Despite Malloy’s support, expansion of medical homes faces obstacles

Dr. Cliff O’Callahan’s practice submitted an application last week to become officially recognized as a patient-centered medical home and, in the process, became critical to Gov. Dannel P. Malloy’s administration’s goals for providing health care to more than 500,000 state residents.

Cliff O'Callahan

Dr. Cliff O’Callahan

As part of an overhaul of state Medicaid programs, the administration plans to aggressively expand the use of patient-centered medical homes, an increasingly popular model for delivering care that is still relatively rare in practice.

Patient advocates have long urged the state to embrace the model, which calls for having health care providers coordinate patients’ care. Some were heartened by Malloy’s campaign pledge to expand a small Medicaid pilot program that pays providers for care coordination.

Details have not been fleshed out, but the administration has indicated that it wants to go even further, encouraging providers in Medicaid to become fully recognized patient-centered medical homes–the designation O’Callahan’s practice is seeking. So far, only four medical practices in the state have achieved it.

The goal of expanding medical homes to all Medicaid programs, which serve more than 500,000 people, puts the state in line with physician groups, private insurers and the federal government in promoting a model that some studies say can improve care while reducing costs.

But it is expected to be a gradual process. Recognized medical homes must meet a wide range of standards, set by the National Committee for Quality Assurance, including being accessible to patients outside office hours, prescribing electronically, following up on tests and procedures done at other facilities, and using data to track patients’ hospitalizations and emergency room visits.

Some practices meet many of the requirements even if they have not yet gone through the recognition process. ProHealth Physicians, the largest primary care practice in Connecticut, is expected to begin a medical home demonstration project for state employees next month, and the project could expand to include other practices.

Still, ProHealth is unusual in a state dominated by practices with fewer than five physicians, and O’Callahan’s family practice has advantages that many do not. The Middletown pediatrician receives a salary, so his pay isn’t directly affected if he sees more patients in Medicaid, which tends to pay less than the cost of care. His patients can get care coordination through Middlesex Hospital, which owns the practice, and a social worker paid for by a state program for children with chronic care needs.

“I don’t know, for all these little practices, how they’re going to do it,” O’Callahan said of care coordination. “Except as part of a slightly larger network.”

Money, Time and Support

Medical homes are in their infancy in the state, according to a 2009 survey by the Connecticut State Medical Society, although some elements of them are more common, including the use of electronic medical records and scheduling designed to get patients with urgent needs seen quickly.

The Medicaid pilot program, HUSKY Primary Care, requires providers to coordinate care but doesn’t require the use of electronic medical records or other hallmarks of a medical home. It will be one option for Medicaid enrollees in the future. But for now it has only 254 doctors and 517 patients participating.

So what will it take to get more physician practices to become medical homes?

Money, time, state support and getting a critical mass of patients and payers involved will all be essential, those involved say.

The start-up costs for becoming a medical home can be hard to justify if a practice isn’t certain to get paid for using the model and saving the health care system money, said Dr. Robert McLean, governor of the American College of Physicians’ Connecticut chapter.

Primary care doctors are often frustrated that work they do for patients isn’t compensated, and time spent coordinating care often falls into that category. HUSKY Primary Care pays providers a $7.50 monthly per-patient care coordination fee, which McLean said is too low to attract many doctors.

“What is going to entice doctors to get into this is the opportunity for the state to take those savings and pay the doctors a fair wage to see these patients and for an opportunity for the doctors to actually share in the savings that their hard work garners,” McLean said.

With a large budget deficit to overcome, the state isn’t likely to be in a position to significantly raise Medicaid fees, but it could get some help from a new federal program aimed at encouraging care coordination for Medicaid patients with chronic illnesses like asthma, diabetes and obesity. States can receive federal funding for 90 percent of the money spent coordinating their care, significantly more than the 50 cents the state typically receives for each dollar it spends on Medicaid.

A Better Recruiting Environment?

Even without significant increases in payments to doctors, patient advocates are optimistic about getting more to participate in care coordination now that the Malloy administration has embraced it.

Advocates have argued that HUSKY Primary Care, which was only open to certain parts of the state, suffered from a lack of promotion from the Department of Social Services. Department leaders have disputed the charge.

Sheldon Toubman, an attorney with Greater New Haven Legal Assistance, said health care providers have had reservations about joining a program that did not appear to have support from DSS.

Sheldon Toubman

Sheldon Toubman

“It’s going to be a lot easier approaching providers and saying ‘This is happening, why don’t you get on board now?'” he said.

And broader forces in health care could help too.

“There is a very strong trend towards medical homes,” Toubman said. “If you’re a primary care provider, that is what you’re expected to be doing soon enough.”

For overworked primary care doctors, the prospect of adding care coordination to their responsibilities can be daunting. Toubman said the problem can be eased by getting more patients into the program. A practice getting paid to coordinate care for 20 patients would get $150 a month for the coordination–hardly enough to hire a staffer to do the work. But if enough patients participated, those $7.50 fees could add up to enough to hire someone.

Alternatively, some have suggested, practices could team up to share a care coordinator. Or an outside group could provide care coordination and receive some or all of the fees the practices would otherwise get.

Having the state get behind the medical home concept could also help spur more practices to pursue the model. States that have higher rates of medical homes tend to be those with state pilot programs or laws that encourage them, said Andy Reynolds, a spokesman for the National Committee for Quality Assurance. Vermont and Pennsylvania in particular have had governors who championed the concept, he said. While Connecticut has 21 clinicians and practices recognized as medical homes, Vermont, with a fraction of Connecticut’s population, has 93. Pennsylvania has 835.

McLean’s New Haven practice already has electronic medical records, but he said it would have a hard time meeting the full medical home requirements by the end of the year.

“It can’t just happen overnight,” he said. “But it’s going to start somewhere.”