Counting on medical homes

Health-care experts are placing a lot of faith in what is called the patient-centered medical home (PCMH). The term is off-putting to some because it sounds like “nursing home.” However, it is simply a physician’s office organized in a different way.

The PCMH recognizes that health care is rarely one doctor treating one patient. It requires a team of health-care providers, educating family members and using community resources. Physicians are more like team leaders, coordinating care with staff members as well as specialists and hospitals. The doctors are rewarded more for keeping their patients healthy and out of the hospital rather than for short face-to-face visits with lots of tests and procedures. Medical homes are usually paid a monthly fee for patients under their care.

The “patient-centered” aspect assumes patients will participate in their own care. They will ask for and receive the care they want and need, and act on the medical advice they are given. The medical home has a number of features that are missing in most doctors’ offices: electronic medical records, email communication, remote monitoring of chronic conditions and frequent reminders about preventive care.

There are many strengths to this kind of approach. Physicians have fewer incentives to provide unnecessary care. Participants recognize that most patient transactions can be handled by email or telephone. A Mayo Clinic pilot study found that “e-visits,” or care provided over the Internet, made office visits unnecessary in 40 percent of the cases.

A 2010 Health Affairs article described the future physician’s office, using medical-home principles. The office might treat 100 patients a day. The doctor might be involved with 30 to 40, of whom perhaps 10 would have traditional face-to-face individual appointments. The other patients interacting with the doctor would do so by telephone, email or group appointments. The remaining 60 to 70 patients would be treated by nurse practitioners, physician assistants or medical assistants, who would handle less complex cases and counsel people with chronic conditions on disease self-management. These team members would spend more time – and likely be more effective – than a physician could in a 15-minute time slot.

The doctor’s office currently is set up to deal with brief illnesses or disease that can be cured mostly by time and medication. It is ill-suited to treat chronic disease, which accounts for about 75 percent of health-care spending. Effective chronic-disease management requires close monitoring and tweaking of treatment to avoid complications that require hospitalization or emergency department (ED) visits, such as heart attacks, stroke or respiratory failure. Medical homes typically have after-hours arrangements for their patients to be able to see a physician or nurse without going to the ED. Less than one-third of doctors’ offices have such an arrangement now.

An estimated 40,000 primary-care physicians work in practices set up as PCMHs. That is about 1 out of 8 physicians and pediatricians. Blue Cross Blue Shield of Michigan said it saved $65-$70 million in 2011 working with PCMHs. It paid an extra $7,500 per physician for the year. However, it saved money because better care yielded fewer hospital and emergency-department visits. The doctors also ordered more generic prescriptions because electronic prescribing allowed them to see lists of covered medicines.

Seattle-based Group Health (GH) is an integrated-care organization with its own health plan. It serves 600,000 members and employs about 1,000 physicians in Washington state and Idaho. Using medical-home care principles, GH has been able to improve quality and lower costs. It resulted in 29 percent fewer ED visits and 6 percent fewer hospitalizations, compared with its patient outcomes prior to becoming a medical home.  In a survey at its clinic in Bellevue, patients expressed higher satisfaction with their care. More patients received recommended health screening tests, chronic-disease management and medication monitoring, compared with its prior traditional approach.

Paying doctors to keep people healthy seems so logical. However, it will not be widespread until health plans recognize this as customary care. In an Internet survey of 1,000 physicians, two-thirds said they believed the current health-care environment is detrimental to care. Less than 1 in 5 said they could make clinical decisions based on what is best for the patient rather than what health plans would reimburse.

While many physicians agree with medical-home principles, they already are stretched thin and are suspicious of what may be unrealistic expectations and extra effort. All of this is fine, they say, if they are properly paid. The government and health plans do not have a good track record in this regard. Many health-delivery innovations have been oversold, only to be swept away after impatient payers fail to see promised savings in short order. Health care has long been regarded as an expense rather than an investment. Unless that perspective changes, the medical home may never gain traction.

The health-care system envisioned by reformers calls for prompt patient access to care despite the next wave of additional demand from health reform and an aging population. They also want to create more  attractive careers for primary-care physicians. That would mean a lightened workload and more income. The math simply does not work.

Two major barriers are money and workflow.

Seattle’s GH invested $1.3 million at its Bellevue clinic to create its medical home. It had a 50 percent return on investment because its patients were also part of its insurance plan. Because GH treats and also insures its patients, it has an incentive to treat patient in ways that minimize hospitalizations and expensive procedures. Few clinics will be able to have that kind of payback. In most cases, the physicians will make the investment while the health plans and patients will reap the savings.

Typical physicians’ offices are built around the doctors’ hectic routines. They see patients at a frenetic pace and have little interaction with staff members. Medical homes, by contrast, require doctors to be managers of care teams, something they have not been trained to do and many are uncomfortable with. The current standard is doctor-centered, not patient-centered, care.

Medical homes will be created by highly motivated, well-funded physician groups willing to overcome the barriers to install an unproven business model. Medical homes appear likely to be islands of excellence rather than the standard of care.