Harbeck said hospitals have been so busy trying to create accountable care organizations that they have let health insurance companies take control of the medical home arena. “Payers are all over it,” he said.
Tim O'Rourke, vice president of provider engagement at Humana, confirmed insurers' attraction to medical homes. He said Humana medical home pilots have resulted in higher patient satisfaction and have generated savings through reduced emergency department visits and improved generic drug dispensing rates.
“We really like the model,” he said. “We have rewards for those practicing in this manner.”
O'Rourke said his company has launched a rewards pilot program where physicians who practice as a medical home can receive a subsidy covering 85% of the cost of implementing an electronic health-record system in an initiative aimed at improving coordination of care for Humana Medicare beneficiaries.
Other insurers also are moving forward with medical home projects and making a point that they are doing so without hospitals. For example, when it announced its medical home pilot involving 90 primary-care physicians in February, Blue Cross and Blue Shield of Texas noted in its news release that, “The ‘medical home' is not a building or hospital.”
“At this pilot or developmental stage, there is not a direct role for hospitals,” said Margaret Jarvis, Texas Blues spokeswoman. “We have had discussions with hospitals about linking them via a health information exchange, an electronic link, to allow the medical home groups access to the hospital information.”
The leading role of insurers may be tied to the function of medical homes. Roland Goertz, a Waco, Texas-based physician and president of the American Academy of Family Physicians, said insurance companies are particularly well-situated to see the advantages of the medical home delivery model.
“The payers have all of the premium dollars to look at and know our current system is not sustainable,” Goertz said. “There is a significant incentive for them to embrace it and see how it works in their different systems and different regions.”
According to principles developed by the AAFP, American Academy of Pediatrics, American College of Physicians and the American Osteopathic Association, the patient-centered medical home involves patients having a personal physician who leads an integrated team of healthcare professionals providing coordinated acute, chronic, preventive and end-of-life care facilitated by information technology tools and based on a foundation of quality improvement. And research increasingly is showing that the cost savings from the medical home largely is coming from reduced hospital care.
Those findings and others likely prompted the American Hospital Association to spur its members to get in the medical home game. In September, the AHA released a report, Patient-centered Medical Home: AHA Research Synthesis Report, which acknowledges that hospitals have been slow to embrace the model. But it also noted among its findings that the nation's primary-care network is ill-equipped to handle widespread implementation of the medical home model—as 65 million Americans live in officially designated primary-care shortage areas.
“Hospitals face the challenge of not having a defined role in the PCMH model,” according to the report. “Still, researchers believe that hospitals will begin a migration to embrace the PCMH model in coming years as a natural extension of clinical IT investments and increasing care coordination.”
The report stated that the medical home operation “poses several challenges for primary-care practices,” and that most primary-care physicians are not trained to provide care coordination, nor are they reimbursed for doing so. Most also lack the information technology that care coordination may require, the report stated.
Not surprisingly, the report suggested that these challenges can be overcome with the help of hospitals.
“Successful implementation of a PCMH will, however, require significant investments on the part of primary-care practices and other providers,” it said. “Hospitals could play a key role in inspiring the practice leadership and personnel, taking pressure off them so they can engage in transformation, and helping them overcome inertia.”
In describing a two-year, 36-practice pilot project undertaken by TransforMED, the AAFP's for-profit medical home consulting arm, the AHA report noted how patient ratings declined in four areas measured in the pilot: easy access to first-contact care, comprehensive care, coordination of care and personal relationship over time.
The AHA report did not, however, mention other results of the pilot, such as practice revenue growing 12% and physician income increasing 14%.
Maulik Joshi, AHA senior vice president of research and president of its Health Research & Educational Trust, said the report examined possible roles for hospitals in the medical home model and denied that hospitals were getting a late start.
“I don't think anyone is late to the game,” he said. “Models are changing everywhere because of the current healthcare environment.”
The National Committee for Quality Assurance, which has a long history of rating the performance of health insurers, started a medical home program in 2008 and, since then, has recognized 1,161 practices as meeting its medical home standards. Practices are judged on a 100-point scale divided into nine standards that include access and communications, patient tracking, care management, and performance reporting and improvement. There is no role spelled out for hospitals, though practices can earn up to five points for coordinating follow-up care for patients who received treatment at hospitals or at an ambulatory facility outside of the primary-care office.
Physician Terry McGeeney, president and CEO of TransforMED, said that although not specifically mentioned, it's implied that the NCQA focus on efficiency and care coordination is designed to keep patients out of expensive inpatient settings.
“That's what accountable care is about,” he said. “But they're trying to stay away from the managed-care idea that spending less money on a patient is a good thing—it's more about appropriateness of care.”
