As a medical student at the Baylor College of Medicine in the heart of the world’s largest medical complex, the expansive Texas Medical Center, I am continually witness to the triumphs of the US health care system: hospitals with state-of-the-art ICUs, cutting-edge imaging centers, and the emergence of personalized genomic medicine. For the people who can access this premier level of care, medical miracles seemingly happen with regularity. However impressive the best of 21st century medicine may be, this world is not reality for most of our nation’s health practitioners and patients. Amidst the towering private hospitals, on the outskirts of the Texas Medical Center, Houston’s largest public hospital is home to an entirely different tier of medicine–providing for an interesting juxtaposition of both the greatest strengths and weaknesses of American health care.

In fact, 45 million Americans do not even have the security of health insurance (i.e. the uninsured), and an additional 16 million have insurance which provides inadequate or sporadic coverage (i.e. the underinsured). ¹ In addition to this most visible problem of the US system, American health care is further troubled by racial, ethnic, and socioeconomic health disparities ², access barriers, uncontrolled costs, diminishing emphasis on primary & preventive care, and challenges to pa- tient & physician autonomy. ³

Considering these shortcomings of American health care which have only continued to grow, the topic of health care reform has once again entered US public and political forums. Enhancing this discourse have been solutions for reform from numerous interested organizations, among these patient advocacy groups, medical societies, insurers, and policy think- tanks. ^4-8 Such proposals vary according to factors such as topic area (access, quality of care, etc.), timeframe (radical vs. incremental reform), and degree of impact (comprehensive vs. piecemeal). This essay will focus on one such solution which has recently been gaining in popularity: The Patient-Centered Medical Home.

In an effort to address the rapidly growing number of Baby Boomers over age 65, an increased need for the management of chronic medical conditions, and an anticipated physician shortage ^9,10, the Patient-Centered Medical home was proposed jointly in 2007 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 of the Patient-Centered Medical Home address numerous topic areas, including access, quality, primary care & prevention, and physician reimbursement. ¹¹ Briefly, these principles include a personal physician, physician-directed medical practice, whole person orientation, coordinated/integrated care (the aforemen- tioned known as the “care principles”), higher quality and safety standards, enhanced access, and appropriate provider payment (these known as the “infrastructure principles”). ^{11, 12} It should be noted that the medical home is not a novel concept, as it was first introduced by the AAP Council on Pediatric Practice in 1967 as part of an effort to bolster care for children with special health care needs. ¹³ Furthermore, the patient-centered medical home is built upon the foundation of primary care medicine, a concept similarly developed in the 1960s. ^{14, 15} Initially proposed as a way for the federal government and medical com- munity to cooperatively provide adequate care, primary care has remained central to health care systems across the world. ¹⁵ To further highlight its importance to quality, integrated, and accessible health care, it was subsequently defined by the Institute of Medicine in 1994, sharing striking similarities to the Patient-Centered Medical Home. ¹⁶

For the past decade, mounting evidence in support of the medical home model in medical literature has gradually increased the visibility of this proposed solution for reform. Although an in-depth review of studies presenting evidence in favor of the patient-centered medical home is beyond the scope of this commentary, it is important to highlight some of the most salient data. Starfield and Shi (2004) and Rosenthal (2008) effectively summarize the literature ^17,18; the most striking of which describes the correlation between the availability of primary care, mortality, life-expectancy ^19,20, and cost of health care in the context of a medical home. ^21,22 The sweeping conclusions of both review articles cited above further emphasize the need for a medical home model in American health care: Rosenthal (2008) concluded that “evidence…supports the ability of medical homes to advance societal health;” ¹⁸ Starfield and Shi (2004) closed by affirming that “a medical home…provides better effectiveness as well as more efficient and equitable care to individuals and populations.” ¹⁷ Considering the wealth of supporting studies, it appears that the medical home model will only continue to garner momentum as medicine moves in the direction of evidence-based practice. However, despite the clear in favor of the model, it seems that the patient-centered medical home model will undoubtedly be limited in implementation until we recognize the barriers to care which might be seemingly absent on paper, but very present “on the front lines” of everyday practice. To expound on this subject, I would like to deviate from the scientific literature and enter a slightly more tangible world. The last four weeks of my medical school training have taken me to a large public community health center in a small industrial satellite city of Houston. While completing my family & community medicine clerkship at the clinic, I have found myself leaving the clinic nearly every day insired. This is due to the profound dedication and compassion of nurses, physicians, and other staff at the clinic who strive each day to deliver much-needed health services to some of Houston’s most underserved. Admittedly, this inspiration has somewhat faded with time as I saw the the barriers which plague our health care system: lack of health insurance, expensive prescription medications, increasingly short visit lengths, long wait times, and not enough physicians, just to list a few.

As part of our clerkship experience, medical students are required to conduct an evaluation of the clinic’s effectiveness as a medical home ²³, the results of which were quite interesting. After completing the survey, I was surprised to find that the clinic received a “good progress” rating, indicating that the clinic was “well on its way to becoming…a true medical home.” Although this particular survey was only one out of several possible evaluation tools, and the survey results indicated that “continued improvement” was necessary, I found it hard to believe that the clinic was in any way actively transforming to become a primary care home for its patients. I subsequently found myself wondering “If this is good, then what does not-so-good look like?” Surely, there is much more work to be done, as a true medical home is much more complex.

As an aspiring primary care pediatrician hoping to work in an underserved community, I most sincerely believe that there is much that needs to be done to improve our ailing health care system. The medical home model is an evidence-based solution to treat some of American’s health care problems – and its importance should not be overlooked. I believe that it should be at the core of any proposal for reform. As physicians-in-training, we are charged with assuring the future health of a nation. How can we make sure that sound proposals for reform such as the medical home become reality? What issues need we address now to secure a sure foundation for progress in the future? It seems to me that the “limiting reagent” in the equation for effective reform does not require the analyses of an economist or a politician, but is actually quite straightforward; the limiting reagent is you and me – the supply of future physicians – specifically those who decide to pursue a career in primary care medicine. This is not meant to oversimplify the issues facing this crucial juncture in American health care, but to emphasize a clear way in which students can lead us towards better health as a nation.

Primary care in the United States is in crisis at a time when we need it most. Overall, medical students are less interested in primary care, ²⁴ and fewer students are becoming primary care practitioners. ²⁵ As described above, the medical home model, along with other proposed solutions for health care reform, are founded upon those same principles of primary care conceptualized nearly 50 years ago. The patient-centered medical home, in particular, is a clarion reaffirmation of the need for primary care in the US. Although primary care medicine may not receive front page notoriety in today’s media, its clear importance to our health and well-being resonates throughout communities nationwide. As students, we are not only called to learn, but also to act; if we are to approach an ideal system which assures quality, affordable, health care for all, we must work cooperatively to develop incentives for primary care medicine, expand the primary care workforce, and ultimately ensure all Americans a medical home.