Some proponents view the PCMH as a vehicle for fundamental reform of how ambulatory care could be organized, provided, and financed in the United States. From this perspective, the medical home promises to counter the overspecialization and fragmentation of care in our system, enhance primary care and coordination of services, support behavioral changes necessary for preventive care, and rebalance expenditures toward a longer term vision of health.5,12,19,20
However, others argue that the medical home should more strictly target persons with complex extant health service needs, particularly at first. From this more incremental perspective, one size does not fit all, the patient should retain the choice of whether to join a medical home, the incentives for providers to coordinate their services may prove complex to align, and the expansion of the role of primary care doctors may be costly.3,4,8,21,22
Except for the pediatric sector, the medical home remains more of a goal than a practical reality thus far. To continue moving forward, we need to establish who will most benefit from a medical home in order to know what to build. Our results show that the medical home should likely include more than just the elderly population. There are indeed large numbers of working-age Americans with chronic conditions and/or disabilities who use multiple health services from different provider types in a given year. Whether we turn our attention to their utilization of services, their access problems, or their costs, in theory, all ACHCN might benefit from the medical home. However, since ACHCN are the majority of the working-aged, it is also important to identify subgroups where service use runs especially high, where access problems are most evident, and where costs are disproportionately large. This is precisely the case for the approximately 27% of ACHCN reporting limitations, who have the most compromised health, the highest levels of service use, and more importantly, the highest use of services which are most costly and difficult to coordinate, such as hospitalizations, emergency room visits, and home health. More specifically, it is ACHCN requiring help with ADLs or IADLs for whom the benefits could be the most direct, assuming that the medical home in question is both physically and programmatically accessible for people with disabilities.
The data presented here also reveal the difficulty of selecting individuals for a medical home or other care coordination activities on the basis of diagnosis alone. Complex, concurrent combinations of chronic and acute conditions are the norm among ACHCN. Hence, targeting patients for medical home benefits on the basis of a short list of health conditions will likely misallocate resources. One possible solution meriting further investigation is the use of patient-reported functional and activity limitations as a supplement to diagnoses when the time comes to identify patients needing a medical home. Alternatively, the choice of which patients to include and exclude could be based on elevated need(s) for particular health services that are expected to persist over time, as has been done in the pediatric realm. Appearing in Healthy People 2010, the CSHCN criteria have not only been adapted for use in clinical and health plan settings, but also have steered broader health policy discussions and health services research. The MEPS itself now contains a series of screening questions that researchers can use to identify and study the CSHCN population directly.
Such criteria and screeners are not yet available for the working-age population and so this study has several limitations. Ultimately, we can only present estimates of the distribution of current service use and not service need. Further, as the present analyses do remain contingent on respondent reports of medical conditions, these estimates may reflect some degree of undercount (particularly of undiagnosed health conditions).23
On the other hand, relative to the medical viewpoint, respondents may also over-report some health conditions.23
For 23 highly prevalent condition categories (some chronic, some acute), a recent study calculated an overall sensitivity rate of 74% when respondent reports in the MEPS were compared with medical provider reports.24
In addition, we observed a range of health care utilization patterns among the groups we analyzed; not every person with a chronic condition is necessarily a “high-end” health care user. Finally, the data we analyzed cannot support conclusions about the potential cost savings (or expenses) of care coordination.
Despite these limitations, these figures do provide a place to start. They describe the likely breadth and scope of chronic health care needs among the working-aged, remind us of the importance of disability, and provide preliminary estimates that can help to inform more formal clinical and research definitions of a population looking for a medical home. Many further questions that concern how to build the PCMH for ACHCN remain to be addressed. Future research should consider such domains as universal design, organizational capacity, administrative issues, reimbursement, and marketing.