Real patient-centered care: where more spending results in net savings

Four primary care sites in the United States constitute “medical home runs” because their patients incur 15–20 percent less (risk-adjusted) total health care spending per year than patients treated by regional peers, without evidence of reduced quality.  Milstein & Gilbertson Health Affairs article

An interesting article and worth reading.  Of particular note is what the practices do that results in the equal-or-better-outcomes and the lower-net-cost:

(1) an exceptional form of individualized caring tailored to preventing ED use and unplanned hospitalization for chronic illness
(2) efficient service provision
(3) careful selection of, and coordination with, medical specialists

Note the intersection between these observed qualities and the attributes of effective primary care:

1. "I can get care when and how I need it" - access
   
2. "I have a PCP/nurse who know me as a person" - relationship
   
3. "My PCP takes care of the bulk of my health care needs" - comprehensiveness
   
4. "My PCP coordinates any care I need in the health system" - care coordination
   

(adapted from Barbara Starfield's/IOM/WHO definition of primary care).

Milstein & Gilbertson call these "exceptional caring characteristics:"

1. we will take enough time during office visits to fully understand your illness and self-management capability and fine-tune your treatment plan
2. between office visits, we will directly provide or mobilize the help you need to succeed in implementing your self-management plan, with special emphasis on medication management
3. we will respond promptly 24/7 when you ask for urgent help between visits
4. we will link you with a small group of carefully selected specialists with whom we actively coordinate
5. we care personally about protecting you from health crises.

Also notable is the lack of correlation between Milstein & Gilbertson's qualities and the tens upon tens of arcane electronic minutia demanded by the NCQA for "medical home" recognition (180+ metrics).

The Ideal Medical Practices project demonstrated that even independent solo and small practices were willing and able to deliver truly patient-centered care if:

1. They were provided a teaching vehicle at reasonable opportunity cost (conference calls & webinar versus time away from patients and travel to meetings)
2. They had real time feedback on their own patient data
3. The results were actionable - they could understand them and do something to make them better
   

Is technology the answer (as implied by the 97% emphasis on technology in the current recognition system for medical homes)?

However, all four sites had achieved their distinguished results without the benefit of such IT. This suggests that recovering the first 15 percent of the 35 percent estimated waste in U.S. health care spending may not hinge on use of health IT or the larger organizational scale required for nuanced, IT-enabled continuous reengineering of clinical processes.

In their conclusions:

The signal to public policymakers is that to attain more health with less health care spending, health plan enrollment must be tilted toward those plans that vigorously reward PCPs and physician groups that excel in low total annual per capita health care spending and clinical outcomes.