Physicians Finally Getting Help to Become Medical Homes

After a long wait, Medicare has revealed how it plans to encourage the development of patient-centered medical homes. In one of the most promising signals to come out of the Obama Administration so far, Health and Human Services Secretary Kathleen Sebelius announced that Medicare will fund medical home projects in several states, starting early in 2010. The pilots will be patterned after that of the Vermont Blueprint for Health, which has been testing the medical home concept for about a year.

In contrast to other medical-home demonstration projects, which tend to emphasize changes within individual medical practices, the Vermont Blueprint for Health stresses the importance of communitywide involvement in health improvement. Not only are physicians receiving extra payments that enable them to coordinate chronic disease care, but they also have access to specially designed community resources that, in theory, should enable them to help patients improve their health outside the boundaries of their offices.

The key innovation is the creation of Community Care Teams that may include nurse practitioners, nutritionists and social workers, among others. According to the Blueprint's 2008 annual report, "Community Care Teams...are intended to assure that each medical home practice, independent of its size, has the local multidisciplinary care support that is essential in order to engage an entire population in effective health maintenance, prevention, and care for chronic disease. The costs for the teams are shared by all insurers, establishing a core community resource that can work closely with providers, across practices, offering the services that are necessary for individual patient care and population management."

The Vermont program, which is funded by private insurers and the state Medicaid program, pays physicians an extra $1.20 to $2.39 per patient per month to coordinate care. They refer patients who need extra help with their health care to one of the Community Care Teams.

Physicians in six Vermont communities began testing the Blueprint ideas three years ago in diabetes care. Last year, doctors in three towns started to create medical homes. Around 60,000 patients will be involved in the program by November. It's a small start, but is reportedly showing progress.

It's not yet clear how much Medicare is planning to invest in this project. But medical homes are mentioned in all five of the current reform bills pending in Congress, and more money is likely to be flowing in this direction.

One of the interesting aspects of the Medicare approach is that, rather than starting a federal demonstration project, as expected, the government is going to provide funds to states that can show that their medical-home initiatives meet certain criteria. In this respect, the medical-home pilot is following the same pattern as the health IT subsidy program, which is funneling money for health information exchanges through the states. The latter can't be ascribed to Secretary Sebelius' experience as governor of Kansas, because it preceded her appointment. Yet there is no doubt that the Obama Administration is sympathetic to the idea of working through the states rather than administering programs directly from Washington.