Implications of Reassigning Patients for the Medical Home: A Case Study

INTRODUCTION

Professional associations, policy makers, and health care providers are recognizing the many, well-documented challenges limiting US primary care’s capacity to deliver high-quality services.^1–5 There is growing enthusiasm among commercial health plans and other private and public entities for implementing a patient-centered medical home model (PCMH) to improve clinical quality, strengthen primary care, improve patient experience, and reduce costs.^6–13 According to PCMH principles, practices must redesign several components of care delivery, including establishing a regular physician or source of care for each patient and understanding patient populations, to provide accessible, high-quality, coordinated care.^14–16 Achieving these goals requires practices to make a deliberate attempt to identify a group of patients for whom a physician or team is responsible and to engender meaningful relationships with that complement of patients. One underappreciated consequence of redesigning a primary care practice around the PCMH is that for many practices where physicians have large or unbalanced workloads, patients may need to be shifted from one physician to another and engender new relationships with different physicians.^14,17,18

Group Health Cooperative, a large, nonprofit, integrated delivery system, is among the first organizations to operationally define, implement, and comprehensively evaluate a medical home redesign initiative for all adult patients enrolled in an urban primary care practice.¹⁸ The initiative resulted in improved patient experience, reduced staff burnout, improved clinical quality, and 29% fewer emergency department visits in the intervention site when compared with control sites. Despite the substantial investment needed to implement the PCMH, the pilot demonstrated savings of $10.30 per member per month after 21 months.¹⁹

As part of the medical home pilot, Group Health aimed to strengthen doctor-patient relationships by reducing physician panel size, expanding standard visit time from 20 to 30 minutes, and allocating an hour each day for secured messaging and telephone communication with patients. Despite overall improvements in patient experience and utilization among patients in the medical home pilot site,¹⁹ we anticipated that patients who had been reassigned to new physicians may have experienced a transitory downside in their care. We noted a lack of research evaluating the impact on patients of the process of adjusting patient panels as part of the medical home.²⁰ This supplementary analysis to Group Health’s PCMH evaluation presents the first quantitative examination of the potential unintended consequences of reassigning patients to new physicians as part of medical home practice redesign.

METHODS

We base our analysis and interpretation of findings on Haggerty and colleagues’ conceptual model of continuity that was developed by means of a systematic review of the literature with multidisciplinary expert input.²¹ This framework proposes 3 conceptually distinct elements of information, management, and relational continuity and suggests that impact of each type of continuity on patient experience and outcomes depends on the context of care.²² This conceptual approach builds on existing literature that demonstrates the importance of continuity to improved patient satisfaction,²³ health behaviors,²⁴ health outcomes,²⁵ reduced use of services,²⁶ and lower total costs.²⁷

RESULTS

As part of Group Health’s PCMH pilot demonstration, physicians were given a list of their patients and were able to select those they believed should be retained in their panel. This step provided a chance for physicians to select patients for whom relational continuity was considered so clinically important to the patients’ well-being that they should be excluded from potential reassignment (personal communication, Practice Manager, September 17, 2009). Though this was the only step before patients were randomly selected for reassignment, it resulted in significant differences between patients who were reassigned and those who were not (Table 1⇓).

Physicians retained in their panels those patients who were sicker and with whom they had longer relationships. Reassigned patients were more often younger, healthier males who utilized approximately one-third to one-half fewer primary care, secure message, telephone, and emergency department/urgent care visits in the baseline year compared with those not reassigned.

Reassigned patients’ experience of care at follow-up appeared to be no lower on the ACES-SF and PACIC subscales after accounting for baseline experience and whether the patient was reassigned to a new or existing physician (Table 2⇓). Furthermore, Cohen’s d effect sizes were calculated (data not shown), but none was significant. Because this study is a subanalysis, we may be underpowered to detect a clinically significant difference. No differences in patient disenrollment throughout 2007 were seen between the 2 groups (5.6% not reassigned vs 4.2% reassigned P = .711); the measure is too variable to establish any definitive conclusions.

After controlling for baseline patient characteristics and utilization, reassigned patients utilized in-person primary care less often in 2007 than did not reassigned patients (P = .004). We were unable to detect differences in emergency department and urgent care visits (P = .143).

DISCUSSION

The differences between the reassigned and the not reassigned patients in terms of longitudinal relational continuity were striking. When given the chance to retain patients in their panels, physicians chose those who were oldest, sickest, and with whom they had the longest relationship. This finding bolsters Hjortdahl’s conclusion that a physician’s extensive knowledge of his or her patients and feeling of responsibility toward them increase with time and with a greater density of visits.³⁴

It also confirms that continuity matters for physicians³⁵ and patients,³⁶ especially more vulnerable patients.³⁷ Contrary to policy concerns, physicians in this demonstration project chose to retain those patients who were older and sicker. Group Health physicians are paid based on a salary, and panel size expectations are not risk adjusted; therefore, physicians face no financial benefit to retain patients with complex conditions. Yet, physicians did just that, preserving the continuity of care for patients to whom it likely matters most.

For those patients who were reassigned, however, the outcomes were not so positive. Patients who were less connected with a physician were more likely to be reassigned. Those reassigned patients used primary care services less often but appear to have used expensive emergency department visits as often as their counterparts. The decrease in primary care, after controlling for past usage, is worrisome, as one of the goals of a medical home implementation is to strengthen the connection between patients and their primary care physician to prevent episodes requiring emergency care. It is unclear whether this decrease in primary care usage represents a transitory effect of reassigning patients to new physician or a long-term disruption to relational continuity.

Interestingly, with this disruption of the patients’ already tenuous doctor-patient relationship, we detected no significant impact on reassigned patients’ care experience. Further, many of the differences in other measured domains were small given that one group suffered discontinuity with its primary care physicians.

Data limitations may have influenced the findings. First, we were unable to distinguish between patients who were ineligible for reassignment and those who were eligible but not randomly selected for reassignment. Baseline differences between these patients may have resulted in confounding. To address these concerns, sensitivity analyses were conducted. We excluded from the analysis those patients that likely comprised a large portion of the population physicians’ deemed ineligible for reassignment—those older than 65 years, those with a DxCG score greater than 2.5, and those with a physician relationship lasting more than 8 years (data not shown). We remained unable to find significant relationships among any of the survey-administered scales. Because this represents a subanalysis, we may be underpowered to detect differences in patient’s experiences of care as a result of reassignment. In addition, the unique patient characteristics of this single site may limit the generalizability of these findings to other clinical settings.

Contextualizing the clinical impact of these changes is difficult, as previous studies have shown conflicting results: Pereria and colleagues found that quality of care did not deteriorate for patients who were reassigned to new physicians, but Flocke et al showed that forced discontinuity led to significantly worse patient-perception of care.^38,39 Because reassignment at Group Health happened within the context of a single clinic, the strength of informational and managerial continuity from the single electronic medical record that was coincidentally developed as part of the medical home intervention may have helped to mitigate the deleterious effects of disrupted relational continuity for reassigned patients. To ensure that practices do not adversely affect their relationships with younger, healthier patients as they work to strengthen existing doctor-patient relationships, more must be done proactively to bind patients to their new physicians and practice teams after being reassigned. Meaningfully adjoining patients and providers in the context of the medical home has the potential to create relational continuity for those who may not have it while strengthening existing relationships.