No Place Like the Patient-Centered Medical Home (


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The patient-centered medical home remains one of healthcare’s hottest topics. Despite its complexities and many moving parts, the concept is seeing greater adoption as health plans, government entities, employers and physicians all try to improve quality and lower costs. This is all happening as healthcare reform, meaningful use, ICD-10 and deliberations on medical loss ratio continue to alter the way care is delivered and paid for. If trying to get a firm handle on the future of healthcare through this unprecedented convergence of external factors makes it feel as if we’re working from the inside of the tornado in the Wizard of Oz, then perhaps we can find the answer in much the same way Dorothy found her way by looking home. In other words, when it comes to navigating the whirlwind of change already starting to blow through healthcare, there may in fact be no place like (the medical) home.

When MEDecision initiated its medical home strategy last fall, we quickly realized that the medical home movement would change the manner in which health plans approach the delivery of utilization, case and disease management services because it moves many of those functions closer to the patient. Given that MEDecision has been the industry’s leading provider of UM, CM and DM solutions for more than 20 years, this potential shift in the landscape has caused us to reflect on how these changes will impact our company and our customers.

Throughout our work in predicting how care management will evolve over the next one to three years, here are some things we’ve begun to consider:

1. While some aspects of care management will remain with health plans, their role will change as that responsibility begins to shift toward the medical home team.

2. All patients have a set of factors that make them unique, which will require many different approaches toward the delivery of care for that individual. For example: Is there a shortage of caregivers in their area? Is the patient comfortable with technology—can they manage a PHR? Are they covered by commercial or government health insurance? Do they have a medical home? Does their primary care practice provide all the services they require?

3. The need for a diverse set of approaches requires the ability for a number of potential entities to steer all of the moving parts and share tasks dependent on what the patient needs. Some medical homes may take on all aspects of the care management spectrum that a health plan and other sources may provide today. Most medical homes will take on some of those aspects of the overall care plan but will also outsource some care management tasks to the health plan or other entities (nutritionists, pharmacy for medication management, lab, behavioral health, cardiology, etc.) that will provide those services due to the specific skill sets and specialized systems required.

4. Having different technical systems and organizations for managing silos of case, disease, utilization and behavioral health management will become less prevalent within the health plan. Instead, care management efforts will take a more holistic approach through technologies and teams that are centered on the patient rather than the process.

5. Health plans will expect care management platforms to support the extension of their patient-centered processes to physician practices. This is something that we have already seen at MEDecision. About 30 percent of our most recent Request for Proposal inquiries have included at least some medical home requirements. These specifications will likely become more refined over the next year and begin to include Accountable Care Organization support. This is an indication that health plans are becoming more forward-thinking and less concerned about catching up to the care management world of three-to-five years ago.

As these factors come to fruition, it will mean that, in order to be effective, care management platforms can no longer simply be payer-based or exist only within the walls of a single entity. These solutions must be re-imagined and extended so that care coordinators in the medical home and the various other team members involved in a patient’s care (including the patient) can take ownership of tasks within the overall care plan and see the results in a timely manner. This creates a virtual medical home team that can be customized or shifted to account for the diversity of patient needs. The concept of a transparent care plan could then lead to improved reimbursement models for physicians (yes Dorothy, we’re not in fee-for-service anymore). This could also address issues of the looming PCP shortage and increase the level of trust and communication between patients, payers and providers.

Your comments are welcome. These are just some of the things we are considering as we continue to build upon our current care management platform and look to the future. We’ll be publishing more insight on care management and the patient-centered medical home in the weeks to come. In the meantime, what do you think? Will the medical home movement change the manner in which health plans approach care management?

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