Leaders at the American Academy of Family Physicians and the American College of Physicians say they welcome the American College of Emergency Physicians' recent statement supporting the concept of a patient-centered medical home, and hope to work with the group to address its concerns.
ACEP issued eight principles that it says should guide the development of a medical home, a concept that was developed by the American Academy of Pediatrics, and has been championed by ACP, AAFP, and the American Osteopathic Association. The idea of a medical home, where patients could receive consistent, coordinated care aided by electronic medical records, has been gaining attention from health policy makers.
The approach is the subject of demonstration projects around the country, with sponsorship by a variety of payers, from Medicare and Medicaid to big employers such as IBM.
But ACEP says it is concerned that widespread implementation could exacerbate challenges in the emergency department (ED), including caring for the uninsured.
“ACEP agrees with the basic tenets of the patient-centered medical home model,” the organization said in its position paper, but it went on to describe several concerns.
“In an ideal world, the concepts in a patient-centered medical home are laudable,” Dr. Linda Lawrence, ACEP president, said in an interview. But the hurdles to making it work are high, she said.
First, there is a shortage of primary care physicians, and access to them cannot be guaranteed 24 hours a day, 7 days a week.
And, there are no studies showing that a medical home will increase access to basic care or reduce the number of unnecessary visits to the ED, according to ACEP.
Many Americans continue to lack health insurance or have less-than-adequate coverage, Dr. Lawrence noted.
“This could drive a greater divide in access to health care in America,” she said. “We have to be a bit skeptical that without overall change in the system, you're going to have more boutique medicine, and the rest are going to fall by the wayside.”
Inevitably, ACEP said, patients will still rely on the ED as their “medical home away from home,” which is how ACEP has dubbed the nation's emergency departments. If health care dollars are shifted to the medical home, EDs might end up being short-changed, and yet still face the same daily struggles, the professional group maintains.
ACEP says that enhanced access should be demonstrated and that once a medical home is established, patients should be able to continue to be a part of that home, whether or not they change or lose their insurance.
Patients also should be able to switch medical homes when necessary, choose their own specialists, and access the emergency department when they determine it is appropriate.
More than a decade ago, emergency physicians fought to codify the notion that a “prudent layperson” could determine when it is necessary to seek emergency care. This came in the wake of frequent payment denials for emergency services by cost-conscious managed care organizations, Dr. Lawrence said. No one wants to repeat that battle, she said.
ACEP also states that the value of the medical home concept should be proven before it is widely adopted.
Dr. Michael Barr, vice president for practice advocacy and improvement at ACP, agreed, noting his commentary in JAMA in late August.
“Data suggest that the model will deliver improved quality and reduced costs and prove attractive to patients and their families,” Dr. Barr wrote (JAMA 2008;300:834–5). “However, it is imperative to test the model in a credible and transparent way in different environments,” he added.
In an interview, Dr. Barr agreed with Dr. Lawrence and her ACEP colleagues that the “medical home is not the answer to all the ills of the American health care system right now.” Like ACEP, ACP has advocated for universal health coverage, he added.
But medical home supporters are not trying to limit patient choice, or to prevent patients from choosing the emergency department when necessary. “What the medical home would do if it works is hopefully reduce unnecessary or avoidable ED visits and at same time not limit appropriate ED referrals and use by patients,” Dr. Barr said.
Dr. James King, president of the AAFP, said in an interview that he's “pleased [ACEP] has thought about and evaluated the medical home.” Emergency physicians are seeing the 47 million uninsured, and “they need to get paid for that,” he said.
“The entire health care system needs reforming, but if we wait we're going to be even farther behind,” he said. The medical home concept will not solve the problem of the uninsured, but it can help more people get good quality health care, Dr. King said.