Report from CEO Terry McGeeney

A House Does Not A Home Make

The Medical Home concept is getting a lot of attention nationally, at multiple levels. Patients are demanding it, payors want to define and test it, and legislatures are mandating it. This is a time of great opportunity but also great risk for primary care. There is no question that the US healthcare system is broken; costs continue to rise and quality continues to decline. There is more evidence of this every day.

Primary care is uniquely situated to be the solution for the problems facing the healthcare system. There are two major hurdles, however, that must be dealt with:

1. Primary care practices need to change to meet the standards of becoming a medical home.
2. The payment system needs to change to adequately reimburse primary care for providing medical home services.

Both of these changes need to happen quickly. It is no longer acceptable for primary care practices to continue in the status quo,  which we have learned does not address the needs of patients. Equally important, it is no longer acceptable for payors not to pay primary care physicians to provide the care that patients need.

There is a perfect storm of sorts brewing that will either guarantee the future viability of primary care or cause its demise. We now know what primary care needs to do — become real, patient-centered medical homes. The challenge is that if the payment system for primary care doesn't change quickly there won't be primary care physicians left to create and staff the medical homes.

The reality is that the current fee-for-service system is not going to go away anytime soon. Also, given the way the deck is stacked against primary care, it is unlikely the fee-for-service system will pay for the cognitive and preventive services provided by primary care.

The four primary care associations are working hard to address these issues by working to reform the payment system. The current proposed model that is getting some traction at multiple levels is a three-tier payment system which consists of a blended model of the traditional fee-for-service, pay-for-performance and a care management fee. This care management fee would pay primary care physicians for being patient-centered medical homes for their patient — for doing many of the things that are not currently compensated for but desperately needed by our patients. There is hope that soon some pilots will be implemented to test the concept of this blended payment model.

Payment reform is one of the necessary critical changes. Practice transformation is the other. Most agree that many primary care practices do not provide what today's patients or the US healthcare system needs. Most also now agree that what patients and thus the US healthcare system need are patient-centered medical homes for everyone— not just for those with insurance or laptops, but for everyone.

This is both an opportunity and a challenge for primary care. The challenges are multiple. First, primary care absolutely must define the medical home and not relegate that to payors. Second, primary care practices must transform now in order to be positioned to warrant the payment reform. It will be a travesty if the system starts paying for medical homes and there are no medical homes to reap the benefits. The third and greatest challenge is the lesson we have learned at TransforMED, working with practices in the National Demonstration Project (NDP): transforming to a patient-centered medical home is not easy.

The TransforMED Medical Home model clearly outlines the components or building blocks of a medical home. The NDP is teaching us how to implement those building blocks. We know that it is not easy, but it is possible. We also have learned that implementing new processes and making changes in order to check off components of the model as having been completed – without a plan to put the patient at the center – does not create a medical home. It creates a practice with all of the components, but it does not address the concept of patient-centeredness.

I think we all know what patient-centeredness implies – everything that goes on in a practice is for the benefit of the patient and the patient is central to all activities and decisions. However, the concept goes much further than this. It implies trust, respect, shared decision-making, cultural sensitivity, mindful communication in the exam room, whole-person orientation and a continuous relationship over time. These are the strengths, the core values of Family Medicine. We are not event focused, single organ doctors. We chose Family Medicine exactly because of the opportunity to be patient-centered.

Now over one year into the NDP, TransforMED has learned a lot about how to make change, create tools and evaluate medical practices. We still have more to learn about the most important and yet trickiest parts of the model – how to ensure a practice is "patient-centered." Given the time and financial constraints facing primary care practices today, it is hard to imagine having the time to focus on the patient as much as we want when we also have to focus on keeping the doors open.

Going forward there will be a lot of discussion on how you know a medical home when you see it. Knowing a "patient-centered" medical home will require a practice that makes all the necessary changes, but more importantly Family Physicians doing what Family Physicians are uniquely qualified to do — providing "a continuous relationship with a personal physician caring for the whole person." Providing the "patient-centered soul" of the practice makes the "medical house" a "medical home."