Medication management key to 'medical home' concept

September 15, 2008

Medication management is part of the new 'medical home,' with primary care physicians taking responsibility for supervision of patient health and coordinated care.

Key Points

In the past two years the so-called "medical home" concept has become a key part of healthcare reform, with medication management being a major part of the concept.

The basic concept of medical home is the primary-care provider taking responsibility for a patient's health and coordinated care - with the provider being compensated for his efforts. Exactly how pharmacists would be connected to the process is still being worked out.

The medical home concept has gathered sustained interest as well as resources for trials from large employers, health plans, local groups, Medicaid, and Medicare. For example, the Patient-Centered Primary Care Collaborative (PCPCC) Web site lists 16 local and state demonstrations. The Commonwealth Fund lists a number of grants for medical home demonstrations. Additionally, a project sponsored in part by the collaborative is aimed at helping state Medicaid programs adopt the model. And a major three-year demonstration under Medicare, mandated by Congress in 2006 and involving possibly eight states, is due to begin next year.

The collaborative says that, in nations in which there is more focus on primary care, people live longer, are healthier, and are more satisfied with care, "and everyone pays less."

A foundational document for the push in this country is the statement of "joint principles" that was adopted last year by the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA). The principles say that, in the medical home, the personal physician leads a team that collectively takes responsibility for ongoing care of the patient; care is coordinated across the complex system; and it is facilitated by registries, health information exchange, and other means.

The principles also state that, among other elements, the medical home payment structure should reflect the value of a physician's and non-physician staff's work to manage care outside the face-to-face visit. That structure, say the principles, should allow physicians to share in the savings from reductions in hospitalizations associated with the physician-guided care management, and it should allow additional payments for measurable quality improvements.

Medication management is certainly in the forefront in medical home advocates' thinking. In a recent discussion, the Medicare Payment Advisory Commission (MedPAC) said a Medicare medical home would be responsible for monitoring its patients' medications, and "ideally, these medication reviews would be coordinated with a pharmacist," noting that medication-therapy management is already required under Medicare Part D.

In another key development earlier this year, the National Committee for Quality Assurance (NCQA), which does quality accreditation of health plans, managed-care organizations, and others, published quality standards and guidelines for medical home practices.

The standards say, for example, the practices should use e-prescribing and have electronic prescription reference information, prescribing decision support, and alerts on the most cost-effective drug choices for the patient, including generic drugs. Under the upcoming Medicare demonstration, medical home practices are to get 80 percent of the shared savings attributable to the medical home, as reduced by the total care management fees paid to the Medical home. Sandra Guckian, RPh, MS, vice president of the National Association of Chain Drug Stores (NACDS), said, "We see pharmacists being a logical partner with the physician in their achieving their medication use outcomes goals in this new medical home concept."

The association is a member of the PCPCP.

Guckian indicated she is talking to groups interested in doing medical home trials to find out how pharmacy can be involved. In general, she says, groups in the collaborative have been very supportive of pharmacy's role and of pharmacists, although the major focus currently is on re-engineering the physician practice.