How do you like my new name for the law? At our PNHP meeting, the abbreviation PPACA was proposed, but I thought this was pretty cool.
I reviewed Section 2703 today. This is a state option to provide “health homes” to people with chronic conditions who are on Medicaid. It is optional– if states do it, the federal matching funds will be 90% for the first 8 quarters. So what’s a “health home”? I don’t know why they picked this terminology– it sounds like the same thing the medical community has been calling a “medical home”. There is usually a reason people change established language (see my title above), but in this case I’ll be darned if I know what it is!
The medical home concept started with pediatricians, decades ago– it is not just a particular building where your chart gets kept, but a whole system of health care. There are several criteria often used to define a medical home, but the gist of it is that you have a consistent, personal healthcare provider (or team of providers) who looks after you as a whole person, not just a set of various body parts. We do comprehensive histories and exams, find consultants for you when you need specialized care, and make sure that everyone who takes care of your health is on the same page, working in a more coordinated way.
In the last few years, other primary care doctors (internists and family medicine doctors) have started to use a medical home model. Insurers have gotten in on it too, and not always in what I think is a good way. Our state Medicaid is working right now to make guidelines for a medical home, and there is even a national organization that can qualify us as medical home providers.
This particular bit is not in HR 676, but there is no reason the essential features of a medical home can’t be done. The problem with having a set of rules to define a medical home is that it resembles “No Child left behind”– in that case, it was clear that some schools and teachers did a better job than others, so people tried to figure out specific reasons why and make everyone else do those items. But what happens is that you get the letter of the law and the spirit gets squashed. People spend so much time checking off boxes that they forget what the boxes were meant to do.
Most good primary care doctors and practices I know have always practiced as medical homes– it really is just good medicine. I think it is important to publish information and provide training on ways to be a better medical home, so that both patients and providers can have a good understanding of how things should be done. But I doubt if all these rules are going to turn poor quality providers into good ones. More likely, when all of us finally have access to real primary care medicine, checkups and all, the essential features of a medical home will be part of that. Anyone disagree?
This part of the law is only going to offer funding for medical homes to people with specific chronic conditions (although states may opt to add others). A person must have 2 chronic conditions, 1 chronic condition plus a risk for another one, or a serious persistent mental health disorder. The chronic conditions must include mental illness, substance abuse, asthma, diabetes, heart disease or a BMI over 25. That seems restrictive, when a medical home really benefits all of us, but then think about it– probably a majority of us would meet the criteria! A BMI of 25 or more is just overweight, not even obese. All you would need in addition to that would be a risk factor, and I’m pretty sure we all have a relative with one of the other conditions (at least one)!
In contrast, a universal comprehensive improved version of Medicare for All would pay for all of us to have the essential features of a medical home. You wouldn’t have to be already sick– the system would be in place for you ahead of time.