Report: There’s no consensus on what constitutes ‘medical homes’

The number of physician practices officially considered “patient centered medical homes” has grown dramatically in the past six months, helped along when the state’s largest group of primary care practices earned the designation last week.

The proliferation mirrors a widespread national push toward the model, which encourages care coordination and making it easier for patients to access care. Private insurers are sponsoring pilots to test the model, and it’s being used in state Medicaid programs, Medicare, and the military’s TRICARE health plan, which has a goal of having 2 million beneficiaries enrolled in medical homes by the end of the year.

Connecticut has a medical home pilot program for state employees and retirees, and is developing plans to encourage health care providers to serve as medical homes for Medicaid patients. Six months ago, just 21 practices and clinicians in the state had been recognized as medical homes by the National Committee for Quality Assurance, one of several accrediting organizations. After the 70 practices of ProHealth Physicians achieved recognition last week, the number was up to 412.

But despite the broad-based support for the concept, there is no broad agreement on what a medical practice must do to be considered a medical home, and no solid evidence about what pieces are required to improve care and reduce costs, a report released this month warned.

“The medical home model does have the potential to transform the way health care is delivered–but potential is the key word here,” wrote the report’s authors, Dr. Robert A. Berenson, Kelly J. Devers and Rachel A. Burton of the Urban Institute. “The danger posed by the current enthusiasm for the concept is that it could lead to the adoption of unproven models on a wide scale nationwide before evaluations of existing pilots can show us what works in what situations, and what levels of reimbursement are needed to get providers to engage in all the new activities encompassed by the medical home model.”

What makes a medical home?

There’s no single definition of a medical home, but the concept centers on making medical practices more attuned to patients’ needs. Doing that includes making it easier to access care by offering extended hours or communicating by e-mail. It also involves more actively coordinating the care a patient receives, including from other providers. In exchange, the practices receive additional payments, although the methods for doing so vary.

The report noted that there are multiple definitions of medical homes, and several groups that offer medical home accreditation or recognition. Differences in the standards include whether electronic health records are needed to coordinate patient care, how quickly patient phone calls must be returned after hours, and how quality should be measured.

“Part of the reason for the lack of agreement on how to define the medical home is that there is not yet rigorous evidence available about which practice capabilities and processes actually improve the quality of care and reduce costs–though evidence does support the use of some of them, and there is evidence of positive benefits associated with primary care more generally,” said the report, which was funded by the Robert Wood Johnson Foundation.

In addition to the need for more rigorous research on the model, the report said it will be important to determine whether the outcomes that early adopters have had can be replicated by other primary care practices that might not be as advanced. It also cited research suggesting that small practices would have to engage in “disruptive innovation” to become medical homes.

“Until payment incentives to do so are made permanent, practices may be unlikely to commit to that level of disruption for an unknown fate,” it said.

Proponents of the medical home model in Connecticut said they’re confident in the concept’s promise, in part because it reflects common sense ways to deliver health care.

“Medical home is really reinventing primary care and what primary care has traditionally done for decades, which is try to be there to coordinate all the health care needs that people would have,” said Dr. Charles L. H. Staub, chairman of ProHealth’s board. “In the old days, people would go see their general practitioner, who would send them to specialists but always kind of be there in the background coordinating things.”

The model, he said, upgrades the infrastructure used to support what doctors have long done in their offices. In recent years, ProHealth practices, which treat 350,000 patients, began using electronic health records, and the organization opened extended hours facilities so patients could have access to a primary care doctor after hours, possibly avoiding emergency room visits.

Sheldon Toubman, an attorney with New Haven Legal Assistance and a longtime proponent of medical homes, said he supports the model because “everybody needs care coordination, whether they have serious multiple chronic conditions or they’re a healthy child.”

“Care coordination is still very important and in the end, it’s going to bring better quality and be more efficient,” he said.

But Toubman said it’s important to make sure that medical homes don’t exist in name only, and that care coordination and other services are actually provided. He said the method chosen to provide the additional payments is critical, because some that are used–giving providers a larger amount of money to cover both medical care and medical home activities, or giving them a portion of the savings the model generates–could give health care providers incentives to deny care.

The “hub” of patient care

The Medicaid medical home program is still being developed, and officials are facing many of the questions addressed in the report: What set of standards should be used for medical homes? How should they be paid? And how can the state encourage providers, particularly the state’s many small practices, to take the costly and time-consuming steps to become a medical home?

State Comptroller Kevin Lembo, whose office is overseeing the medical home pilot program for state employees and retirees and their families, said his confidence in the model comes in part from research on the elements of it and the experiences of other places that have employed the concept. He also cited its design of having the primary care provider as the “hub” of patient care and having providers available beyond the standard workday so patients could more easily access primary care.

“While I wouldn’t say that there is a robust body of research, that is one of the challenges of being ahead of the curve,” he said.

The pilot program for state employees and retirees grew out of discussions by a joint committee of the state and employee union representatives. They noticed from claims data that state employees and retirees were underusing primary care and overusing specialists and hospitals, including emergency rooms.

In the pilot, health care providers that are recognized by NCQA as medical homes–in at least the second of three levels–are eligible for bonus payments as well as additional payments based on performance on measures including reducing preventable emergency room visits, giving children and teens proper vaccinations and well care visits, getting patients with high blood pressure and diabetes to target levels, and educating patients on medical conditions they have.

So far, ProHealth, which treats about 30,000 people covered by the state employee and retiree health plan, is the only health care provider participating, although others could be added.

Lembo said decisions about the pilot were based on “lots of research, but not research of the thing as a whole.”

There’s much to be excited about, Lembo said, but he added that he doesn’t want to oversell it. The best thing, he said, is that the pilot will produce the data needed to measure whether the medical home model makes a difference.

“And there is no shame in saying at the end of a number of years, ‘Maybe we’re wrong,'” he said. “The shame is really in just sitting around knowing the present system is not giving us exactly what we need and doing nothing to try to make a difference.”