Home, sweet medical home

The patient on the line is startled when his doctor, James Bergman, answers the phone himself at 9 am. "Any diarrhea?" asks Dr. Bergman, a family physician for 26 years at Group Health Cooperative's Factoria clinic in Bellevue, pulling the patient's chart up on his computer. "Can you come in today? How about 2 o'clock? See you then?" Bergman hangs up and smiles. "They are always surprised to get the doctor on the phone," he says.

Few Americans can contact their doctor by phone immediately and schedule a same-day appointment. But Bergman's clinic lets patients phone and e-mail their doctors directly to discuss medical concerns and schedule a visit on short notice.

That’s part of Group Health’s successful, two-year experiment with the one of the hottest concepts in health care delivery — the patient-centered medical home. It appears to be working. This week, Group Health’s Center for Health Studies published a report in the American Journal of Managed Care showing greater patient and physician satisfaction and less use of emergency rooms and hospitals due to better primary care delivered through the medical home model.

The idea is to have a primary care physician lead a team of professionals, including nurse practitioners, physician assistants, pharmacists, health educators, and medical assistants, who provide or facilitate all the patient’s health care needs. Team members also work closely with patients to involve them more in taking care of themselves.

Policymakers hope the medical home approach will keep patients healthier, reduce ER and hospital use, and make primary care attractive again to medical students and doctors who have been moving away from this overworked, underpaid field of medicine. They want to boost the nation’s shrinking supply of family physicians, general internists, pediatricians, and geriatricians.

Congress last year approved Medicare demonstrations of the medical home concept in eight states, and the Democratic health reform legislation in Congress would encourage expansion of medical homes. Many states also are funding or considering medical home projects. But private insurers have gone slow in paying doctors more to operate medical home practices because they have lacked proof that it will improve care and save money.

Now some preliminary results are in, and payers may be more willing to pony up. The new study found that even though Group Health invested an additional $16 per year per patient for primary care by hiring more doctors and other medical staff at the Factoria clinic, that extra cost was offset by $54 in savings per patient on ER use. The study compared a random sample of 9,200 patients at the Factoria clinic with a control group of patients at Group Health’s other clinics.

At the Factoria clinic, patients are contacted before office visits to make sure all the necessary procedures and tests are done, explains Dr. Robert Reid, Group Health’s associate medical director for preventive care and one of the authors of the study. After the visit, patients are followed up to make sure they’re doing well. “So they don’t end up going to the ER because they couldn’t get in to see the doctor or their problems weren’t addressed.”

Group Health reported 29 percent fewer ER visits for the medical home patients, 11 percent fewer preventable hospitalizations, and 6 percent fewer in-office visits; on the other hand, the patients on average used $37 more physician specialty care over the year. Medical home patients expressed greater satisfaction in six areas. And a higher percentage received recommended screening tests, management of chronic conditions, and medication monitoring.

“These findings are important because they prove that investments in a medical home can achieve relatively rapid returns across a range of key outcomes,” Reid says. “People will take notice that primary care is a good investment to reduce overall health care costs.”

Now Group Health, a nonprofit HMO that employs its own doctors, is expanding the medical home model to all 26 of its medical clinics. Reid says the HMO soon hopes to see lower overall costs rather than just breaking even on its investment.

Group Health also is talking with the primary care doctors with whom it contracts around the state to explore development of the medical home model in their practices, Reid says. But that will be more challenging because Group Health is just one of a number of insurers those independent doctors work with.

Group Health is one of many physician groups around the country trying out the medical home model as a way to rescue nation’s collapsing primary care system. To date, there are 25 medical home projects in 17 states. In Pennsylvania, Geisinger Health System is expanding its medical home program after getting excellent results at two of its clinics over nine months. Geisinger reported earlier this year that its medical home experiment reduced hospital admissions by 20 percent and costs by 7 percent while patient status improved. Diabetic patients, for example, gained better control of their blood glucose levels and blood pressure.