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Who is on the home team? Redefining the relationship between primary and specialty care in the patient-centered medical home.

Recent attempts to tame relentless medical cost growth in the United States through provider reorganization and health insurance reform are rooted in efforts nearly a century old. In the mid-1920s, American medical costs in the United States began to surge in the wake of the Flexner report, buoyed by an expansive array of new and effective biomedical technologies for freshly minted specialists trained in specialized hospital settings. 1 In 1927, provider involvement in the emerging field of health economics was catalyzed through the creation of a blue ribbon panel of physician-led experts known as the Committee on the Cost of Medical Care (CCMC). 2 Five years later, when the peak of the Great Depression and heightened medical costs threatened the solvency of the poor and middle classes, the CCMC issued its final report. The 1932 report concluded with 5 recommendations that echo strikingly with those of today’s Affordable Care Act. These included (1) the provision of medical services through organized groups of providers, emphasizing high standards of coordinated care and personal relationships with patients; (2) increasing efforts in disease prevention; (3) distribution of costs through voluntary insurance; (4) formation of community agencies to coordinate care services; and (5) improving professional education for physician and nonphysician providers. 2 In the current era of unsustainable health care cost growth and recently passed health reform, the patient-centered medical home (PCMH) model has been touted as a way to reinvigorate primary care while promoting better overall care at lower costs. At its essence, the PCMH can be envisioned as a home team of providers centered around a patient’s needs, with care functions and team processes coordinated through interconnected health information technology. Payment reform to compensate providers for currently unreimbursed care management and coordination activities is also an essential part of the model. As of 2009, at least 5 million patients were enrolled in 26 PCMH demonstration pilots with meaningful payment reform across the country, and almost every state has a current or planned demonstration in place. 3 Early PCMH demonstration evaluation results in integrated, high performing systems suggest trends toward improved quality, patient experience, and greater efficiency. 4,5 Although the challenges of transforming primary care practice microsystems toward the medical home model are significant, 6 increasing attention is also being paid to the macro-environment in which medical homes operate. Defined as medical neighborhoods, their topography and connectivity to outpatient specialist and acute care are crucial to the realization of improved quality and efficiency within this model. Thus, understanding the current landscape of outpatient specialty care provision is important for predicting and accelerating the future of PCMH initiatives as well as the deployment of accountable care organization frameworks. In this issue of Medical Care, Hollingsworth and colleagues report on the amount of care delivered by specialists for 7 prevalent ambulatory chronic conditions and estimate the impact of reallocating some of this work among primary care physicians in a PCMH