Matching Patients to a Medical Home: Balancing Operational Ease with Physician and Patient Choice

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Matching Patients to a Medical Home Balancing
Operational Ease with Physician and Patient Choice

• Deborah Peikes, Ph.D.
• Hoangmai H. Pham, M.D.
• Ann S. O'Malley, M.D.
• Myles Maxfield, Ph.D.

Patient-Centered Primary Care Collaborative March
10, 2009
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Why Patient Assignment Matters

• Physicians need to know which patients they're
  responsible for to (a) predict revenue and (b) to
  know which patients they should manage.
• Patients need to know who and what their medical
  home is to know who to count on to coordinate and
  manage their overall care.
• Payers need to link patients to specific
  providers to (a) pay the correct amount to the
  appropriate provider, (b) provide use and quality
  feedback data to providers, and (c) evaluate
  outcomes.

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Temptation is to use historical claims data
expeditiously to make assignments without
involving providers or patients. But the medical
home intervention is first and foremost an
intervention based on a care relationship.
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Patients See Multiple Physicians
Medicare beneficiaries see a median of 2 PCPs and
5 specialists working in 4 different practices
(IQR 3-7) a year.
-Pham et al. NEJM 2007
?
?
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Claims-Based Approaches Are Attractive

• Easy for the insurer to identify all of patients
  physicians
• Dont have to coordinate input from physicians
  and patients

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But Claims Alone May Not Correctly Identify the
Patients Primary Provider

• Example Among 724 Medicare beneficiaries with
  CHF in MHS who identified their primary physician
  -Simon et al. 2007
• Claims showed 13,000 providerbeneficiary
  combinations
• Using plurality of EM office visits
  condition-specific care
• 124/724 (17)the algorithm did not identify the
  patient-reported primary physician
• 600/724 (83)the algorithm identified 5
  potential providers per beneficiary (1 of 5 was
  correct)
• May depend on population and market.

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And Some Patients Will Lack Medical Homes

• Pham et al. found 15 of Medicare beneficiaries
  only saw a specialist in a 1-year period
• 6 had no EM visits with any type of doctor
• The number of homeless will increase in a
  healthier commercial population.

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Claims Alone Can Miss Reality
Further evidence of the unreliability of
claims-based assignment

• 33 of beneficiaries appear to change to a
  different PCP from year to year (Pham et al.)
• This number is too high based on separate
  beneficiary surveys about the stability of
  patients care relationships.
• To possibly use claims, we need to test
  claims-based assignments versus patient-reported
  physician.
• Note over time, if Medical Home physicians
  deliver more email and telephone care, and it
  isnt reimbursable, claims algorithms will be
  less predictive of actual relationship.

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Without Active Patient Agreement, Patients Wont
Change the Way They Use Care

• British Columbia Primary Care Demonstration
  (2001)
• The demonstration changed its registration
  process
• Practices began to educate patients about
  benefits of continuity of care with PCP, role of
  PCP
• Patients used less specialty, ER, and other PCP
  care

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Requiring Patient Opt-In is Costly, But Critical

• Patients learn to view their medical home
  physician as their personal quarterback, and
  understand how to alter health use behavior.
• Without it, sharing information between insurer
  and providers may alarm patients.

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Tradeoffs of Different Assignment Procedures
Hybrid (Claims, Claims-Based Ask Patients P
hysicians, Algorithms Physicians Sign
Up Patients)
Operationally Easy for Insurer Yes
Yes No No Operationally Easy for
Physician Yes No Yes No Physician
Choice No Yes No Yes Patient Choice No No Yes Yes
Correct Assignments Not always Not
always Yes Yes Patients Know MH
Rights/Responsibilities No No Yes Yes
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Recommendation A Hybrid Approach

• Use claims to support relationship building.
• Step 1 Use claims to identify all patients seen
  by a practice.
• Step 2 Send medical home practices their
  potential lists and ask them to enroll patients.
• Step 3 Allow patients the opportunity to decline
  the physicians request if they prefer another
  medical home.
• Step 4 Ask homeless patients to select a home
  if they dont, assign one.

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Recommendation (continued)
Step 5 Require or promote a formal, bilateral
acknowledgement between medical home and
patient. Step 6 Allow patients the opportunity
to change medical home designation periodically.

• Explain the services the medical home will
  provide, and that the patient still retains
  choice over all service use.

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Conclusion

• Correct and meaningful patient-medical home
  linkages support

• Patient buy-in to use new MH services differently
• Physicians have clear responsibility over care
• Insurers pay physicians fairly and provide
  information to the right physician
• Outcomes of the medical home can be evaluated

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My contact informationdpeikes_at_mathematica-mpr.co
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