Consolidating care (American College of Physicians annual meeting)
■ A medical home for all patients, with its lure of quality improvements and cost savings, is a concept gaining attention.
By Susan J. Landers — Posted June 16, 2008
Key to a high-performing, cost-effective system of health care may be the establishment of a patient-centered medical home -- a site where each patient has an ongoing relationship with a personal physician who provides continuous and comprehensive care.
Several sessions of the American College of Physicians Internal Medicine 2008, held May 15-17 in Washington, D.C., focused on this concept.
It's an idea that's attracting the attention of a widening range of players. Physicians, employers, insurers, states and the federal government are thinking about abandoning business as usual in order to try this approach. On May 16, Pennsylvania Gov. Edward Rendell unveiled a program based on a medical home model that is being piloted in the southeastern part of his state. The program, which is expected to be statewide next year, is a collaborative effort between the state and several insurance companies to support primary care practices that change the way they deliver care.
The AMA Council on Medical Education will present a report on "Educational Implications of the Medical Home Model" at the American Medical Association's June 14-18 Annual Meeting in Chicago. The report recommends that the AMA encourage integration of medical education into patient-centered medical home demonstration projects.
Additionally, medical organizations, including ACP, the American Academy of Family Physicians and others, collaborated on the development of "Joint Principles of the Patient-Centered Medical Home." Among them: Care is coordinated and/or integrated across all elements of the complex health care system.
"Patients with medical homes receive better preventive care and report getting more of the care they need, when they need it, as compared to patients without medical homes," said Karen Davis, PhD, president of the Commonwealth Fund, a research foundation in New York City, who gave the ACPmeeting's keynote address.
Medical homes would track referrals, identify abnormal tests and support patient self-management, Davis said. Practices that adopt such measures should be rewarded with extra payments or new methods of payment, as is done in other industrialized nations. Currently, only about 30% of U.S. physicians report receiving such incentives, she added.
An AMA-convened panel recently outlined how Medicare might increase payments to physicians who manage the care of chronically ill patients in its upcoming medical home demonstration project. If the Centers for Medicare & Medicaid Services takes this advice, medical home compensation for physicians could run into the thousands of dollars each month. CMS hopes the extra pay will be offset by cuts in the complex services and hospitalizations required by these patients.
The need for cost-effective changes in the way patients with chronic conditions are managed became clear in a conference session during which physicians discussed the care received by a hypothetical older patient.
The patient was an 83-year-old widow living alone in Washington, D.C. Her daughter, a single mother, lived and worked in the D.C. suburbs. The patient developed fever, malaise and mild shortness of breath and went to her local emergency department, where community-acquired pneumonia was diagnosed. She was admitted to the hospital under the care of a hospitalist. She had last seen her primary care physician two years earlier.
Upon discharge, she had many new diagnoses, medicines and appointments, said geriatrician and primary care physician Bruce Leff, MD, associate professor of medicine at the Johns Hopkins School of Medicine in Baltimore, who moderated the session.
"She left the hospital on a very different horse from the one she rode in on," he said. She was newly diagnosed with dementia, depression, diabetes and high cholesterol to accompany her arthritis, osteoporosis and chronic obstructive pulmonary disease.
After a cardiologist, endocrinologist and geriatrician provided their views on what the patient required next -- steps that reduced the number of medications and diagnoses, but not by much -- the audience questioned why the woman wasn't provided a care plan that included her primary care physician.
After all, these illnesses are common among patients they see, several internists said. "The health care delivery system didn't take care of this patient," said one audience member. "The three of you should have sat down together and then sent her home with one action plan."
The panelists agreed that primary care should have been the patient's first stop. "As one of the specialists, she does not need me," said endocrinologist Sanford R. Mallin, MD, a Milwaukee-based clinical professor of medicine at University of Wisconsin School of Medicine and Public Health in Madison.
"Hopefully, a patient-centered medical home would be able to help this patient," Dr. Leff added.