Medical Homes: Collaborative Care
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The idea of elevating the importance of primary care isn’t new. Most health maintenance organizations require patients to choose a general practitioner and get his or her okay to see a specialist. Yet in those systems, physicians have responsibility but little authority. Their decisions can be second-guessed and overruled by insurance company officials, for whom cost control is the order of the day. Physicians who are insufficiently business-minded could be paid at lower rates, or even excluded from managed care networks.
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The medical home model attempts to promote frontline physicians from gatekeepers to patient advocates with clout and resources. And although most pilot programs are relatively new, several have shown promise. The oldest, started in 1998, is Community Care of North Carolina, the state’s managed care program for Medicaid. It links independent practices, larger clinics and hospitals to coordinate care for beneficiaries. CCNC began with nine pilots and has expanded to encompass 14 community networks, more than 3,500 physicians and more than 970,000 patients. Each patient is enrolled in a practice that serves as a medical home and provides acute and preventive care, manages chronic illnesses, coordinates specialty care and offers 24/7 on-call access. CCNC facilitates Medicaid’s payment of physicians an extra $2.50 per month per Medicaid patient ($5 for those who are aged, blind or disabled) to be a care manager and provide more comprehensive services. (That might seem like a pittance, but it adds up for practices that see large numbers of Medicaid patients.)
Each local community network also receives an additional $3 per patient ($8 for the aged, blind or disabled) per month to pay for outside case managers, including a medical director and even pharmacists, who may help implement disease and care management guidelines for asthma, diabetes and other chronic conditions. This part of the program educates patients, develops treatment plans and monitors outcomes.
Human resources consulting company Mercer, in assessing the CCNC medical home pilot, estimated that CCNC saved North Carolina $60 million in fiscal year 2003, and by 2006 savings had increased to $161 million. CCNC, meanwhile, conducted its own evaluation, finding that quality of care had also improved. Between 2003 and 2006, for example, there was a 40% decrease in hospital admissions for patients with asthma.
Two other widely cited medical home studies involve Washington’s Group Health Cooperative and Pennsylvania’s Geisinger Health System. Both are HMOs employing their own physicians and serving as health insurer for at least some patients, and both already had sophisticated electronic health record systems. Those characteristics make the systems inherently collaborative, and hardly typical; only about 5% of care is delivered through such integrated networks. Even so, results of the groups’ medical home pilots have been impressive.
