OBSERVATIONS - October 6, 2008
Medical Homes: Marcus Welby Revisited, or Marcus Welby Writ Large?
The concept of the patient-centered medical home (PCMH) is gaining traction as a model for organizing the delivery system in a way that makes sense to providers and feels “right” to patients. The heart of the PCMH model is the primary care practice – a trusted home base for the patient, where, much like the famous bar in Boston, “everybody knows your name.” The PCMH is an overhaul of the old “gatekeeper” concept, in which the family physician’s role was to control access to the rest of the delivery system. In the new model, the family doc is more of a “navigator” who helps the patient make sense of the rest of the system through education, decision support, and proactive care coordination. As a navigator, the primary care physician is supported by health information technology, performance feedback, and financial rewards for care coordination activities. He or she can then focus on the “whole patient,” rather than engaging in the extreme disease- or organ-specificity that has become the job of modern specialists.
Let’s say that for most health care experts, not to mention patients, the idea of this type of home base has great resonance. But how do we get there, and do we have any models to build upon? Arguably, there are two potential places we could look. The first is the small, family practice – the kind of place where indeed everybody knows your name – perhaps even a concierge practice. However, there must be a 21st century twist – the practice must be supported by state of the art information technology to truly fit the definition of a medical home. We’ll call this model Marcus Welby Revisited.
The second place we could look for a model of the modern medical home would be the large, multispecialty group practice, in which a team of providers (physicians, nurses, social workers, pharmacists, administrative staff, etc.) is responsible for the total health of a population. To some, this might seem the very opposite of a medical home, conjuring up images of a large, impersonal bureaucracy, where staff don’t know each other’s names, let alone their patients’. But, proponents of this model will tell you that they can - and do – know patients. They know patients by keeping accurate, accessible, complete electronic medical records, by organizing into smaller, patient-centered units within larger groups, and by providing patients with multiple means of connecting to their providers (by phone, e-mail, or in-person) and accessing information and health support tools in a variety of convenient forms. Rather than dear Dr. Welby sitting behind his desk, the “doctor” in this model is the entire system of care that supports the patient. We’ll call this model Marcus Welby Writ Large.
From which of these two models will the patient-centered medical home spring forth, or will it come into being through multiple channels?
In a recent study published in Health Affairs, Diane Rittenhouse and colleagues took a step toward answering this question. They asked whether specific components of the patient-centered medical home are more likely to be found in larger or smaller physician practices. They also examined the extent to which the PCMH characteristics are more likely to be found in practices owned by hospitals and HMOs (representing the more integrated end of the delivery system) versus those owned by physicians themselves (representing the more fragmented end of the delivery system).
Their results were either encouraging for Marcus Welby Writ Large or not, depending on one’s definition of “large.” The researchers limited their analysis to medical groups with at least 20 doctors, providing comprehensive care services (i.e., they did not include single-specialty or disease-specific groups). Certainly, groups with at least 20 physician could be considered “large,” given that nearly 90 percent of office-based physicians in the United States practice in groups of 1 to 10. Disappointingly, among groups with 20+ physicians, the mean score on a measure of “PCMH-ness” was only 7 out of a total of 20. No single group, of any size, scored a perfect 20.
Do these data tell us that large groups are not the starting place for building a medical home? Maybe not. The researchers also found that among their groups of 20+, the very largest (with 141+ doctors) and those owned by HMOs or hospitals looked more like PCMHs than did smaller practices and those owned by physicians. From this one could conclude that the very large groups that are part of even larger health care systems are, in fact, a good starting place for building a medical home. (Anecdotal evidence reinforces this point: Geisinger Health System, an integrated delivery system with over 700 physicians, has achieved impressive results in early implementation of a PCMH model: a 20 percent drop in all-cause hospital admissions and 7 percent total medical cost savings.
The two different interpretations of the Rittenhouse findings were reflected in the headlines with which different organizations publicized the results. According to Health Affairs, the publisher of the article, it was bad news: “Large Physician Groups Score Low on Key Measure of Medical Home Approach to Care.” But according to the Commonwealth Fund (the funder of this work), there was reason to be optimistic: “Largest Physician Group Practices Most Likely to Adopt Medical Home Model.”
To me, it sounds like good news for Marcus Welby Writ Large, and perhaps also for the PCMH concept. While it might be nice to imagine kindly Dr. Welby at our beck and call, the very small, family practice simply can’t keep up with the vast complexity of modern medicine and the sophisticated coordination that it requires. Dr. Welby may have access to an electronic health record, but he most likely does not have easy access to practice decision support, in-house education, and patient ancillary care, such as dieticians, clinical pharmacists, etc. In addition, and perhaps most importantly, he does not share financial incentives with the specialist with whom he must coordinate care. These factors are the makings of real “team based care,” and many of them are a function of size and asset base.
So let’s be realistic when we talk about patient-centered medical homes and what it takes to get there - let’s not ignore the promising models that already exist – the large, multispecialty, group practices that are part of integrated delivery systems.
- Laura Tollen, Senior Policy Consultant,
KP IHP
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