Full text is available at:
http://content.healthaffairs.org/cgi/content/abstract/
27/5/1246?ijkey=CH.hWlq1HBaiA&keytype=ref&siteid=healthaff

In the Literature

Synopsis

A study of 291 large medical group practices (i.e., those with more than 20 physicians) finds that adoption of medical home infrastructure is low, with very large groups having the highest levels of adoption.

The Issue

The U.S. health care system delivers, and pays for, care that is disorganized, fragmented, and lacking on many measures of clinical quality. The patient-centered medical home (PCMH) represents an attempt to address these issues through the provision of comprehensive, coordinated, and accessible care. However, the extent to which medical practices have adopted the model—and have the infrastructure in place to do so—is not known.

Key Findings

• About one-third of the medical groups participating in the study reported they use primary care teams at a majority of their practice sites.
• Forty-one percent reported that a majority of their physicians use electronic medical records (EMRs) featuring basic functionalities. Just over half have substantial electronic interchange with specialists and hospitals.
• One of four routinely uses nurse care managers for patients with severe illnesses.
• Sixty-five percent of groups participate in quality improvement collaboratives.
• Only 30 percent of medical groups provide physicians with performance feedback for at least four of the five clinical conditions measured.
• Almost two-thirds of groups surveyed said that they distribute guidelines to patients about proper care for chronic diseases.
• Only 10 percent received high scores on incorporating feedback from patients to improve their practices.
• The mean and median scores on the PCMH index were seven out of a possible 20.
• Increased practice size is positively and significantly associated with increased PCMH infrastructure.

Addressing the Problem

The PCMH model faces several challenges to widespread adoption. The first is the development of standard measurement data, although the National Committee for Quality Assurance and similar organizations have begun to take the lead in this area. Implementation also involves costs. Changing the way primary care physicians are paid, by aligning incentives, paying for coordinated and integrated care, and rewarding high performance, is essential for success.

About the Study

The sample included 291 medical groups of 20 or more physicians. Using data from the second National Study of Physician Organizations and the Management of Chronic Illness, the authors examined four components of the PCMH model: physician-directed medical practice (e.g., use of primary care teams); care coordination and integration (e.g., use of EMRs, electronic registries of patients with chronic illnesses, and nurse care managers); quality and safety (e.g., provision of performance feedback to physicians, participation in quality improvement collaboratives, and use of patient reminders); and enhanced access (e.g., ability of patients to access their EMR and communicate with their doctor via e-mail).

The Bottom Line

The level of adoption of PCMH infrastructure components among large medical groups is low, although there was wide variation among practices. In general, very large organizational size is strongly associated with greater PCMH structure. Ownership by a larger entity—a hospital or HMO—is associated with increased PCMH infrastructure compared with physician-owned groups.