An Innovative Way to Improve Care for Chronically Ill Patients

Given the shortage of primary care physicians in the U.S. — and the well-documented frustrations felt by both doctors and patients during the delivery of health care – the need for new approaches to improving access and outcomes is especially acute.

Against this backdrop, Wharton health care management professor Guy David and four colleagues — Candace Gunnarsson, Phil Saynisch, Ravi Chawla and Somesh Nigam — analyzed a new model of primary care that is both team-oriented and centered on the patient. They present their findings in a research paper titled, “Do Patient-centered Medical Homes Reduce Emergency Department Visits?” published recently in Health Services Research.

In an interview with Knowledge@Wharton, David discusses the research and its implications for better, less costly health care delivery.

An edited transcript of the conversation appears below.

Knowledge@Wharton: Can you give us an overview of your research?

Guy David: There is dissatisfaction and even frustration among patients and physicians with the state of primary care in the U.S. Physicians are facing low managed care fees [along with] increases in the costs of running a practice. That is inevitably leading them to see more patients during the day, spend less time with them, and have patients wait a very long time for appointments. Obviously, this has the potential to deteriorate the level of care, hurt the quality, and lead to inadequate care.

Patients have the same issue. They don’t [get] enough time with the physicians. Very little face time leads the physician to rely heavily on referrals to specialists. And, of course, waiting a long time for an appointment has its own problems. Your condition may deteriorate. You are delaying very necessary care. At the end of the day, you actually might have to resort to going to the emergency room or suffer some other consequences. This is not going to get better, because these issues related to inadequate access to care and mismanagement of health conditions are only going to get worse with an aging population, with increasing chronic condition prevalence and with insurance expansions.

So with the shortage of primary care physicians that we currently have in the U.S., we see regulators, we see policymakers, we see employers and we see health plans looking for innovative ways to change the landscape of primary care. One of those innovations – probably the most notable one – is the Patient-centered Medical Home, which we study in this particular research. We are trying to see if the adoption of the Patient-centered Medical Home model leads to a reduction in the reliance on emergency room services.

“The practices that went through this transition have reduced the number of emergency room admissions for their patients by 5% to 8% if the patient had a chronic illness.”

Knowledge@Wharton: What is a Patient-centered Medical Home (PCMH)?

David: A Patient-centered Medical Home can be best described as a model of primary care centered on the patient. It is team oriented. It relies on accessibility to care, care coordination, and the use of IT to provide better care and better outcome for patients. Most of the Patient-centered Medical Homes in the U.S. are recognized by the National Committee for Quality Assurance, NCQA.

NCQA is a non-profit committed to improving quality in primary care. In order to be NCQA-recognized, the practices have to put in processes for scheduling appointments with patients, for communicating with patients, for organizing, documenting and measuring clinical outcomes, for implementing evidence-based guidelines in their practices, and for organizing and tracking referrals. There is a whole long list of other things that they need to put in place to receive this recognition.

Every one of those standards, elements and factors that are being reviewed is getting scored. And when you aggregate the score, there is a determination whether this clinic becomes a Patient-centered Medical Home or not. Not only that; it also determines whether the recognition is low level or high level. So there are different levels of recognition. If you are a Patient-centered Medical Home recognized by the NCQA, you have access to financial incentives that are provided by health plans, by employers and — in the early days of Patient-centered Medical Homes, which we study — also by state and federally sponsored pilot programs.

Knowledge@Wharton: What are the key takeaways from your research?

David: We find that practices that went through this transition and became a Patient-centered Medical Home become the home for the patient. They are not going anywhere. There is a team-based approach that provides a home for every need that the patient has. The practices that went through this transition have reduced the number of emergency room admissions for their patients by 5% to 8% if the patient had a chronic illness. If the patient did not have a chronic illness, there was absolutely no reduction. This is the primary finding. Then when we drill down and look at the different chronic conditions, we see that a lot of those benefits – and the biggest reductions that we see – happen for patients who have either hypertension or diabetes.

In addition to that, a very interesting thing that we have looked at is: What is the mechanism that leads to this reduction in E.D. [emergency department] admissions? One of the findings we see is that the reduction in E.D. admissions is not very sensitive to the timing of the visit. What does that mean? That the reductions in E.D. admissions are not coming necessarily from the fact that the Patient-centered Medical Home is open for longer hours or that it has more accessibility, but actually from better management of chronic conditions. That basically means that even if you seek care in the emergency department on weekends when most of those primary care clinics are closed, you would still have the same reduction, the same benefit, and that tells me that your chronic condition is under control and is better managed.

“If the Patient-centered Medical Home model is the poster child for innovation in primary care, the stepchild would be a variety of retainer-based medicine models, also known as concierge medicine models.”

Knowledge@Wharton: What sets your research apart from other studies?

David: I believe what sets our research apart is its scale. We looked at 460,000 patients over four years in 280 Patient-centered Medical Homes. This was never done before – not on this particular scale. For 115,000 of those patients, we see each and every year in our sample. That allows us to do things that, again, were never done in the literature. So it is not just that we can see what happened to the patient population when a practice decides to switch to a Patient-centered Medical Home. But we can see what happened to an individual patient when the practice switches to a Patient-centered Medical Home, and we can follow the patient and see if there is a different experience for that particular patient during that particular transition.

