Approximately 130 million Americans have chronic illnesses, while 70 million have multiple chronic health problems. In 2008, 126 million outpatient follow-up visits provided to Medicare recipients were by family practice or an internal medicine specialist (IMS). Almost 25 percent of these visits were to an IMS, according to an American College of Cardiology (ACC) white paper, "The Patient-centered Medical Home (PCMH)." In addition, 17 percent of the 3.8 million Medicare new patient evaluations were provided by an IMS. Some architects of PCMH models suggest that a specialist team should lead patient management within the medical home. But regardless of who owns the patient—and by proxy, the PCMH—better coordination of care is needed.
The roundtable participants are:
- Jack Lewin, MD, CEO of the American College of Cardiology (ACC)
- Donald R. Lurye, MD, CEO of Elmhurst Clinic in Elmhurst, Ill., a National Committee for Quality Assurance-recognized medical home
- David C. May, MD, PhD, chair of the ACC's Patient Centered Medical Home Committee and cardiologist/president at Cardiovascular Specialists in Lewisville, Texas
- Mary Norine Walsh, MD, medical director of heart failure and cardiac transplantation at Care Group/St. Vincent's Health System in Indianapolis
Please define the model(s) of the specialist patient-centered medical home.
May: The concept of patient-centered care and the patient-centered medical home does not differ fundamentally between the primary care or specialty models of care. The medical home has its origins in pediatrics as a way to provide an archive for the patient's medical record. Over the years, the model has evolved to a single physician or a care team that is in charge of ensuring that care is patient-centered, well-communicated as well as socially and culturally appropriate.
As there are approximately 70 million people in the U.S. with multiple chronic problems, the concept of the IMS serving as the care team leader for those patients doesn't differ materially between the model of the primary care physician (PCP) being the physician leader and the specialty physician serving that role. The specialty physician in that instance would be responsible for overseeing the patient's general care. It is, however, true that patients in the specialty physician medical home would have advanced chronic illnesses in many instances, such as congestive heart failure or oncology. The physician and care team involved in the management continue to provide the same level of support globally for the patient. However, in the specialty physician environment, there would be the ability to manage that particular ongoing chronic problem.
Walsh: As a heart failure and transplant cardiologist, the medical home model exists already. Patients who have advanced heart failure are functionally in a medical home model, with the medical home being the transplant ventricular assist device center. In cardiovascular medicine, the heart failure model is probably the most robust example of a specialty medical home.
Lurye: From the primary care perspective, the medical home still is seeking a precise definition. The organizations providing recognition or accreditation emphasize different aspects. However, all medical home models should share the joint principles that are espoused by the major primary care societies: namely, a personal physician leading a team, focusing on the whole person to provide coordinated care by communicating well with other practices and entities with an emphasis on measured quality and safety. We hope this all triggers enhanced reimbursement.
However, if a specialist is taking care of specific chronic conditions, is that physician also making sure that patients get Pap smears, colonoscopies and flu shots on time? Is there an awareness of general disease burden within a patient population if it's not related to the condition that the specialist has the expertise to manage? The real answer isn't what you call it, but that the care is well-coordinated and connected to the other providers patients see.
Lewin: There needs to be a specialty version of the PCMH with the same requirements and caveats proposed for primary care. The specialty medical home would benefit patients with difficult-to-manage heart failure, arrhythmia or other cardiac conditions, in some cases congenital heart disease conditions, where it results in almost a reverse handoff. The specialist would see the patient on a more frequent