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Medical Homes -- More Evidence of Improved Quality for Less Cost

Medical Homes -- More Evidence of Improved Quality for Less Cost

September 14, 2008

One of the most important provisions of chapter 305, the Health Cost and Quality bill that was passed this summer, is section 30, which directs MassHealth to establish a "medical home" demonstration project. In addition, section 44, which establishes the Special Commission on the Health Care Payment System, puts the issue of medical homes on the agenda for the entire health system.

The term "medical home" means more than just managed care. While there's some disagreements on details, over the past few years there's been a growing consensus on what constitutes a medical home. The key concepts include a team-based model of care led by a personal physician who provides continuous and coordinated care, with a focus on preventive services. Lots of details and links are here, from the American College of Physicians.

Medical homes have a bit of the flavor-of-the-year quality, where a concept ("HMOs," "patient-directed care") is hailed as the salvation of American health care. There'll never be a single answer to anything as complicated as health care.

However, a 2007 study found medical homes can reduce or even eliminate health care disparities. This week, Health Affairs published results from a study of Geisinger Health System in Pennsylvania, a cutting-edge experimenter with medical homes. The study found that "Geisinger is improving its quality of care and achieving better outcomes for patients, while at the same time lowering costs and increasing value."

Impact of medical homes.

The Massachusetts health policy gang should be very familiar with Geisinger. Their CEO presented at one of the Brandeis-led health care cost meetings back in February (powerpoint, and discussion summary), and their Chief Technology and Innovation Officer presented before the Mass Health Council in April (powerpoint).

Commenting on the study, Arnold Milstein found a very human element is critical if medical homes are going to reduce costs and improve care:

At least one primary care team member demonstrates saliently to each chronically ill patient that they care deeply and personally about them and protection of their health. This includes mobilizing family members, social services, and other resources required for successful patient self-management. In addition, as soon as a chronically ill patient senses impending health crisis, a member of the health care team familiar with their history is readily reachable and prepared “to go the extra mile” to prevent hospitalization, including actively coordinating with ER physicians and hospitalists in exploring alternatives to hospitalization.

An attitude of “protection of your health matters to me personally” and “I’m prepared to invest special effort to spare you a health crisis” was memorably captured in Atul Gawande’s 2004 New Yorker magazine portrait of Dr. Warren Warwick in The Bell Curve [also this interview]. It is the exception rather than the rule in American health care delivery. Because it reflects a personality characteristic of clinical team members rather than a readily teachable behavior or a structural enhancement of a primary care practice, assuring this expression of patient-centeredness requires new selection criteria for medical home team members serving the chronically ill.

Massachusetts is behind the curve on medical homes. We need to mobilize government and the health care industry to get us there. I'd encourage people to comment with observations or updates.
Brian Rosman