AHIP Coverage (Jan/February 2008)
Medical Homes: The Prescription to Save Primary Care?
By Helena Gail Rubinstein
Health policy researchers have known for decades that elevating the stature of primary care physicians—family practitioners, pediatricians, geriatricians, and internists—is essential to improve health care access and quality. The evidence is also overwhelming that capitalizing on primary care physicians’ training and experience is key to reining in health care costs. According to research published in 2005 by Barbara Starfield, M.D., professor of health policy, Johns Hopkins Bloomberg School of Public Health, improving primary care physicians’ status is not merely desirable—it may just be a matter of life and death.
Writing in The Milbank Quarterly, Starfield suggests that the addition of one primary care physician per every 10,000 Americans could result in a reduction of more than 127,000 deaths per year. Her research established that states with higher ratios of primary care physicians have lower smoking rates, fewer obese people, and higher seatbelt use than do states with lower ratios of primary care physicians to population. In addition, there is a positive correlation between higher numbers of primary care physicians and early detection of breast cancer, colon cancer, cervical cancer, and melanoma.
Despite the widespread understanding that real health reform depends on this, nowhere in health care is the gap between knowledge and action more profound. “Primary care is in danger,” says Don Liss, M.D., regional medical director for Aetna.
“Fewer than 8 percent of medical school graduates went into family medicine residency programs last year,” according to Rick Kellerman, M.D., chair of the American Academy of Family Physicians Board of Directors. That’s not because the challenge of being a primary care physician is unattractive, says Paul Grundy, M.D., director, health care technology and strategic initiatives, IBM. “Incoming medical students want to become primary care physicians. Their idea for why they wanted to be doctors was to provide comprehensive care in their communities.”
But, says Michael Barr, M.D., vice president, practice, advocacy and improvement, American College of Physicians, “When medical students leave medical school with debt exceeding $120,000 and they look at the business case for the practice of internal medicine, we see that they are voting with their feet and going into other specialties.”
Fearing the imminent collapse of our nation’s primary care infrastructure, medical associations, payers, and employers are rallying behind the concept of medical homes as a way to re-engineer primary care so that it is attractive to patients as well as physicians. The medical home concept originated in pediatrics more than 50 years ago as a way to ensure that special-needs children received the comprehensive care that they needed to thrive in mainstream society. In 2006, the American Academy of Family Physicians and the American College of Physicians began to explore an extension of that concept to care for patients with chronic diseases. Last year these groups, joined by the American Osteopathic Association and the American Academy of Pediatrics, released a joint statement defining the patient-centered medical home (PCMH) and extending it to the primary care context. The model is based on evidence that recipients of coordinated primary care live healthier, longer lives.
Last October, representatives from several prominent health plans—including Aetna, CIGNA, Humana, MVP Health Care, UnitedHealthcare, and Wellpoint, Inc.—joined the Patient-Centered Primary Care Collaborative, which is dedicated to advancing the patient-centered medical home. PCPCC membership includes professional societies, national employers, quality advocacy groups, and consumer groups. The health benefits companies will help the collaborative develop and implement a series of medical home pilot demonstrations.
Working with the National Committee for Quality Assurance (NCQA), PCMH advocates have developed a voluntary process based on the existing NCQA Physician Practice Connection Module to recognize physician practices that adopt the model. A Web-based tool helps physicians determine whether their practices meet the criteria for designation as a PCMH.
Too Many Patients, Too Little Time
The primary care physician shortage partly stems from the way in which they are compensated for their services. Medicare’s Fee Schedule, based on the Resource Based Relative Value Scale that sets the benchmark for physician fee schedules nationally, compensates physicians only for face-to-face patient visits. “Fee for service does not provide recognition and reimbursement for the time, effort, skill, and office capability that it takes to provide accessible, coordinated care for patients,” says Dick Salmon, M.D., Ph.D., national medical director for CIGNA Health Care.
Because reimbursement systems incentivize quantity, primary care physicians find that they must see more patients to make ends meet, explains Thomas Bodenheimer, M.D., clinical professor of family and community medicine at the University of California at San Francisco. “They have to do lots and lots of visits, and patient visits get too short to do all that we need to do per encounter,” he says.
The financial incentives, which have caused patient loads to rise to approximately 2,400 patients per doctor, leave physicians with little time to do more than acute care. “We do some chronic and preventive care but not anywhere near what we should be doing,” Bodenheimer says. “And coordinating care with the rest of the health system…we barely do that at all.”
Dawn Bazarko, senior vice president for clinical innovation at UnitedHealthcare, concurs: “It’s not possible to deliver a high quality of care experience in this environment.” A physician “would have to practice more than 24 hours a day to do everything that we think is in accordance with evidence-based guidelines, good preventive care, and good screening of patients with chronic disease. It’s untenable.”
Grundy observes, “As a buyer of care, I can buy a pretty good amputation for my diabetic, but in much of the United States, I have no way to obtain comprehensive care to prevent my patient from developing diabetes, or if she has diabetes, to do secondary prevention or control of the disease.”
Physician as Facilitator
A standardized recognition tool is important to physicians and payers because a key element of the PCMH concept is that physicians who commit to the model can receive better compensation. Physicians seeking designation as PCMHs must evaluate their practices against nine different standards, each of which has numerous sub-elements. Some of the elements are designated as “must pass.”
