Good Neighbors: How Will the Patient-Centered Medical Home
Relate to the Rest of the Health-Care Delivery System?
Hoangmai H. Pham, MD, MPH
Center for Studying Health System Change, Washington, DC, USA.
Recent policy focus on models of the patient-centered
medical home raises questions about how medical
home practices will relate to the rest of the health-care
delivery system. This paper presents a conceptual
framework of how patients and clinicians might interact
in a medical neighborhood; outlines key features of a
neighborhood and incentives for medical neighbors to
participate in care coordination; identifies the policy
considerations in designing neighborhoods; and puts
forth a research agenda to support the development
and evaluation of medical neighborhoods.
J Gen Intern Med 25(6):630–4
DOI: 10.1007/s11606-009-1208-1
© Society of General Internal Medicine 2009
W
hile current models for the Patient-Centered Medical
Home (PCMH) do not depict the medical home physician
and practice working in isolation
1,2
, how to most effectively
establish relationships between the PCMH and its “neighbors”
is uncertain. The current ideal for the PCMH may set unrealistic
expectations, given how care is currently organized and
financed—that the PCMH: (1) functions as the hub of care
coordination and is recognized as such by all other providers; (2)
has complete access to information on the priorities and actions
of patients and other providers; (3) can effectively influence
decision-making by patients and other providers in order to
coordinate care; and (4) can be confident that his/her under-
standing of a patient’s best interests is reasonably aligned with
those of other clinicians and indeed of patients themselves.
In reality, patients and other clinicians may not agree that
there is any single effective hub for comprehensive care coordi-
nation, and other providers may have motivations not aligned
with PCMH ideals. Currently, care patterns are highly fragmen-
ted, and physicians are often unaware about all of the care that
patients receive.
3
Clinicians outside the medical home may have
a poor understanding of what comprises good coordination, and
for this and other reasons (such as lack of reimbursement and
compatible information systems), may not engage adequately
with the medical home to improve coordination. Patients and all
clinicians are also hobbled by the paucity of accessible, accurate,
and objective data on care outcomes and the contributions of
specific clinicians and services to those outcomes as well as lack
of a uniform electronic medical record. Given current time
pressures on most clinicians,
4
and reimbursement pressures
on those who deliver primarily cognitive services,
5
few clinicians
are likely to invest substantial effort or resources to improving
care coordination without expecting to be paid for it or unless
they are under regulations that tie desired coordination activities
to other types of incentives.
The challenge for policymakers is to craft interventions that
simultaneously acknowledge the realities of health-care markets
and build upon their strengths to promote improved care quality
and reduced costs. One potential model is to explicitly articulate
the expected contributions of other providers—clinicians outside
of but interacting with the medical home—to care coordination.
From the perspective of patients and insurers, such an extended
“medical neighborhood” could be jointly held responsible for the
care outcomes of a given population of patients.
This paper presents a conceptual framework of how patients
and clinicians might interact in a medical neighborhood; outlines
key features of a neighborhood and different types of incentives
for medical neighbors to participate in care coordination; identi-
fies the key policy considerations in designing medical neighbor-
hoods; and puts forth a research agenda to support the
development and evaluation of medical neighborhoods.
CONCEPTUAL FRAMEWORK
In a sense, the medical neighborhood concept attempts to bridge
(1) the PCMH model of concentrated coordination responsibility
on a primary care team within a single practice with (2) that of
large integrated delivery systems that include hundreds of
clinicians, multiple facilities, and that function as a single
accountable entity jointly responsible for comprehensive care
delivery within their boundaries for a given patient. The best
existing examples of commercial integrated systems (non-VA or
Department of Defense) are staff/group model health plans such
as Kaiser Permanente that deliver comprehensive care for a
specified patient panel in return for a fixed premium. Because
integrated delivery systems do not exist in most markets, medical
neighborhoods may offer communities an avenue for improving
integration of care delivery on a smaller scale and possibly, in a
more patient-centered way. Moreover, even existing integrated
delivery systems may fall short of the care coordination ideal, for
services delivered both within and outside their boundaries, if
their patients do not have an identifiable medical home clinician
within the system to help them navigate care processes and
synthesize information from disparate sources. Integrated deliv-
ery systems may thus also improve internal processes for
coordination based on the medical neighborhood model.
The collective patients affiliated with each medical home are at
the center of the neighborhood, figuratively and literally driving
decision-making through their expressed preferences and shared
decision-making. Patients would also be expected to accept
certain responsibilities as the primary agent in their own care,
including clearly identifying the clinicians they consider their
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