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

After presenting the article to a large family practice residency and several faculty members, the conclusion was benefits were still better than the possible negative outcomes. When the PCMH model is completely implemented into our program, the implications discussed would likely not affect us. Our patient failure and ED/urgent care utilization is already elevated. Our patients are turned-over every three years or more frequently due to residents graduating the program. There is an inherent graduated scale of patient volume givien the class year, so it would be difficult to have even panels. We truly doubt the care experience scores would be less with reassigned vs current.

Therefore, any benefit from the PCMH model would only serve to benefit our residency and our patient population. More stream-lined, better care would outweigh the potentional implications that the article discussed.

Unfortunately for the study, the age of the patients as well as the length of the study made significant limitations. Like previously mentioned, healthier younger patients don't frequent offices or care settings as much as older patients. We feel that the power of the study is greater reduced given the patient population and the tracking length and method of the study.

Further research regarding implication of PCMH should include populations in the urban, under-served areas of more diverse age groups as well as PCMH that include multi-specialty groups.

Competing interests:   None declared

Thanks for highlighting the important issue of prevention. We agree that preventive care – in addition to good chronic and acute care - is an essential component of high quality primary care. As part of the medical home demonstration, Group Health aimed to put systems in place to improve care across the whole practice for all patients.

In fact, two of the components of the intervention – outreach and pre -visit preparation - were targeted directly at patients whose planned care needs were unmet. In our year 1 and year 2 analyses, we found practice- wide improvement on HEDIS measures, including measures of both primary and secondary prevention, across patient populations. Though we did not publish the results of the measures individually, they are included in the quality composite measures outlined here:

Reid RJ, Fishman PA, Yu O, Ross TR, Tufano JT, Soman MP, et al. Patient-centered medical home demonstration: a prospective, quasi- experimental, before and after evaluation. Am J Manag Care. 2009 Sep;15(9):e71-87.

And here:

Reid RJ, Coleman K, Johnson E, Fishman P, Hsu C, Soman MP, Trescott CT, Erikson M, Larson EB (2010). The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout For Providers. Health Affairs 29(5):835-843.

In regards to the patients who were reassigned to different providers as part of the effort to reduce panel size and increase visit length, our results hardly indicate that patients were abandoned. Indeed our study showed no difference in patient experience of care, electronic communication or ED utilization. Perhaps this finding bolsters your point that a re-examination of the meaning of continuity for a young adult population is in order.

For those practices interested in expanding the time physicians have to interact with their patients as part of the medical home, panel sizes may need to be reduced. The goal is to do that in a way that disrupts care as little as possible. Asking providers to flag those patients for whom continuity is most clinically important may be a way to do just that.

Competing interests:   None declared

Your November/December 2010 article entitled “Implications of Reassigning Patients for the Medical Home: A Case Study” is a great example of the power and limitations of the Patient Centered Medical Home (PCMH) model. Thus far in the literature, the strengths of the PCMH have been focused on secondary prevention of chronic illnesses such as diabetes and hypertension. While the PCMH shows great promise in more optimal management of chronic illness, the model fails to emphasize the importance of preventive services for healthy patients. Just as this case study demonstrates, younger, healthier patients were more likely to be reassigned to other physicians than their older, sicker counterparts. Intuitively, sicker patients should have priority for health care services, but the PCMH cannot continue to neglect the healthy population. It is within this young, healthy population that the PCMH has the distinct opportunity to showcase the power of primary care – prevention. So far, only one study (Ferrante, March 2010) has examined delivery of preventive services in the PCMH model. The Ferrante study concludes that “Relationship-centered aspects of PCMH are more highly correlated with preventive services delivery in community primary care practices…”, but even in this study, the average patient age was 64, and very few patients were under 50 years old.

Although the case study reveals that the healthy population had decreased use of primary care after reassignment, the decreased use does not necessarily equate to poorer outcomes. We must re-examine what primary care and continuity of care should entail for a young adult population. This healthy population does not require frequent use of primary care, but instead requires effective preventive services such as appropriate screenings and vaccinations. Contrary to the perception that these reassigned patients are low-priority in the healthcare setting, these patients possess the most valued asset in medicine – a clean bill of health. The PCMH must focus more attention on preserving the health of the young population rather than concede to the temptation of abandoning them by reassignment.

Ferrante J, Balasubramanian B, Hudson S, Crabtree B. Principles of the Patient-Centered Medical Home and Preventive Services Delivery. Ann Fam Med. 2010 March; 8(2): 108–116.

Competing interests:   None declared