By Karen Davis and Steve Schoenbaum
Insurance coverage helps people gain access to health care, but the next thing you have to ask is 'access to what?'
—Anne Beal, M.D., Assistant Vice President, Quality of Care for Underserved Populations, The Commonwealth Fund
As discussed in a previous column
, practitioners and policymakers are looking to the medical home model as a way to improve the quality of primary health care. The model has been promoted by professional organizations such as the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association and discussed in congressional debates as a way to improve preventive care and control health care costs. As defined by the American Academy of Pediatrics, "A medical home is not a building, house, or hospital, but rather an approach to providing comprehensive primary care. A medical home is defined as primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective."
The Commonwealth Fund 2006 Health Care Quality Survey
found that adults who have medical homes not only have enhanced access to care but also receive better-quality care. For the survey, medical homes were defined simply as regular health care providers that offer timely, well-organized care and enhanced access. Specifically, we asked respondents whether they had any difficulty contacting their regular providers by telephone or on evenings or weekends, and whether their office visits were generally well organized and running on time.
The survey found only one of four adults (27%) reported that their regular provider had all four of these indicators of a medical home. Three-fourths (74%) of those with a medical home said they always get the care they need, compared with only half (52%) of those with a regular provider that did not meet the criteria of a medical home and 38 percent of those without a regular source of care.
What's more, the benefits of medical homes are spread across all patient groups with access to them. The survey found that, when minorities have insurance coverage and a medical home, racial and ethnic differences in terms of access to and quality of care are reduced or even eliminated. It found disturbing evidence that many black and Hispanic adults lack access to coverage, but even uninsured patients fortunate enough to have medical homes reap some of the benefits. It is encouraging that the findings highlight two important strategies to reduce disparities and provide better care to all—expand insurance coverage and provide enhanced primary care services.
The survey reveals some of the benefits of having a medical home. It found that, when African Americans and Hispanics have medical homes, they are just as likely as white patients to receive reminders to get preventive care. Use of patient reminders substantially increases rates of routine preventive care, such as cholesterol screening, breast cancer screening, and prostate cancer screening.
Having well-coordinated primary care is particularly important for the millions of Americans with chronic conditions and here, too, the medical home model shows great promise. Only 23 percent of adults with a medical home reported their doctor or doctor's office did not give them a plan to manage their care at home, compared with 65 percent of adults without a regular source of care. Among hypertensive adults, 42 percent of those with a medical home said that they regularly check their blood pressure and that it is well controlled. Only 25 percent of hypertensive adults with a regular source of care, but not a medical home, reported this. It Is Time for Change
To encourage primary care providers to become medical homes, several changes are needed. In particular, we need to:
- reform primary care payment;
- measure and reward medical homes;
- test care delivery models; and
- maximize the potential of health information technology.
There are important initiatives around the country that are pointing the way. Case in Point: Reform Primary Care Payment
To promote the types of health services provided in medical homes, we need to be willing to pay for them. Most providers are not reimbursed if they take steps to coordinate with specialists or other providers, make themselves available to patients by e-mail or telephone, counsel patients in managing their chronic conditions, or invest in health information technology to support such efforts. The dysfunctional primary care payment system is one reason that fewer medical school graduates are choosing to enter the field.
Allan Goroll, M.D., a primary care internist at Massachusetts General Hospital, and colleagues, including one of us, has put forth a new payment model
for adult primary care. Under what Goroll describes as a "new social contract," he would substantially increase payments to primary care providers in exchange for a new way of practicing to improve the accessibility and quality of care. Practices would receive monthly payments for each patient under their care, with payments adjusted to account for patients' varying levels of need and risk. It is expected that more than two-thirds of the payments would be designated for multidisciplinary health care teams to provide comprehensive care services, and for information systems to monitor safety and quality. Fifteen to 25 percent of payments would be linked to performance in meeting benchmarks of cost-effectiveness, efficiency, health outcomes, and patient-centered care. Case in Point: Measure and Reward Medical Homes
We also need consistent standards to define medical homes. The National Committee for Quality Assurance has created an evaluation program, Physician Practice Connections,
to recognize practices that use information technology to connect physicians with patients and systematically improve the quality of care. Such practices need to be patient-centered. They should be able to access all patients' medical histories readily, track their conditions, and ensure that patients receive preventive care.
Some pay-for-performance programs across the country, including Bridges to Excellence,
have begun to use the Physician Practice Connections standards as a means to assess and reward practices.
With Fund support,
NCQA is working with the four primary care specialty societies to reach consensus on a limited set of measures that would qualify primary care practices as patient-centered medical homes. The standards set out conditions that practices must meet in the areas of access and communication, patient tracking and registries, care management, support for patients' self-management, electronic prescribing, tracking of tests and referrals, performance reporting and improvement, and advanced electronic communications. Case in Point: Test Care Delivery Models
Once there are agreed-upon standards to define medical homes, practices will need new tools and care delivery systems to achieve them. Well-known models of coordinated, patient-centered care—such as the idealized design of clinical office practice
and the Chronic Care Model
—offer roadmaps, which have been tested and refined at practices around the country. TransforMED,
a nonprofit initiative of the American Academy of Family Physicians, is in the midst of a two-year demonstration program to test the potential of a new model of primary care in 36 U.S. practices. The model sets forth core goals, such as superb access to care, establishment of patient registries, and team-based care. To test the best way to achieve these goals, half of the practices will work together to implement the model and half will develop their own systems. The Fund is supporting an evaluation
of the demonstration program to assess the impact of the changes from the perspective of patients. Case in Point: Maximize the Potential of Health Information Technology
Health information technology is a crucial foundation for medical homes. While many doctors' offices use electronic health records for billing or other administrative functions, few practices exploit health IT systematically to measure and improve the quality of care they provide. For example, automated alert systems can remind practitioners to deliver preventive care. Electronic health records can generate reports to ensure that all patients with chronic conditions receive recommended tests and are on target to meet their treatment goals. Computerized ordering systems, particularly with decision-support tools, can prevent medical and medication errors, while e-mail and interactive Web sites can facilitate patient–provider communication and patient education.
The Institute for Urban Family Health, a New York City network of community health centers, has invested in electronic health records
as part of their efforts to proactively measure and improve their quality of care. Among other benefits, the system has enabled them to monitor the care provided and the health outcomes of all diabetes patients. While the records showed that clinics were providing the same care to all patients, regardless of their race and ethnicity, outcomes for African Americans, Latinos, and Asian Americans lagged behind those for whites. By closely analyzing the electronic records, they were able to pinpoint systems that seem to improve diabetes outcomes—including more frequent visits and working with a staff nutritionist—and target their resources to improve health outcomes.
Providing support to community health centers and other safety net providers to acquire and use health information technologies and become medical homes could make an enormous difference in addressing health disparities among the most vulnerable populations.
As always, we are interested in your feedback. Please e-mail us at firstname.lastname@example.org
July 2007Written with the assistance of Martha Hostetter, editorial adviser.