In a recent blog posting, I described Group Health’s medical home for 8,000 patients. It proved to be a boon for primary care physicians, who were able to reduce the size of their patient panels, see fewer patients per day, refer more patients to specialists and maintain or increase their incomes. Patients liked it, too. And Group Health was happy because expenditures per patient were 2% lower. But poor patients had trouble getting through the front door of the medical home, so based on demographic differences alone, expenditures should have been lower by 10% or more. Nonetheless, they declared victory.
Now news filters south from Ontario’s eight year experiment with medical homes for 8,000,000 patients, and the news is similar. Participation is skewed to healthier and wealthier patients, who, in the absence of risk adjustment, yield profitable capitation for primary care physicians. Incomes have soared an average of 25%. But while better service was promised, it hasn’t been delivered, at least not for the medical needy and not after hours. Indeed, patients who have sought such extra care (which is charged to the medical home) have been removed from the roster, further improving the risk profile of those who remained.
The conclusion reached by Glazier and Redelmeier, whose JAMA commentary I have drawn upon, is that Ontario’s medical homes were laudable in their innovation and scope and successful in increasing primary care physicians’ incomes. However, the result has been gaps for vulnerable groups and suboptimal access for those most in need. And once again, the urban poor have been left out in the cold.
Health care reform is in love with medical homes, and in theory, there’s a lot to love. But before we rush head-long into a new care model, with too few physicians to do it, we’d better look carefully at what has occurred elsewhere and think about how we might build homes for all of our citizens, not just the healthiest and wealthiest ones.