to authorize their nurses or physician assistants to periodically conduct home visits for patients unable to come into the office. It would cover such services as medical assessment, medical monitoring, and medication management. Delivery of such services would allow the physician to receive more direct knowledge than could be obtained if similar services were provided through a separate home health agency. This approach of legislating additional benefits could potentially be applied to other types of services, such as chronic-disease self-management training and caregiver education and support.

Advanced Medical Homes

Finally, a more radical departure from the current FFS system is a proposal that calls for the creation of advanced medical homes through comprehensive payment for primary care (Goroll et al., 2007). In this system physicians would be paid a risk-adjusted, per-member, per-month fee that would cover care coordination and medical services provided to the patient (Berenson, 2007). Payment would be considerably higher than current FFS or MA payments, allowing practices a greater opportunity to support different models of care. Participating practices would be required to undergo structural and organizational changes (e.g., the adoption of interoperable electronic health records with decision support and the use of interdisciplinary teams) that follow established standards. A portion of the payment would then be based on performance.

Risk adjustment would make it less likely that physicians would avoid high-risk or psychosocially disadvantaged patients and would also influence the pay-for-performance goals (Goroll et al., 2007). Several validated diagnosis-based models of risk adjustment exist and have been modified for payments to health plans (Ash et al., 2000; Kronick et al., 2000; Newhouse et al., 1997). Those models would need to be further modified for the practice level and need to include the spectrum of risk determinants, including patient behaviors. Although costs would initially be high, proponents of this revised payment system believe that long-term costs would be tempered by reductions in administrative costs, inefficiencies, and overutilization.

This proposal differs from some capitated payment systems in that physicians would not be at risk for hospital, specialist, and ancillary service costs. Appropriate utilization of services would be achieved through the use of evidence-based guidelines and decision-support systems, and the pay-for-performance bonuses would be based both on outcomes and efficiency. If responsibility for a patient is transferred to a specialist—for example, in the case of a patient with cancer—the specialist may receive some or all of the per-member, per-month payment.

Additional payments to practices under this proposal provide the means

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