Insurers latest to champion medical homes

With evidence mounting that patient-centered medical homes can reduce costs and improve outcomes, more insurers are pushing them. That means primary care physicians will be under increasing pressure from payers to adapt their practices to the model.

“This type of clinical integration really cannot be ignored,” said Mary Campagnolo, MD, president of the Medical Society of New Jersey. “Physicians need to ask how to join forces with like-minded physicians to develop the infrastructure to deal with this new environment.”

Programs supported by commercial and government insurers now exist in nearly every state, according to a report issued Sept. 7 by the Washington-based Patient-Centered Primary Care Collaborative, an organization supportive of the medical home model.

For example:

• Programs run by member organizations of the national BlueCross BlueShield Assn. supply care to 4 million patients in 39 states, the District of Columbia and Puerto Rico.
• Humana offers medical home services in 10 states for 70,000 Medicare Advantage members and 35,000 commercial members.
• The Centers for Medicare & Medicaid Services announced Aug. 22 that 500 practices with more than 2,000 physicians across the country will participate in the comprehensive primary care initiative.
• WellPoint, Aetna and UnitedHealthcare have announced in recent months that their medical home programs are expanding.

The momentum is growing, the report said, because insurers see evidence that medical homes save money and improve care. Among the examples:

• Horizon Blue Cross Blue Shield of New Jersey cut emergency department use by 26% and hospital readmissions by 25% among participants.
• Blue Cross of Idaho saw a $1 million reduction in single-year medical claims for medical home patients and a return on investment of $4 for every dollar spent on the program.
• HealthPartners in Minnesota saved $1,282 in outpatient costs per patient for those taking 11 or more medications.

“We’re seeing a lot of insurers testing out this model, and the picture is incredibly promising,” said Marci Nielsen, PhD, MPH, executive director of the Patient-Centered Primary Care Collaborative. The organization is supported by commercial entities such as the National Business Group on Health and medical societies, including the American Academy of Family Physicians and the American College of Physicians.

Health Affairs published in its September issue the results of a pilot project run by WellPoint. The insurer earned $2.50 to $4.50 for every dollar invested in the medical home program because hospitalizations and the use of inpatient services declined. Patient satisfaction was high, with 95% saying the practices were well-organized and efficient. Diabetes care improved, and quality measures for other medical conditions are being analyzed. WellPoint is expanding its program from three states to 14.

“We can really support better patient care, and we can support the doctor in giving that care,” said Sam Nussbaum, MD, WellPoint’s executive vice president of clinical health policy and chief medical officer.

Not a new model

The patient-centered medical home, a team-based health care approach with the primary care physician as the “home” base, grew out of work in the late 1960s by the American Academy of Pediatrics to improve care for special needs children. In the last few years, several medical societies suggested that the model could be expanded to improve overall primary care. Insurers later accepted the idea.

Under insurer programs, practices usually are given significant leeway in how they achieve the main characteristics of a medical home. For instance, some practices increase access by staying open longer. Others allow for a greater number of same-day appointments. To improve care coordination, some insurers provide money for practices to hire case managers or embed them to provide additional help in handling patient needs. Insurers usually pay extra for a practice’s participation in a program. Additional bonuses are possible for practices achieving various quality metrics or reducing the amount of money spent to care for a population.

“It’s like primary care on steroids,” said Thomas McCarrick, MD, a family physician with Vanguard Medical Group, which has 11 physicians in three offices in New Jersey and participates in the Horizon Blue Cross Blue Shield of New Jersey program.

American Medical Association policy supports the patient-centered medical home concept as one option for providing care to patients without restricting access to specialty care.

But not all insurer programs run smoothly. Another study in the September Health Affairs analyzed the results of the Colorado Multi-payer, Multi-state Patient-Centered Medical Home Pilot, which has six insurance plan participants. The program, which was supported by the Colorado Medical Society, reduced hospital admissions and emergency department use. Practices, however, ended up providing medical home services to patients with insurance plans that declined to pay related fees. Health plans didn’t deliver key data when promised to physicians and didn’t attribute patients appropriately. Payments for medical home services were delayed.

Small practices, in particular, need to make sure they have significant support from outside entities before establishing a medical home. A paper, published online Sept. 7 in the Journal of General Internal Medicine, compared 18 practices of one to 10 physicians that received a great deal of support and financial incentives to become patient-centered medical homes with 14 practices of a similar size that did not. After 18 months, 95% of the supported practices were recognized as patient-centered medical homes by the National Committee for Quality Assurance. This was true of only 21% of the control practices.

“This is hard for practices,” said Judith Fifield, PhD, lead author on that paper and professor and director of the research center at the University of Connecticut School of Medicine in Farmington. “There are multiple standards that practices have to achieve. It’s like changing a tire on a bicycle while you’re riding it.”