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ABSTRACT
Existing research suggests that models of enhanced primary care lead to health care systems with better performance. What the research does not show is whether such an approach is feasible or likely to be effective within the U.S. health care system. Many commentators have adopted the model of the patient-centered medical home as policy shorthand to address the reinvention of primary care in the United States. We analyze potential barriers to implementing the medical home model for policy makers and practitioners. Among others, these include developing new payment models, as well as the need for up-front funding to assemble the personnel and infrastructure required by an enhanced non-visit-based primary care practice and methods to facilitate transformation of existing practices to functioning medical homes.
There is near-unanimity that a truly reformed U.S. health care system will require at its foundation a robust system of primary care.1 Other health care systems throughout the developed world are based on a strong primary care foundation and deliver health care services at an average of half the per capita costs of the U.S. system at the same or higher levels of quality. In contrast, the specialist-dominated U.S. health care system produces care of mediocre quality, with excessive use of costly services that have little marginal health benefit.2
Within this context, the patient-centered medical home has become policy shorthand for rebuilding U.S. primary care capacity. It incorporates not only enduring primary care principles such as access, coordination, and comprehensiveness, but also twenty-firstcentury approaches using new tools such as electronic health records; asynchronous communications independent of time or location, such as e-mail; and informed decision making.
The core principles of the medical home were endorsed by the major primary care associations in 2007 and serve as a general guide.3 However, questions remain about how to best put these principles into operation and close the gap between the current primary care system and that envisioned under the medical home model. For instance, the principles do not specify an optimal reimbursement strategy with regard to the level or structure of payment, or the concrete steps that a practice should take to improve access to care. In this paper we highlight these and other policy challenges for implementing the patientcentered medical home.
Policy...