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If you could build the ideal pediatric practice for your family, what would it look like?

My guess, after years as a practicing pediatrician and parent of two children, is that it would be:

  1. Accessible
  2. Family centered
  3. Continuous
  4. Comprehensive
  5. Coordinated
  6. Compassionate
  7. Culturally effective

I didn’t make these up. These ideal qualities are the core attributes in what is known as the “medical home” model, outlined in a landmark policy statement published by the American Academy of Pediatrics (AAP) in 2002. The AAP’s National Center for Medical Home Implementation points out that a medical home “is not a building, house, hospital, or home healthcare service, but rather an approach to providing comprehensive primary care.”

Comprehensive, primary care does not simply entail doing annual checkups in 10 minutes and making sure all the physical exam boxes are checked off. It’s about caring for the whole child in the context of their family, their culture and their community. It also takes time and effort. For those of you who have followed my posts on integrative medicine over the years, you’ll note that these medical home principles are synonymous with the integrative medicine philosophy.

Well, this all sounds ideal, right? I think, for parents and pediatricians alike, we would love to see all practices functioning as medical homes. The big question is, given our current health care system issues, does the medical home model actually deliver cost-effective, high quality care? Bottom line—does having a medical home keep us healthier at a reduced cost? In preparing for a talk I gave with John Weeks (author of the must-read Integrator Blog) at the annual Integrative Healthcare Symposium in NYC, I reviewed everything I could that related to this question.

What I concluded, based on published data from pilot program assessments, is that the answer appears to be a very resounding “yes.”

A 2012 editorial in the Journal of the American Medical Association (JAMA), “Patient-Centered Medical Homes Offer a Model for Better, Cheaper Health Care,” describes promising findings from a recent Commonwealth Fund survey on perceptions of patients with complex health care needs.

The latest survey, involving patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States, found that adults seen at primary practices with attributes of patient-centered medical homes—where clinicians are accessible, know patients’ medical history, and help coordinate care—gave higher ratings to the care they received and were less likely to experience coordination gaps or report medical errors (Schoen C et al. Health Aff [Millwood]. 2011;30[12]:2437-2448). 

“There is clearly a positive effect in every country where patients have an association with a primary care provider with attributes of the medical home,” said Cathy Schoen, MS, lead author of the survey and senior vice president for policy research and evaluation at the Commonwealth Fund.

The Commonwealth Fund also co-sponsored the publication of “Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the United States,” with the Patient-Centered Primary Care Collaborative (PCPCC), a formidable Washington, D.C.-based trade group advocating for the patient centered medical home model.  The PCPCC brings together major stakeholders in health care delivery and actually possesses the political and economic clout to move the medical home agenda forward. The report’s findings are summarized:

Investing in primary care patient centered medical homes results in improved quality of care and patient experiences, and reductions in expensive hospital and emergency department utilization. There is now even stronger evidence that investments in primary care can bend the cost curve, with several major evaluations showing that patient centered medical home initiatives have produced a net savings in total health care expenditures for the patients served by these initiatives.

Paul Grundy, MD, MPH, president of the PCPCC and co-author of the aforementioned brief, firmly states, “The proof is in. This document shows that primary care that is more comprehensive, integrated and coordinated, that follows the model of the patient centered medical home, delivers better care and better quality at lower costs. For anyone who questions this, I challenge you to prove otherwise.”

No argument from me. My main concern is not whether an integrative patient-centered medical home is the ideal primary care solution, but how best to implement it. The National Committee for Quality Assurance (NCQA), a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality, certifies medical practices as medical homes. As a practitioner currently going through the certification process, I can testify that there remain major barriers to widespread adoption. Organizational challenges include access to sophisticated technological practice management support and the time and resources to document fulfillment of numerous certification criteria. I estimate it will take me about a year to complete certification. And though I firmly believe that medical home certification is the right thing to do, as it stands today, there are no financial incentives for me to go through the process. There are an increasing number of federal, state and private payer incentive pilot programs, but enrollment is quite limited and it is unclear how health care dollars will be redistributed to maximize cost efficiency. This I know—I can keep my patients healthier at reduced cost based on the way I practice integrative primary care. But will the health care system provide the incentives for me to do so? Currently, doctors and hospitals make more money by seeing more patients, diagnosing them with more diseases, subjecting them to more tests and procedures, and treating them with more pharmaceuticals.  Something’s got to give.

Given these barriers, how close are we to the ultimate goal of 100 percent of families being able to identify a medical home for their children? Not nearly close enough, according to “The Health and Well-Being of Children: A Portrait of States and the Nation,” a report published by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. The report, based on the 2007 National Survey of Children’s Health, notes that 57.5 percent of children nationally are identified as having a medical home. The percentage varies widely by state, from Nevada at 45.4 percent to New Hampshire at 69.3 percent. Furthermore, although children with special health care needs (CSHCN) are perhaps in greatest need of medical homes, only 47.1 percent claim to have one (per the 2005/06 National Survey of Children with Special Health Care Needs). The report also details racial and socioeconomic disparities with respect to access to medical homes. As usual, those in greatest need go most without.

I expect you will hear more about patient- and family-centered medical homes as we strive to create a true health care system that promotes health and well being while maximizing cost-efficiency. Keep an eye on integrative medicine as a solution; a system that values partnership between patients, families and practitioners is, in my opinion, the optimal model to cure our health care woes.

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