Knowledge@Wharton: Which, if any, of your conclusions surprised you?

David: Previous research is very mixed on this issue of the benefits of Patient-centered Medical Homes. So we did not really know what to expect. I see our findings as somewhat comforting because we see the effect where we expect to see it, and we do not see it where we expect not to see it. Let me give you an example. For patients who do not have a chronic condition, we do not expect the Patient-centered Medical Homes to have a big impact on E.D. admissions. The main reason why a person ends up in the emergency room when they do not have a chronic illness are things like trauma and motor vehicle crashes. There is nothing in the Patient-centered Medical Home that makes you a better driver. They are not claiming to do that.

On the other hand, if you have a chronic condition, better management of that condition using all of the processes that NCQA puts in place in the practice can have an impact, and it is very comforting to see that 5% to 8% of admissions to the emergency room are being avoided. Now we have a lot of research that documents that many of the visits to the emergency room can be prevented. It is either that the visit is legitimate – somebody has a problem – but if they had better management, that visit could have been avoidable. And we still have a lot of visits to the emergency room where the setting is wrong. You could have gone to your primary care physician or to another setting and received care. You did not have to go to this high level of acuity type care.

Knowledge@Wharton: Are there alternatives to the Patient-centered Medical Home?

David: If the Patient-centered Medical Home model is the poster child for innovation in primary care, the stepchild would be – at least judging from the lack of interest among researchers – a variety of retainer based medicine models, also known as concierge medicine models. At the heart of those models is a monetary transfer from patients to their physicians in the form of a retainer fee, which averages about $150 per month. In return, the physicians are able to reduce the size of their panel from about 3,000 patients to no more than 600. This allows the physician to spend more time with the patient, have extended visits – about half an hour – and make sure that patients can come in on the same day – i.e., accessibility to care. A patient can call their physician and they can email their physician. So the service aspect and the convenience aspects are enhanced.

“I think in spirit, Obamacare — the Affordable Care Act — fits very well with this trend of innovation in primary care.”

Retainer based models stem from the same dissatisfaction and frustration that the Patient-centered Medical Home models stem from – but retainer based models have not received much attention in the literature and to some extent in the media. Not all the attention is favorable. You might ask yourself why. There are two main reasons.

One, people view this as medicine for the rich. This a little bit ignores the fact that most people who receive services nowadays in those concierge practices and retainer based medicine models are middle class. And $150 a month – we can debate that, but for a lot of people, this is considered to be affordable. The second, and probably the biggest criticism of retainer based models, is its sustainability. We have a fixed supply of physicians. If every physician downsized their practice, we are just going to exacerbate the shortage of primary care physicians.

This is a valid criticism, but it ignores a couple of things. One, many physicians, especially at a certain age in their life, contemplate retiring, contemplate maybe changing direction professionally – working for a pharmaceutical company or something like that. Instead, if they can go into this retainer based model, it buys them a couple more years where they can work in this field at a different pace. The second issue is that retainer based models tend to make primary care more attractive to young doctors who are choosing which field of medicine they want to go into. And if we want to solve the shortage of primary care in the long run, we have to make primary care more attractive. We see that happening on the ground.

The last point is that there are many models of retainer based medicine that do not rely on major reductions in the panel size. Those models, typically called hybrid models, have a huge potential because they are scalable and also because they tend to segment patients into those who value access to their physicians from those who see their physicians just for routine checkups and for very basic care.

Knowledge@Wharton: Will Obamacare have much of an effect on this model?

David: I think in spirit, Obamacare — the Affordable Care Act — fits very well with this trend of innovation in primary care. This innovation, when we look at Patient-centered Medical Homes, places the patients in the center and, in a way, it transitions us from a world in which physicians were paid based on volume to a world in which we are trying to shift and pay physicians based on value that they create for their patients. That is very much in the spirit of the Affordable Care Act.

What else is in the spirit is the reliance on information technology, on cost containment, on finding ways to have other non-physicians in the clinic [be] part of this medical home and work at the top of their license. They will engage in population management, will reach out to patients with chronic conditions, and will follow up and try to improve care to reduce the burden of downstream utilization that can happen when those breaks in continuity of care occurs.

Knowledge@Wharton: Do you plan to conduct further research in this area?

David: There are a couple of research projects already underway. The first stream deals with these heavily understudied retainer based medicine models. This [involves] a partnership with one of the leading companies in the industry to study the real effects of patients who stay within a retainer based framework and those who find themselves outside of that framework. What happens when you spend half an hour with the physician instead of eight minutes or 12 minutes? What happens to referrals? What happens to outcomes? What happens to your health? And what happens on the financial side in terms of health costs?

On the other venue of the patient centered medical homes, our partners at Independence Blue Cross and I have received very unique data from NCQA allowing us to look at all the individual scores on all standards, elements, and factors for those practices that we have studied in the research I have described today. This will allow us to look under the hood at the very granular level of what is driving change and innovation in primary care and allow us for the first time to understand the elements that are driving the various improvements in care both in terms of outcomes and costs.

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