Diane R. Rittenhouse

The Patient-Centered Medical Home: Will It Stand the Test of Health Reform?

THE FUNDAMENTAL CHALLENGE FOR HEALTH CARE REform in the United States is to expand access to all US residents, while rapidly reengineering the delivery system to provide consistently high-quality care at lower overall cost. Current reform discussions recognize that success will require a shift in emphasis from fragmentation to coordination and from highly specialized care to primary care and prevention. One prominent model of delivery system reform is the patient-centered medical home (PCMH). Crafted by the primary care professional organizations in 2007, the model has been endorsed by a broad coalition of health care stakeholders, including all of the major national health plans, most of the Fortune 500 companies, consumer organizations and labor unions, the American Medical Association, and a total of 17 specialty societies. Currently, 22 multistakeholder demonstration pilot projects are under way in 14 states, and the Centers for Medicare & Medicaid Services will conduct Medicare demonstration pilot projects in 400 practices in 8 regional sites in 2009. Twenty bills promoting the PCMH concept have been introduced in 10 states.

Primary Care and Accountable Care: Two Essential Elements of Delivery-System Reform

The “patient-centered medical home” and the “accountable care organization” are two widely discussed models for delivery-system reform. Drs. Diane Rittenhouse, Stephen Shortell, and Elliott Fisher have identified several strategies for ensuring that these models are mutually reinforcing.

Small And Medium-Size Physician Practices Use Few Patient-Centered Medical Home Processes

The patient-centered medical home has become a prominent model for reforming the way health care is delivered to patients. The model offers a robust system of primary care combined with practice innovations and new payment methods. But scant information exists about the extent to which typical US physician practices have implemented this model and its processes of care, or about the factors associated with implementation. In this article we provide the first national data on the use of medical home processes such as chronic disease registries, nurse care managers, and systems to incorporate patient feedback, among 1,344 small and medium-size physician practices. We found that on average, practices used just one-fifth of the patient-centered medical home processes measured as part of this study. We also identify internal capabilities and external incentives associated with the greater use of medical home processes.

Measuring The Medical Home Infrastructure In Large Medical Groups

The patient-centered medical home is taking center stage in discussions of primary care innovation as a new delivery model that provides comprehensive, coordinated care across the lifespan. Although the medical home is widely discussed by policymakers, payers, and other stakeholders, the extent to which physician practices have the infrastructure in place to function as medical homes is not known. Using data from the 2006-07 National Study of Physician Organizations, we examine the extent of adoption of medical home infrastructure components among large primary care and multispecialty medical groups and their association with medical group size and ownership.

Improving chronic illness care: A longitudinal cohort analysis of large physician organizations

Background:An increasing number of people suffer from chronic illness. Processes exist to provide better chronic illness care and yet for the most part, they are not used. Objective:To examine the change in use of commonly recommended chronic illness care management processes (CMPs) in large medical groups between 2000 and 2006 and the factors associated with the change. Design and Measures:Cohort analysis of data from a national telephone survey in year 2000 and again in 2006. Participants provided information on their organizations’ ownership, size, use of defined chronic illness CMPs, financial incentives, quality improvement involvement, profitability, and use of electronic medical records. Setting:Medical groups and independent practice associations of 20 physicians or more (N = 369) that treat patients with asthma, congestive heart failure, depression, and diabetes, and that responded to the survey in 2000 and 2006. Results:Use of CMP increased from 6.25 to 7.67 (of a total of 17; P ≤ 0.001), that is, by 23%, between 2000 and 2006. Increases were greatest for those practices receiving financial rewards for quality; those participating in quality improvement activities; and those practices that were profitable. Most of the increase was in use of registries and in patient self-management support services. Conclusions:There is significant opportunity for improving chronic illness care even in larger physician organizations. Public policies that promote financial rewards for improving quality and that encourage quality improvement initiatives are likely to be associated with improved chronic illness care.

