Humboldt County —The North Coast is at the forefront of California's patient-centered medical home movement, but the state, as a whole, is far behind the national curve, according to experts.
Nationally, as of December 2009, there were at least 26 medical home pilot projects involving 18 states. These pilots included 14,000 physicians caring for nearly five million patients.
Humboldt County has some of California's most developed medical home models, but according to care providers in the area, the state as a whole is far behind the rest of the country. "One reason could be that we are such a vast and diverse state. Urban areas may need different models from rural areas," said Herman Spetzler, CEO of Open Door Community Health Centers. The centers serve 50,000 rural patients in Northern California.
Defining Medical Home
It's called a "medical home," but it's not a house or a hospital. It's a way, according to advocates, to provide comprehensive medical care that's efficient, cost-effective and ensures the best outcome for the patient and the physician.
Many patients, especially those with chronic conditions, often receive care at numerous sites from multiple providers and that care can be unevenly coordinated and fragmented.
Federal health care reform calls for a team approach where a primary care doctor works with specialists, nurses and, most importantly, the patient and family to coordinate care for all of the patient's health care needs.
A good medical home also goes beyond purely clinical issues, according to Spetzler.
"Navigating the spectrum of the health care delivery system is one of the functions of a medical home. That could mean environmental needs, like housing and access to good food or services for a medical disability," Spetzler said.
In a position paper, the California Medical Association touts potential benefits for patients, physicians and insurers. "For the patients, they receive more personal high quality care. For physicians, they can take a more comprehensive approach to managing their patients' care. For the insurers, the Patient-Centered Medical Home Model offers enormous potential savings as duplication and inefficiency are eliminated and costly hospital visits avoided."
There is some debate over what constitutes a "medical home," according to the California Center for Rural Policy at Humboldt State University, which produced a report on the subject.
"We want to see the broadest definition implemented," said Melissa Jones, CCRP health policy analyst and author of the report. "Nurse practitioners are playing an increasingly important role in providing primary care to patients, especially in areas where physician shortages exist. Expanding the medical home definition to include NPs and PAs (physician assistants) will increase access to preventative care for everyone."
Family physician Alan Glaseroff, a member of Primary Care Renewal, a collaborative of practices in Humboldt County using this team approach, said the patient should be the center of the medical home, “not the practice, or the office or the clinician.”
He said the team also should include mental health professionals and dieticians along with nurse practitioners and physician assistants.
"The core of the medical home model is the partnership between the patient and the clinician," Glaseroff said. "There are expectations on both sides -- that the clinician will do the best by the individual but the individual needs to assume responsibility for his or her health, including taking prescribed medications and eating nutritionally," he added.
"In my office, the receptionist making the appointments and the medical assistant are just as important as I am. They all have ways to contribute to a person's care and should, therefore, have input," Glaseroff said.
Medical Home Legislation
Bills establishing medical homes are making their way through the California Legislature. AB 1542 by Dave Jones, chair of the Assembly Health Committee, is designed to ensure uniform standards and easy access.
"It's apparent to me we need to proactively coordinate care to achieve better outcomes and reduce costs," Jones said.
"There are competing schools of thought on what a medical home should look like. We address the role of nurse practitioners and other providers without changing their scope of practice. My bill at least establishes a floor upon which others can build and creates a consensus in California," Jones added.
One of the big concerns about moving toward a medical home model is a change in how medical providers are paid. "Payment for health care services will morph away from a fee-for-service for each thing that is done for a patient to a quality- and outcome-based reimbursement system," Spetzler said.
"Currently there are no incentives for clinicians to take on additional duties to make the model work, like emailing patients in between visits to check on their progress and communication with other providers," Glaseroff said.
According to the CMA, the medical home must be carefully constructed to prevent further erosion of the safety net.
"Persistently low reimbursement rates have forced many physicians to limit the number of Medi-Cal patients they see or quit taking them altogether," according to the CMA position paper. "More physicians will drop out of the program if rates are not improved and more burdens -- such as new requirements -- are added," the CMA paper said.
The Legislature required California to renew its Section 1115 Medicaid waiver with the federal government this year. The Medicaid waiver application builds on existing Medicaid managed care models and employs medical homes to coordinate care for a number of high-cost target populations.
CMA calls for a multipronged approach to the medical home model. It includes applying for federal funding as soon as it becomes available, codifying the definition of a medical home in state law and working with the governor to implement a medical home model in the Medi-Cal waiver.
Glaseroff said he will "continue to beat the bushes to get local and statewide pilot projects, as well a certification for medical homes."
"Regardless of semantics, the concept of a medical home is critical to improving health in our communities," said Jones.