AMA Backs 'Medical Home' Despite Specialists' Concerns

The AMA is supporting the concept of the “medical home,” a patient-centered philosophy of universal access to care championed by four primary care medical organizations. AMA delegates at last month's Interim Meeting in Orlando, Fla., voted to adopt the Joint Principles of a Patient-Centered Medical Home, formulated in 2007 by the American Academy of Pediatrics, American Academy of Family Physicians, American Osteopathic Association, and American College of Physicians.

The medical home concept was endorsed by the AMA with the addition of a resolution that the association continue to study the concept “with particular emphasis on funding sources and payment structures”—a caveat added by delegates in response to considerable anxiety in the House of Delegates about whether the medical-home concept would put primary care physicians in the position of a “gatekeeper” with power to control access to specialty services and whether it would divert finite resources toward primary care and away from specialty services (see AMA Suggests Ways to Change How Medicare Pays M.D.s).

The concept was supported by John McIntyre, M.D., chair of the Section Council on Psychiatry. McIntyre is a member of the AMA Council on Medical Services, which is charged with studying the financing structure of the medical-home model, with a report on the subject due at the AMA's 2009 Annual Meeting in June.

“My feeling is that it's a very good concept,” McIntyre told Psychiatric News. “I think we need to move in this direction.”

“The Joint Principles of a Patient-Centered Medical Home” include the following fundamental concepts, as elucidated in a March 2007 press release issued by the four primary care organizations:

In reference committee hearings and on the floor of the House of Delegates, some physician groups—especially obstetrician-gynecologists and surgical specialists—cautioned that endorsement of the medical home was inherently an endorsement of a financing structure that would favor primary care within a system in which financing was a “zero sum game.”

“If we adopt these principles, we are in effect adopting a financing structure,” said Erin Tracy, M.D., M.P.H., an obstetrician and at-large representative from Boston. “We are prematurely deciding how to allocate resources.”

Peter Schwartz, M.D., also an ob-gyn, added that “Medicare Part B is not expanding any time soon” and that funds diverted to primary care would inevitably mean less money for specialty care. He urged that the concept not be adopted until the Council on Medical Services came back with its report in June.

McIntyre said that the medical-home concept and other issues related to health system reform were bound to be front and center at the annual meeting of the house in June 2009.

Also approved by the AMA delegates—but again with concerns about how it might impact payment to physicians—was a report by the AMA's Council on Medical Services calling for the creation of an independent entity to do comparative effectiveness research (CER). The report outlined 11 principles around which such an entity should be formed (see What Principles Should Guide Treatment Effectiveness Study?).

“Most research on medical treatments to date has focused on comparing the effects of a given treatment to no treatment, rather than comparing alternative treatments to each other,” the CMS report stated. “The lack of comparative research on the effects of alternative services and treatments has led to a lack of knowledge about whether new treatments outperform existing treatments. In cases in which there are multiple, alternate interventions to treat a health condition that have been proven to be effective, studies have also shown that the treatment patients receive often depends on where they live.... Ultimately, having evidence that compares outcomes of alternative treatments, as well as treatment costs, will not only increasingly integrate value into the health care decision-making process, but will also equip physicians with the ability to achieve the right care for each patient.”

The report also noted that there is already significant federal legislation introduced in this area and that it is very likely that some sort of body to perform comparative research will be established. Most prominent is the Comparative Effectiveness Research Act of 2008, introduced earlier this year by Sens. Max Baucus (D-Mont.) and Kent Conrad (D-N.D.). The bill would establish an independent comparative effectiveness research institute.

The council report, and much testimony at the house, emphasized the importance of the composition of whatever entity will be created. “This will be independent from [industry and other influences] and would have on it consumers, physicians, and health care executives,” McIntyre told Psychiatric News.

“I think the whole idea of comparative effectiveness research is a step beyond developing practice guidelines,” said McIntyre, who has led APA's practice-guideline effort. “The next step is comparing treatments with each other to determine which is more effective and being able to do that independently and without being dominated by [the pharmaceutical or device manufacturing] industry.”

But as with the medical-home resolution, the report on CER raised some concern about how such an entity would affect physician payment for various treatments, particularly if the body doing the research incorporates cost-effectiveness research.

“The way the council felt about this is that the CER body shouldn't be making coverage or payment decisions, but we did think there has to be some recommendation that items that are of very, very high cost be looked at first,” McIntyre explained. “So the exact role of cost-effectiveness wasn't refined at this point.”

McIntyre noted, however, that the house did defeat an amendment that would have made cost-effectiveness off limits as a subject for the proposed new CER entity.

As one delegate on the house floor, Robert Hughes, M.D., of New York, put it, “Cost is an everyday part of my practice, and I would like some guidance.”

“The Joint Statement of Principles of a Patient Centered Medical Home” is posted at<www.medicalhomeinfo.org/Joint%20Statement.pdf>. Reports and resolutions from the AMA Interim Meeting are posted at<www.ama-assn.org/ama/pub/category/16552.html>.▪