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'ês part of Group Health'ês 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'ês 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'ês 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'ês 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'ês 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'ês 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'êre doing well. 'êSo they don'êt end up going to the ER because they couldn'êt get in to see the doctor or their problems weren'êt addressed.'ê
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.
'êThese findings are important because they prove that investments in a medical home can achieve relatively rapid returns across a range of key outcomes,'ê Reid says. 'êPeople will take notice that primary care is a good investment to reduce overall health care costs.'ê
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'ês 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.
In Seattle, Swedish Medical Center recently opened the first new clinic in the country that started right out as a medical home model. The Community Health Medical Home Clinic in Ballard has four to five primary care physicians and one nurse practitioner. It will serve as a prototype for Swedish'ês network of 470 primary care physicians.
The new site is tied into Swedish'ês electronic medical records. It offers quick access to appointments, evening and weekend hours, and communication with providers via phone and e-mail. A care coordinator works with patients and doctors to make sure patients get such things as timely screenings for colon cancer.
Premera Blue Cross has agreed to pay the Swedish clinic extra to support the enhanced patient services. The new payment structure will focus on quality of care and healthy patient outcomes rather than just volume of services delivered. Patient copayments at the new clinic will be waived.
'êThen everyone wins,'ê says Dr. Jay Fathi, medical director for primary care and community health at Swedish. 'êThe patient gets unlimited access, the practice will make the same amount as in the traditional setting, and the payer will save money, too.'ê
Group Health had built-in advantages in adopting the medical home model. It'ês a combined multispecialty physician group practice and a health insurer. It already had a sophisticated electronic medical record system, with pop-up alerts for doctors on preventive care.
Reid acknowledges that it may be harder to implement the medical home approach in private physician practices. Group Health'ês salaried doctors aren'êt paid extra fees for seeing more patients in the office and performing more tests and services. So the medical home approach of providing as many services as possible to patients without their coming to the office doesn'êt reduce their pay. But for most U.S. primary care doctors, who receive fees for each visit and service, insurers would have to pay them extra for the medical home services, just as Premera is doing with the Swedish clinic.
Group Health chose the Factoria clinic for the demonstration because it was already one of the best-performing clinics but its physicians were feeling burned out and considering retirement. Group Health leaders met with the doctors and staff and went through a joint process of designing changes to implement the medical home principles. A major expressed need was to reduce the size of each doctor'ês patient load. Group Health budgeted $600,000 a year for two years to add staff, including 1.5 doctors, reducing each doctor'ês workload from 2,400 patients to 1,800.
In addition, the clinic assigned a registered nurse to share each family physician'ês office and to work closely with the doctor on patient follow-ups, including calling patients discharged from the hospital to go over their care plans. Plus, the clinic shifted two pharmacists from working mostly on cost control to consulting directly with patients and doctors on drug regimens.
The new study found that the medical home model succeeded in reducing staff dissatisfaction. Only 10 percent of the medical home doctors and staff said they felt burned out, compared with 30 percent of staff members at other Group Health clinics. Dr. Harry Shriver, the chief of staff at the Factoria clinic, used to see 24 patients a day. Under the medical home model, he now sees 12 to 14. He can spend 30 minutes with each patient and accomplish a lot more than before. While he still has a long day, starting at 7:30 a.m. and leaving at 6 p.m., he says he feels he accomplishes more, has better closure with patients, and enjoys his work more.
As to the direct e-mails from patients, Bergman says the fear was that patients would engage in lengthy digital exchanges with the doctors. But that hasn't happened. "Patients know you and respect your time. It's efficient and effective, cuts down visits, and improves satisfaction. And we avoid e-mail ping-pong by getting out of e-mail and phoning the patient or getting them here for a visit."
Thanks to the medical home experiment, Shriver and Bergman, who were feeling burned out and planned to retire, decided to stay on. 'êWe'êre feeling rejuvenated,'ê Bergman says.
Here's a handy check-list of the hallmarks of the patient-centered medical home concept. It's worth comparing with the medical arrangements you now have:
- Patient has a personal relationship with the physician
- Extended office hours
- Open scheduling for same-day appointments
- Electronic medical record
- Proactive tracking of patients'ê conditions and preventive care needs
- Comprehensive services and coordination of all types of care
- Doctors and other medical professionals work as a team with the patient
- Evidence-based clinical decisionmaking, with computerized support tools
- Patients have direct phone and e-mail access to doctors and staff
- Patients can make appointments, refill prescriptions, and check lab results via the doctor'ês office Web site