Community Insight
Medical Homes Promise Better Access to Quality Health Care
Melinda K. Abrams
Assistant Vice President, Patient-centered Coordinated Care Program, The Commonwealth Fund
Practicing medicine is both an art and a science.
We all need the right person to help us make sense of the latest treatment options and scientific studies. But the answers are not always clear, especially for patients with complex or chronic medical challenges. That's where the art comes in.
Think back to Robert Frost's iconic American poem, The Road Not Taken:
"Two roads diverged in a yellow wood.
And sorry I could not travel both
And be one traveler, long I stood."
The complexity of our world today gives us far more than two paths among which to choose. Especially when it comes to health care, we can feel lost in a labyrinth.
A promising model is beginning to emerge. Multiple studies are showing the benefits of investing in primary care practices and medical homes for patients. We're finding that medical homes create winners on all fronts. Patients win because they get better care and are more satisfied with their health care experiences. Doctors win because they get rewarded for spending time – whether on the phone, in person or via email – helping their patients stay well. And the payers win because healthier patients save money.
Medical home models are sprouting up around the country, with hundreds of practices testing the concept. They are not all the same. They have emerged community by community. We are in the middle of an exciting movement to reinvest in primary care. More than 31 states are engaged in medical home demonstration projects. The federal government is planning three large medical home demonstrations. And, in the private sector, dozens of medical home projects have emerged at hundreds of medical practices across the country.
The Health TeamWorks' (formerly the Colorado Clinical Guidelines Collaborative's) Patient-centered Medical Home Pilot is among the most promising programs in the country. From the beginning, Health TeamWorks sought buy-in from all the players, both public and private health plans. They attracted the biggest insurance companies, including Aetna, Anthem-Wellpoint, CIGNA and United Healthcare. Medical practices are receiving enhanced payments for at least 20,000 patients covered by those insurers along with Colorado Medicaid and Colorado Access.
The pilot will be evaluated by Meredith Rosenthal, PhD, from the Harvard School of Public Health to determine the effect on quality, cost trends and satisfaction for patients and their health care team. Should the data show that medical homes rein in costs while improving quality of care and patients' health care experience, these models can serve as catalysts for making medical homes the norm. The participating national insurers could then spread the model to multiple private markets across the country. Indeed, the support of the national insurance companies and large public programs is vital.
Some challenges remain. The jury is still out on the best payment models. Colorado's program is using a hybrid system. Providers still get paid partially based on "fee-for-service," the traditional model where a patient comes in for a face-to-face visit and the doctor bills for the services provided. Health TeamWorks also negotiated monthly per-patient care management fees that allow doctors to invest time in patient care outside of office visits. Finally, doctors can earn bonuses for meeting or exceeding quality goals. This "blended" payment model is designed to give doctors the freedom to provide comprehensive, holistic care that gives them more time to talk with patients and address medical concerns early before their condition becomes chronic and more costly to treat. If doctors and their care teams take time to ensure better outcomes for patients, studies show that quality improves, patients and providers are more satisfied and the cost of care declines.
We don't yet know exactly which payment model works best. It's clear that we have to move away from strict fee-for-service. We need to pay for value over volume. We must measure and report on quality. And we must reward practitioners for keeping patients healthier. My hunch is that there may not be one distinct payment model that works for all medical home models. Like the diverse medical homes that are cropping up around the country, varying payment models will also emerge. We will learn what works and what doesn't.
While payment issues remain thorny, there is evidence that we need to promote, replicate and continue to test the medical home model.
Patients appreciate having access to a trusted clinical partner. They want to be able to see their practitioner on short notice at times that are convenient for them. They want to be able to ask questions without having to schedule an office visit. Sometimes they need medical advice or care on weekends, evenings or holidays. They should be able to get that care through – or arranged by – their medical home, not at an expensive, overcrowded Emergency Room. Those with complex issues yearn for a trusted medical guide to help them navigate conflicting treatment options and a fragmented system of hospitals and specialists. They want a wise partner to help them choose the best course of treatment. This is where the medical home fuses both art and science.
Practitioners are eager for help, too. Most physicians have little training in business practices and no time to interpret metrics. In a traditional medical practice, taking time to chair a staff meeting or analyze trends in office operations, such as timeliness of notifying patients about abnormal test results, cuts into billable time and reduces revenue. While some medical providers may be comfortable with technology, few know exactly how to maximize digital tools to interpret complex data, then take action based on results.
These issues will be especially challenging for sole practitioners or doctors in small practices. They may not have the resources to hire technology consultants or care coordinators. The Collaborative is tremendously promising on this front. It's a great national model of what I call a shared resource. These are locally based, but centralized resources that can provide anything from technical assistance to shared clinical services, such as a care coordinator who supports several practices.
We are seeing significant and consistent data that medical homes provide better access to quality care. Patients thrive. Studies show clinicians are much happier too. They report less emotional exhaustion, higher satisfaction with patient care and better work-life balance. Medical homes also help increase efficiency. We've found substantial reductions in ER usage and unnecessary hospitalizations.
The energy, enthusiasm and pioneering approach to medical homes in Colorado may be contagious. As the pilot progresses, we will get a better understanding of one new payment model, uniform criteria for medical home certification and standard measures for monitoring and evaluating progress.
Based on the lessons from Colorado, we will better know which road to take. It's time to put the medical home model on a fast track.
