A. C. Beal, M. M. Doty, S. E. Hernandez, K. K. Shea, and K. Davis

Medscape Today

Medical home demonstration projects and pilot programs have proliferated in the last year, and more are expected:

Medicare has a legislative mandate to implement a medical home demonstration project; the Tax Relief and Health Care Act of 2006 requires that this project commence by 2010. Centers for Medicare & Medicaid Services staff have already begun the work of defining a CPT code for care management that will facilitate payment to medical home practices as called for by the legislation.

Private payers aren't waiting to follow Medicare's lead. In August, United Healthcare announced plans for a medical home pilot project that would pay participating physicians a per-member-per-month care management fee in addition to regular fee-for-service payments for offering medical home services in their practices. The program will be launched in Florida.

CIGNA, Humana, Wellpoint and Aetna have expressed interest to the AAFP in developing their own medical home pilot projects, and the Blue Cross Blue Shield Association has developed a model demonstration project that could be adopted by their member plans. A few Blues plans have developed chronic disease management pilot programs involving care management payments to primary care physicians, and several others have medical home pilot programs in the works.

Large, self-insured employers want to study medical homes as well. IBM is working with the AAFP to develop a medical home initiative that would occur in a community where a large number of IBM employees and their families live. In Washington state, the Boeing Company is implementing a medical home pilot involving high-risk employees who require intense care coordination in primary care practices.

IBM, Boeing and the AAFP are members of the Patient-Centered Primary Care Collaborative, a coalition representing 50 million American workers and 330,000 doctors that advocates for primary-care-based health system reform. The coalition's goals include working to stimulate additional medical home pilots by large, self-insured employers and legislation at the state and federal levels. The group has worked to get medical home language into several bills pending in Congress, according to Kevin Burke, AAFP's director of government relations.

The AAFP has invested $8 million in TransforMED, a national demonstration project launched in June 2006 that is focused on helping participating practices implement a new model of care that includes medical home components (see "TransforMED Tries to Rebuild Family Medicine," FPM, May 2007).

A growing number of state governments are interested in incorporating medical homes into the health care programs they fund. Seventy-seven bills have been introduced in 21 states and the District of Columbia, according to Greg Martin, state policy analyst for the AAFP. "These bills run the gamut from a mere passing use of the term 'medical home' to bills creating medical home demonstration projects or systems of care," Martin says.

Many states would like to follow in the footsteps of Community Care of North Carolina (CCNC), a program in which physician-led networks offer medical homes to Medicaid enrollees. CCNC pays each network $3 per Medicaid patient per month, and each physician receives an additional $2.50 per month for each of his or her Medicaid patients. The program was launched in 1998 with nine pilot networks covering 250,000 enrollees and has since been rolled out across the state. CCNC saved the state $60 million in Medicaid costs in 2003 and $120 million in 2004, according to one analysis.^[3]

Of course cost is only half of the value equation, and proponents of the medical home concept expect to demonstrate improved quality as well. Several studies have established that having a regular source of care and continuous care with the same physician over time leads to better health outcomes as well as lower costs,^[4-6] and medical homes are designed to provide this type of care. A recent survey by the Commonwealth Fund concluded that adults who have medical homes have enhanced access to care and receive better quality care.^[7] The survey defined medical homes as regular health care providers that offer timely, well-organized care and enhanced access.