What Do Medical Home Studies Indicate?

Another publication, this time from Pediatrics, indicates the value of a medical home. But is this value about the term “medical home” or is this value about the concepts that are associated with “medical home”- concepts that any number of providers and clinics can address.

In addition, this is a poorly conceived study with a major failure to consider the real reasons for differences - social determinants that shape access, continuity, and better outcomes.

What Do Medical Home Studies Indicate?

• Associations and researchers are willing to use data sources that are not from “official medical homes” to indicate medical home value.
• Concepts are considered more important than the primary care people who deliver the care. Of course those who cut primary care funding fail to understand they are cutting the experienced people needed to deliver primary care. Primary care is about people – repeat often, especially when examining studies about primary care. 
• Methods that select patients with better social determinants will have better outcomes. Methods tha select patients with higher levels of continuity will have better social determinants and better outcomes as well as better access to care. Substantially more is also invested in health care for those who have greater access and higher social determinant levels. One would also have to ask how many criteria were needed by researchers to demonstrate a difference. 
• In the study, those of advantage were more likely to have continuity home experiences. In almost every instance of lower probability of preventive visits (age less than 1, single mom, lower income, lack of health insurance, less educated parents), those that preserved continuity had greater proportional improvement (close to 2 to 1). In other words those that somehow bucked social determinants had better care. The continuity home definition did little for those with social determinant advantages and did the most for those that managed to have a continuity home despite odds against. 
• In the study the differences are significant, but the differences are so small as not to be relevant.
• Children with a medical home were more likely to receive higher health ratings (excellent or very good) as compared to those without that were lower rated (good, fair or poor). Many would consider the noted outcomes as a matter of differences in health status.
• As with other pediatric studies, the experts consider near universal access to pediatric care. They have of course overlooked the problem of maldistribution and limited access for over half of children due to workforce limitations in 30,000 zip codes with low or lower health workforce concentrations.
• Then the study considers a 30% decreased ER utilization discussed in association with a continuity home.

At this point I just have to stop looking. This is a poor study by any number of measures. These are good people that are well intentioned. Some if not most have delivered care where needed. Sadly there is a loss of perspective.

There are significant investments of time and effort by associations and this is a likely reason why such studies are published. What is obvious from this and other studies is that changes in social determinants are required as a top priority with reorganizations of care way down the list.

The current pediatric study does not prove the value of the Medical Home as headlines indicate in Medscape – proof is almost impossible to prove in medical studies. What the Medscape headlines do indicate is poor understanding of medical studies by the medical media (or at least dramatization that is deceptive).

The investment in medical home terminology is so high that family medicine leaders have protested when studies fail to show the expected benefit. After devoting substantial funding to this area, perhaps objectivity is lost. Does Family Medicine Need New Leaders?

I am certainly for the concepts of team care, continuity of care, integration of information, and other aspects that are considered medical home concepts. These are obvious to those who have experienced the great pleasure of delivering challenging care with a supportive team. Who would be against such a design?

The problem remains that continuity home interventions are not going to solve primary care woes or the associated social determinant maldistributions.

Diverting a Nation from Real Solutions

The continuity home has been touted as a solution for the primary care woes of the nation. In fact, the Continuity Home will not improve the major health access problems of the nation. When providers present “cures” that do not work and distract patients from treatments that do work, this is considered a serious offense.

Offensive Literature and Offensive to Dedicated Primary Care Practices

It is hard not to find much of the literature developing around the medical home concept to be “offensive.”

I will continue to assert first that social determinants are far more important and that any primary care practice that has dedicated health professionals that function together as a team to provide health care, that stay together as a team, that keep the same patients, that keep the same location for care, and that have sufficient funding to accomplish the above – will have the optimal care with or without medical home designation.

If the cost of a medical home designation impedes care, medical home designation will not improve the care and may damage care.

If the medical home designation comes with more funding, the care may improve but this is likely the result of the additional funding rather than a medical home focus (beware government promises of more funding as this may not materialize).

If sites receive continuity home grants, then they will have better care because the additional funding is likely to give them an advantage in recruiting and retaining the best primary care personnel. Continuity care is clearly more likely with those that are easiest to care for, as demonstrated in the study.

Of course a real design for the care of all Americans provides sufficient primary care spending across the nation, not just for those who have grants or cost-based reimbursement.

Quality Arises from People and Relationships from the Ground Up, Not from Concepts Thrust on People from Above

Quality is the result of reflective process by dedicated team members with objective consideration of all relevant aspects of care – especially very basic awarenesses and understandings of the patients served. This process does not require certain terms such as continuity home, stroke center, chest pain centers, etc. Continuity home focus can improve care and can raise awareness of methods that can improve care, but a continuity home itself will not be the reason for change.

But if you desire a nice name or certification there are numerous places to contact, meetings to attend, and others willing to take money away from delivery of primary care. Your choice of the following or dozens of others.

On-Site Certification. The Mark of Quality that Sets Your Medical Home Above the Rest. The Joint Commission: Primary Care Medical Home 2011 StandardsAccess and Continuity in the Medical Home SettingBlueprints for Building a Medical Home

The Problem Facing Primary Care

The problem facing primary care remains the same. The problem is that revenue derived from primary care services is insufficient to keep up with rapidly rising costs. When the cost of delivering care is insufficient, the result is cuts in personnel, less experienced personnel, fewer personnel, and decrease in the ability to deliver more care and better care.

When the costs of delivering care are increased due to various innovations and reorganizations without increasing the revenue, it is possible to also result in less primary care delivery.

