A term you will hear used frequently in the months to come is "Medical Home." The concept of a medical home is already being developed in a few of the major medical centers in the nation and has been shown to correct many of the deficiencies in our present healthcare system . Briefly it comprises all elements of health care, for the most part under one roof. A sort of "one-stop-shopping" approach to the delivery of medical care. If the concept--as it now exists in some centers--is analyzed carefully, it can be seen that it might well be the answer to reform of the deplorable healthcare system we now have in place--a system that we can blame on no one but ourselves.
To understand the potential of a "Medical Home" we need to take a look at health care in years past: How did our present system evolve? What is the root cause of its deterioration into the costliest among the industrialized nations of the world and that produces the worst outcome of care?
For the moment, envision what medical care was like immediately following WW II, about the time antibiotics came on the scene. Most people had a family doctor that they turned to for whatever ailment that arose. The family doc managed most illnesses with the tools available. He/she often did surgical procedures, delivered babies, treated broken bones, and even provided much of the psycho-social counseling of that era. The family physician was always available, accessible--a quasi-member of his patient's family--and never appeared to be obsessed with financial reward for his services.
As time passed, more specialization emerged: specialists in surgery, orthopedics, internal medicine subcategories, to name a few. Their presence in every community of any size provided the primary care physician, the family doctor, a referral source for complex problems. Quality of care, as measured by today's standards, improved remarkably with the arrival of more specialists, but at the same time the cost of care escalated.
Next came the federally funded Medicare and Medicaid programs and the beginning of the spiraling growth of private insurance. Blue Cross/Blue Shield led the pack. The insurance industry grew by leaps and bounds. This was followed by the "Managed Care" concept--the HMOs and Preferred Provider Organizations, and multple variant systems--structured to capture as many of the health care dollars as possible. These embryonic sub-systems of the 1990s as well as those of today have focused on profit margins, often using denial of benefits to achieve operating profits. Unfortunately most have neglected to impose adequate quality control measures as they have grown.
Now, add to the hodgepodge of super-specialists, primary care physicians, insurance payers, the various reimbursement systems, and the multiple other healthcare providers that are competing for a share of the healthcare dollar--Hospitals, Nursing Homes, Day Surgery Units, Imaging Centers, Laboratories, Home Health Organizations, Rehab Centers, Specialty Hospitals--and you have our present fragmented system. It is the most costly per capita and has produced the worst outcome among idustrialized nations and leaves millions uninsured or underinsured.
So, what happens? Cost of care escalates out of control, quality of care deteriorates, greed drives providers to reach for more and more of the medical care dollars, some by performing medically unnecessary procedures and diagnostic testing, and others by having a financial interest in entities to which they refer. Consumers demand more care, whether or not medically necessary. Insurance companies simply smile when the cost and abuse increases: they raise the premiums, co-pays, and deductibles to cover the increase in skyrocketing cost, and take their management percent to the bank.
Not eveyone can afford the costly health insurance even if it is available. It's not unusual for a family to have to allocate 50% of their expendable income either for healthcare insurance or for the staggering medical care expenses that they face if they don't have coverage. So often the only alternative is to choose bankruptcy.
How would a so-called "Medical Home" concept gives us a healthcare system that leaves no one behind, that contains overall cost, and improves the quality of care? The "Medical Home" model--an example is the Mayo Clinic in Rochester, Minnesota--is a comprehensive integrated concept that assigns patients a lead doctor, a primary care physician, who coordinates all of the patients care. This includes referrals for diagnostic testing, referrals to specialists, and referrals to ancillary facilities. The key to the success of health delivery systems, such as the integrated "Medical Home" model is simply this: Accountability. Every patient of the totally integrated system has access to needed healthcare: preventive care, emergency-urgency needs, treatment of crippling chronic disease, and necessary mental health care. Every treating provider--physicians, qualified medical provider, ancillary facilities--is held accountable for appropriate care, from the standpoint of quality, medical necessity, and cost.
Regarding reimbursement, an essential element for comprehensive healthcare is adequate compensation for the front-line primary care physicians who are in a postion to provide necessary preventive care and oversee referrals to competent secondary providers. Almost daily I hear stories of the difficulty people have in finding primary care physicians--family practice physicians and internist. Many of these sorely needed physicians are dropping out of practice or pursuing other medical fields. There has been a significant drop in the number of young physicians entering primary practice training programs. This must be corrected by adequate compensation for these doctors who will play such an important role in overseeing utilization and quality in integrated "Medical Home" concept or in any plan that's adopted to reform our healthcare system.
Another essential element that will insure quality of care as well as appropriate cost and outcome is the Electronic Medical Record (EMR)--it should be made available to all providers involved in the care of any specific patient, assuring transparency in the continuum of care by all caregivers.
Is any system that conforms to the above description of a "Medical Home" attainable? Of course it is; but only if payers, consumers, and all providers buy-in to the concept, have input in developing criteria for medical necessity of care, and if our lawmakers refuse to yield to lobbyists for the greedy special interest groups who have produced the present national healthcare disaster and who advocate a continuation of the status-quo system.
Charles Clark, Sr., M.D.