Medical home pays off, improving primary care and cutting cost at 2 years

SEATTLE—In a two-year evaluation at Group Health Cooperative, transforming primary care into a "patient-centered medical home" model paid off. Published in the May 2010 Health Affairs, the evaluation compared the medical home prototype to Group Health's other medical centers, showing:

• The quality of care was higher, patients reported having better experiences, and clinicians said they felt less "burned out."
• Patients had 29 percent fewer emergency visits and 6 percent fewer hospitalizations, resulting in a net savings of $10 per patient per month.
• For every dollar Group Health invested, mostly to boost staffing, it recouped $1.50.

This evaluation prompted Group Health to spread the medical home to all 26 of its medical centers, which it finished doing in January 2010.

"A medical home is like an old-fashioned family doctor who really knows you as a person," explained evaluation leader Robert J. Reid, MD, PhD, an associate investigator at Group Health Research Institute and Group Health's associate medical director for preventive care. "The fresh twist is that the doctor leads a team of professionals." And the team makes the most of current knowledge and technology—including e-mail and electronic health records—to deliver first-rate primary care and reach out to help patients stay healthy.

"Many American patients miss that old 'Marcus Welby' feeling of being truly known by their doctor," said Dr. Reid. "Patients feel rushed when their doctor visits are too short. Likewise, many primary-care doctors say one downside of the expansion of medical knowledge is that they feel stressed by having to do too much in too little time."

That's why Group Health lowered how many patients each salaried primary care doctor (family physician or general internist) is responsible for: down to 1,800 from 2,300. That left more time for planning, outreach, coordination, daily "team huddles," staying in closer touch with patients by e-mail and phone, and longer office visits: 30 instead of 20 minutes.

Group Health invested $16 more per patient per year in extra staffing for its pioneering medical home prototype. This investment didn't include a robust health information technology infrastructure, which Group Health already had in place.

The investment paid off quickly in a broad range of improved outcomes, including better-quality care, better experiences for patients, less burnout for clinicians, and cost neutrality in the first-year results. At year 2, most of these outcomes were even more pronounced, particularly for costs: The overall return on investment was 50 percent, mostly from curbing visits to emergency rooms and hospitals.

"Nationally, the patient-centered medical home is emerging as a key way to improve health care and control costs," Dr. Reid said. "Our findings strongly support this model and its ability to address these concerns. The medical home is here to stay."

For others implementing medical homes, Dr. Reid suggests:

• Invest in primary care by hiring enough clinicians so they can serve their patients well.
• Involve patients in designing care that comprehensively meets their needs.
• Have strong leaders who focus on what patients want, clearly articulate those wants, and let care teams take charge of their change process.
• Have good managers who break big changes into carefully staged parts, so teams aren't overwhelmed.
• Invest in health information technology, and thoughtfully integrate it into the daily practice of the medical home.

Group Health pays primary-care doctors a salary to care for a group of patients. But in most of the United States, they are paid based mostly per office visit. For policy makers, Dr. Reid recommends:

• Reform how health care is financed so that primary care can realize the savings that it makes in hospitalization and emergency room use.
• Train more primary-care doctors, physician assistants, nurses, pharmacists, and medical assistants to work in teams and make the most of health information technology.
• Pay primary-care doctors not only for office visits but also for outreach, coordination, planning, team-based care, and e-mail and phone visits to help their patients stay healthy.
• Federal criteria for "meaningful use" of electronic health records should include asking patients how they like it—and promoting transparency, communication, and coordination.

"The findings of the Group Health medical home prototype jibe with prior research on the critical role of primary care in achieving high-quality, lower-cost care," said Elliott S. Fisher, MD, MPH, director of Dartmouth Medical School's Center for Health Policy Research, in Hanover, NH. "They also underscore the importance of a supportive medical neighborhood in which the other elements of an integrated delivery system work together to support the success of the medical home and improve care for patients."

Group Health Cooperative funded the medical home pilot and two-year evaluation. Dr. Reid's co-authors are Katie Coleman, MSPH; Eric A. Johnson, MA; Paul Fishman, PhD; Clarissa Hsu, PhD; Michael P. Soman, MD, MPH; and Claire Trescott, MD; Michael Erikson, MSW; and Eric B. Larson, MD, MPH.

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears each month in print, with additional Web First papers published weekly at www.healthaffairs.org/.

Founded in 1947, Group Health Cooperative is a Seattle-based, consumer-governed, nonprofit health care system. Group Health Research Institute changed its name from Group Health Center for Health Studies in 2009. Since 1983, the Institute has conducted nonproprietary public-interest research on preventing, diagnosing, and treating major health problems. Government and private research grants provide its main funding.