Research ArticleOriginal ResearchA

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

Katie Coleman, Robert J. Reid, Eric Johnson, Clarissa Hsu, Tyler R. Ross, Paul Fishman and Eric Larson
The Annals of Family Medicine November 2010, 8 (6) 493-498; DOI: https://doi.org/10.1370/afm.1190

Article Figures & Data

Tables

  • Table 1.

    Baseline Characteristics of Not Reassigned and Reassigned Patients

    Demographic CharacteristicsNot ReassignedReassignedPValuea
    ACES-SF = Ambulatory Care Experiences Survey-Short Form; PACIC = Patient Assessment of Chronic Illness Care.
    a P value from χ2 test comparing percentages and from t test comparing means between reassigned and not reassigned patients.
    b The ACES-SF and PACIC questions (scored on 6- and 5-point Likert scales, respectively) were totaled within the subscales and then transformed to 100-point summary scores.
    Eligible patients from automated data, n6,1881,817
    Age in years, n (%)
        ≤351,137 (18.4)456 (25.1)<.001
        36–45713 (11.5)333 (18.3)
        46–551,199 (19.4)411 (22.6)
        56–651,377 (22.3)359 (19.8)
        66–75870 (14.1)147 (8.1)
        ≥76892 (14.4)111 (6.1)
    Male sex, n (%)2,500 (40.4)962 (52.9)<.001
    DxCG case mix score, n (%)
        Low morbidity (0.10–0.87)1,732 (28.0)790 (44.0)<.001
        Moderate morbidity (0.97–1.85)2,092 (33.8)641 (35.3)
        High morbidity (1.85–106)2,364 (38.2)377 (20.8)
    Length of relationship with primary care physician, n (%)
        <1 year771 (12.5)274 (15.1)<.001
        1–5 years2,300 (37.2)1,025 (56.4)
        5+ years3,117 (50.3)518 (28.5)
    Continuity of care index, mean (SD)0.495 (0.382)0.442 (0.401).001
    Patients assigned to newly hired doctors, n (%)356 (5.8)1,217 (67.0)<.001
    Information from baseline patient survey (2006)
    Patient survey complete, n938160
    Education, n (%)
        Less than college127 (13.9)13 (8.4).063
        Some college279 (30.5)42 (27.3)
        College graduate or postgraduate508 (55.6)99 (64.3)
    White race, n (%)801 (87.9)125 (81.2).028
    Patients assigned to newly hired doctors48 (5.1)105 (65.6)<.001
    Self-reported health status, n (%)
        Excellent or very good461 (51.8)80 (53.7).633
        Good302 (33.9)52 (34.9)
        Fair or poor127 (14.3)17 (11.4)
    ACES-SF subscales,b mean (SD)
        Quality of doctor-patient interactions85.8 (16.3)85.1 (16.4).627
        Shared decision making85.1 (22.3)84.8 (21.7).883
        Coordination of care81.3 (21.5)79.4 (22.6).327
        Access87.1 (17.2)86.3 (19.3).645
        Helpfulness of office staff91.4 (15.6)92.3 (13.0).499
    PACIC subscales,b mean (SD)
        Patient activation/involvement77.7 (27.0)72.7 (29.7).056
        Goal setting/tailoring69.0 (30.8)69.4 (31.3).893
    Utilization measures (contacts per person in 2006)
    Eligible patients from automated data6,1881,817
    Primary care visits, mean (SD)3.67 (4.40)2.44 (2.92)<.001
    Emergency department/urgent care visits, mean (SD)0.374 (0.978)0.241 (0.694)<.001
    Secure message threads, mean (SD)1.29 (3.46)0.85 (2.96)<.001
    Telephone encounters, mean (SD)3.74 (6.10)1.89 (3.48)<.001
  • Table 2.

    Contrast in Adjusted Patient Experience and Utilization at 12 Months Between Not Reassigned and Reassigned Patients

