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Medical homes—the kinds of health practices where patients and their caregivers have easy access to comprehensive and coordinated care and are fully engaged in the decision-making process—have been touted by many as the future of health care.
But for many patients, that future is a long way off.
That is the conclusion of a new study by John Hollingsworth, MD, MS, an assistant professor at the University of Michigan Medical School and an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (2008-1010).
Nearly half of medical practices (46%) fail to meet medical home standards as defined by the National Committee on Quality Assurance (NCQA), Hollingsworth and his coauthors found. Multi-specialty practices were more likely than primary care practices to meet NCQA medical home standards; nearly three in four multi-specialty practices (72%) met the NCQA criteria, but only one in two (50%) solo or partnership practices did.
The findings mean that many of the nation's patients do not have access to the benefits of the medical home model of care, which helps prevent patients—especially those with multiple chronic conditions—from getting "lost in the shuffle" of the nation's complex, fragmented health care system, Hollingsworth says. "A patient may receive higher quality care if she has a physician 'quarterback' managing her medical team who facilitates communication among her providers."
But more worrisome for those who support this new model of care, the majority of Americans may not have access to medical home practices anytime soon, the study suggests. Larger, multi-specialty facilities have greater potential of meeting medical home standards, but the vast majority of Americans—nine out of 10—receive health care from physicians who practice in smaller, single-specialty groups.
For the study, Hollingsworth and his coauthors mapped physician practice data from the National Ambulatory Medical Care Survey (NAMCS) to the NCQA standards for medical home recognition. The study was published online on October 18, 2011, in the journal Health Services Research. It is part of a special issue on "Bridging the Gap Between Research and Health Policy" that features research articles from current and former RWJF Clinical Scholars. The print edition will be published in February 2012.
Hollingsworth's co-authors are Sanjay Saint, MD, MPH, a professor at the University of Michigan Medical School and an alumnus of the RWJF Clinical Scholars program (1996-1998); Joseph Sakshaug, MS, a doctoral student in survey methodology at the University of Michigan; Rodney Hayward, MA, a professor at the University of Michigan Medical School and co-director of the RWJF Clinical Scholars program at the University of Michigan; Lingling Zhang, MA, a doctoral student at Harvard Business School; and David Miller, MD, MPH, an assistant professor at the University of Michigan Medical School.
Move Toward the Medical Home Model Gets a Boost from the Federal Government
The health care system is gradually moving toward the medical home model of care, which features evidence-based care pathways, performance measurement and feedback systems, and multi-dimensional health information technology, Hollingsworth says. The shift got a boost from the federal government in 2009, when it enacted an economic stimulus package that authorized funds for health providers who adopt and use electronic health records. Another jolt came in 2010, when the federal government enacted a health reform law that provided grants and contracts to build medical home capacity.
While the authors support a gradual shift toward the medical home model of care, they caution against the possibility of unintended negative consequences. Rural health providers may not be able to take advantage of higher reimbursements for services provided by practices designated as medical homes because they are less able to affiliate with larger groups, they note. That, in turn, could cause some practices to close and further restrict access to care in rural areas.
In addition, certain vulnerable groups are overrepresented in practices that are not recognized as medical homes, which could widen health care disparities, they write. "People who reside in poorer communities are more likely to be seen by practices that wouldn't meet current medical home standards," Hollingsworth says. "These people are already economically disadvantaged and, on top of that, they wouldn't have access to the higher quality of care offered by this delivery system reform."
Hollingsworth and his coauthors offer a variety of policy solutions to support the adoption of the medical home model of care and to address potential problems that may arise. They suggest legislative incentives to help solo or small practices to affiliate with larger physician organizations, practice team-based care, and adopt health information technology. They also suggest initiatives that would support regional centers aimed at facilitating the medical home reforms in less populated areas.
Full realization of the medical home model, however, depends as much on politics as anything else, Hollingsworth says. "The current administration has emphasized a variety of delivery system reforms including the medical home, accountable care organizations, and value-based purchasing. Moreover, it has made pilots and demonstration projects a priority. But with the political waters being what they are, it's hard to forecast the future."
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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