Medical Homes as Centerpiece of Healthcare Reform

Orlando—In nearly 5 decades as a doctor, Sam JW Romeo has seen numerous industry innovations that did not improve care or cut costs. He is now the medical director at Tower Health & Wellness Center in Turlock, California, which he and other partners opened in 2005.

Of Dr. Romeo’s 6 children, 5 are physicians. The sixth is a licensed clinical social worker. Due to his childrens’ occupations, Dr. Romeo is familiar with all of the recent proposals, particularly those included in the Patient Protection and Affordable Care Act (ACA).

At the Spring Managed Care Forum, Dr. Romeo addressed the medical home concept that is gaining in popularity, and provided attendees with a history of previous attempts at reforming healthcare in a session titled The Medical Home: The Cornerstone for the Future of Managed Care.

“Healthcare reform is inevitable,” Dr. Romeo said. “I do not care what political persuasion you are.”

Dr. Romeo emphasized that regardless of the Supreme Court’s decision on the ACA or the results of the 2012 presidential election, the current fee-for-service payment model is outdated and will not be around much longer. A fee-for-service environment makes it easy for providers to charge health insurers for each procedure and for patients to request additional tests and services, according to Dr. Romeo, which leads to medical inflation and soaring healthcare costs.

There have been numerous attempts to control costs and improve quality, with the introduction of organizations such as the Institute for Healthcare Improvement and the National Committee for Quality Assurance. However, Dr. Romeo said, the same problems remain.

Dr. Romeo cited an article written by Robert Brook, MD, ScD, in the Journal of the American Medical Association [2010;304(16):1831-1832]. In his commentary, titled The End of the Quality Improvement Movement, Dr. Brook wrote that “more than 40 years later it is unclear what the quality movement has accomplished” and that “there is insufficient evidence about whether or how the quality of care has actually improved.”

Dr. Romeo suggested that improving health outcomes could only be achieved on the patient level and not on the population level in which quality data are aggregated for a large number of individuals. For instance, he said that to improve the obesity epidemic in the United States, providers and healthcare professionals must treat each person individually rather than as a collective group.

The medical home is a potentially good solution at solving some persistent healthcare issues, according to Dr. Romeo. However, he cautioned that medical homes improve quality and lower costs only if they are focused on improving wellness and lifestyle choices.

The core principles of the medical home include a doctor-patient relationship based on medical ethics, trust, and patient empowerment; access to care 24 hours a day, 7 days a week; continuity of coverage; comprehensive care; and a focus on evidence-based care and quality measurements.

“The medical home is not defined by the delivery system,” Dr. Romeo said. “It is defined by the relationship between the provider and the patient. The medical home is more than a name. It is a patient-provider responsibility and commitment.”

Still, Dr. Romeo said a major concern is the dearth of primary care physicians, who are central to coordinating care in the medical home. He said most medical students are becoming specialists, with only 7% choosing to enter family or primary care, partially because the salaries associated with specialty care are much higher than for primary care. However, primary care physicians, not hospitals, are the primary entry point for patients in a medical home and are crucial to ensuring that patients thrive in new systems such as accountable care organizations.

In the short term, medical homes can contribute to savings by providing quality improvement plus utilization and case management that can lead to shorter hospital stays and fewer hospitalizations, emergency department visits, tests, x-rays, and drugs. In the long term, Dr. Romeo said medical homes are designed to have patients be happier and more active, make better lifestyle choices, and see wellness as a responsibility to be taken seriously. He added that he hoped the implementation of medical homes would rejuvenate primary care as a career choice for aspiring physicians.

To reform healthcare, Dr. Romeo said the industry should follow 7 principles: (1) emphasize the doctor-patient relationship to improve accountability for cost, quality, and value of care; (2) achieve a sustainable payment mechanism by reforming healthcare’s entry process; (3) utilize the medical home as the centerpiece of reform; (4) have consistent standards applied to all medical homes; (5) focus on medical ethics and empathy; (6) base the payment system on the care of the whole patient, not just his or her diseases or procedures, or a population of patients; and (7) verify that the medical home is patient-centered and physician-directed, provides continuity of care and accessible care, provides high quality of care as measured by patients and medical evidence, and focuses on comprehensive care including wellness, prevention, healthy lifestyle, end of life support, acute care, and chronic disease care.

From a payment perspective, Dr. Romeo said there should be a fee-for-service component as well as a simple capitation component, and that cost, quality, and value of care must be measured and should include patients’ feedback about the medical homes. He concluded that medical homes should be created for patients, not for providers and payers. If patients and providers collaborate and invest in medical homes, managed care will flourish, according to Dr. Romeo.

Although medical homes could cut costs and help from an economic perspective, Dr. Romeo said the more important benefit is that they can help patients live longer, healthier lives.

“There is no choice—the current system is unaffordable and unsustainable,” Dr. Romeo said. “It must change. The system is perverse. It is based on economic return, not care. It is crazy what we are doing. We must take care of patients.”