If a national focus on higher quality (by less volume, more costly technology, fewer personnel) results in less primary care delivered per primary care provider, the nation will have much greater problems with cost, quality, and access because the missing link is primary care personnel of all types.

The Problem of Social Determinants Ignored

If primary care experts ignore social determinants, then they do not understand the most important variables regarding cost, quality, and access. If Pay for Performance pays more for “quality,” relatively less will be paid to practices that have lower and middle income patients. This is because practices that are more likely to care for those in need of care will have lower quality ratings because of the patients that they care for. Higher quality ratings and greater pay will go to those who have better quality because of who they are.

The authors of this Pediatrics article have built another very good case for social determinants yet they have claimed that the reason is the continuity home. This is a quite serious problem for Pediatrics, for primary care, and for most Americans in need of real solutions for health access.

Better Ratings with Better Pay, or Care Delivered Where Needed?

To get lower quality ratings and less pay, continue to care for underserved, poor, near poor, rural, disadvantaged, and lower income patients.

To get better quality ratings and better pay, be sure you care for less complex people. The nation will overall have lower health care quality, higher costs, and declining access to care – but you and your practice will do better.

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D.        Basic Health Access Web    Basic Health Access Blog

SMART Basic Health Access     World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies

Why are 2008 HRSA Projections of Primary Care Workforce indicating substantial increases when the reality is decreases in primary care?

Primary care workforce is substantially less than annual graduate numbers depict due to departures from primary care during primary care training, at graduation, and each year after graduation.

The Health Resources and Services Administration projection of 2020 physician primary care was last posted in 2010. This document indicates increases in primary care that are impossible for internal medicine and family practice. To properly guide the nation, HRSA must not wait for new data or studies. It should remove the erroneous projections. This major document represents much good work tainted by the primary care projections.

	Family Medicine	Internal Medicine	Pediatrics
Annual Graduates since 1980	3000 and steady for zero growth for 30 yrs	About 1% annual growth to 7200	About 2% annual growth to 3200
% Primary Care Entry	85% - surveys, office based retention, COGME 91%	20 - 25% for senior resident surveys and COGME	44% for senior resident surveys and COGME
2010 Primary Care	100,000	80,000 – 90,000	45,000 – 50,000
2020 Primary Care	100,000	60,000 – 70,000	45,000 – 50,000
2030 Primary Care	100,000	40,000 – 50,000	45,000 – 55,000
Steady State 30 yr Entry	3000 per year	1400 per year	1400 - 1600 per year
HRSA 2020 Primary Care Projection Exhibit 18	143,350 family/general practice	155,330 IM Primary Care	72,730 for PD Primary Care
Past Entry into Primary Care in recent years	2500 - 3000	3000 – 3500	1200 - 1400
Annual Primary Care Entry 2010 to 2020 to reach HRSA 2020 Projections	Double from 3000 to 6000 FM Grads 2010 to 2020	Five times entry requiring all 7000 IM Grads to stay in PC	Double the current annual entry to 2600 each year 2010 to 2020

Family medicine has not changed and given 30 years of zero growth, is not likely to change. Internal medicine primary care retention has been cut in half in primary care entry in the past 15 years and 20,000 internists, typically those younger, have entered the hospitalist workforce in recent years. The decline in primary care internal medicine is a worst case scenario for the elderly doubling 2010 to 2030. Any increase in annual graduates in family medicine would have been most specific for the elderly, poor, near poor, rural, CHC, and other populations in most need of primary care.

Pediatric experts have indicated saturations of pediatric primary care in the locations where pediatricians locate primary care practices (Cull, Committee, Freed). Because PD primary care is saturated, increased pediatric annual graduates have resulted in lower proportions remaining in primary care. Expansions of PD annual graduates have demonstrate lack of an ability to increase primary care via expansion. 

Government and foundation reports indicate nurse practitioner and physician assistant contributions to be made in primary care. It is true that primary care contributions have increased, but it now takes 2 to 3 times more graduates for the same primary care, rural primary care, and underserved primary care delivery since 1980. This is because fewer remain in family practice employment – the predominant primary care, rural, and underserved delivery vehicle.

Government and foundation reports also are not specific and the media reports of these efforts are even worse. The reports imply indicate "nurse substitution for physicians" or "nursing as a solution" or "nurse practitioners as solutions." Generic solutions such as more nurses or more nurse practitioners are not specific primary care solutions. Specific solutions for primary care are only 1 in 50 nursing school graduates and only 1 in 4 nurse practitioner graduates that are specific to employment in family practice as a direct care clinician.

Retention in family practice for MD, DO, NP, and PA graduates

is the only significant primary care, rural primary care,

and underserved primary care solution.

Retention in primary care is required

for any source of primary care to result in primary care workforce.

How can viable workforce discussions proceed if major association, foundation, and government reports are in error? Getting beyond agendas to people in need of basic health access is the specific requirement for primary care to be able to address basic health access.

Projection methods for primary care fail when graduates fail to remain in primary care. Projection methods fail when assumptions intercede and displace reality. Common sense tests must be applied to be sure that projections during rosier times (such as the 1990s for primary care) do not result in inflated projections.

Studies must encompass entire careers of contributions using realistic estimates such as those based on years in a career, primary care retention, and activity levels. With only 30% of primary care graduates serving in primary care careers and wide variations in activity and years in a career, the folly of depending upon annual gradutes is quite apparent.

SMART measuring tools are required that assign future workforce to the class year of graduation. This is illustrated in the Standard Primary Care Year – a method that can Specifically Measure Achievable primary care in a Realistic and Timely way.