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Editorials |

Is There Room for Specialists in the Patient-Centered Medical Home? FREE TO VIEW

Robert A. Berenson, MD
Author and Funding Information

From the Urban Institute.

Correspondence to: Robert A. Berenson, Institute Fellow, The Urban Institute, 2100 M Street, Washington, D.C. 20037; e-mail: rberenson@urban.org


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(1):10-11. doi:10.1378/chest.09-2502
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The Patient-Centered Medical Home (PCMH) is one of the new ideas being proposed as a transformative health system innovation. More than 30 states are testing medical homes in Medicaid and State Children’s Health Insurance Programs, which is sensible given the medical home’s long-standing use by some pediatrics practices.1 But medical homes are also now being broadly tested in practices serving adults; more than 20 multistakeholder demonstration projects are underway in 14 states, and the Centers for Medicare and Medicaid Services are prepared to initiate PCMH demonstrations in 400 practices in eight sites, pending possible expansion of the demonstration as a result of health-care reform legislation.2

In broad terms, a medical home is a physician-directed practice that provides care that is “accessible, continuous, comprehensive and coordinated and delivered in the context of family and community.”3 And despite ongoing differences in opinion as to what the primary attributes of a medical home should be, there is hope that primary care practices, serving as medical homes, can provide a source of confidence, advocacy, and coordination for patients as they encounter the increasingly disconnected parts and daunting complexity of the health-care system.4

The article by Kirschner and Barr1 in this issue of CHEST (see page 200) brings the prospective roles of specialists and subspecialists into the medical home discussion. Until now, the PCMH has focused on primary care physician practices, raising reasonable concerns from specialists about whether they have been left out of the discussion; it has long been recognized that specialists are often the “principal” physicians for patients with chronic conditions, such as COPD and asthma.5 Indeed, as noted by Kirschner and Barr,1 some internal medicine subspecialists, such as pulmonologists and endocrinologists, might be well positioned to qualify their practices as medical homes because of their ongoing roles as principal physicians, that is, by providing first-line care for a patient’s complex care needs associated with a chronic condition while also meeting that patient’s general health-care needs.

For their part, primary care physicians have raised concerns that they will be held accountable for the activities of the specialists concurrently providing care for their patients, particularly the activities related to patient-centered aspects of care, a core component of the PCMH concept. Specifically, primary care physicians often complain that patients call them to try to gain an explanation of the information given to them by the hard-to-access specialists they have seen. In calling for a “medical neighborhood” to house the medical home, Fisher6 has pointed out that there are no current incentives for other physicians or hospitals to share information, improve coordination, or support shared decision making for patients who are in the medical home.

Considerations regarding how to deploy the medical home raise fundamental questions about the relationship between primary care physicians and specialists in providing care to patients who have one, or increasingly, multiple, serious chronic conditions. In a recent, insightful editorial in the Annals of Family Medicine, Strange and Ferrer7 identified the paradox of primary care. They write, “The paradox is that compared with specialty care or systems dominated by specialty care, primary care is associated with the following: (1) apparently poorer quality of care for individual diseases, yet (2) similar functional health status at lower cost for people with chronic disease, and (3) better quality, better health, greater equity, and lower cost for whole people and populations.”

They suggest that the paradox can be understood by evaluating care not only at the level of specific illnesses but also in the context of the whole person, communities, and populations, with the whole person and community foci currently undervalued. They attempt to resolve the paradox by asserting that systems of care are needed that value both generalist and specialist care and that foster integration. In short, care needs to be shared, or comanaged, between primary care physicians and specialists, yet that aspect of the medical home has received little attention.

Specialists report sharing care with primary care physicians in only about 30% of all visits with patients, many with chronic conditions.8 Most of the time, specialists were providing routine and disease-specific preventive care directly, without collaborating with a primary care physician, but were not necessarily doing a good job at it. The record suggests that most specialists did not function as satisfactory principal physicians because they rarely provided care outside their usual clinical domain and did not take responsibility for routine preventive care, such as immunizations.9 Their tendency was to refer to others for problems that primary care physicians should handle directly, producing greater care fragmentation.

In short, although adopting the core elements of the medical home is proving to be a major challenge for primary care physicians,10 it is even more of a stretch for those well-intentioned specialists who are willing to adopt PCMH attitudes and attributes. The challenge is compounded as patients age and have multiple comorbidities. According to a recent analysis, virtually all Medicare spending growth from 1987 to 2002 could be traced to beneficiaries who were treated for five or more conditions.11 The medical home physician will be expected to manage and coordinate the care for these patients, most of whom are likely to continue to receive care from an assortment of expert specialists. The skills and team support to carry out this expanded coordination function are at the heart of the medical home approach.

