The medical home in health reform’s attempt to fix primary care

Originally published in MedPage Today

by Kristina Fiore, MedPage Today Staff Writer

Encouraging “medical homes” to deliver care outside the emergency room should be a key aspect of healthcare reform, according to researchers, policymakers, and business leaders.

The medical home in health reforms attempt to fix primary care “It’s not rocket science to put a nurse practitioner near a public housing project,” said Jeffrey Brenner, MD, a physician in private practice in Camden, N.J., who analyzed hospital claims data there and is in a pilot program with the Camden Coalition to improve healthcare delivery.

Brenner found that the “leading” patient among area hospitals was seen 324 times, and that 90% of costs were attributable to just 15% of the patients.

There were also 12,000 emergency department visits for upper respiratory infections over that time period.

He suggested that establishing a nurse practitioner in these communities would improve care while reducing costs and burdens on emergency departments.

“The fix to this whole mess is primary care, or the medical home,” Brenner said at a healthcare symposium organized by the New Jersey Chamber of Commerce here.

The organization’s goal invited representatives from hospitals, pharmaceutical companies, academia, and business to discuss solutions to healthcare reform issues.

The so-called medical home could reduce costs by streamlining care, improving patient education and understanding, and reducing medical errors, researchers said.

Nurses and pharmacists would have significant roles in the medical home, participants said.

Susan Hassmiller, PhD, RN, of the Robert Wood Johnson Foundation, one of the sponsors of the event, said inadequate nursing can lead to reduced quality of care and an overburdened nurse staff.

For that reason, addressing an impending nursing shortage is critical, Hassmiller said. In New Jersey, the average age of nurses is 50 years, and the vast majority are expecting to retire within five years.

The same is true of nursing educators, a shortage that may leave insufficient faculty to teach new nursing students.

“Improving health and healthcare for all Americans can’t be possible without an adequate nursing force,” said Susan Blackwell-Sachs, PhD, RN, dean of the College of New Jersey’s school of nursing and director of the New Jersey Nursing Initiative, a project of the Robert Wood Johnson Foundation.

“Shortages directly affect the quality of care.”

Brenner said change won’t come easily. Healthcare currently accounts for 18% of the gross domestic product, and some forecasters say it could rise to 25% in 10 years.

“When something becomes a quarter of the economy, getting control of it is going to be incredibly difficult,” he said. “The healthcare reform bill does not begin to chip way at this.”

He equated fixing healthcare to a “whack-a-mole” game: “You fix it in one spot, it pops up somewhere else.”

He said an essential question is whether to first cover everyone, then try to control costs, or do both at the same time.

Brennar said he preferred “an incremental approach,” and noted that “if you cover everyone, then we can really talk about the cost issue.”

He added that the take-home message is that state chambers of commerce have a large role in healthcare reform.

“We really need to fix this state by state,” he said.

Dana Egreczky, a senior vice president with the New Jersey Chamber of Commerce, said business owners should make their voices heard on reform, at both a national and state level.

“I’m not sure we can do anything about federal decisions on reform from here in New Jersey,” she said. “What we can do in this state is to fix this system.”

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  • David Voran

    We’re obsessed with tackling health care costs by bemoaning the poor state of primary care here in this country. I’m a primary care physician and there are times I have to remind myself there are countries that have pretty good healthcare systems where there is no primary care. Japan is one of these countries.
    The patient is essentially the “medical home.” The country is populated with private and public physicians of which almost none of them engages in primary care.
    I spent the greater part of my childhood in Japan and lived for a stretch in a small town of around 90,000 people. We had a state run hospital staffed by teachers and the equivalent of residents (about a 400 bed hospital). Scattered around town were around 40 hospitals (most were less than 10 beds and attached or above the physician’s clinic). Each of these were specialty hospitals. When I had a stomach ache we trotted down the street to the GI doctor’s hospital, waited in line and got seen that day. When I had a ring-worm, I made frequent trips to the Dermatologist’s clinic and small ward about 2 blocks away. Cut yourself and you go to one of the many surgeon’s hospitals.
    Only if it was major did an ambulance come get you and you wound up at the State hospital.
    Interestingly each of these places would look at the health card (similar to the Post Office checking account books we had) and if we were behind on an immunization we’d get it at any of those places, or at school.
    So we have to think. With information technology and a universally accessible patient record we might not need primary care physicians to deliver coordinated care.

  • Miriam Volpin

    This might seem trivial, but I have a real issue w/the name “medical home.” To quote Mathy Mezey, EdD, RN, FAAN (director of the Hartford Institute), and also in alignment with the quotes in the original post “Consistent with past and current practice in models that deliver comprehensive services to patients, nurses in this new model would be the provider responsible for most of the service coordination and patient follow-up. And in fact, nurses achieve impressive patient outcomes when they coordinate services to complex patients.”

    Some other suggestions:
    “Health home”
    “Caring home”
    “Care management”
    “Health Care Management Home”
    “Health Care Home”

  • alex

    Well, I’m sure the primary care doctors will be totally on board with the idea that the “medical home” excludes them so much that it shouldn’t even be called “medical”. Yikes.

    In other news, I continue to await actual evidence that this saves money. Most of these “preventative services will save money!” ideas appear to have failed miserably when actually implemented and analyzed for cost savings. Honestly, the real problem US health care is so bloody expensive is that the “standard of care” is a million times higher than the rest of the world. And it’s not going to be any cheaper until there’s some mechanism to push doctors to not order every CT, SPECT or coronary cath that walks in the door.

  • Miriam Volpin

    Why do you say it excludes primary care doctors alex?

    As for preventative services save money, I think it depends on how you analyze the data. For example, several studies involving on-going home visits to at risk mothers by home health nurses found that, not only did the women have fewer problems with parenting but they spaced their pregnancies further apart, and there were lower incidences of abuse. Following the children over time there were higher rates of HS graduation and lower rates of criminal activity.

    Seems to me that’s some pretty major cost savings to society.

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