Are specialists serving as medical homes an appropriate model?

November 1, 2010

As policymakers grapple with the details of the Patient-Centered Medical Home, one contentious issue has arisen: can specialists serve as anchors of a PCMH?

As policymakers grapple with the details of the Patient-Centered Medical Home (PCMH), one contentious issue has arisen: Can specialists serve as anchors of a PCMH?

PCMH is an approach to providing comprehensive primary care that centers on a personal physician who serves as a first contact and leads a team of healthcare providers who collectively take responsibility for ongoing patient care. The personal physician takes responsibility for all of the patient's healthcare needs, which includes arranging care with other qualified providers for acute and chronic care, preventive services, and end-of-life care.

The principles of the PCMH were developed by the American College of Physicians, the American Academy of Pediatrics, the American Academy of Family Physicians, and other physician groups and were endorsed by the American Medical Association and some specialty organizations.

However, a recent survey conducted by Lawrence P Casalino, MD, PhD, and colleagues argues against most specialists functioning as medical homes. In their survey of 373 leaders of single-specialty cardiology, endocrinology, and pulmonary practices, 81% said that they serve as primary care providers for less than 10% of their patients. Only 2.7% said that they do so for more than 50% of their patients.1

"Given the goals of the PCMH, it is clear that serving as a medical home requires much more than merely providing primary care," the researchers write.

Contacted by Contemporary OB/GYN, Casalino indicated in an email that he didn't believe that ob/gyn practices met the standards of PCMHs. "They often serve as 'primary care physicians' for their patients-this is not the same as being a PCMH; it is less-but I don't believe that they are as capable as 'real' PCPs in dealing with pulmonary, cardiac, dermatologic, or orthopedic problems, for example," he wrote.

Casilano, chief of the Division of Outcomes and Effectiveness Research and the Livingston Farrand Associate Professor of Public Health in the Department of Public Health at Weill Cornell Medical College, believes that specialist-based medical homes should be required to meet the same standards as primary care-based medical homes, which means providing first-contact care, continuous and comprehensive care, and using systematic processes to improve the health of their patients.

In an editorial in Chest, Robert A Berenson, MD, senior fellow at the Urban Institute, points out that specialists usually do not meet those needs because they rarely provide care outside their specialist domain and infrequently provide routine preventive care, such as immunizations.2,3 Berenson notes that specialists serving as a PCMH face an added challenge as patients age and develop multiple comorbidities. He writes: "The medical home physician will be expected to manage and coordinate the care for these patients, most of whom are likely to continue to receive care from an assortment of expert specialists. The skills and team support to carry out this expanded coordination function are at the heart of the medical home approach."

1. Casalino LP. Rittenhouse DR, Gillies RR, Shortell SM. Specialist physician practices as patient-centered medical homes. N Engl J Med. 2010;362(17):1555-1558.

2. Berenson RA. Is there room for specialists in the patient-centered medical home? Chest. 2010;137(1):10-11.

3. Rosenblatt RA, Hart LG, Baldwin LM, Chan L, Schneweiss R. The generalist role of specialty physicians: is there a hidden system of primary care? JAMA. 1998;279(17):1364-1370.