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New Atlas Features Roadmap To Medical Homes



April 7th, 2008

Because the most glaring geographic variations in health care use have been observed in specialty and end-of-life care, policymakers have had trouble coming to terms with the work of John Wennberg and his Dartmouth colleagues. The questions the Dartmouth researchers raise about spending and quality are too disruptive, too threatening. Specialty and end-of-life care are too sensitive for the blunt instruments of policy to address.

But with publication today of the latest edition of the Dartmouth Atlas, focused on chronic care, Wennberg and company carry their analysis to the most fundamental, everyday questions about the organization and delivery of care. The new Atlas joins the battle for health system improvement on a level that everyone can understand. It engages with questions that have immediate meaning for Congress, consumers, and many medical professionals and throws its weight behind policy proposals that already have widespread support. Wennberg is no longer a lonely voice crying out in the wilderness.

Building on earlier work, the new Atlas explores variations in care during the last two years of life among patients with one or more chronic conditions. Some of the work was previewed in Health Affairs’ November/December 2007 twenty-fifth anniversary issue. But while the approach is familiar, the 2008 Atlas throws down a new challenge to the conventional wisdom. The eye-opener here is that “higher utilization and spending in ambulatory settings, skilled nursing facilities and home health care was associated with higher utilization and spending for inpatient care.”

Not only did increased use of less intensive services fail to offset hospital use, but primary care, per se, did not seem to improve care coordination or overuse. “Simply increasing the number of primary care physicians alone will not improve coordination. Spending on ambulatory visits, many of them to primary care physicians, is positively correlated with inpatient days and inpatient physician visits,” the authors found. “There are no tradeoffs.”

The Atlas derives a menu of policy prescriptions from these findings, several of which align with and reinforce an emerging nucleus of ideas about attacking delivery system fragmentation at its roots. One of the options is “a scenario in which CMS (the Centers for Medicare and Medicaid Services) would offer shared savings partnerships to providers that agree to coordinate care among the various sectors” – a notion that echoes the Medicare Payment Advisory Commission’s (MedPAC’s) interest in bundled payment (a discussion recently reviewed on this blog).

More intriguing still, the Dartmouth authors weigh in strongly in favor of exploring “medical home” arrangements that have been explored and promoted by the American College of Physicians, the American Board of Internal Medicine, and MedPAC (see transcript cited above), among others.

Among proponents of the medical home, there is some controversy about whether the concept should be described and designed as a simple add-on to primary care that would allow maximum participation among generalist physicians who assumed some responsibility for coordination; or as a more sophisticated capability that would entail “systems-based practice” and information management and might be able “to reduce overall use for by the 10 percent to 20 percent of patients who use the most services,” as ABIM puts it. But this high-end version would not be easy to implement for many small physician practices.

The Dartmouth finding that “simply increasing the number of primary care physicians alone will not improve coordination” is an important contribution to a growing policy debate about medical homes. If a new national policy conversation about health reform does in fact occur in the wake of next November’s elections, there may be an opportunity to consider delivery system organization as a basic element, along with cost and coverage. A magical, payment-driven transformation of the delivery system into integrated entities cannot be assumed to be inevitable, as it was in the early 1990s. If there’s going to be real change, it will have to be organized from the ground up. The new Atlas ought to be an invaluable navigation aid to the next wave of pioneers. Perhaps the next step is to understand how primary care works in low-spending areas.

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4 Trackbacks for “New Atlas Features Roadmap To Medical Homes”

  1. The Medical Home and a Preference Sensitive Read of the 2008 Dartmouth Atlas on Tracking the Care of Patients with Severe Chronic Illness | Diario BV
    April 6th, 2009 at 5:10 am
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5 Responses to “New Atlas Features Roadmap To Medical Homes”

  1. jenny@gilesandmcgee.com Says:

    Yes, there is some controversy about whether the medical home “concept should be described and designed as a simple add-on to primary care” and that “simply increasing the number of primary care physicians” will improve patient-centric population health improvement strategies. Currently, many health plans, as well as disease management companies, now see the medical home as the ideal way to achieve improvements in both quality and efficiency. There is a great deal of medical home discussion across the industry.

    For those who might be interested in additional information about this debate, DMAA: The Care Continuum Alliance will broadcast from its annual meeting a complimentary, live Webcast of a keynote presentation on the medical home and population-based approaches to care Monday, Sept. 8, from 10:15 to 11:30 a.m. Speakers are Bruce Bagley, MD, medical director for quality improvement, American Academy of Family Physicians; and Paul Grundy, MD, MPH, chair, Patient-Centered Primary Care Collaborative. Drs. Bagley and Grundy are highly respected experts in this debate. They will discuss the evolution of the medical home and the contributing role of prevention, wellness, disease management and other population health improvement strategies, as well as recognition of the physician as the leader of the care team. If you are interested, you can register at TheForum08.org/Webcast

  2. Arvind Cavale Says:

    Without reading the Atlas, I would like to concur with Bob’s assessment “that more primary care visits did not offset a high volume of specialty visits” and disagree with Dr. Starfield’s comment “In fact, all the evidence—even that provided in this Atlas—is that it is visits to ’specialists’ in the ambulatory care sector that is largely responsible”.

