Another Bump on The Road To The Medical Home

In health care, the change we’re supposed to believe in this year depends on something called the “advanced medical home.” Under this approach, which is being investigated by both public and private payers, primary-care physicians would receive monthly capitation payments in return for better care coordination. Since these payments would be in addition to the fee-for-service reimbursement that most doctors receive, practices serving as medical homes could potentially see a significant revenue increase.

Some experts have warned, however, that the medical home concept might be asking too much of small primary-care practices. Aside from the cost and difficulty of acquiring an electronic health record system—which some see as an essential ingredient of a medical home—primary-care physicians are often too overwhelmed by the daily press of acute care to spend sufficient time tracking patients with chronic diseases.

Dr. Elliot Fisher, who has done important research on practice variations, points out that primary-care physicians who want to provide a medical home need not only full access to all clinical information about a patient, but also cooperation from all the physicians involved in the patient’s care. “There are no incentives for other physicians or hospitals to share information, improve coordination, or support shared decision making for patients who are in the medical home,” he observes.

A new study published in Annals of Internal Medicine adds a quantitative perspective to the medical home debate. Authored by researchers at the Center for Studying Health System Change, Memorial Sloan-Ketting Cancer Center, and the Dana-Farber Cancer Institute, the study shows that, in the course of a year, the average primary-care physician who treats Medicare patients must coordinate care with 229 other doctors in 117 practices. Based on a survey sample of 2,284 physicians, the study also found that, for every 100 Medicare patients, each primary care doctor typically has to coordinate care with 99 other physicians in 53 practices.

Physicians working in solo or two-person practices had more peers to coordinate with than those in larger group practices and institutional work settings. The median number of peers was also higher in urban areas than in rural areas, and increased with the supply of specialists in the market where the primary-care physician practiced. In regions where the specialist supply was in the highest quintile, generalist physicians had to coordinate care with 143 doctors in 62 practices per 100 Medicare patients.

The average Medicare beneficiary sees seven different physicians in four practices in the course of a year, and those with multiple chronic diseases have even more providers. Primary-care physicians must coordinate care with specialists, ER doctors, and other generalists. If you define a patient’s primary provider as the doctor whom they see most often, only half of a primary care physician’s Medicare panel consists of his or her primary patients, the study says. This fragmentation, the researchers note, “probably reflects the freedom of [Medicare] beneficiaries to seek care from any participating provider without previous approval, the incentives that fee-for-service payment creates for providers to deliver more services, the lack of disincentives for providers to limit referrals, and the greater care needs of an elderly population.”

Even if primary-care physicians are aware that one of their patients is seeing a particular specialist—which often isn’t the case—the challenge of communicating with other physicians is a major obstacle to medical home efforts. “Given the efforts required for effective communication and shared decision making between just 2 providers caring for a single patient, care coordination across all patients and all peers for a given primary care physician may be formidable in a fee-for-service context,” the researchers point out.

This doesn’t mean that patients don’t need some kind of medical home. But it’s hard to see how they’re going to get one in our fragmented, fee-for-service system.