Improving Chronic Illness Care: Findings From a National Study of Care Management Processes in Large Physician Practices

The use of evidence-based care management processes (CMPs) in physician practice is an important component of delivery-system reform.The authors used data from a 2006-2007 national study of large physician organizations—medical groups and independent practice associations (IPAs) to determine the extent to which organizations use CMPs, and to identify external (market) influences and organizational capabilities associated with CMP use. The study found that physician organizations use about half of recommended CMPs, most commonly disease registries, specially trained patient educators, and performance feedback to physicians. Physician organizations that reported participating in quality improvement programs, having a patient-centered focus, and being owned by a hospital or health maintenance organization used more CMPs. IPAs and very large medical groups used more CMPs than smaller groups. Organizations externally evaluated on quality measures used more CMPs than other organizations. These findings can inform efforts to stimulate the adoption of best practices for chronic illness care.

Specialist Physician Practices as Patient-Centered Medical Homes

Widespread support has emerged for the patient-centered medical home model of health care delivery. Dr. Lawrence Casalino and colleagues write that some specialist physicians are raising concerns about the medical homes implications for their practices.

Developing a policy-relevant research agenda for the patient-centered medical home: a focus on outcomes.

BackgroundThe Patient-Centered Medical Home (PCMH) is a widely endorsed model of delivery system reform that emphasizes primary care. Pilot demonstration projects are underway in many states, sponsored by Medicare, Medicaid, major health plans and multi-payer coalitions.MethodsIn this paper we consider the development of a long-term policy-relevant research agenda on outcomes of the PCMH. We provide an overview of potential measures of PCMH impact, identify measurement challenges and recommend areas for further study. Although the PCMH should not be expected to solve every problem in the health care system, developing a research agenda for measuring outcomes of delivery system innovations such as the PCMH should be considered in the context of the larger effort to improve the US health care system, with the ultimate goal to improve population health.ResultsAs a framework for our discussion, we have chosen the Institute of Medicine’s six specific aims for 21st century health care: (1) safe, (2) effective, (3) patient-centered, (4) timely, (5) efficient and (6) equitable. In addition, we include potential areas of PCMH outcomes that do not easily fall under this framework and consider unintended consequences.ConclusionMulti-stakeholder involvement will be essential in developing a long-term policy-relevant research agenda for outcomes of the PCMH.

Improving Quality in Medicaid The Use of Care Management Processes for Chronic Illness and Preventive Care

Background:Care management processes (CMPs), tools to improve the efficiency and quality of primary care delivery, are particularly important for low-income patients facing substantial barriers to care. Objective:To measure the adoption of CMPs by medical groups, Independent Practice Associations, community clinics, and hospital-based clinics in Californias Medicaid program and the factors associated with CMP adoption. Methods:Telephone survey of every provider organization with at least 6 primary care physicians and at least 1 Medi-Cal HMO contract, Spring 2003. One hundred twenty-three organizations participated, accounting for 64% of provider organizations serving Medicaid managed care in California. We surveyed 30 measures of CMP use for asthma and diabetes, and for child and adolescent preventive services. Results:The mean number of CMPs used by each organization was 4.5 for asthma and 4.9 for diabetes (of a possible 8). The mean number of CMPs for preventive services was 4.0 for children and 3.5 for adolescents (of a possible 7). Organizations with more extensive involvement in Medi-Cal managed care used more CMPs for chronic illness and preventive service. Community clinics and hospital-based clinics used more CMPs for asthma and diabetes than did Independent Practice Associations (IPAs), and profitable organizations used more CMPs for child and adolescent preventive services than did entities facing severe financial constraints. The use of CMPs by Medicaid HMOs and the presence of external (financial and nonfinancial) incentives for clinical performance were strongly associated with use of care management by provider organizations. Conclusions:Physician and provider organizations heavily involved in Californias Medicaid program are extensively engaged in preventive and chronic care management programs.

Managing Chronic Illness: Physician Practices Increased The Use Of Care Management And Medical Home Processes

The effective management of patients with chronic illnesses is critical to bending the curve of health care spending in the United States and is a crucial test for health care reform. In this article we used data from three national surveys of physician practices between 2006 and 2013 to determine the extent to which practices of all sizes have increased their use of evidence-based care management processes associated with patient-centered medical homes for patients with asthma, congestive heart failure, depression, and diabetes. We found relatively large increases over time in the overall use of these processes for small and medium-size practices as well as for large practices. However, the large practices used fewer than half of the recommended processes, on average. We also identified the individual processes whose use increased the most and show that greater use of care management processes is positively associated with public reporting of patient experience and clinical quality and with pay-for-performance.