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Thursday, October 28, 2010

So how homey is a medical home?

The new health care legislation is looking to primary care doctors to create "medical homes", defined as primary care practices that provide 24/7 access to their doctors, electronic medical records with exchange of information with other providers, a patient-centered holistic approach, and coordination of care by other specialists.

A study published today funded by the Commonwealth Fund, carried out by the American Academy of Family Practice, shows that to achieve this, doctors need a lot of help, and that even with this help, they may actually not improve things, as evidenced by patients being less satisfied than before. The national demonstration project published today showed that 36 family practices made small improvements in clinical quality measures, summarized as "better preventive care and access". Access meant ability to get in for an appointment or reach someone to talk to...not related to patient's views of their access or whether they were able to go to the best specialist, surgeon, and the best hospital they could have for specific medical conditions requiring intervention). Patients with high blood pressure and diabetes had slightly better control of their blood pressure and hemoglobin A1C (a measure of blood sugar control for patients with diabetes) levels. However, patients actually rated their care worse after the practices made changes. Patients' ratings of access to care, care coordination, comprehensive care, and service relationship were worse after implementing more of the features of the "medical home". I guess the medical home can be not too homey.

In contrast, Group Health Cooperative of Puget Sound, a large health care system, mounted a successful demonstration project of the "medical home", showing it boosted quality and patient satisfaction and saved money by helping its practices become "medical homes".

The message is that big organizations will be much better able to achieve the "medical home" features in a way that does not impair service to patients. Large organizations may also already have had lower levels of patient satisfaction, so they did not fall by becoming "medical homes", which generally rely on ancillary practitioners for more things and may reduce access to doctors. For smaller practice, electronic medical records, registries and greater use of ancillary support do not necessarily mean that things will get any homier for the patient. On the contrary.

Unfortunately, big organizations may also provide perverse incentives to helping patients choose the best specialty and surgical care. We've seen this with the Medicare Advantage plans. When primary care doctors have incentives to choose doctors and specialists and hospitals in the same health care delivery system, or coverage requires them to, patients lose out, because it will limit the specialty and surgical providers and hospitals to whom primary care doctors refer their patients. Often there are financial incentives within the same system to choose providers there, and this will be even worse when payment moves to an "episode of care" approach, meaning that patients will have to go to the same system of care for an entire "episode", even if there were better providers around for specific pieces of that episode. So, for example, you will no longer be able to receive your follow up care from surgery in a different system than the surgery itself, since the payment is likely to be bundled.

Many patients would prefer to go to smaller practices for their primary care, with a more personal feel where they still feel like human beings, and prefer to be able to choose the best specialty surgical provider and hospital for their particular problem. Unfortunately, the direction in which our health care system is moving will make this model more difficult. If episode-of-care bundled payment happens, small primary care practices unaffiliated with surgeons, specialists and hospitals will be forced out of business.

The authors of the summary article reached that same conclusion and recommended that third-party payers turn to arrangements such as monthly capitation payments to make medical homes worthwhile for physicians. "Expecting practices to front the cost of transformation with the hope of more appropriate reimbursement in the future is unlikely to succeed," they write.

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