The New Health Dialogue

The New America Foundation's health policy program has a new director for a new era. Kavita Patel, MD, MS, is a primary care physician who has more than ten years of policy experience, working on national health care reform at the Senate's HELP Committee and in the White House Office of Intergovernmental Affairs and Public Engagement. She has a particular interest in developing national policies to support innovation in health care delivery including payment reform and quality improvement. She also still loves practicing medicine. In her first post, she writes about medical homes -- an area where her policy interests and her priorities as a physician overlap.

Since the passage of the historic law affectionately known as PPACA, we have seen a flurry of activity, including Health and Human Services Secretary Kathleen Sebelius's call to end insurance discrimination against women with breast cancer, encourage private plans to allow young adults to stay on their parents’ plans until age 26 and really push the envelope to narrow the administrative costs of health insurance plans so that more of each premium dollar is spent on patient care.

That's just the achievements of the first few weeks. Looking forward, we have many tasks ahead of us, including reinventing primary care, a subject close to my own heart both as a policymaker and as a physician. I spoke about one aspect of that, medical homes, at an all-day discussion on primary care hosted by the journal Health Affairs this week, in concert with the release of a special issue devoted to primary care as an urgent priority for health reform. (Some of my colleagues here will post on other aspects of that event and the special issue soon. The webcast is available here.)

I and former colleagues from the White House contributed a paper that discussed the promise of seven innovative medical home programs that offer a new way to look at patient-centered primary care as a model for the rest of the nation. We found that a number of the criteria around what exactly constitutes a “medical home” can be confusing and often times quite different from each other. We wrote:

Practically speaking, the complexity in the various guidelines and criteria may limit the number of physician practices that could implement a medical home model successfully. Indeed, the Congressional Budget Office (CBO) estimated in 2008 that only about one percent of medical practices at the time could meet the criteria for medical homes as defined in the Centers for Medicare and Medicaid Services (CMS) demonstration criteria. This complexity would make it more challenging to scale medical homes to make them the standard practice.

But as we looked more deeply at the country’s leading medical home programs profiled in our paper, we were able to identify four domains  -- four "value-generating elements" that stood out -- that led to improved quality and/or lower costs.  They are:

• Dedicated care coordination. Effective care coordination requires a dedicated non-physician who is well trained and has an appropriate patient load.
• Expanded access to caregivers. Patients must be able to access necessary care round-the-clock to reduce emergency room visits and unnecessary hospitalizations.
• Data Driven Analytical Tools. These tools  must allow the care team to both track the care of individual patients and the patient-population (i.e. to identify the highest risk patients served by the medical home). Practices need tools to evaluate quality and outcomes, too.
• Incentives to Providers. Our research found that physicians need -- and respond to -- payments aimed at improving care coordination and lowering costs. But they don't necessarily have to be large payments. It's not yet clear what specific form or amount of payment will yield the best results.

These domains seem so simple on paper, yet are so far out of reach for most providers, payors and consumers. Health reform contains incentives -- in Medicare, Medicaid and yes, also in the private insurance market -- to build on what we know, learn more, and then build some more. I hope that as I embark on a new journey at the New America Foundation directing our health program, I will be able to explore how we can bring these four domains from paper to reality for the country. In particular, I want to work on how we can truly make the patient the center of our health care system. 

In the future, you can expect more frequent postings on this topic and others including our primary care workforce needs, the role of research in delivering health care and how we can help our country understand PPACA without taking law classes at night. I also hope to give you all a glimpse in the lives of primary care providers as I blend my work here at New America with my return to clinical medicine, working as a general internist in an ambulatory care setting for adults in Washington DC.