McGeeney added that—although the patient-centered medical home model is all about keeping patients out of the hospital and away from hospital emergency departments—hospitals are an integral part of the accountable care movement.
“We're never going to bend that cost curve unless hospitals are at the table,” McGeeney said.
McGeeney said that, particularly in rural areas, there is “a potential for synergy” between primary-care doctors with few resources and local hospitals that may have the information technology and infrastructure for care coordination that physician practices in the area lack.
“Skeptics could say hospitals are late to the table,” McGeeney said, but he added that more are looking to involve themselves with local medical home initiatives. “Frankly, when done correctly, we welcome that. … I think the key word is ‘partnership'—working with primary care and not trying to drive the boat.”
In an online column titled “The patient-centered medical home and the accountable care organization” on the TransforMED website, McGeeney noted the worries doctors have about hospital involvement in their practices.
“There is valid concern in the physician world that if the accountable care organizations are hospital systems, then the value of primary care and the principles of PCMH might be lost or at least severely diluted,” he wrote.
While the NCQA long has worked with insurers, the Joint Commission long has worked with hospitals. The fact that the Joint Commission may consider an accreditation program for medical homes could bode well for its longtime client base.
Michael Kulczycki, executive director of the Joint Commission's ambulatory-care accreditation program, said it's possible that his organization or another could develop an accreditation program for hospital-based medical homes.
“We hear from a large amount of hospitals expressing interest for a product in their setting,” he said, but he added that currently for hospitals, the focus is on becoming an ACO because that would have “a greater impact on their financial relationships given the risks and rewards being anticipated.”
Although no concepts have been revealed or trial balloons floated, McGeeney said he thinks the hospital-medical home confluence is where the Joint Commission will position itself.
“My gut tells me that is a market the Joint Commission will try to fill,” he said.
Affiliation with New York's 1,490-bed Montefiore Medical Center helped the 18-doctor Bronx East primary-care center achieve recognition from the NCQA as a medical home. The 1,000th practice to be so recognized by the NCQA, Bronx East is one of 21 facilities in the Bronx and the neighboring community of Westchester that make up the 250-physician Montefiore Medical Group.
Bronx East staff members give some credit for their success to Montefiore's physician employment model and to the parent system's sharing of resources to allow more hiring of support staff.
“In the late '70s and early '80s, physicians were leaving the Bronx for economic reasons, and Montefiore stepped to the plate and started to employ physicians because they weren't practicing in the Bronx anymore,” said Richard Celiberti, senior vice president of network development for Montefiore Medical Center. “You need primary-care physicians to deliver care in the medical home model.”
Support staff also is needed, and Bronx East has hired registered and licensed practical nurses, social workers and patient educators to help with care coordination, patient education, medication management and other nonclinical tasks.
“Because of the connection to the hospital, we were given an additional funding source to enhance our staffing,” said Maureen Warner, a registered nurse and director of clinical services and education. “Becoming a medical home has given us an opportunity to redesign our workplace, so physicians are working on physician things.”
Warner added that Montefiore is looking to the medical home model as a way of reducing visits to its hospital emergency departments, which are among the busiest in the country.
Physician Donald Raum, regional medical director of Bronx East, agreed but explained that, “It's not so much hospitals against primary care; it's about delivering care in the most appropriate setting.”
The highest concentration of NCQA-recognized medical homes is in the Hudson River Valley of New York state, where 51 practices have been so designated. But the area with the most clinics operating as medical homes may be New Orleans, where 42 of the 89 primary-care locations that have opened since Hurricane Katrina and the subsequent flooding devastated the city five years ago have been recognized by the NCQA.
The network was helped along with a $100 million federal grant in September 2007 and has grown with the participation of 25 institutions and groups that includes hospitals, health systems, state agencies and others.
Karen DeSalvo, vice dean of community affairs and healthcare policy at Tulane University School of Medicine, describes it as “a highly collaborative, but pretty loose organization of providers.”
Hospitals involved in the effort include 196-bed Children's Hospital and 283-bed Medical Center of Louisiana at New Orleans.
“The medical home principles were philosophically important to us,” DeSalvo said. “But, as opposed to ‘Let's take existing centers and transform them,' we started from scratch.”
In addition to working with the NCQA on accreditation, Blue Cross and Blue Shield of Louisiana is bringing the Bridges to Excellence pay-for-performance program to the area, which will allow practices and clinics to be eligible for its medical home recognition and quality bonuses, DeSalvo said. Last month, Tulane also received a $1.1 million grant from the U.S. Health Resources and Services Administration to develop a medical home primary-care curriculum.