Transforming health care through the medical home: the example of heart failure

Amid ongoing legislative efforts to achieve universal coverage and reduce costs while improving quality of care, heart failure represents a major public health problem, challenging us to restructure systems of reimbursement and care. The "medical home" represents the best option for aligning and incentivizing multidisciplinary groups of providers to optimize decision-making for individual patients and the population, at large, and to compete based on quality and cost. For the medical home to meet the needs of patients with heart failure, it must eliminate barriers and facilitate collaboration among specialists, primary care physicians, and other providers. It must provide sufficient expertise for the complex and diverse population of heart failure patients to individualize recommendations that range from heart transplant to palliative treatments. Where appropriate, patients should be offered the choice between an emphasis on quality versus quantity of life. Although rewards and penalties based on specific externally driven metrics may be useful as an intermediate step in the current fee-for-service environment, this approach has important limitations and should transition quickly to a medical home approach. The current drive to change US health care should seek to transform our system of reimbursement and care to one that provides for continuous multidisciplinary management of all patients, including those with complex, chronic conditions such as heart failure.