To mix metaphors, the PCMH train may have left the station, but not very fast. There will be time to ascertain whether those specialists who are truly providing principal care to patients with chronic conditions can themselves be recognized as medical homes. In the meantime, there is a more urgent need for primary care physicians and specialists to improve their comanagement of patients with chronic conditions.

References

Kirschner N, Barr MS. Specialists/subspecialists and the patient-centered medical home. Chest. 2010;1371:200-204. [CrossRef] [PubMed]
 
Rittenhouse DR, Shortell SM. The patient-centered medical home: will it stand the test of health reform? JAMA. 2009;30119:2038-2040. [CrossRef] [PubMed]
 
American College of Family Practice, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association Joint principles of the patient-centered medical home. 2007; March http://www.acponline.org/running_practice/pcmh/demonstrations/jointprinc_05_17.pdf. Accessed October 20, 2009.
 
Berenson RA, Hammons T, Gans DN, et al. A house is not a home: keeping patients at the center of practice redesign. Health Aff (Millwood). 2008;275:1219-1230. [CrossRef] [PubMed]
 
Aiken LH, Lewis CE, Craig J, Mendenhall RC, Blendon RJ, Rogers DE. The contribution of specialists to the delivery of primary care. N Engl J Med. 1979;30024:1363-1370. [CrossRef] [PubMed]
 
Fisher ES. Building a medical neighborhood for the medical home. N Engl J Med. 2008;35912:1202-1205. [CrossRef] [PubMed]
 
Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med. 2009;74:293-299. [CrossRef] [PubMed]
 
Valderas JM, Starfield B, Forrest CB, Sibbald B, Roland M. Ambulatory care provided by office-based specialists in the United States. Ann Fam Med. 2009;72:104-111. [CrossRef] [PubMed]
 
Rosenblatt RA, Hart LG, Baldwin LM, Chan L, Schneeweiss R. The generalist role of specialty physicians: is there a hidden system of primary care? JAMA. 1998;27917:1364-1370. [CrossRef] [PubMed]
 
Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;73:254-260. [CrossRef] [PubMed]
 
Thorpe KE, Howard DH. The rise in spending among Medicare beneficiaries: the role of chronic disease prevalence and changes in treatment intensity. Health Aff (Millwood). 2006;255:w378-w388. [CrossRef] [PubMed]
 

Figures

Tables

References

Kirschner N, Barr MS. Specialists/subspecialists and the patient-centered medical home. Chest. 2010;1371:200-204. [CrossRef] [PubMed]
 
Rittenhouse DR, Shortell SM. The patient-centered medical home: will it stand the test of health reform? JAMA. 2009;30119:2038-2040. [CrossRef] [PubMed]
 
American College of Family Practice, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association Joint principles of the patient-centered medical home. 2007; March http://www.acponline.org/running_practice/pcmh/demonstrations/jointprinc_05_17.pdf. Accessed October 20, 2009.
 
Berenson RA, Hammons T, Gans DN, et al. A house is not a home: keeping patients at the center of practice redesign. Health Aff (Millwood). 2008;275:1219-1230. [CrossRef] [PubMed]
 
Aiken LH, Lewis CE, Craig J, Mendenhall RC, Blendon RJ, Rogers DE. The contribution of specialists to the delivery of primary care. N Engl J Med. 1979;30024:1363-1370. [CrossRef] [PubMed]
 
Fisher ES. Building a medical neighborhood for the medical home. N Engl J Med. 2008;35912:1202-1205. [CrossRef] [PubMed]
 
Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med. 2009;74:293-299. [CrossRef] [PubMed]
 
Valderas JM, Starfield B, Forrest CB, Sibbald B, Roland M. Ambulatory care provided by office-based specialists in the United States. Ann Fam Med. 2009;72:104-111. [CrossRef] [PubMed]
 
Rosenblatt RA, Hart LG, Baldwin LM, Chan L, Schneeweiss R. The generalist role of specialty physicians: is there a hidden system of primary care? JAMA. 1998;27917:1364-1370. [CrossRef] [PubMed]
 
Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;73:254-260. [CrossRef] [PubMed]
 
Thorpe KE, Howard DH. The rise in spending among Medicare beneficiaries: the role of chronic disease prevalence and changes in treatment intensity. Health Aff (Millwood). 2006;255:w378-w388. [CrossRef] [PubMed]
 
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