Medical Homes

Research suggests that the availability and use of more primary care resources improves health outcomes for a population.  The most prominent initiative to encourage greater use of primary care is the medical home concept.  A report from RWJ and the Urban Institute provides a status of current medical home efforts and identifies issues for validating its value.   (RWJ Report) The report begins by noting the history of the concept and the lack of a single consistent definition of a medical home.  A number of physician groups have endorsed a set of principles on the medical home and NCQA, the Joint Commission on Accreditation and other groups have released their own definitions as well.  While some payers sponsoring medical home pilots have adopted the NCQA requirements, others have developed their own criteria.

Some of the important issues in setting up a medical home model include whether the concept really provides benefit to all patients or just those with chronic illnesses, whether physicians must be leaders of the medical home or can other providers such as nurse practitioners do so, and whether it just applies to primary care physicians or specialists.  The report points out that there is very little evidence from good quality research that a medical home either improves quality or lowers costs.  That research should focus on what attributes create value, because right now implementing some medical home definitions and criteria can cost a lot, which offsets any potential health care savings.  Knowing the minimal set of attributes that creates improvement would likely lead to lower cost and simpler implementation.  Another major issue is identifying appropriate payment mechanisms; a number currently abound.

Despite the lack of evidence, many pilots are underway and Medicare and Medicaid are sponsoring some of these efforts.  The military services have been particularly aggressive in moving their covered persons into this model.  As the report suggests, the critical juncture for widespread use of the medical home concept is development of credible evidence that it actually improves health outcomes and status and/or lowers costs.  In the absence of that evidence, the medical home pilots that are underway will eventually dry up and be abandoned.