Challenges in Transforming Smaller Practices into Medical Homes

The Patient-Centered Medical Home (PCMH) model of primary care has been held up as a model for renovating out nation’s problematic primary care system due to its focus on reducing costs and improving patient outcomes by using team-based care that is accessible, comprehensive, continuous, and coupled with payment reform.

Despite those goals, however, there is limited use of PCMH processes in practices with fewer than 20 physicians, according to a study published recently in the Journal of Clinical Outcomes Management.

“Internal capabilities and external incentives were associated with greater use of medical home processes, as were larger practice size and ownership by hospital or HMO,” according to the study, which was lead by Diane Rittenhouse, MD, MPH, an associate professor in the Department of Family and Community Medicine at the University of California, San Francisco.

The findings have applications for clinical practice, according to a review of the study written by Lydia Flier, BS, and Asaf Bitton MD, MPH, an instructor in medicine at the Division of General Medicine at Brigham and Women’s Hospital and instructor in health care policy at the Department of Health Care Policy at Harvard Medical School.

“This study found a limited presence of many PCMH processes in a national sample of small and medium-sized practices, indicating that these groups will need significant assistance to transform into fully-fledged Medical Homes. Small practices are clearly lagging behind their larger counterparts,” they wrote.

“To maximize PCMH transformation, practice change needs to be catalyzed through the use of local and regional sharing of common resources. … At the end of the day, payment reform will catalyze practice change and start rebuilding our fragmented primary care base.”

The retrospective cross-sectional study used data from the telephone-based National Study of Small and Medium-Sized Physician Practices, conducted between July 2007 and March 2009. The sample featured practices from the IMS Healthcare Organization Services database, a private, nationally representative database of 793,235 physicians.

The researchers based inclusion eligibility on whether the practice had one to 19 physicians, with at least 60% being adult primary care providers, endocrinologists, pulmonologists, or cardiologists.

Those specialties were included because they treat diabetes, asthma, and congestive heart failure, three of the major chronic illnesses the survey focused on. Hospital-owned practices were included, while academic faculty practices were not.

The researchers found that small and medium-sized practices earned only 21.7% of the possible points for use of PCMH processes on average. The prevalence of use of

processes varied by type of process, from 73.2% for having electronic access to emergency department notes to 2.4% for use of depression care managers.

“Fewer than 10% of practices had nurse care managers for chronic disease or reported that a majority of physicians use e-mail to communicate with patients,” the authors wrote. “Although one- and two-physician practices were more likely to incorporate feedback from and use e-mail communication with patients, they generally used fewer PCMH processes than larger practices. Indeed, larger practice sizes were associated with higher

scores on the medical home index (p < 0.001), with a range from 18.6% for solo or two-person practices to 32.7% for practices of 13—19 physicians.”

Source

Small Practices Need Big Help to Transform Toward the Medical Home [Journal of Clinical Outcomes Management]