Medical home demo reports some positive outcomes -- with caveats

An AAFP demonstration project may become a model for future efforts, although practices showed only modest gains in quality of care and required external support.

By Chris Silva — Posted June 21, 2010

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Moving to a patient-centered medical home model of care can present significant challenges for physician practices, but given the necessary resources and guidance, some early adopters have found that the move can be worth the effort. That's according to a new report commissioned by the American Academy of Family Physicians and its for-profit subsidiary, TransforMED.

Most of the medical practices that participated in the organizations' two-year national demonstration project from June 2006 to May 2008 achieved positive results in quality of care, chronic disease care and prevention outcomes, stated the report published in a special supplement to the May/June 2010 Annals of Family Medicine.

But those quality gains were modest, and the project created no positive movement on patients' ratings of their own care, researchers found. The project also revealed that successful transformation to a patient-centered medical home "requires a great deal of effort, motivation and support."

Developing care coordination teams -- a key component of the medical home model -- requires substantial cross-training efforts, as well as the development of a uniform strategy among all staff about how best to manage patient care, the project's evaluators found. The results showed that most practices would need to add additional financial and human resources staff to help achieve the full medical home transformation.

Still, officials at the AAFP and TransforMED said the project, which was adapted several times during its run to overcome challenges and meet goals, was an overall success and will assist in crafting future medical home efforts.

"The pioneers at TransforMED, as well as the family medicine practices who gave their time and effort to this project, have laid the groundwork for what has become a driving force in practice improvement, as well as in larger health system reform," said Lori Heim, MD, AAFP's president.

Maximizing skill sets

Thirty-six family medicine practices were chosen to participate in the project, although five dropped out before the end of the two years. One of those practices was denied participation by its health system's institutional review board, and another withdrew after it determined the data collection requirements were too burdensome. The remaining practices were split into two groups, with one group having the assistance of practice facilitators and the other practices working out strategies on their own.

The Myrtue Medical Center in Harlan, Iowa, was part of the first group, and officials there said they were pleased with how the assistance helped their project along.

"For us, this represented a way to step back and look at how we were doing things," said Don Klitgaard, MD, a family physician and the center's medical director. "We had a lot of staff that may not have been using their full skill sets. I think now we're definitely working more as a team. For me, more of my day is spent doing now what I was actually trained to do."

Permanent changes made at Myrtue included adding an electronic medical records system, an online patient medical data portal, an advanced scheduling system and an e-prescribing process. The medical center also added some new nursing positions, including dedicated health coaches, and built a new wellness center.

Dr. Klitgaard said the changes have produced a renewed level of commitment from staff, who are emboldened by the new efficiencies that the project helped them discover. "It changes your perspective on how you care for patients."

Discovering the downsides

Despite the positive experiences reported by practices like Myrtue, the report cautions that the challenges facing a new patient-centered medical home can be daunting.

"We find that although it is feasible to transform independent practices into the [demonstration's] conceptualization of a PCMH, this transformation requires tremendous effort and motivation, and benefits from external support," researchers wrote. "Most practices will need additional resources for this magnitude of transformation."

Another segment concluded that without a "fundamental transformation" of the health care system, including substantial payment reforms, it will be difficult for physician practices to launch medical homes on their own.

TransforMED acknowledged that during the early stages of the project, too much emphasis was placed on overhauling the practice and not enough on the patient. The demo's evaluation team reported that implementation of the medical home model actually seemed to worsen patients' perception of care in the short term due to the perceived trade-off of implementing practice changes at the expense of physicians' personal relationships with patients, and other key factors.

Dr. Klitgaard said his medical center's results were positive only because of a high level of dedication. "It's not easy," he said. "It's a never-ending process with this."

Now that the demonstration is over, however, he can't imagine practicing without being familiar with aspects of the patient-centered medical home model.

"In the future, if you can't provide this type of care to your patient, you'll be at a disadvantage," he said. "It can be difficult and messy sometimes to get there, but the technologies available and coming online are improving and coming of age more, so that's going to help folks in the future. It's a lot of work, but there's no way in the world we'd go back to how we used to practice."

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Medical home pioneers

Physician practices that participated in a national demonstration project on patient-centered medical homes varied in practice size and location, as well as on whether they directed the home on their own or had additional help:

Facilitated Self-directed
Solo 35 22
Small (2-3 physicians) 24 12
Medium (4-6 physicians) 17 44
Large (7 or more physicians) 24 22
Rural 29 33
Suburban 53 55
Urban 18 11

Source: "Implementing the Patient-Centered Medical Home: Observation and Description of the National Demonstration Project," Annals of Family Medicine, May/June (link)

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New AMA resource on alternative delivery models

The health reform law opened up several avenues to begin testing new payment and delivery reform models. To help guide physicians through the nuances of these models, the American Medical Association on June 10 announced a new white paper available to its members, "Pathways for Physician Success Under Healthcare Payment and Delivery Reforms."

In addition to establishing a CMS Center for Medicare & Medicaid Innovation, the new law calls for creation of accountable care organizations, a national payment bundling pilot program, team support for patient-centered medical homes and an extension of the Medicare gainsharing demonstration.

The AMA says these new programs must be patient-centered and physician-led if they are to become viable strategies. Although the current fee-for-service system poses significant challenges for physicians, at least doctors are used to dealing with them, states the white paper, which was written by Harold D. Miller, executive director of the Center for Healthcare Quality & Payment Reform.

"Any new payment system will reduce some or all of the opportunities and challenges in the current system and add new ones, but since it is new, it will also inherently create uncertainty for a physician about his or her ability to capitalize on the opportunities and overcome the challenges," Miller said.

Most discussions about alternative payment structures have focused on three basic models -- patient-centered medical homes, episode-of-care payments, and comprehensive care or "global" payments.

However, there is no one best approach to any of these models, Miller said. The building blocks of these programs can be modified to address specific problems and goals.

Miller said opportunities for physicians under these types of payment changes include: receiving more pay for services that are uncompensated today; receiving more pay for delivering high-quality care; having more flexibility to determine what combination of services is most appropriate for patients; receiving more predictable revenues; and receiving rewards for managing total health care costs and utilization.

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External links

"Pathways for Physician Success under Healthcare Payment and Delivery Reforms," American Medical Association white paper, June, members-only access (link)

"Evaluation of the American Academy of Family Physicians' Patient-Centered Medical Home National Demonstration Project," supplement to Annals of Family Medicine, May/June (link)

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