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Large Physician Groups Score Low On Key Measures Of “Medical Home” Approach To Care

Health Affairs Thematic Issue On Innovations In Health Care Delivery Also Explores Efficacy Of Retail Clinics, Other Alternative Delivery Options

Bethesda, MD -- Nearly everybody agrees that the U.S. health care delivery system is broken --  but there’s no clear consensus on how to fix it. One leading alternative is the “patient-centered medical home,” designed to put primary care doctors in charge of coordinating care. But despite the growing promise that this health care model offers, even many large physician practices lack the essential elements to create a medical home for patients to receive care, according to a new study published today in the journal Health Affairs. http://content.healthaffairs.org/cgi/content/abstract/27/5/1246

When researchers examined large medical groups with at least 20 physicians, they found that these physician practices are lagging on key measures of what it takes to create a “medical home,” a model of health care delivery that emphasizes comprehensive primary care to ensure the best outcomes for patients. The medical home model is now widely recognized by health care providers, large employers such as IBM, and increasingly patients as a promising blueprint for delivering comprehensive care over a patient’s lifespan.

The study, by researchers at the University of California at San Francisco (UCSF), UC Berkeley, and the University of Chicago, appears in the September/October issue of Health Affairs. The issue, funded by the California HealthCare Foundation, focuses on competing models of innovation in health care delivery. http://content.healthaffairs.org/current.shtml

Between March 2006 and March 2007, researchers surveyed all large physician practices across the United States that treat patients with asthma, diabetes, congestive heart failure, and depression. They looked at four key aspects of the medical home model: whether physicians work closely with other health care providers in patient care “teams”; how well care is coordinated and integrated; whether care is delivered in ways that maximize quality and safety; and whether patients can reach physicians in nontraditional ways, such as by e-mail. Researchers also looked at physicians’ use of electronic medical records, disease registries, patient reminders, and performance feedback as well as their distribution of educational materials to patients.

“The medical home model holds great promise for the transformation of primary care, but this transformation won’t happen overnight,” said Diane Rittenhouse, M.D., M.P.H., the study’s lead author and an assistant professor at the UCSF School of Medicine. “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.” Rittenhouse’s study was supported by the Robert Wood Johnson Foundation, the Commonwealth Fund, and the California HealthCare Foundation.

The largest of the groups in the study -- those with more than 140 physicians -- and those owned by a hospital or health maintenance organization (HMO) scored highest on critical measures of the medical home model, perhaps because they have more resources to invest, Rittenhouse said. She and her colleagues also found that certain components of the medical home model appear to be more prevalent than others. For example, 41 percent of groups surveyed said that they use electronic medical records with basic functionalities, and just over half share information electronically with hospitals and specialists, but fewer than one-third rely on primary care teams to deliver care. Almost two-thirds of groups surveyed said that they distribute guidelines about proper care for chronic diseases. However, only 10 percent scored high on incorporating feedback from patients to improve their practices.

Rittenhouse and colleagues are currently studying smaller practices with fewer than 20 physicians, and study results will be available in late 2009.

Retail Health Clinics. The medical home model represents one end of the spectrum of approaches to reforming the delivery system. At the other end of the spectrum, some advocates of cheaper and more convenient health care are placing bets on retail health clinics, often located in drug stores and staffed by nurse practitioners or other nonphysicians. New findings about retail health clinics show that they may become a safety-net provider for patients who would otherwise seek routine care at hospital emergency departments.

Ateev Mehrotra and colleagues at RAND and the University of Pittsburgh compared demographics and reasons for visits among retail clinics, primary care physicians (PCPs), and emergency departments (EDs). They found that the vast majority of retail clinic visits are for a short list of acute problems or preventive care. Compared to PCPs, retail clinics serve a patient population that is younger, less likely to have a PCP, and more likely to be uninsured.

If they become commonplace, the authors estimate, retail clinics could replace up to 18 percent of PCP visits and 12 percent of ED visits. There are now almost 1,000 retail clinics in the United States, a number that is expected to surge to 6,000 by 2011. The authors discuss how retail clinics could affect coordination of care, disruption of care, and financial implications for PCPs. http://content.healthaffairs.org/cgi/content/abstract/27/5/1272

Report from the Field. In a complement to the research on retail clinics in this issue by Mehrotra and others, Los Angeles Times journalist Dan Costello reports on the competing views of retail clinic “bulls” and “bears” about the future of these clinics. Bulls argue that access and coverage problems may drive future growth in retail clinics, but bears “point to an increasingly littered landscape of failed operators as a signal that the industry’s heyday is behind it.” http://content.healthaffairs.org/cgi/content/abstract/27/5/1299

Costello’s article marks the debut of a new Health Affairs feature called “Report from the Field,” a collaboration between Health Affairs and Kaiser Health Reporting, a new initiative of the Henry J. Kaiser Family Foundation. Beginning with this volume, every issue of Health Affairs will include a timely article that views health care through a journalist’s lens.


ABOUT
HEALTH AFFAIRS:

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org. The full text of each Health Affairs Web Exclusive is available free of charge to all Web site visitors for a two-week period following posting, after which it will switch to pay-per-view for nonsubscribers. Web Exclusives are supported in part by a grant from the Commonwealth Fund.

 

©2008 Project HOPE–The People-to-People Health Foundation, Inc.