medical Home is indeed a place for better care, coordination of care, and management of data. But in both of your models you have the insurace company as the major player, I read that you did not believe that was the case for the medical home, but graphically it is very similar to the insurance model.

The primary care medical home is an opportunity for providers to take back control of their practice, consumers to have easier, coordinated access to their community of medical services, employers to have access to real-time or near real-time untilization data, and the insurance companies to become more akin to a bank. There is a role for all involved and it is a win win for everyone, even the insurance groups. True they may have less total gross revenue but they will also be reducing their cost of transactions, management of data, and frequncy of use as they will simply raise the deductible on the plan to achieve a better bottom line each year. They will still have contracts with the providers and be moving a great deal of their work onto them.

The Medical Home Model is the way many providers operated prior to now, there just was not reimbursement models for the work that they did. We offer that plan at my company, a reimbursement model dedicated to the medical home model, it is a direct to provider payment vehile that gathers all the data at the time of the vists and makes it instantly available for all concerend parties, in addition we train the providers into the best practices of the medical home to help them run a more efficient business.

There is an approach that is tried and true to this model. It is a retail approach. The terms of disease management, primary care, referrals and follow up to name a few are simply good customer service. If we teach providers good customer service skills then these concepts come to them naturally. They become competitive advantages for the provider.

It is important for the industry to not let the insurance players influence this model too much or they will ruin it with their gestapo tactics on confining costs. However they can and will play an equal role in this model. I agree they will become more like traditional insureance plans.

ER overcorwding will stop when a better alternative to the ER exists in the local community, whether it be a medical home style practice or not. The ER is the Wal-Mart of mediciane, open 24hrs a day, has everything you may need in one place, and does not require payment at the time of service in many cases…is it really a wonder why people use it over pre approvals, appointments and requirements of payment that exist in most primary care practices.

As far as e-visits are concerened, we did some research on that with our own facilities and found that we spend a total amount of time per patient of about fifteen minutes in clinic and twenty-three minutes in an electronic enviorment. We found that the electronic enviorment was cumbersome and required a great deal more questioning of the patient. We also found that repeat visits (in clinic after e-consultations) were nearly double that of face to face visits and letting a patient “self-diagnose” was a risky proposal, they were not correct on their diagnosis often and frequently were just requesting medication based on direct to consumer advertising….simply put…it is not better in any way.

So the debate will continue, but you can rest assured that the free market is gearing up to offer a solution to the cost of healthcar…remember healthcare is not that expensive, health insurance is.

Dan Francis, CEO
Medical Homes of America
http://www.equityhealhplan.com (under construction)
http://www.medicalhomes.org

Thank you for your thoughtful presentation of the medical home model, especially its reporting aspects and value to employers, which are rarely emphasized. The Healthcare Intelligence Network has been covering the emergence of the medical home and its impact on primary care for several years now, and I would like to respond to several of your points.

First, there has been much confusion, even in the industry itself, about the term. When we surveyed healthcare execs in 2006, more than half of them had never heard of the concept, or confused it with a physical structure. Thankfully, a similar survey we conducted earlier this year revealed a growing awareness.

Secondly, the key to the medical home model is a coordinated approach to care that is reliant upon an exchange of data among all medical home team members (pharmacies, payors, community organizations, physical therapists, and the patients themselves). In most but not all cases, care will be coordinated by the primary care physician. We cannot talk about the medical home without discussing tandem efforts to redirect consumers who visit the ER with non-emergent health issues to more appropriate health settings such as primary care. The dollars that payors and hospitals spend today to dispense primary care in costly ERs can be redirected to the medical home team. CMS last week announced $50 million in grants to 20 states that have proposed strategies to encourage Medicaid beneficiaries to avoid improper use of costly ERs, and nine of those proposals center around the creation of medical homes for these individuals.

Third, the medical home is a natural haven for the uninsured and the elderly. Several pilots in the medical home model have already been directed toward the uninsured. In North Carolina, doctors with Community Care of North Carolina served as medical homes for their Medicaid patients with diabetes. The ongoing care, information and support that physicians and case workers gave these patients made a huge difference. These patients missed fewer missed doctors’ appointments, made fewer non-urgent trips to the emergency room, and had fewer unnecessary hospitalizations. These changes saved North Carolina taxpayers more than $231 million in 2005 and 2006. North Carolina is planning related pilots for beneficiaries with other chronic illnesses.

And lastly, as we see it, the real key to the medical home’s success is education. Health plans have a huge challenge in marketing the medical home to consumers, who may confuse it with the old HMO “gatekeeper” model of care. PCPs, ER staff and payors need to teach consumers the benefits of the medical home and guidelines for determining when an ER visit is necessary. Primary care doctors need to know when patients are using the ER unnecessarily and address this during patient visits. During its pilot, Community Care equipped its physicians and patients with disease management toolkits and pamphlets on medical home vs. ER use in English and Spanish. Other health plans have found that putting these materials into consumers’ hands does reduce unnecessary ER use. Many payors have placed case managers in ERs as an educational and redirection resource. Education of ER staff and patients on the medical home also figures prominently in many of the CMS grant projects.

There are so many issues related to the medical home model that we have launched a Web page called “The Medical Home Monitor” at http://www.hin.com/medicalhome/medicalhome.html where we have posted our survey results and relevant video, podcasts, blog entries. etc on the topic, which will be updated continuously. Thank you for allowing me to respond to the issue here.

I have worked with a number of people on this whole idea and am pretty confident of my interpretation of medical home being correct. It is a system that puts much more control into the hands of the primary care physician and much more information in the hands of the patients and businesses.