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Medical Home Concept Still a Work in Progress, Panelists Say

By Jane Norman, CQ HealthBeat Associate Editor

May 3, 2013 -- The verdict is still out on whether a patient-centered medical home really can turn out to be a home, sweet home for patients and providers as well as achieve measurable cost savings and higher-quality health care.

But experts who are working on the concept and also researching the outcomes said at a recent Capitol Hill briefing that they're willing to keep plugging away despite the hurdles. "Change is hard," said Barbara Tobias, medical director of the Health Collaborative of Greater Cincinnati, which includes a medical home program.

Physicians in medical home models need to "not just lead teams but work effectively as members of teams," said Tobias, who's also a professor at the University of Cincinnati College of Medicine.

It is a culture change for doctors who often have an "oldest child" syndrome of wanting to direct everything, but "I think ultimately this is the kind of system we want to practice in," she said.

Patient-centered medical homes are a model of primary care considered an ingredient in the transformation of the U.S. health care system. They are made up of teams of health care providers who coordinate care and are proactive in reaching out to patients rather than waiting for patients to come to them, panelists said at the briefing sponsored by the Alliance for Health Reform. In demonstration programs, either the government or insurers often chip in money to physician practices to help make changes.

That means, for example, that doctors figure out ways to free up time in their schedules so patients can make same-day appointments and wait times are brief. Consultation is available over email or on the phone, and offices are open outside traditional work hours. Patients engage in decision-making with their doctors in active discussions.

Melinda Abrams, vice president at the Commonwealth Fund, said the idea is attractive because so many Americans have problems finding a primary care doctor and find inefficient and uncoordinated care when they enter the health care system. At the same time, primary care doctors are working on what one audience member described as a "hamster wheel" of longer hours for lower wages, and young residents are not attracted to such a regime.

A January report by the Commonwealth Fund proposed policy options for cost savings in the health care system totaling $2 trillion over 10 years, and a quarter of that was tied to changes in the primary care system, said Abrams. Commercial health plans in 49 states are testing medical home pilot programs.

Patient-centered medical homes are "the vehicle right now to strengthen primary care," Abrams said.

But will they really save money? Studies of some large health systems like Geisinger that have used the model found major savings. But in February 2012, another set of researchers found less evidence for savings in a study commissioned by the Agency for Healthcare Research and Quality.

Meredith Rosenthal, a professor of health economics and policy at the Harvard School of Public Health, said it's going to take more time to determine how much can be saved by medical homes. Getting broad participation from a variety of payers, including insurers and public programs, is important, as is getting them to contribute funds to physician practices in order to help make the changes work, she said. The most cost savings are found when there are fewer emergency department visits and fewer hospitalizations for chronic illnesses, she said.

Small primary care practices can make great strides with adequate financial and technical support, said Rosenthal. Success is more likely when there are strong ties with hospitals and specialists, she added, but ultimately may depend on larger payment reforms moving the system away from fee-for-service.

Sean Cavanaugh, acting deputy director of programs and policy at the Centers for Medicare and Medicaid Services (CMS), said it's important to have many different types of payers involved in a medical home model because a single payer can't pay practices enough in incentives to transform the office. CMS and its Innovation Center are in the midst of a comprehensive primary care initiative launched late last year in practices in seven markets across the country with about 313,000 Medicare beneficiaries served. In the program, Medicare offers bonus payments to doctors who do a better job of coordinating care.

Robert Graham, a research professor of health policy at George Washington University and a former federal health official, said the idea of medical homes has only very recently been put to large-scale tests and it's very difficult to make a "huge amount of change" in just a few years. Primary care doctors who felt the way they practiced was not sustainable were the ones who pushed the medical home concept, he said.

"This movement came from the provider community, and it will continue to be driven by the provider community," he said.

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