Building a medical neighborhood for the medical home.

n engl j med 359;12 www.nejm.org september 18, 2008 1202 tients would be free to leave their medical home at any time — with no explanation required — and either enroll in another one or return to the traditional fee-forservice model. The demonstration program, if successful, will be one small step along what many policymakers view as a path toward slower growth of expenditures and improved care under Medicare. Further steps would involve restructuring the delivery system by providing physicians with financial incentives to aggregate into larger, more integrated groups that could coordinate care more effectively. Such a goal is outlined in the June 2008 report of the Medicare Payment Advisory Commission, an influential agency created by Congress to provide legislators with health policy options.4 Noting that if it is left unchanged, Medicare will be fiscally unsustainable, the commission asserted that “fundamental change in the organization and delivery of health care is needed.” It urged Congress to pursue three initiatives “expeditiously”: a medical-home demonstration program, the bundling of Medicare payments for all care provided during a given hospitalization (to be paid to a single provider entity composed of a hospital and its affiliated physicians),5 and the creation of accountable care organizations that would resemble existing multispecialty group practices.5 The commission, while underscoring the need for fundamental change, recommended only targeted reforms, perhaps by way of acknowledging the limits of the American (and Congressional) appetite for sweeping change, as reflected in the decisive defeat of the Clinton administration’s comprehensive plan. Should the next administration and Congress take up the challenge of reform in 2009, they would do well to heed the commission’s advice, in its latest report, to recognize that “the process of fundamental reform is evolutionary, and not knowing the final design should not deter us from beginning.”