After returning from a Nevada hiking trip in June, Catherine Helling, 45, of Dubuque, Iowa, landed in the hospital for cellulitis, a dangerous skin infection. Early into Helling's six-day stay, her internist visited, coordinated Helling's hospital and follow-up care and made sure the mother of three got circulation stockings, vital to getting Helling back on her feet quickly. "People are amazed my doctor would do that," says Helling, who was back to work after a week.
Helling's doctor, Christine Sinsky, requires no special fee for the extra service. Same- or next-day appointments by doctors who coordinate patient care are just the tip of the iceberg at Sinsky's multi-specialty medical group practice, Dubuque's Medical Associates Clinic. The clinic's acute care center has extended hours, open daily from 7 a.m. to 9 p.m. Clinic patients email their doctors, get their medical records via the practice's secure website, are encouraged to share their thoughts and concerns about possible treatments with doctors, and receive a next-step care plan after each visit. But Helling says what's "truly amazing" was what happened when she was diagnosed with diabetes nearly two years ago. After prescribing medicine, Sinsky asked how she could support Helling in getting her blood sugar and weight under control. When Helling said unreliable scales frustrated past efforts, Sinsky arranged for her patient to come in once a week for free to get weighed on clinic scales. That support was vital: "I've been able to lose over 150 pounds in the last 18 months," says Helling, who is no longer diabetic.
Is this level of care a relic of a bygone era? No. Sinsky is on the leading edge of an innovation shaking up the practice of medicine: the patient-centered medical home (PCMH). Think of the idealized patience, caring and individualized attention that actor Robert Young showed his patients on TV's "Marcus Welby, M.D." Combine that with a modern approach where patients are supported by a team—including doctors, nurses, health coaches, pharmacists, social workers and others—interested in taking care of all their patients, not just those who arrive sick, and engage patients with 21st century information technology tools, such as email, text, Web 2.0 tools and electronic medical records. That's what a medical home is like – and private practices, hospitals, health plans, Medicare and states are embracing and financing them.
"Part of what's happening in a medical home is moving from being reactive to being more proactive, and making sure patients' care is coordinated and followed," says Robert Reid, a physician and senior investigator at Group Health Research Institute. Reid studied the effects of a PCMH pilot at Group Health Cooperative, a large Seattle-based integrated delivery system, and found that it produced higher-quality care, more patient satisfaction and enough cost savings to convince Group Health to spread PCMHs to all 26 of its medical centers. For every dollar Group Health invested, it recouped $1.50, largely by reducing emergency room and hospital use.
PCMHs are not new—the concept dates to the 1960s as a way to care for special needs children. "The biggest challenge to medical homes is payment," notes Michelle Shaljian of the Patient-Centered Primary Care Collaborative, an advocate for PCMHs. Fee-for-service payment, which encourages more costly specialty and acute care, has long prevented primary care practitioners from reorganizing their practices to better serve patients. Traditionally, doctors do not get paid for educating patients or coordinating their care, only for providing services, tests and treatments.
With health care costs rising sharply over the last decade, health insurers started using incentives and risk-based payments to slow fee-for-service cost growth. Insurers, like Wellpoint, also started paying a bonus to primary care practices recognized as PCMHs by the National Committee for Quality Assurance (NCQA), a national accrediting body, in hopes that the approach could improve overall health and lower costs.