It's an aspect of health care reform that rarely draws headlines.
But those in the know realize how much is riding on the concept of coordinated care, known as the medical home or health home model.
"It's the centerpiece, by the way, of the entire Affordable Care Act in terms of improving quality and saving costs," said Dr. F. Daniel Duffy, until recently the dean of the University of Oklahoma School of Community Medicine.
The model's influence extended to the authors of what's become known simply as the Leavitt report, a 123-page document outlining ways to help the low-income, uninsured population in Oklahoma.
"The population's prevalence of chronic, co-occurring conditions will require multiple approaches to address its varying needs -- and a possible solution to this problem is the implementation of health homes," the Leavitt report states.
It's not a physical, bricks-and-mortar creation, but rather a restructuring of patient-doctor relationships, according to Duffy, an advocate of the model.
"Every patient has a team within the medical home who knows them, and they know that team," said Duffy. In this way, preventive care can be planned for the patient, especially those with chronic conditions. Medical technology plays a larger role, allowing doctors to more easily share patient information.
As for cost savings, the result should be fewer unnecessary tests ordered by doctors with a lack of knowledge about the patient, Duffy said.
"They don't know about the total patient context, therefore they don't want to risk not doing that test," Duffy said.
Also, "the medical home will pay particular attention to patients who tend to use the emergency department for primary care," Duffy said. "The medical home will work with those people to make care more available to them."
And if a patient does need hospitalization, "when patients are discharged from the hospital, the medical home will coordinating that care," he said.
Expanded health care coverage, of course, is another way to keep people out of the emergency room. So far, opposition remains strong in Oklahoma and several other states to federal Medicaid expansion, which would allow many childless adults to take part in Medicaid for the first time.
In Medicaid expansion, enrollees could sign up if they earned up to 138 percent of the federal poverty level, currently defined as a yearly income of $11,490 for a single-person household. By comparison, a worker in a minimum-wage job earns about 136 percent of the federal poverty level.
When discussion about the Affordable Care Act (aka ObamaCare) became highly politicized, state leaders essentially tasked the Utah-based Leavitt Group to develop what Gov. Mary Fallin termed an "Oklahoma plan."
A state-developed expanded health care coverage program may be a part of that plan.
The Leavitt report authors also included quite a bit on the potential how an expanded home health model could boost that effort. For example, according to the authors, care coordination can "reduce barriers to achieving individual accountability." Report authors noted that the amount of individual payments, like co-pays, could be linked to the patient following a recommended course of treatment.
Even apart from explicit incentive programs, Duffy described how medical homes can lower costs for individuals.
Tulsa is one of only seven urban markets nationwide taking part in a Medicare and Medicaid pilot project aimed at exploring the potential benefits of the medical home model.
Duffy said 68 primary care practices are involved, along with insurance companies Blue Cross Blue Shield of Oklahoma and CommunityCare as well as the Oklahoma Health Care Authority.
He described positive feedback from physicians taking part in the program.
"They are really understanding it. They're getting it and they're transforming it, is unbelievable. They love it," Duffy said.
In an email, Jack Sommers, senior vice president and chief medical officer for CommunityCare, described the pilot project as attracting attention from elsewhere.
"We are getting quite the reputation among the 7 national regions in which CPCI is operating ... we held a training session locally in early July and had participants from Arkansas, Colorado and Oregon," Sommers wrote, describing the organization as "taking great pride" in being involved.
The belief is "that cost savings will be substantial enough to be able to split cost savings with the providers," Duffy said.
He noted that primary care in many ways has been a neglected area of medicine.
"Of all the sectors of the health care economy, primary care has been the most squeezed financially over the past 30 years," Duffy said. "The amount of money coming into these practices to build their infrastructure has steadily diminished over the years, where the opposite has occurred in hospitals."
The result has been doctors leaving primary care, with "almost nobody" choosing primary care as a career, Duffy said.
However, at OU's School of Community Medicine, "the new graduates are all coming out understanding" the medical home model, he said.
In Oklahoma, SoonerCare, the state's name for Medicaid, began using the medical home model in 2009. However, Insure Oklahoma, a program that involves subsidized health insurance, does not rely on the medical home model. The Leavitt report recommends that the program be modified by "incorporating a health home model and adding specific health home benefits."
The Leavitt report also described a "health home" as featuring more wide-ranging services, including those related to behavioral health -- for example, helping people avoid substance abuse or to improve their mental health.
This is the key distinction between the terms "medical home" and "health home," said Carter Kimble director of governmental relations for the Oklahoma Health Care Authority.
"The only behavioral health services that are tied into our current medical home are screenings, whereas the health home model tried to key in and focus a lot more on behavioral health ser
vices," said Kimble.
Duffy said that the home model can be especially beneficial for older patients on Medicare, who aren't the focus of the Leavitt report because they have some form of insurance.
The model dates back to the 1960s, Duffy said. However, it received a renewed emphasis with a push by big business in favor of the model.
In 2006, businesses helped primary physicians found the Patient-Centered Primary Care Collaborative. The Washington, D.C.-based group advocates for policy changes to boost medical homes.
Recently, for example, the group released a statement to federal legislators urging Congress to "support public policies that shift the current fee-for-service (FFS) system to a fee-for value system built on a strong foundation of patient-centered primary care."
Duffy said there now exist three "tiers" of such homes, with the top tier offering the most characteristic of the concept, like electronic data sharing, for example. Four OU clinics in Tulsa recently earned that top tier designation from a national accreditation group, said Duffy, the Steven Landgarten Endowed Chair in Medical Leadership at the medical school.
Looking at the total Tulsa population, it's hard to estimate how many people have a medical home currently, he said.
"The short answer is, nobody knows the answer, mainly because this concept of the medical home is pretty vague," Duffy said.
Without coordinated care, Duffy noted how patients might visit one specialist and then another, but "nobody is playing quarterback for that team."
If a patient has a medical home, "the most important benefit is the patient's understanding of what's going on with each of the players in the field," Duffy said.
Insure Oklahoma faces an uncertain future, with federal leaders advising the state that funding for it won't continue. But state leaders have vowed to work to continue the program, and Duffy praised the Leavitt report's recommendation to make health homes a part of the program as a way to build in "expectations of performance" for physicians and patients alike.
In general, it's dollars and efforts to contain costs that have sparked changes to health care, Duffy said.
"Most of the policy wonks on this issue believe that the medical home is one of the best armaments we have to improve quality and reduce costs. And bending this cost curve in heath care, that is the driver of all of this reform. The medical home is seen as one way of doing that," Duffy said.
Send all comments and feedback regarding City to firstname.lastname@example.org
Share this article: