Executive Summary
Thank you, Mr. Chairman, for this invitation to testify on person-centered care for older adults in ambulatory care settings. I am Melinda Abrams, assistant vice president at The Commonwealth Fund, where I direct the Patient-Centered Primary Care Initiative.
The patient-centered medical home is an approach to providing person-centered care in primary care settings. This model organizes care around the relationship between the patient and the personal clinician. In February 2007, four primary care specialty societies representing more than 300,000 physicians released joint principles outlining and defining key characteristics of a medical home.
In practical terms, a medical home offers each patient a personal clinician with a practice that provides better access and effective care coordination within the context of an ongoing relationship.
- In a medical home, a patient can expect to obtain care from the physician practice on holidays, evenings and weekends without going to the emergency room. He or she may also expect to have medical questions answered by telephone or e-mail on the same day they were asked.
- In a patient-centered medical home, the primary care clinician helps the patient select a specialist and, with support from designated staff, follows up with both the providers and the patient about test or examination results, reviews treatment options, and helps to resolve conflicting advice received from multiple providers.
- To carry out these enhanced functions, medical homes require improved infrastructure—such as electronic health records, patient registries to organize clinical information, the ability to review test results remotely, and the capacity to collect and analyze data about quality of care provided.
I want to emphasize the importance of the medical home for older Americans. Since 86 percent of Medicare beneficiaries have one or more chronic conditions, investing and improving coordination of care in primary care is critical to reduce unnecessary and redundant services, gaps in service, problems with care transitions, and medical errors.
Patient-centered medical homes also require fundamental payment reform. Many medical home services are reimbursed either inadequately or not at all by the current fee-for-service system. Primary care practices would submit to a voluntary and objective qualification process to be recognized as a medical home and in exchange, the practice would be supported with an enhanced or additional payment to cover the improved care management, infrastructure, and care coordination.
There is substantial evidence showing that a strong foundation of primary care can reduce costs and improve quality.
The Commonwealth Fund's 2007 International Health Policy Survey found that only half of all adults in the United States have a medical home. Patients with a medical home were more likely than those without to report better access to care, more time with their doctors, and fewer duplicate tests. Among adults with chronic illnesses, patients with a medical home were less likely to report medical errors and more likely to have a written care plan to manage their illness at home.
The Commonwealth Fund is supporting evaluations of several medical home demonstrations to determine if the model can slow the growth of health care expenditures. There are data to suggest this approach can reduce health system costs.
For example, a medical home pilot project at The Geisinger Health System, an integrated delivery system in northeast and central Pennsylvania, showed a 20 percent reduction in hospital admissions and 12 percent decrease in hospital readmissions at their Lewistown Hospital. Although they do not serve a large proportion of elderly patients, a few state Medicaid programs, such as the one in North Carolina, have demonstrated cost savings of $225 million in 2004 when beneficiaries are enrolled in networks of medical homes. In both these examples, primary care clinicians were paid an additional per-member, per-month fee to manage and coordinate patient care beyond the standard care covered by traditional fee-for-service payments.
Congress has recognized the potential value of stronger, patient-centered primary care. The Tax Relief and Health Care Act of 2006 instructs the Centers for Medicare and Medicaid Services to develop an eight-state demonstration of the medical home model. The recently passed Medicare Improvements for Patients and Providers Act of 2008 provides an additional $100 million dollars to augment that demonstration. I commend Congress for its willingness to test this promising approach in Medicare.
As the committee considers legislative and regulatory strategies to encourage person-centered care for older citizens in ambulatory care settings, there are a number of steps Congress could take. They are:
Ensure transparency of the Medicare medical home demonstration.
In light of the keen interest from numerous stakeholders (large employers, labor unions, state and commercial payers, consumer groups) to reform and improve primary care, regular reporting to Congress and the public about the progress of and early lessons from the Medicare demonstration can inform policy and practice around the country, as well as ensure timely release of evaluation results.
Direct the Centers for Medicare and Medicaid Services to join commercial and state payers in the Medicare medical home demonstrations.
With explicit encouragement from Congress, Medicare could collaborate with the several commercial payers and state Medicaid programs that are willing to change payment rates to primary care practices to test the patient-centered medical home.
Pursue intermediate and incremental financing changes to promote medical home components.
- One option is to authorize a separate payment for discrete services associated with key care coordination functions, such as hospital discharge planning, which could help reduce unnecessary hospital readmissions.
- Implement the recent recommendation of the Medicare Payment Advisory Commission to increase payment levels for evaluation and management services provided by primary care clinicians to help support care management and care coordination.
Implementation of scholarships or educational loan forgiveness programs to encourage medical students to choose careers in primary care.
This strategy would address the shortage of primary care physicians to staff medical homes.
Thank you for this opportunity to participate in today's hearing. I look forward to addressing your questions.