    Having been a Primary Care Internist many years ago and an Endocrinologist for 8 years, I can say without a doubt that as an Endocrinologist, I am able to care for my diabetics much more effectively, efficiently, and more importantly, to their satisfaction, than I ever did as a Generalist. After having participated in the 2-year Center fro Practice Innovation project sponsored by the ACP (working with the main author of the PC-MH manuscript) I can say that certain chronic diseases can be managed much more effectively by “Principle Care Physicians” than conventional “Primary Care Physicians” – so it would be valuable, Rob, to include this concept in the PC-MH process. Example of such diseases include Nephrologists being Principle Care for patients on dialysis, Oncologists for cancer patients, Endocrinologists for diabetics, etc.

    It is also important not to just look at the number of ambulatory care visits in isolation, but to view them in terms of effectivness. There should be no harm if more frequent visits to specialists results in high quality care with high efficiency and comprehensive coordination. In fact, we provide an example of just such service – as evidenced by our recent involvement in a research project on Coordination of Care being conducted by the Center for Studying Health System Change.

    Therefore, in our effort to control cost, one must not ignore the fact that quality almost always trumps cost, whether generalists or specialists are concerned. It would be good to know if the authors of the Atlas actually questioned patients (especially with chronic diseases) as to their experiences with respect to quality and comprehensiveness of care they received from their primary care and specialists.

  3. Rob Cunningham Says:

    I thank Dr. Starfield for her comments, defer to her advanced knowledge on this subject, and agree it is important to recognize that ambulatory visits to specialty providers are by all accounts a major concern — although I believe that there has been significant attention paid to this problem in work on specialty service competition by Bob Berenson and colleagues at the Center for Studying Health System Change, among others.

    At a glance through the Atlas, I can’t find a breakdown between specialist and primary care ambulatory visits, and so must rely on the language cited above about such visits (“many of them to primary care physicians”). I didn’t think the Atlas authors implied that primary care visits were the cause of excess utilization and spending. The insight seemed to be more that there was not a negative correlation — that more primary care visits did not offset a high volume of specialty visits.

    This observation resonated with an April 2 commentary in JAMA by Richard Baron and Chris Cassel on “21st-Century Primary Care,” which explored the depth and complexity of the competencies needed to coordinate care effectively enough to achieve improvements in both quality and efficiency. With MedPAC poised to recommend that Medicare move aggressively into experimentation with the medical home concept, the Dartmouth findings seemed to represent an intriguing and hopeful convergence of interest around a critical subject. I hope Dr. Starfield will be patient with those of us who are so far behind her in grasping these issues as we struggle to catch up.

  4. Barbara Starfield Says:

    The statement that ‘Spending on ambulatory visits, many of them to primary care physicians, is positively correlated with inpatient days and inpatient physician visits,” is ambiguous with particular regard to ”
    ‘many of them being primary care physicians’. In the US, more ambulatory visits are now being made to NON-primary care specialists than to primary care, and this is especially true among the elderly—-even by evidence provided in the Dartmouth Atlas. The basis for implying that it is visits to primary care physicians that account for higher costs does not exist. In fact, all the evidence—even that provided in this Atlas—is that it is visits to ‘specialists’ in the ambulatory care sector that is largely responsible. Controlling costs in the US will require attention to appripriateness and quality of care of ambulatory care specialists—a subject that currently receives little if any attention.

  5. Theresa Green Says:

    While I did not read the entire Atlas, and it no doubt provides a fabulous amount of data for explaination, I would like to point out that the article that is referenced here is titled “Tracking the Care of Patients with Severe Chronic Illness. It is not suprising therefore that “higher utilization and spending in ambulatory settings, skilled nursing facilities and home health care was associated with higher utilization and spending for inpatient care.” This population is a group of high users regardless. Those that used primary care less were most likely less severely ill. I would caution against making causal inferences with such information, such that primary care did not improve care coordination. It may be simply that these are sicker patients requiring more primary and secondary care, hence the positive correlation. I agree with the Dartmouth authors recommendation of exploring medical homes – either at this high level of need or with healthy younger people devoid of chronci illness, in which case a decrease in impatient utilization has definitely been demonstrated.

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