|Implemented in this survey?|
In 2006, Pennsylvania?s Geisinger Health System began piloting a series of initiatives to improve healthcare value, one of which was a medical home program. The program began in three pilot sites and has since been rolled out to ten more. Advantages of the model are only just becoming apparent, but have been positive enough to garner attention from policymakers looking to reform the nation?s healthcare system.
In 2006, the Geisinger Health System, located in rural central Pennsylvania, began piloting a series of initiatives to improve healthcare value, which the organization defined as "outcomes relative to input costs." One of those innovations was a medical home program, which began in three sites and has since been rolled out to at least ten more sites.
In 2006, Geisinger began testing a medical home project, in response to a call to innovate from the system's board of directors. The program assigns each patient a Personal Health Navigator (PHN), an employee of the system who acts as a contact to respond to patients' everyday concerns and queries. A risk assessment and care plan are developed for each patient, and each patient has twenty-four hour, seven-day-a-week access to primary and specialty care. Every patient has electronic medical records (EMRs), which they can access (as read-only versions) through a web-based interface. The web portal also allows patients to see lab results and performance over time, make appointments, refill prescriptions and receive care alerts and reminders, among other features.
Practices that participate in the medical home program receive a monthly payment of US$1800; they also receive US$5000 per thousand Medicare members they serve. The payments cover the cost of additional staff, added workload and extra hours necessary to meet the demands of the program.
The general objective of medical homes is to build stronger relationships between patients and their primary care provider by having the provider coordinate all of the patient's medical needs and be available to the patient at all times. Geisinger has implemented the model in order to improve value, by promoting health, managing chronic care, reducing hospitalizations, and shortening lengths of stay. The approach also aims to cut down on unnecessary and duplicate -and therefore costly - testing and procedures.
Geisinger's medical home program includes an incentive pool from which payments are made to practices, based on success in meeting quality performance measures (performance reports are completed monthly). Payments are shared between providers and employees of the practice. Geisinger predicts that these incentive payments will eventually supplant monthly payments currently paid to all participating practices. Geisinger points out that the incentives are larger than those of more traditional pay-for-performance initiatives, totaling up to 20% of a physician's total compensation.
Patients, Providers, Payers
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
Geisinger describes itself as an "open yet integrated" and "physician-led" healthcare system. The system, founded in 1915, serves 41 counties and 2.5 million people, and consists of three hospitals and 700 physicians, 200 of which are primary care physicians. The system has its own health plan, which serves around 200,000 members, about a third of which use the system for their care. Geisinger Health Plan (GHP) members thus comprise a minority of the patients served by the system.
|Implemented in this survey?|
According to a recent issue of Health Affairs, with a section dedicated to the medical home model (Health Affairs 2008), the idea of a medical home dates to the 1960s, when the American Academy of Pediatrics introduced it as a way to serve children with special needs. Geisinger is one of many sites that has been revisiting the approach in recent years. While most agree that the medical home model is centered on patient need, consensus beyond this point is lacking. Some medical home programs focus on chronic disease care, while others, for example, focus on electronic coordination of care. The definition of what, precisely, constitutes a "medical home" is at the center of a current debate about whether it's a useful model for informing national health reform.
The approach of the idea is described as:
While the call for innovation was issued by Geisinger's board of directors, the development of initiatives was a collaborative process that culled input from providers, operational and financial staff, payers and patients. New innovations developed by collaborators included a chronic disease care model and a program called ProvenCare, which outsiders have described as a "warranty" on health care services, in addition to the medical home program. New innovations are typically tested on GHP members who are served by the health system, and then expanded if successful.
Geisinger's medical home project is patient-centered; it is also reliant on electronic record keeping and places an emphasis on chronic disease management. The project began at three pilot sites, two of which were chosen for their large proportion of Medicare recipients. At pilot sites, patients received risk assessments and plans of care, all records were kept electronically (as they are throughout the system), and both providers and patients were given access to patient records. Success at the pilot sites was determined based on performance on chronic disease, preventive service and patient satisfaction measures(some of which are described below). In early 2008, based on evidence of the program's promise, Geisinger expanded the medical home project to more than a dozen total sites.
Advantages of the medical home model are only just becoming apparent, but have been positive enough to garner the attention of policymakers looking to reform the nation's health care system. Pilot sites that adopted the medical home model in 2006 saw a nearly 8% reduction in hospital admissions among Medicare patients assigned a medical home and a 4% reduction in medical costs in the first year. The positive trend appears to be continuing; according to results published in Health Affairs in 2008 (Paulus 2008), "preliminary data show a 20% reduction in all-cause admissions and 7% total medical cost savings." Separately, the system reported that GHP members assigned a Personal Health Navigator experienced an 11.7% decrease in hospital readmissions compared to those served by sites that did not offer patients a PHN. Additionally, Geisinger has reported that electronic identification of chronic care needs and automated referrals have, in the case of chronic kidney disease patients, improved performance measures and resulted in drug cost savings of $3,800 per patient per year.
The medical home model is being scrutinized by policymakers at the national level who are looking to reform the healthcare system under the current administration. The model is often viewed as a remedy for a system in which care is often fragmented, uncoordinated, and in which most individuals lack a primary care physician. At the same time, cautionary experts warn that the medical home has not yet proven scalable, lacks a universally accepted definition, and lacks sufficient evidence of its ability to yield significant cost-savings.
Geisinger itself has concluded that its experience to date has three key implications for national health care policy:
With additional evidence, the project may also provide the further proof of cost-savings that critics have called for.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
Health Affairs, Special section on the medical home model. Vol 27, September/October 2008. See in particular Paulus, Ronald et al. "Continuous Innovation in Health Care: Implications of the Geisinger Experience". Health Affairs Vol. 27, no5, pp. 1235-1245.
"Primary Care Innovation: The Patient Centered Medical Home". Sponsored by the Alliance for Health Reform and Commonwealth Fund, September 22, 2008. Transcript available at www.allhealth.org/briefingmaterials/Transcript-1304.pdf
Wangsness, Lisa. "Medical Home Approach Brings Back Managed Care". Boston Globe, April 9, 2009.
Elena Conis, Emory University