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Wonks' Medical Dream Home: Easy to Design, Tough to Build

By John Reichard, CQ HealthBeat Editor

September 10, 2008 -- Panelists at a Washington, D.C., forum Wednesday offered a sober assessment of the prospects for redesigning the health care system around the concept of a "medical home," but at the same time offered some evidence of its tantalizing potential.

Much discussed in policy circles of late, the medical home idea aims to make a long-term relationship with a trusted primary care doctor or team of primary care doctors the foundation of care for the chronically ill. The idea entails sorting through the complex treatment needs of the patient to figure out the most efficient way of getting the best possible medical outcomes.

That means deciding which specialist to see and when, whether to go to a clinic or a doctor's office or a hospital for tests and procedures, and ensuring the patient takes the right mix of medications to prevent complications from conditions such as diabetes, depression, congestive heart failure, and other cardiovascular disease.

It means much more frequent contact with the patient through expanded hours and the use of e-mail messages and the telephone. The freer communication is intended to answer questions, issue reminders to get tests, take medications, exercise, and eat properly and to more closely monitor the patient's medical condition.

But doing all that is a tall order for doctor's offices, many of which consist of only a single doctor or just a few doctors. In many cases, they lack computer systems to keep detailed medical histories of patients, to send e-mail messages to patients in a way that protects their privacy, consult the latest treatment guidelines, issue reminders to the patient for tests and procedures, and measure and improve their own treatment methods—all activities that medical home advocates say are needed to address the nation's looming fiscal health cost crisis.

A study released at Wednesday's forum reported that in many cases even the largest medical practices lack the elements needed to provide patients with a medical home. The findings "highlight the gap between the current state of medical practice and widespread adoption of the patient-centered medical home," said the study led by Diane R. Rittenhouse, an assistant professor of family medicine at the University of California, San Francisco. The study, which was limited to practices that treat asthma, diabetes, congestive heart failure, or depression, was published in the September/October issue of the policy journal Health Affairs.

In surveying 1,162 medical practices with 20 or more doctors, researchers found that under half—42 percent—reported that most of their doctors used electronic medical records "with basic functionalities." Only about a third used primary care teams at the majority of their practice sites. Under a third maintained registries of patients with specific diseases to better manage treatment of those conditions. Only one of four used nurses to routinely manage care for patients with severe illness.

While 65 percent of the practices ran some form of quality improvement program, only 34 percent provided doctors with feedback on their performance for at least four of five clinical conditions measured. Fewer than half did much in the way of issuing reminders to patients and assessing their health risks. "Only 10 percent reported that most of their physicians would 'strongly agree' with statements that the group regularly incorporates feedback from patients in improving care and developing new services," the researchers wrote. Only about 30 percent said doctors communicated with patients by e-mail message even occasionally.

But Glenn D. Steele, president of Pennsylvania-based Geisinger Health System, told the forum sponsored by Health Affairs that results from a Geisinger pilot test of the medical home concept were "probably one of the most dramatic things I've seen in 30 years of practice and leadership." Geisinger's use of the model delivered a 20 percent reduction in hospital admissions at two pilot sites according to very preliminary data cited by another study in Health Affairs authored by Geisinger chief technology officer Ronald Paulus, Commonwealth Fund President Karen Davis, and Steele. The data also showed a 7 percent total reduction in medical costs. Geisinger now plans to expand the program to 10 more clinical sites.

The Geisinger model entailed monthly payments of $1,800 per doctor to recognize the expanded scope of practice. Monthly stipends of $5,000 for every 1,000 Medicare patients are also paid to the practice to help finance additional staff and extended hours. The program features round-the-clock access to primary and specialty care, a "personal care navigator" to respond to patient inquiries, and the use of nurse care coordinators.

There are other signs of the medical home concept making small inroads into actual medical practice. The National Committee for Quality Assurance, an industry-based standards-setting group, has begun a program to recognize medical practices as medical homes. The Rittenhouse study also noted that advocates of the medical home concept are encouraged by the use of the concept in the North Carolina Medicaid program, quoting an estimate that it saved the state government $231 million in fiscal years 2005 and 2006.

But Rittenhouse warned that a transformation based on the medical home won't happen overnight. "Medical groups are being asked to make fundamental changes in the way they deliver care and make up-front investments in electronic systems and personnel, which are not routinely compensated."

Urban Institute analyst Robert Berenson cautioned the forum that the concept is at risk of becoming the latest "failed silver bullet" in health care because of the challenges involved in implementing it and high expectations surrounding it. He warned that it is no substitute for separate efforts needed to build up the nation's primary care workforce. And Harvard Business School lecturer Richard Bohmer warned that system planners will get things wrong if they focus too much on the resources needed to make the medical home concept work and not enough on the nature of the work providers must perform. Steele noted that widespread adoption would have a major impact throughout the system. A dramatic reduction in inpatient admissions would entail a fundamental change in the services delivered by hospitals, he said.

It would involve paring away services and staff layoffs—"a tough thing," Steele noted.

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