Medical 'homes' improve access, quality, and equity

Responses to the Common-wealth Fund's 2006 Health Care Quality Survey demonstrate the importance of having stable insurance, a regular health care provider, and a medical home for improving health care access and quality among vulnerable populations. Over the past 20 years, the survey report says, much work has been done to identify and develop a set of indicators to best capture components of a medical home. The report defines a medical home as a health care setting that provides patients with timely, well-organized care and enhanced access to providers.

The concept of a medical home was first introduced by the American Academy of Pediatrics and has been described as a place where health care is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. In medical home practices, the report says, patients develop relationships with their providers and work with them to maintain a healthy lifestyle and coordinate preventive and ongoing health services.

Survey respondents who say they have a medical home reported four key features: they have a regular provider or place of care, they have no difficulty reaching their provider by phone; they have no difficulty getting advice or care on weekends or evenings; and they say their office visits are always well organized and on schedule.

Only 27% of adults ages 18-64 reported having all four indicators of a medical home. The survey report says many providers don't offer medical care or advice during weekends or evenings. Thus, only two-thirds of adults who report having a regular provider or source of care say it is easy to get care or advice after hours. And compared with other populations, Hispanics are least likely to have access to after-hours care.

Among adults who have a regular doctor or source of care, African Americans are most likely to have a medical home that provides enhanced access to physicians and well-organized care. Some 34% of African Americans have a medical home, compared with 28% of whites, 26% of Asian Americans, and just 15% of Hispanics.

Uninsured least likely to have one

The uninsured are the least likely to have a medical home. Only 16% of the uninsured receive care through a medical home and 45% don't have a regular source of care.

The vast majority of adults with a medical home (74%) always get the care they need, compared with 52% of those who have a regular provider but don't have a medical home, and 38% without any regular source of care or provider.

The researchers say when minorities have a medical home, racial and ethnic differences in terms of access to medical care disappear. Some 75% of whites, African Americans, and Hispanics with medical homes reporting getting the care they need when they need it.

The survey also found that using reminders for preventive care is associated with higher rates of preventive screening. The use of reminders substantially increases the rates of routine preventive screenings, such as cholesterol screening, breast cancer screening, and prostate cancer screening, it says. Thus, 82% of adults who received a reminder had their cholesterol checked in the past five years, compared with 50% of adults who did not get a reminder. Men who received a reminder were screened for prostate cancer at twice the rate (70%) of those who did not get a reminder (37%).

When minorities have a medical home, the researchers said, their access to preventive care improves substantially. Regardless of race or ethnicity, about two-thirds of all adults who have a medical home receive preventive care reminders.

More than half of insured adults (54%) received a reminder from a doctor's office to schedule a preventive visit, compared with only 36% of uninsured adults. When minority populations are insured, they are just as likely as white adults to receive reminders to schedule preventive care. Even among the uninsured, having a medical home affects whether patients receive preventive care reminders. Two-thirds of both insured and uninsured adults with medical homes receive preventive care reminders, compared with half of insured and uninsured adults without medical homes.

The researchers report that adults with medical homes are better prepared to manage their chronic conditions and have better health outcomes than those lacking a medical home. Only 23% of adults with a medical home report their doctor or doctor's office did not give them a plan to manage their care at home, compared with 65% of adults who lack a regular source of care.

Thus, among hypertensive adults, 42% of those with a medical home reported that they regularly check their blood pressure and that it is well controlled, while only 25% of hypertensive adults with a regular source of care, but not a medical home, reported this. Likewise, adults with a medical home reported better coordination between their regular providers and specialists. Among those who saw a specialist, 75% said their regular doctor helped them decide whom to see and communicated with the specialist about their medical history, compared with 58% of adults without a medical home.

Unfortunately, the researchers say, community health centers and public clinics, which care for many uninsured, low-income, and minority adults, are less likely than private doctors' offices to have features of a medical home. Patients who use community health centers or private clinics as their usual source of care are less likely than those who use private doctors' offices to have a medical home. Only 21% of adults using community health centers or public clinics reported that they have a regular doctor, have no difficulty contacting their provider by telephone or getting care or medical advice on weekends or evenings, and reported that their doctors' visits are always well organized and running on time. In contrast, 32% of patients who use private doctors' offices reported all features of a medical home.

Difficulty in getting medical advice or care in the evenings or on weekends is more pervasive in community health centers and public clinics than in private doctors' offices or clinics, they say.

The researchers say the survey results "suggest that all providers should take steps to help create medical homes for patients". Community health centers and other public clinics, in particular, should be supported in their efforts to build medical homes, as they care for patients regardless of ability to pay. Improving the quality of health care delivered by safety net providers can have a significant impact on disparities by promoting equity and ensuring access to high-quality care.

Lead researcher Anne Beal, MD, Commonwealth Fund assistant vice president for the Program on Quality of Care for Underserved Populations, tells State Health Watch that a major problem in providing a medical home for more people is that the current reimbursement system doesn't encourage that sort of wraparound services in a fee-for-service environment. "Conceptually," she says, "providers have wanted to provide medical homes to their patients for some time."

Incentives toward providing medical homes, Dr. Beal says, will come from insurers, contracts with major purchasers, patients who voice expectations for a particular standard of care, and providers who are looking for a better way to practice medicine.

She says some demonstration projects through the Centers for Medicare & Medicaid Services show "real promise." However, Dr. Beal notes that all plans need to become involved in providing incentives and support for medical homes because doctors often work with five or six plans and could not provide a medical home for some patients but not for others. "To work," she says, "the entire practice will have to go through a system redesign.

Asked to comment on the Commonwealth Fund recommendation that community health centers do more to become a medical home for patients, National Association of Community Health Centers senior vice president Dan Hawkins tells State Health Watch the report points out how much all providers, including community health centers, have to do to become true medical homes.

"The nation's community health centers welcome this report, in particular because it states in the clearest terms that achieving equity in health care involves both the availability of affordable comprehensive insurance coverage and the presence of a committed, regular source of care," he says.

Centers 'shine' in some areas

Wile community health centers applaud the report and its findings, they are concerned that in the analysis they were lumped together with other public clinics that may not be able to share community health centers' commitment to being a medical home, Mr. Hawkins says. "Clinics rely on volunteer staff, for instance, and may not be able to provide all the attributes of a medical home," he says. Thus, while there was criticism of community health centers for not providing after-hours care, Mr. Hawkins says it is a requirement of the community health center program that they have coverage after hours. He said that is an item that is evaluated as part of funding grants to the centers and all centers in the program have arrangements for after-hours coverage and admitting relationships with one or more hospitals.

"With 40% of health center patients uninsured, securing such services is often difficult," Mr. Hawkins says, "because centers don't have the resources to pay for services that are provided to their patients."

He also says he wished the Commonwealth Fund had looked at other factors that have been recommended by physician groups as being part of a medical home. One such factor that centers excel at, he says, is providing care continuously over time and across changes in health status and insurance coverage. "Health Centers shine on those criteria," Mr. Hawkins tells SHW. Another important criteria, he says, is that a medical home is linked with other health care services in a community. He notes that most community health centers now provide dental care and mental health services on-site and also have close relationships with other community services such as job training and enrollment in social service programs.

Download the Commonwealth Fund report at Contact Dr. Beal at (212) 606-3854. Contact Mr. Hawkins at (301) 347-0400.