Medical Home Concept and Describe the Principles

¶ … medical home concept and describe the principles (operational characteristics mentioned above) of the PC-MH as defined by these organizations. How does this concept differ from the gatekeeper concept of Managed Care Organizations?

According to the 'gatekeeper' philosophy of health management organizations (HMOs), physicians are intentionally given incentives to reduce access to care. This is based upon the assumption that patients will want to obtain as much care as they can receive and physicians will want to bestow that care to please patients and incur more revenue. HMOs encourage physicians to do the opposite and often financially reward physicians for cost reductions and limiting access of patients to specialists or heroic treatments. In the HMO model, physicians try to restrict access to specialists when they do not deem it necessary.

In contrast, the medical home concept is viewed as a partnership between "individual patients, and their personal physicians, and when appropriate, the patient's family" (Joint principles, 2007, AAFP). In the PC-MH model, the physician is viewed responsible for arranging care to promote whole person wellness in a proactive fashion, including establishing connections with other physicians. Close communication between the patient, caregivers, and other members of the treatment team is vital. Instead of a gatekeeper, the PC-MH model views the primary care physician as a navigator of the healthcare environment. "The PCMH should ensure that the health care team pulls together to best serve patient needs in all arenas. In the PCMH, integration will have to be a system-property, with information systems, teams, and organizational linkages promoting integration" (Case for change, 2011, ADA).

In the HMO model, a general practitioner must be consulted first for a referral to ensure that the patient's condition is serious enough to warrant the intervention of a more costly specialist. This is viewed in the PC-MH model not as a cost-reduction philosophy, but as part of a holistic, whole person orientation in which "each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care" (Joint principles, 2007, AAFP). The physician serves the patient and generates cost savings through directing care on a primary as well as a tertiary level. PC-MH is a "physician-directed medical practice -- the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients" (Joint principles, 2007, AAFP). Even when specialists are involved, care is integrated. "Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner" (Joint principles, 2007, AAFP). Throughout every phase of a patient's treatment, using these advances in technology, the primary care physician acts as a coordinator. Patients currently labor under the responsibility to coordinate their own care (and to fight with insurance companies when care is denied) despite being the "least trained in the complex culture and language of medicine" (Case for change, 2011, ADA).

Question 2-: The principles describe the advantages of a PC-MH. Describe the disadvantages of a PC-MC concept.

PC-MH does not necessarily improve access throughout the healthcare system to patients that lack insurance. Also, by emphasizing primary care to such a strong degree, it could actually limit access to specialists for patients that truly need such care. There is a severe deficit of primary care physicians in the U.S., particularly in rural areas. This is unlikely to be rectified in the near future, thus PC-MH care could make it difficult for patients without access to a primary care 'navigator' nearby.

Question 3-: Ideally, how would you integrate PC-MH into our present system? How would you make it work with the current scarcity of primary care physicians?

Integration of PC-HM into the current system will only be possible with expanded scholarship opportunities to new physicians. Specialist medicine, rather than primary care medicine currently dominates the practice of medicine in the U.S. For example, Medicare patients see an average of two primary care physicians for every five specialists. "Only 27% of working age adults -- an estimated 47 million people -- had a PC-MH [in a recent survey]. Another 54% of adults have a regular doctor or source of care, but they do not have the enhanced access to care provided by a PC-MH" (Case for change, 2011, ADA). There is a deficit of primary care providers within the U.S., due to the fact that specialist medicine is both more lucrative and also less onerous in terms of hours the physician must work. Doctors graduate with high levels of student loans and often feel pressured, even if they do not desire to, to 'go where the money is' in terms of their practice. First and foremost, the incentive structure for physicians to enter primary practice must increase. Greater availability of scholarships for physicians entering primary practice is essential if enough Americans are going to have primary care doctors in the future.