There are three levels of accreditation determined by a practice’s cumulative score. A practice can earn up to 100 points, but the minimum requirement for the PCMH designation is 25 points, provided that certain must-pass elements are also fulfilled.
At the core of the PCMH model is an ongoing relationship between the patient and the primary care physician. The primary care physician is expected to take responsibility for all of the patient’s health care needs and to appropriately arrange care with other qualified professionals. The model elevates the physician’s role to leader of the patient’s health care team. The physician is expected to ensure that all stages of care—preventive care, acute care, chronic care, and end-of-life care—are coordinated and/or integrated across all elements of the complex health care system.
The model recognizes that technology plays an increasingly important role in care management and coordination. It encourages the facilitation of care by disease registries, information technology, health information exchange, and other means to ensure that patients get the indicated care when and where they need it. Ideally, medical homes will make full use of the electronic medical record, but the NCQA guidelines allow for paper records.
Proponents insist this is not managed care by another name. In the medical home model, the primary care physician is “not a gatekeeper, but a care facilitator,” explains Carole Flamm, M.D., executive medical director at the Blue Cross Blue Shield Association. “Patient choice is very important. The patient designates ‘my medical home.’ And if patients want to change to a different medical home that provides a better environment or a better value, they can and will do that.”
“This is not managed care, but managed quality,” notes Edwina Rogers, vice president of health policy at the ERISA Industry Council (ERIC), and PCPCC executive director. She predicts that the medical home model will meet with wide consumer acceptance. “It’s hard to have good health care when you don’t have a good relationship with a personal physician. Increased access is one of the model’s key components.”
Melinda Abrams, senior program officer, Commonwealth Fund, believes that the high level of patient engagement in the medical home model will prove attractive to consumers. The model encourages shared decision-making and feedback from patients about their experiences and the quality of care. UnitedHealthcare’s Bazarko emphasizes the prospects for improvement in patient safety with one doctor coordinating care. “There’s evidence that the more doctors you have in your life, the more opportunity for patient safety errors.”
The proposed physician payment formula is also different than it was under managed care, as well as under the current fee-for-service payment system. “Capitation encourages very little volume, fee for service encourages lots of volume, and neither one encourages good results,” observes Francois deBrantes, national coordinator, Bridges to Excellence.
The medical home payment model uses blended fees. Fee for service remains a component of physician compensation. In addition, physicians receive a care management fee, which ideally will be risk-adjusted to account for the demands of a particular physician’s patient population.
Another component is performance-based compensation, which could include a shared-savings model or more traditional pay for performance. This introduces accountability and responsibility at the level of practice for satisfying quality, cost of care, and safety metrics.
The Bottom Line: Better Care
Initial tests of the medical home model are causing payers to think outside the box on how they can work better with physicians to deliver higher quality care. Bazarko notes that UnitedHealthcare will go live early this year with a plan to offer technology support, integrated care management, and enhanced payments to assist physicians to further invest in infrastructure and transform their health care practices for long-term sustainability.
Wellmark Blue Cross and Blue Shield of Iowa and Wellmark Blue Cross and Blue Shield of South Dakota saw that small physician practices could not afford to employ full-time chronic care management nurses to assist patients who present with multiple chronic conditions. So Wellmark is working with clinicians, members, and employers to redesign member support services to allow physicians to direct care and align support services with patients’ needs. One solution may be to make chronic care management nurses available to medical home physicians via webcam. Some plans, including Wellmark, Blue Cross, and CIGNA, are supplementing physician practices that do not have data capabilities with the provision of informatics and clinical resources.
North Carolina’s Medicaid system first piloted the medical home concept in the late 1990s. The state provided case managers and coordinators to ensure that patients did not fall through the cracks. The North Carolina program leaders are now considering dispatching clinical pharmacists to the homes of patients who are not complying with their medication orders.
L. Allen Dobson, M.D., who served as North Carolina’s state Medicaid director, says, “It was sort of empowering to the providers, giving them a significant role and connecting their individual practices with hospitals, health departments, social services, and other health care providers and putting resources toward making sure patients got better care.”
The public-private partnership was not intended to control costs but to build primary care infrastructure. Dobson says, “We focused on quality to start with but then realized that we could improve quality and cost at the same time. We learned that improving the quality of care actually saves money.” An evaluation of the North Carolina program by Mercer Government Human Services Consulting estimates that the state has saved $231 million through its innovative partnership. More important for North Carolina is that it built a primary care infrastructure in the rural communities and improved the quality of care.
Although proponents look to government to encourage these demonstration projects, ERIC’s Rogers is confident that large employers will come to appreciate the value of medical homes. As the physician’s office begins to address many of the prevention issues that employers are currently paying disease management companies to address, employers can leave that work to physicians, and in this way, care can become less fragmented.
Aetna’s Liss says, “Even if we don’t save a dime, if we attract more young medical school graduates to the practice of family medicine and facilitate better patient care, this will be a success.”
Perhaps the medical home concept will prove to be the prescription that cures what ails the health delivery system.
Helena Gail Rubinstein, the former director of policy and program management of the Group Insurance Commission of the Commonwealth of Massachusetts, is working toward completion of a Doctorate in health policy and management at the Harvard School of Public Health.
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