    CharacteristicNot Reassigned Estimate (CI)Reassigned Estimate (CI)Mean Differencea Estimate (CI)PValue
    CI = confidence interval.
    a Adjusted mean difference and P value from linear regression with cluster-adjusted standard errors. Comparisons are between reassigned and not reassigned patients, over 12-month patient experience measures adjusting for sex, age, educational attainment, self-reported health status at baseline, assignment to new vs existing physician, and 2006 patient experience.
    b The ACES-SF and PACIC questions (scored on 6- and 5-point Likert scales, respectively) were totaled within the subscales and then transformed to 100-point summary scores.
    c Adjusted percent difference and P value from a generalized linear model with a log link and Poisson variance, adjusting for overdispersion. Comparisons are between reassigned and not reassigned patients, over 12-month utilization adjusting for sex, age, morbidity, duration of relationship with primary care physician, assignment to new vs existing physician and 2006 utilization.
    Patient experience
    Ambulatory Care Experiences Survey (ACES-SF)b
        Quality of doctor-patient interactions86.1 (84.9 to 87.2)86.9 (83.5 to 90.4)0.88 (−2.99 to 4.75).656
        Shared decision making86.4 (84.7 to 88.2)84.0 (78.0 to 90.0)−2.51 (−9.20 to 4.19).462
        Coordination of care82.0 (80.2 to 83.8)80.3 (75.1 to 85.4)−1.76 (−7.63 to 4.12).558
        Access86.8 (85.5 to 88.2)85.3 (81.3 to 89.2)−1.57 (−5.94 to 2.79).479
        Helpfulness of office staff90.9 (89.5 to 92.3)88.7 (84.6 to 92.8)−2.14 (−6.77 to 2.48).363
    Patient Assessment of Chronic Illness Care survey (PACIC)b
        Activation81.1 (79.0 to 83.1)80.0 (74.7 to 85.4)−1.03 (−7.19 to 5.13).743
        Goal setting74.0 (71.7 to 76.3)73.9 (67.6 to 80.1)−0.15 (−7.30 to 7.00).967
    Utilization (contacts per person per year)% Difference Estimatec (CI)
    Primary care visits3.00 (2.93 to 3.08)2.67 (2.53 to 2.83)−10.9 (−16.7 to −4.7).001
    Emergency department/urgent care visits0.295 (0.279 to 3.12)0.324 (0.289 to 0.363)9.8 (−4.2 to 25.8).181
    Secure message threads2.28 (2.20 to 2.36)2.42 (2.26 to 2.59)6.1 (−2.3 to 15.2).157
    Telephone encounters2.84 (2.74 to 2.94)2.82 (2.63 to 3.03)−0.6 (−9.7 to 8.1).884

Additional Files

  • Supplemental Appendix

    Supplemental Appendix. Medical Care Survey

    Files in this Data Supplement:

  • The Article in Brief

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

    Katie Coleman , and colleagues

    Background As part of its pilot test of the patient centered medical home, the Group Health Cooperative reduced clinician panel size in order to strengthen the doctor-patient relationship. This required the reassignment of approximately one-quarter of the practice�s 8,000 patients to new clinicians. This study examined the effects of reassigning patients to new physicians.

    What This Study Found Practice redesign initiatives aimed at improving the patient experience may have unanticipated consequences. In this study, researchers found that reassigned patients were less likely to use primary care services but equally likely to use expensive emergency department care as patients who were retained by their existing physicians. Even with the disruption, however, reassigned patients were no less satisfied with their care experience. Physicians in this demonstration project, when given the chance to retain patients in their panels, chose to retain � not drop � those patients who were older and sicker. Patients who were less connected with a physician were more likely to be reassigned.

    Implications

    • To ensure that practice redesign does not adversely affect relationships with younger, healthier patients, the researchers call for more to be done proactively to connect patients to their new physicians and practice teams after being reassigned.

  • Annals Journal Club:

    Nov/Dec 2010

    Mitigating the Effects of Discontinuity

    The Annals of Family Medicine encourages readers to develop a learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club and sharing the results of your discussions in the Annals online discussion for the featured articles. RADICAL is an acronym for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word radical also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care and then acting on those discussions.1

    How it Works

    In each issue, the Annals selects an article or articles and provides discussion tips and questions. We encourage you to take a RADICAL approach to these materials and to post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Comments: Submit a response.") You can find discussion questions and more information online at: http://www.AnnFamMed.org/AJC/.

    CURRENT SELECTION

    Article for Discussion

    Discussion Tips

    As practices change toward becoming patient-centered medical homes (PCMHs) there are consequences. This article provides an opportunity to consider how to manage those consequences. Group Health Cooperative appears to be having great success in its PCMH transformation.2,3 This article assesses how efforts to reduce panel size affect the patient�s experience. The study also is an opportunity to reflect on one of the fundamental tenets of primary care: continuity of care and ongoing relationships.

    Discussion Questions

    • What question(s) are addressed by this article?
    • What is the larger context of the PCMH movement in which this article can be interpreted?
    • How is the Group Health approach to PCMH transformation different/similar to other approaches?
    • What are the strengths and weaknesses of the study design for answering the question?
    • To what degree can the findings be accounted for by:
    1. The larger and local contexts into which this study is nested?
    2. How the practice, physicians, and their patients were selected?
    3. How the main variables were measured?
    4. Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)?
    5. How the data were analyzed and interpreted?
  • What are the main study findings?
  • How comparable is the study sample to similar patients in your practice? What is your judgment about the transportability of the findings?
  • What are the parallels between Group Health�s need to reassign patients to reduce panel size as part of its PCMH transformation and the training practices� need to reassign patients when trainees move on?
  • How might this study change your practice?
  • What are the implications of this study for reform at both the practice and policy levels?
  • What are the study�s implications for the design of clinical education programs?
  • What important researchable questions remain?

    • References

    1. Stange KC, Miller WL, McLellan LA, et al. Annals journal club: It�s time to get RADICAL. Ann Fam Med. 2006;4(3):196-197. http://annfammed.org/cgi/content/full/4/3/196.
    2. Reid RJ, Fishman PA, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009;15(9):e71-e87.
    3. Reid RJ, Coleman K, Johnson EA, et al. The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29(5):835-843.
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