American College of Physicians: Internal Medicine — Doctors for Adults ®

Tuesday, May 11, 2010

Does Group Health's "Medical Home" Leave The Poor Behind?

This post by Richard A. Cooper, FACP, appeared at Better Health.

Group Health has published two papers recently, one in Health Affairs and the other in JAMA, both extolling the virtues of its medical home. These follow their brief report last fall in the NEJM and the lengthy description of their model in the American Journal of Managed Care. Their model has been promoted by the Commonwealth Fund, and it is cited in the current issue of Lancet.

The big news is that costs were a full 2% lower than conventional care, hardly a great success--it wasn't even statistically significant. But was even this small difference due to the medical home, or was it because the medical home patients were less likely to consume care?

Group Health assured us that the 7,000 patients still enrolled in their medical home were the same as the 200,000 controls because "burden of disease, as measured by Diagnostic Cost Groups (DxCGs), was similar." But while the DxCG system adjusts for diagnoses, age and sex, it does not adjust for sociodemographic factors, the strongest determinant of utilization. Nor does it appear to have accounted for health status. The chart below, from the AJ Managed Care publication, shows just how different these two groups are. Sadly, these differences are not described in papers in the NEJM, JAMA or Health Affairs, which are read more widely.

Anyone should be able to get better outcomes with patients who are more highly educated (and presumably higher income), who are more often white and whose baseline health status is better. Indeed, it's remarkable that the DxCGs could have been so similar, since health status was so much better among medical home patients. What's most amazing is that this favorable group consumed only 2% less resources. I would have expected at least 20% less.

But even if the model were valid, it's important to recognize the practical limitations in generalizing from it. It took eight physicians to constitute the six FTE physicians who provided medical home care, and these physicians had patient panels that were almost 25% smaller than Group Health's usual clinics.

Nonetheless, medical home patients were more frequently referred to specialists (and that was statistically significant). Not surprisingly, physicians in the medical home had less stress. Patients were more satisfied, too. But there are not 25% more primary care physicians available (really 50% more, when their part-time nature is considered) to allow all of the primary care physicians in America to reduce their panels and work part-time as these eight did, nor will there be enough specialists for them to refer to if the nation doesn't train more (see: No One is Home in the Medical Home).

Beyond all of this, I'm left with two nagging questions. Why, if the Medical Home is patient-centered, did it start with 9,200 patients in 2006, decline to 8,094 by the end of 2007 and fall further to 7,018 by the end of 2009, a loss of 24% of the patients in less than three years? Where did they go? And why?

And why, if Group Health's Medical Home is to be a model for the nation, does Group Health accept commercially-insured patients from eighteen counties (top panel) but Medicaid patients from only three (bottom panel)?

If we want high-performance primary care, it will have to be delivered in high-performance systems that use scarce physician resources more efficiently. Panel size will have to be increased, not decreased, as physicians defer more care to others. And physician satisfaction will have to increase not because of less stress but because physicians are rewarded for exercising the complex knowledge that they worked so hard to attain.

Most of all, if we want to decrease health care spending, we will have to recognize that the major remedial costs are associated with the added care that is provided to low-income patients. It is time to stop talking about wasteful medical homes for college grads and start talking about safe neighborhoods, high-quality schools and workable systems of care for a diverse and needy nation.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Anonymous Robert Reid MD PhD said...

Revitalizing primary care is critical to reforming the American health care system. Our recent Health Affairs and American Journal of Managed Care (AJMC) papers report real-world empirical findings about the patient-centered medical home - a redesign that’s happening across the country, including in the “safety net.” We address Dr. Cooper’s concerns below:

WE EXPECTED BASELINE DIFFERENCES AND ADDRESSED THEM. Baseline differences, like those in the demographic table from our patient survey (at our medical home and 2 control clinics) that Dr. Cooper mentions, are common and expected in quasi-experimental evaluations like ours. Health Affairs’ space constraints did not permit that table to be reprinted there. Readers were referred to the AJMC paper. For the cost and utilization analyses that included patients at 19 control clinics (not just a sample in 2 that we surveyed), our team used accepted and state-of-the-art methods to adjust for patient differences. We chose in advance different comparison groups and adjustment methods for the patient survey and the utilization and cost analyses; we provide valid information about our methods and the basis for our comparisons.

THE ROI IS NOT NEGLIGIBLE. Dr. Cooper questions a difference of $10 per patient per month and a return on investment of $1.5 for every dollar spent. But these are notable, especially since this rather modest investment brought significant improvements in quality of care and patient satisfaction. Savings of this magnitude translate into millions of dollars yearly for health care systems.

GROUP HEALTH OFFERS COVERAGE WHERE MOST WASHINGTONIANS LIVE. We share Dr. Cooper’s concern for improving health and health care for everyone in our nation, including the poor. Group Health delivers care in the most populous counties in Washington State; nearly half of all Washingtonians below the federal poverty level live in the three counties Dr. Cooper mentions. To explore if our findings apply to poor, disadvantaged and uninsured populations, Group Health’s MacColl Institute is also helping to implement the Safety Net Medical Home Initiative supported by the Commonwealth Fund.

DISENROLLMENT WAS SIMILAR ACROSS GROUPS. All U.S. health plans have voluntary and involuntary disenrollment. Of the 8,499 adults enrolled for at least 6 months at the medical home clinic in 2006 (the study population at baseline), 83% were enrolled through 2008. Most of the remainder disenrolled from Group Health in proportions similar across clinics - and typical of many other U.S. health plans.

PRIMARY CARE IS VITAL AND MUST BE ADEQUATELY RESOURCED. Like most people committed to solving America’s health care challenges, my co-authors and I believe strengthening primary care is vital. We believe that increasing panel sizes for primary care teams, as Dr. Cooper advocates, runs counter to the well-known advantages of strong, ongoing patient-provider relationships on which primary care is based. The medical home has the potential to reverse the recent declines in primary care in the United States compared with other developed nations. Our results are among the first of many to assess how well such models works in disparate settings and populations. We look forward to the results of these other demonstrations.

May 12, 2010 at 3:19 PM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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