Medical home gives patients better primary care at no more cost

Much national attention is focused on the medical home model as a way to improve health outcomes, control costs, and help solve the U.S. shortage of primary care (from generalists). A medical home provides expanded primary care that is personalized, focuses on prevention, actively involves patients in making decisions about their care, and helps coordinate all their care and get their health needs met.

The new study provides some of the nation's first empirical evidence of the benefits of this new type of care. It compared a random sample of the 9,200 patients at Group Health's medical home to a control group. At one year, patients at the medical home:

• Had 29 percent fewer emergency room visits, 11 percent fewer hospitalizations that primary care can prevent, and 6 percent fewer in-person visits
  
• Reported higher ratings on six scales of patient experience
  
• Used 94 percent more e-mail, 12 percent more phone, and more group visits and self-management support workshops Received better health care, including needed screening tests, management of their chronic illnesses, and monitoring of their medications

"A medical home is like an old-style family doctor's office, but with a whole team of professionals," explained evaluation leader Robert J. Reid, MD, PhD, an associate investigator at Group Health Center for Health Studies and Group Health's associate medical director for preventive care. "Together, they make the most of modern knowledge and technology—including e-mail and electronic medical records—to give patients excellent care and reach out to help them stay healthy."

Now 25 medical home projects are active in 17 states. Still, to date, much enthusiasm for the medical home has been based on qualitative observation. This evaluation provides more quantitative evidence.

Only 10 percent of the medical home doctors, nurses, and staff felt "burned out" or emotionally exhausted, vs. 30 percent of controls. Reducing burnout is key to improving health care. "Many primary care providers work so hard, they feel like they're on a hamster wheel," Dr. Reid said. They often also earn much less than specialists, particularly outside such systems as Group Health, which pay doctors a salary to care for a group of patients, not "fee for service" (more money for more tests and treatments). The shortage of U.S. primary care providers is a crisis, he added. Most U.S. medical students choose to specialize, and primary care physicians retire earlier than specialists do.

Group Health put much thought—and resources—into improving primary care in the medical home pilot. Each primary care doctor (family physician or general internist) was responsible for fewer patients: 1,800 instead of 2,300. That left time for outreach, coordination, daily "team huddles," and longer office visits: 30 vs. 20 minutes. But it also meant investing $16 more per patient over the year in extra staffing: for 72 percent more clinical pharmacists, 44 percent more physician assistants, 18 percent more medical assistants, 17 percent more registered nurses, and 15 percent more primary doctors. On average, patients at the medical home used $37 more specialty care, perhaps because the enhanced primary care detected previously hidden health problems.

"Our evaluation showed these costs were recouped within the year," Dr. Reid said. The main reason was emergency room savings of $54 per patient in the course of the year. "These findings are important because they provide a 'proof-of-concept' that investments in a medical home can achieve relatively rapid returns across a range of key outcomes." Impressed by the return on investment, Group Health is expanding the medical home model from its Factoria medical center in Bellevue, WA, to all 26 of its medical centers.

"Patients fortunate enough to have health care centered on their needs and delivered by Group Health have already seen the future," said Paul Grundy, MD, MPH, president of
the Patient Centered Primary Care Collaborative. "This work is a new model that can help address our nation's need for better access to primary care."

Source: Group Health Cooperative Center for Health Studies