Lack of Adequate Pay Reduces Effectiveness of Medical Home

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From Medscape Medical News

Lack

of Adequate Pay Reduces Effectiveness of Medical Home

Lowes

June 7, 2010 — The historic healthcare reform legislation that

Congress passed in March makes 19 references to the term " medical

home, " and for good reason.

Reformers

are betting that the medical home, with its physician-led team delivering and

coordinating holistic patient care in the exam room and online, is just what

the country needs to improve quality and lower costs. At the same time, giving

primary care physicians extra pay for operating medical homes — and

operating them well — promises to deliver these clinicians from

fee-for-service medicine and its piecemeal, perverse, and punishing incentives.

Creating

such nirvanas, however, is easier said than done, especially when physicians

attempt to reform their practices in an unreformed system with inadequate compensation,

according to a set of 8 articles in a special supplement of the ls of Family Medicine, released

today, which evaluate a 2-year medical-home demonstration project.

Working

" feverishly, " the 36 participating family practices registered modest

improvements in quality-of-care measures but backslid in terms of how patients

rated them. The demonstration project is the first of its kind on a national

scale.

The

authors of the summary article in the collection concede that it is possible

for practices to become medical homes, but that this transformation

" requires tremendous effort and motivation, " and that most practices

would need outside help, as well as adequate compensation, to make the switch.

" Fixing

primary care in the midst of a still broken system will not be sufficient or

possible, " the authors write.

This

assessment may sound discouraging, but students of the medical-home movement

say other experiments have fared better, largely because physicians received

the support and compensation lacking in the family practice project.

" These

articles aren't a verdict on the medical home, " Ann O'Malley, MD, a senior

health researcher at the Center for Studying Health System Change, told Medscape Medical News. " Other

projects are more promising. "

Goals of Project Changed Over Time

The

medical-home trial chronicled in the ls

of Family Medicine was launched by the American Academy

of Family Physicians (AAFP) with financial support from The Commonwealth Fund,

a private healthcare reform foundation. TransforMed, an AAFP subsidiary,

designed and implemented the trial, called the National Demonstration Project

(NDP).

The 36

practices in the NDP fell into 2 groups: A " facilitated " group

received extensive help from consultants and vendors of health information

technology, and a self-directed group went it alone with Web-based tools and

services.

At the

beginning of the 2-year study period, both groups of practices on average had

roughly 46% of the largely technological components of the medical home they

were trying to build, with the self-directed groups being somewhat ahead. These

components ranged from same-day appointments and optimized office design to

electronic prescribing, electronic health records, and practice Web sites. By

the study's end, the groups had put in place approximately 70% of these

components, although facilitated groups implemented more.

The

authors of the articles in the ls of

Family Medicine noted that the AAFP project initially promoted

an early version of the medical home, which put a heavy emphasis on digital

technology. As the concept of the medical home evolved, the AAFP and its

TransformMed subsidiary redesigned the NDP midstream to give more weight to

less tangible primary care virtues.

" They

were trying to test things that were changing, " said Barr, MD,

vice president of practice advocacy and improvement for the American College

of Physicians. " They did a nice job adapting. "

Patients Felt Slightly Less at Home in Their Medical Homes

In the

words of the authors, " the jury is still out " on whether the NDP

model of the medical home improves the quality of patient care. Preliminary

results, though, offer some encouragement. Adopting components of the medical

home was associated with better patient access, more preventive care, and a

higher percentage of chronically ill patients receiving recommended treatments

and assessments. In addition, both groups posted roughly a 5% gain on the

scorecard of the Ambulatory Care Quality Alliance for managing chronic disease

— keeping HbA1c levels under control and blood pressure at target, for

example.

However,

how patients rated their medical-home experience was disappointing. Both

facilitated and self-directed groups nudged up 2% in terms of patient

empowerment and self-rated health status, but when it came to access to care,

care coordination, comprehensive care, and service relationship satisfaction,

both groups dipped slightly.

The

authors of an article on patient outcomes speculate that the patient ratings

may have decreased because the intense effort to implement digital technology

such as electronic health records " may have temporarily distracted

attention from interpersonal aspects of care. " Likewise, the hard work of

building a medical home may have simply left physicians and staff too tired to

improve the patient's experience once he or she stepped inside.

New Medicare Pilot Project Adds Medical-Home Sweetener

The 36

practices in the NPD did not receive extra compensation from payers for their

efforts to be a medical home. Instead, they continued to get paid on a

fee-for-service basis. Dr. O'Malley of the Center for Studying Health System

Change views this compensation arrangement as a major handicap.

" Given

that primary care doctors are already overwhelmed and underpaid, expecting them

to transform their practices without additional funding is unrealistic, "

said Dr. O'Malley.

The

authors of the summary article reached that same conclusion and recommended

that third-party payers turn to arrangements such as monthly capitation

payments to make medical homes worthwhile for physicians. " Expecting

practices to front the cost of transformation with the hope of more appropriate

reimbursement in the future is unlikely to succeed, " they write.

Dr. O'Malley

and others note that private health insurers and public payers such as state

Medicaid programs have already rolled out medical-home pilots that reward

physicians for care coordination and other medical chores that go unpaid in the

fee-for-service world (for a comprehensive list of initiatives, visit the

Patient-Centered Primary Care Collaborative Web site).

And just last week, Medicare invited states to apply for the first of 3 medical-home

demonstration projects that will combine fee-for-service payments with a

medical-home sweetener, which could take the form of monthly capitation

payments, add-ons to usual fees, or pay-for-performance incentives. Medicaid

and private payers also will participate with Medicare in this project.

Another Demonstration Project Put Up Good Numbers

The

authors who evaluated the AAFP medical home project in the ls of Family Medicine concluded that

physicians probably need more than 2 years to get up to speed in this new form

of medical practice. Dr. Barr of the American

College of Physicians

counters that under the right conditions, 2 years may be feasible.

" Demonstration

projects show that when physicians have support, they can move through the

changes quickly, " Dr. Barr told Medscape

Medical News.

He points

to the success achieved by a medical-home project sponsored by Seattle-based

Group Health ative, a nonprofit healthcare system. An article in the May

issue of Health Affairs

reports that at the 2-year mark, the organization's experiment improved

clinical-quality scores, reduced emergency department visits and

hospitalizations, reduced staff burnout, boosted patient satisfaction, and

saved about $10 per patient per month.

Dr. Barr

acknowledges that Group Health ative is a " mature health

system " with the kind of built-in support that medical practices in the

AAFP demonstration project generally lacked.

" You

need systemic change for the medical home to flourish, " he said.

Medscape

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