Medical Homes May Be an Option to Reduce Costs and Improve Care

Las Vegas—Utilizing patient-centered medical homes and increasing the use of health information technology may help the healthcare industry battle growing healthcare costs while providing high-quality care. The benefits of medical homes and the role pharmacists can play in the treatment system were recently discussed in a session at the ASHP meeting.

According to David W. Bates, MD, the current medical system is broken and has “untenably” high costs and high levels of harm. Dr. Bates, who is the chief of the division of general internal medicine and primary care at Brigham and Women’s Hospital, also said that about 50 million people in the United States do not have health insurance. He said the current Congress will likely try to address the issue of healthcare reform by focusing on coverage for the uninsured and exploring ways to reduce costs.

Chronic diseases remain common in the United States and can be attributed to about three quarters of the country’s health expenditures. Dr. Bates said that 83% of the population over age 65 has a chronic condition, and that by 2015 it is estimated that 150 million people will have at least 1 chronic condition in the United States.

Primary care physicians can play a critical role in the healthcare system. This comprehensive and continuous method of care has been linked to improved health outcomes, lower costs, and a more equitable distribution of care.

Medical homes are one option to revitalize the primary care industry. Medical homes are physician-led teams that provide integrated and comprehensive care. This format uses clinical information systems to assist in patient care and includes routine patient feedback to physicians and a focus on dignity and respect. Medical homes also involve the patient in the decision-making process.

Across the country, medical home demonstration projects are being conducted to evaluate this treatment approach. Most of the demonstrations are funded by the Commonwealth Fund and have a fee-for-service payment structure. The Commonwealth Fund was established in 2005 with the goal of creating a path for the US healthcare system.

Dr. Bates outlined attributes necessary for organizing and delivering healthcare. The attributes include making sure that patient information is available to all providers through electronic record systems, ensuring that patient care is coordinated among multiple providers, and making sure that all members of the care team are accountable to one another and can review each other’s work. Patients also need to have access to care and information even after hours.

Medical home demonstrations are important for the future of healthcare because research indicates that they can improve the patient experience and help provide better quality and efficiency. Dr. Bates noted, however, that there are gaps in the evidence and that demonstrations need to be rigorously evaluated to determine their effectiveness.

The components of a medical home vary substantially from one practice to another, including payment methods. For instance, the Goroll Payment Model is structured so that practices receive a yearly, risk-adjusted payment for the comprehensive care of every patient in the practice. This payment covers the cost of expenses in the practice and salaries.

The medical home system can help physicians gain greater control over patient conditions like hypertension, cholesterol, and asthma. Dr. Bates noted, however, that there is a need for more care management, social services, psychiatric support, and information technology.

The role of pharmacists in the medical home has not been clearly established, but Dr. Bates said that pharmacists can play a key role in reducing medication-related costs and promoting adherence to medications. Pharmacists can also improve clinical care and can reduce the frequency of adverse drug events. He added that it would be important for pharmacists to get a seat at the table and demonstrate their value as the industry evolves.

Previous research on group health results has shown that patient-centered medical homes are associated with less staff burnout, higher scores on patient experience scales, higher levels of quality, and no change in costs.

Benefits have also been noted in electronic healthcare information systems. Key findings from the Center for Information Technology Leadership shows that standardized and encoded electronic information would save the healthcare system $337 billion over a 10-year implementation period, would dramatically reduce the administrative burden, and would decrease the unnecessary duplication of laboratory tests.

According to Dr. Bates, to transform the quality of healthcare there needs to be an electronic health record, registry tools, team care, clinical decision support, and performance measures. To ensure safety, essential processes need to be made more reliable through new approaches like bar coding and checklists. He concluded by saying that the primary care industry needs to be revitalized and the medical home concept is an exciting way to do it.

Stephen M. Setter, PharmD, associate professor, Washington State University, also discussed medical homes and provided more detail about a medical home demonstration. Medical homes include direct physician supervision and management of the comprehensive care of a patient with at least 1 chronic condition or prolonged illness.

In the first tier of a medical home demonstration, a physician-led team provides a patient with ongoing support and oversight. Together the team works to develop an integrated plan for the patient’s medical care. This plan is regularly revised as new information or additional medical therapy is added.

Medication changes are also approved and tracked based on the pharmacy benefit plans.
The medical home team reviews the patient reports from other physicians or healthcare professionals on a regular basis and uses evidence-based medicine and clinical decision support tools in previsit planning and postvisit testing or follow-up. Communication is a key component of the medical home, including contact with the patient or caregivers as treatment decisions need to be made.
Finally, the medical home demonstration includes a self-management plan for patients and includes arranging and evaluating preventive services that could benefit the patient.—Jill Sederstrom