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ARTICLES: W. Carl Cooley, Jeanne W. McAllister, Kathleen Sherrieb, and Karen Kuhlthau Improved Outcomes Associated With Medical Home Implementation in Pediatric Primary Care Pediatrics 2009; 124: 358-364 [Abstract] [Full text] [PDF]

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The road to the medical home

Carlos F. Lerner, Thomas J. Klitzner, Leslie Hamilton   (31 July 2009)

The road to the medical home 31 July 2009
Carlos F. Lerner, General Pediatrician David Geffen School of Medicine at UCLA, Thomas J. Klitzner, Leslie Hamilton Send letter to journal: Re: The road to the medical home clerner{at}mednet.ucla.edu Carlos F. Lerner, et al.	In the span of a few years, the concept of the medical home has evolved from a relatively obscure model of pediatric primary care to one of the cornerstones of the current efforts to reform health care. The widespread adoption of this model will likely depend on evidence demonstrating that it can improve health care quality while reducing health care costs. Such evidence remains fragmentary. Cooley, McAllister, Sherrieb and Kuhlthau present evidence that patients that receive care in pediatric practices with greater degrees of medical homeness exhibit modestly decreased rates of hospitalization and emergency room visits (1). Their study intentionally focused on children with prevalent chronic conditions. Not surprisingly, their sample was dominated by children with asthma (59.3%) and ADHD (31.6%). On average, these children were relatively low users of health care, with more than half of the children having no hospitalizations or ER visits during the study year. Children with >100 ambulatory visits, which represented less than 1% of the initial sample, were excluded as outliers. We believe that, in future studies, the best opportunity to prove the value of the medical home concept rests with these outliers. In an analysis from a single health plan, children with catastrophic or multiple significant chronic medical conditions (excluding cancer) represented 0.5% of the total members, but incurred over 15% of total medical charges (2). In our own experience, medically complex children benefit most substantively from the core components of the medical home. Only one published study in the pediatric literature reports on an intervention implementing the medical home concept, a pilot project focusing on children with serious medical problems (3). Persuading private and public payors of the value of investing scarce health care resources to transform pediatric primary care practices into fully realized medical homes will require a greater number of larger-scale studies. In adult primary care, these efforts are already underway. In 2010, Medicare is scheduled to begin a 3-year medical home demonstration project including 400 practices in 8 sites(4). Of note, enrollment will be limited to “high need” patients. Similarly ambitious projects are urgently needed in pediatrics. Carlos Lerner, MD, MPhil Medical Director, Children’s Health Center, Mattel Children’s Hospital UCLA Leslie Hamilton, MD Medical Director, UCLA Medical Home for Children Thomas J. Klitzner, MD, PhD Executive Director, UCLA Medical Home for Children 1. Cooley WC, McAllister JW, Sherrieb K, Kuhlthau K. Improved outcomes associated with medical home implementation in pediatric primary care. Pediatrics. 2009;124:358-364. 2. Neff JM, Sharp VL, Muldoon J, Graham J, Myers K. Profile of medical charges for children by health status group and severity level in a Washington state health plan. HSR: Health Services Research. 2004;39:73 -89. 3. Palfrey JS, Sofis LA, Davidson EJ, Liu J, Freeman L, Ganz ML. The Pediatric Alliance for Coordinated Care: Evaluation of a medical home model. Pediatrics. 2004;113:1507-1516. 4. Centers for Medicare and Medicaid Services. Medical Home Demonstration: Fact Sheet. January 9, 2009. (http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/MedHome_FactSheet.pdf.) Accessed July 29, 2009. Conflict of Interest: None declared