So-called “medical homes” are finally receiving national attention from the Centers for Medicare and Medicaid and foundations after their purported inception over 30 years ago by pediatricians (home care nurses have been coordinating health care for people with chronic illnesses for more than a century). But we’re about to make the same mistake that we’ve made in developing other approaches to improving health care nationwide—we’re medicalizing it, instead of focusing on health.

Medical homes are proposed to be primary care practices where people can get help with coordinating their care, particularly for chronic illnesses. The U.S. health care system emphasizes specialty practice rather than primary care. It’s one of the reasons why we pay more than any other nation for health care but have outcomes that lag behind those of even moderately developed nations. If I have diabetes and heart failure, I go to one specialist for treatment of my diabetes, the cardiologist for my heart failure, the gynecologist to get my annual GYN exam, a podiatrist, a retinopathist or ophthamologist, a dentist who may prescribe medications before and after procedures, a shrink to help me cope with this mess, and possibly others to screen my various body parts for myriad diseases. Each is prescribing medications that may interact in adverse ways. In fact, I may end up with a costly hospitalization because of these adverse effects. No one knows all of me or focuses on my overall health—unless I have a primary care provider who can oversee all of these specialties, follow all of my treatments and medications, and coordinate my care.

Unfortunately, Medicare, Medicaid, and private payers have heretofore refused to pay for such care coordination. So primary care physicians have been loathe to spend their time doing this and, I would argue, it’s probably not a good use of their time to do. First, there aren’t enough primary care physicians to meet the nation’s need, with only 1% to 2% of physicians are going into primary care. But nurse practitioners (NPs) and physicians’ assistants (PAs) are filling the gap. In some rural areas of the country, NPs and PAs are the only primary care providers available. They may have a consulting physician to whom they refer complex cases or use telehealth technology to get advice from physicians in academic medical centers. NPs have demonstrated that they have outcomes similar to if not better than primary care physicians, so it’s not second-rate care, as organized medicine likes to claim.

Second, registered nurses are educated in care coordination but physicians are not. Some people are proposing that physicians get trained to coordinate care but it’s not a good use of resources that are getting scarcer every day. While it might make sense for a physician in solo practice in a rural area to do so, it would be more economical for that physician to hire an RN to coordinate the care for patients in the practice. Nurses are also more likely to focus on promoting the health of individuals and families, educating and coaching them in how to develop healthier lifestyles, reduce their risk for disease, and better manage their chronic illness.

One fine example of this care coordination is Evercare, a nurse-led service available in 35 states aimed at keeping older adults healthy and out of nursing homes. Developed by two nurse practitioners in Minnesota, Evercare has reduced hospitalizations for nursing home residents by 45% and emergency room visits by 50%; kept people out of nursing homes, and saved the state of Texas $123 million in Harris County alone during a two-year period. (For more information on Evercare, go to www.aboutevercare.com; or go to www.aannet.org and read about the Raise the Voice initiative by the American Academy of Nursing that highlights Evercare and other innovative models of care developed by nurses.)

Minnesota has decided that a focus on health rather than illness is just what it needs, so it’s using the phrase “health” home in recognition that many people think of nursing homes when they hear “medical home.” And health promotion should be the mantra if we want to have healthy citizens while reducing the cost of health care.

So I was stunned to learn that both Cigna and the Commonwealth Fund are supporting a number of demonstration projects for “medical” homes that all focus on physicians as the providers who will do the care coordination, rather than RNs, NPs, or PAs. And a study of the adoption of “medical” home concept in physician group practices published in the September/October issue of Health Affairs concluded that “The level of adoption of PCMH [primary care medical home] infrastructure components among large medical groups is low.”

When will the “reformers” in health care learn that we must break out of traditional models of care and stereotypical notions of who should do what and be paid for what? We need a health care system that focuses on health, pays for health promotion, expects excellent outcomes, and uses and pays for the skills and knowledge of all providers who can help us meet this goal.

This entry was posted on Tuesday, November 11th, 2008 at 10:39 am and is filed under Consumer Health Care, Health Professions, Personalized Medicine. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.