Rheumatology and the Patient-Centered Home

Leaders in primary care medicine in the U.S. have advocated a model of healthcare delivery called Patient Centered Medical Homes, in which all patients would receive care through primary care practices.^1,2 In its realignment of providers, this model calls for major changes in the relationship between primary care providers and specialists. Motivating this initiative are data indicating an association between lower costs and better population health on one hand and more primary physicians and fewer specialists on the other. The association has been documented in health systems of other countries, as well as some areas of the U.S.^3-6

Although a cause-and-effect relationship between outcome and provider mix has not been established for the individual patient or for the population, these findings have fueled a drive to create Medical Homes. Pilot testing of this approach is ongoing at present, and has received funding from the Agency for Healthcare Research and Quality (ARHQ) and the Centers for Medicare and Medicaid Services (CMS). Other proposals linked to the Medical Home model include government financing to increase medical school enrollment of primary care providers, forgiving educational loans for primary care physicians, and altering the structure of physician payment mechanisms. Some multispecialty group practices, including our own are implementing this approach even before its effectiveness is established rigorously.

While momentum for the Medical Home model has grown, some physicians and policy experts have questioned the current Medical Home approach and its readiness—indeed, some specialty organizations, including the ACR, have been unwilling to endorse it.⁷ Concerns about the model include:

• Variable definitions of the Medical Home that may confound the analysis and implementation of this model;^8,9
• Unresolved questions about costs and scalability;8
• The complexities and challenges identified in the pilot testing within family practices;¹⁰ and
• The lack of evidence for large-scale improvement in outcomes or cost savings.^8,9,11

We share these concerns based on our experiences within our own health systems and our work developing system-based rheumatic disease management programs.^12,13 As we see it, the central problem in the model concerns the relative roles of subspecialists and primary care Medical Homes in the management of chronic diseases. These diseases account for much of the population morbidity and 70% of healthcare costs in the U.S.¹⁴

We are also concerned that our society is being asked to invest time and money in pursuing a solution that seems unlikely on its own to solve the recognized problems that plague healthcare in the U.S. We suggest that system-based chronic disease management is preferable to either traditional healthcare or the Medical Home model.

What Is the Medical Home?

The current Medical Home model proposes that primary care practices should be redesigned as interdisciplinary teams to provide or coordinate all care for all patients, including those needing services for prevention, acute and chronic disease management, and end-of-life care.¹ This concept was developed initially during the 1960s in the field of pediatrics; in the past decade, it was expanded to include internal medicine and family medicine as well. The changes considered essential for transforming traditional primary care practices into Medical Homes include:

• Continuous access of patients to a personal physician;
• Responsibility for all of the patient’s acute, chronic disease, preventive, and end-of-life care;
• Coordination of patient care with specialists;
• Adoption of “patient centeredness”; and
• Use of information systems.

Medical Home proposals are generally silent about any active role for specialists in planning or delivering patient care, other than that requested by primary physicians for complex cases and procedures. The American College of Physicians 2006 position paper, “The Advanced Medical Home: A Patient-Centered, Physician-Guided Model for Healthcare,” may have added further confusion by suggesting that, “For most patients, the personal physician would most appropriately be a primary physician, but it could be a specialist or subspecialist for patients requiring ongoing care for certain conditions (e.g., severe asthma,[etc.]).”¹⁵

Concerns About Managing Chronic Diseases

We advance the following set of propositions that reflect studies from the literature as well as our personal opinions.