A transcript of the meeting is available at www.medpac.gov/transcripts/04090410medpac.final.pdf
The time for hospitalists to become involved with and essential to “medical home” systems of health care is now, while these programs are still in the design or pilot stage, according to experts interviewed for this article.
The “home” is not a physical location but rather a centralized and coordinated network of multidisciplinary providers. Having a primary care physician or specialist at the center of a medical home promotes enhanced and more efficient patient care. Patients enrolled in such a system experience better overall quality of care and lower health care expenditures, according to a review study (Pediatrics 2004;113[suppl. 5]:1493-8).
The Centers for Medicare and Medicaid Services (CMS) and private insurers are investigating the medical home approach because these plans likely will save money, for example, through fewer unnecessary diagnostic tests and less redundancy of services.
“Medical home initiatives are gaining attention of late. Some private payers are starting them, and some state Medicaid agencies, frankly, have been working with them for many years,” Cristina L. Boccuti, senior analyst for the Medicare Payment Advisory Commission (MedPAC), said at a public meeting held by MedPAC in Washington.
Although a medical home primarily provides chronic care management, hospitalists will have a role, Dr. Amir K. Jaffer, chief of the division of hospital medicine, University of Miami, said in an interview. “My own feeling is, hospitalists have a place here when patients with a chronic disease get sick and need to be admitted.”
The American College of Physicians (ACP), the American Academy of Family Physicians, and the American Academy of Pediatrics are promoting medical homes as a means to improve patient care and outcomes, Dr. Jaffer said. However, “a lot of these organizations talking about medical homes have not linked them to the hospitalist model of care.” Therefore, hospitalists need to be proactive.
The Society of Hospital Medicine (SHM) in Philadelphia “has no official policy on the medical home,” chief executive officer Dr. Laurence Wellikson said, when he was asked to comment. “SHM has worked with ACP and others on developing a consensus document on transition of care, and we have long supported efforts to bolster primary care.”
A link to the hospital is very important to these medical homes, Dr. Jaffer said. However, the hospitalists' role goes beyond communicating with a patient's primary physician during hospital admission. “The idea in the first place is to prevent the hospitalization, to prevent them from getting sick. You may be able to avoid these admissions.”
The medical home construct also aims to reduce fragmentation of care. “The medical home is about centralizing care versus everyone working in silos. It's a coordinated care model, and the hospitalists are really vital to this and should be in a position to champion this idea,” William J. DeMarco said in an interview. Mr. DeMarco is president and CEO of DeMarco & Associates Inc., a national, independent health care consulting firm in Rockford, Ill.
“Ideally, through better care coordination, medical homes could enhance communication among providers, thereby eliminating redundancy and improving quality,” Ms. Boccuti said during the meeting. “They may also improve patients' understanding of their conditions and treatment, and reduce the use of high-cost settings such as hospitals and [emergency departments].”
A hospitalist can work with the primary care physician or specialist to get the patient out of the hospital earlier, Mr. DeMarco said. “Even if they can save 1–2 days of hospitalization per month, the hospitalist[s] would pay for themselves.”
“Hospitalists can and should play an essential role,” said Dr. David Bronson, chair of the Medicine Institute at the Cleveland Clinic. “No one physician can cover 24/7/365, and teamwork amongst physicians will be essential for success of the medical home model.”
The main roadblock for physicians regarding medical homes is reimbursement, Dr. Jaffer said. The CMS “will have to take into account this continuous interaction we have with patients … versus the episodic, fee-for-service, procedure-based system we have now.”
To date, there is no specifically defined, ideal model of reimbursement for the medical home, either for primary care, hospitalists, or specialty care, Dr. Bronson said. “The most likely model is a care coordination fee that rewards the medical home physician for ensuring appropriate coordination of care and care transitions.”
Mr. DeMarco agreed with this approach: “There should be a management fee in exchange for the extra time to coordinate care and document.”
Health information technology, including centralized electronic medical records (EMRs), is essential to the implementation of the medical home model, which focuses on chronic disease management and preventive services, Dr. Jaffer said.