Specialists who do want to provide a medical home may even have an advantage, according to Dr. McGeeney, who pointed out that specialty practices tend to have more resources to invest in practice transformation. That said, specialists often have not been trained to provide the types and level of care required of medical homes.
Where specialists may fit in more easily, Dr. McGeeney said, is in the “medical home neighborhood,” which includes all the physicians caring for a patient, as well as the emergency department, the hospital, and the pharmacy.
TransforMED is encouraging medical home practices to have letters of agreement with specialists regarding care coordination. As part of the agreement, the primary care physician promises to send all the patient's information to the specialist and to communicate with them about tests and results. These agreements aren't legally binding on either party, but they force everyone to have a conversation about coordination of care, he said.
One group that has given a lot of thought to how specialists could and should function in the medical home model is the American College of Physicians, whose membership includes both subspecialists and primary care physicians.
Dr. Michael S. Barr, the ACP's vice president for practice advocacy and improvement, said the medical home model is set up so that some subspecialists would have the opportunity to qualify. For example, a nephrologist who cares for patients with end-stage renal disease would certainly be a good candidate. Whether that physician would want to go through the recognition process is a separate issue, he said.
“There is definitely a place in the restructuring of the way we deliver health care for general internists, family physicians, pediatricians, and all of our subspecialty colleagues,” Dr. Barr said. “This is about providing better care for people and populations.”
Down the line, subspecialists are also likely to play a role as part of a medical home neighborhood, he said. That concept is still being defined, but the idea is to improve communication among physicians on patient hand-offs and find a way to reimburse physicians for some of the interactions that currently go unrecognized, Dr. Barr said. For example, a conversation between an orthopedic surgeon and an internist about managing a patient's back pain could save the health care system a significant amount of money on unnecessary procedures. Right now these conversations are done on a collegial basis, but in the future, the medical home neighborhood model might allow payment to both physicians for this type of early collaboration, he said.
The hope is that the money to fund additional payments for specialists and primary care physicians could come from overall health system savings, such as reductions in unnecessary emergency department visits and hospital admissions and readmissions, Dr. Barr said.
Some specialists remain skeptical about their role in the medical home and the medical home neighborhood. Dr. Alfred Bove, past president of the American College of Cardiology and emeritus professor of medicine at Temple University, Philadelphia, said cardiologists frequently act as a medical home for heart failure and transplantation patients, for example, and don't want to be left out. For years, many cardiologists have worked in multidisciplinary care teams, used electronic health records, and provided immunizations and screening, he said.
“We have all the ingredients needed to be a patient-centered medical home in an area of chronic disease that probably is better done by cardiologists that have a lot of experience in managing very sick heart failure patients than in a primary care practice where there's a broad spectrum of different kinds of patients,” Dr. Bove said.
The ACC has been advocating for specialty-based patient-centered medical homes in specific areas where the cardiologist's expertise is unique and they would be willing to assume responsibility for preventive care.
But another issue is what to do about specialty practices that act as a medical home for only a portion of their patients. In a recent article in the New England Journal of Medicine, researchers looked at single-specialty practices in cardiology, endocrinology, and pulmonology to find out to what extent those specialty practices function as medical homes.
They found that a large percentage of the practices provided both primary care and specialty care, but generally for a subset of patients. For example, 81% of the 373 practices surveyed said they served as primary care physicians for 10% or fewer of their patients. Only 2.7% of the practices said they act as primary care physicians for more than 50% of their patients (N. Engl. J. Med. 2010;362:1555-8).