Medical home potential

A SHARED-savings initiative used in a US-based medical home model that reduced patient hospitalisation and increased primary care visits has potential in Australia, according to experts.

A US study, published in JAMA Internal Medicine, found pilot medical home practices that received bonuses of up to 50% of any savings generated, contingent on meeting quality targets, had lower rates of all-cause hospitalisation and all-cause emergency department visits, and higher rates of ambulatory primary care visits across the 3-year study period. (1)

Royal Australian College of General Practitioners (RACGP) president Dr Frank Jones welcomed the findings, saying the research, together with existing evidence of reduced emergency department presentations and improved patient satisfaction, vindicated the College’s continued support for the medical home model.

In April, the RACGP released a consultation paper calling for the adoption of the medical home model and reform of funding mechanisms for general practice to support more patient-focused care. (2)

“The medical home model places continuity of care at its core, with support for ongoing practitioner–patient relationships”, Dr Jones told MJA InSight.

“Implementing the medical home model [in Australia] will require both initial and ongoing investment. However, any investment will be at least cost neutral because of the efficiencies in the system that can be achieved”, he said.

In the US research, general practices participating in a medical home model of care were eligible to receive shared-savings bonuses if annual spending on patients was less than expected. They also received timely feedback regarding the hospitalisation of their patients.

Dr Jones said shared savings and the provision of timely data regarding hospital episodes were key and the RACGP would support trialling both these measures in Australia.

“General practices have little access to information about a patient’s admission and discharge from hospital and this significantly interferes with a practice’s ability to plan for patient care so that readmission can be prevented and continuity of care ensured”, he said.

 “Shared-savings bonuses … might be another method for rewarding achievement of quality benchmarks if they reduce the administrative burden of claiming incentive payments.”

Dr Tony Lembke, executive director of the Australian Centre for the Medical Home, said thousands of Australian general practices were informally operating as medical homes, but financial incentives and connection with the broader health system were lacking. (3)

The centre describes a medical home as a practice where patients and their families have a continuing relationship with a particular GP, supported by a practice team. Care provided was comprehensive, coordinated and accessible with a focus on safety and quality, Dr Lembke said.

“GPs want to provide [medical home-style] care and patients want to receive that sort of care, so it’s not uncommon in Australia for patients to get this level of care”, said Dr Lembke, who is also a GP in northern NSW.

“But the business incentives for practise don’t align with the GPs’ professional incentives. So although we all aspire to provide care with those features, the more you provide this care, the less your income is in the current system.”

However, Dr Lembke told MJA InSight a shared-savings approach to funding was not appropriate here. He said the professional drive to provide this higher level of care and broader financial support, rather than incentive payments, were more likely to further encourage this style of practice.

As well as improved funding, formalised support and recognition in other sectors of the health system was crucial to the success of the medical home model, he said.

“We are providing comprehensive and coordinated care for our patients, but when they go to hospital other carers ignore that”, Dr Lembke told MJA InSight. “Having high-functioning general practices is important, but having the rest of the health services wrap around those practices to support team-based care is just as important. And we’re not so good at that.”

Dr Grant Russell, professor of general practice research at Monash University, said the US research added to the evolving understanding of the potential role of the patient-centred medical home, but was not “groundbreaking”.

Dr Russell said the medical home model had many variations in the US and Canada, where he worked in a medical home practice for about 6 years. The innovative feature was the shared-savings initiative.

“[This research suggests] that if you’re feeding a few of the benefits back into the practice, it helps the practice to maintain the changes.”

Dr Russell said providing feedback to primary care was “something that we don’t do well in Australia”. Providing information to practices about how their patient population was faring in terms of hospitalisation, emergency department visits and access to care would make it easier to plan, organise and improve care.

“We would be unwise to ignore what’s happening in America around the patient-centred medical home”, Dr Russell told MJA InSight, saying some parts of the US were moving towards a model of primary care that could be more durable in the “looming epidemic of chronic disease”.

1. JAMA Intern Med 2015; Online 1 June
2. RACGP’s vision for a sustainable health system
3. Australian Centre for the Medical Home
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