Sunday, January 31, 2010

The Canadian Version of the Patient Centered Medical Home: Still Not Ready for Prime Time in the U.S?

If you are interested in the Patient Centered Medical Home (PCMH), you may want to check out this January 6th New England Journal article titled 'Patient Centered Medical Homes in Ontario' by Walter Rosser, Jack Colwill, Jan Kasperski and Lynn Wilson. It describes how the province of Ontario decided to fund 'family health teams (FHTs). Modeled much the PCMH, this Canadian version of government sponsored primary care site transformation-ing was seen as a way to reinvigorate the primary care providers by a) paying extra money for a basket of services, b) provided by a multidisciplinary team.

Docs merely sign a contract. There is no FHT certification or audits. Reimbursement is based on 'electronic data.' The authors estimate at at the present time, there are about 720 physicians in 150 FHTs in Ontario that:

- include nurses, nurse practitioners, psychologists, pharmacists, social workers, and health educators;

- have a defined panel of about 1400 patients. A nurse practitioner is expected to add another 800 patients to the expected practice size;

- receive funding for salaries for the other health professionals and for an approved electronic record system

- are paid using age and sex-based capitation with additional fees for services requiring 'added emphasis' such a visits for infants or patients over 75 years of age, procedures and visits to hospitals, homes, and nursing home visits

- receive bonuses based on prevention goals plus $100 to $300 for every new patient, depending on the complexity.

- forfeits 1 month’s capitation fee when a patient seeks care elsewhere.

Outcomes you ask?

'One study has shown that control of hypertension is better among patients in FHTs than among those in fee-for-service practices. The use of integrative electronic record systems appears to improve efficiency and communication, and we believe that quality incentives have made participating physicians more proactive in providing preventive services and providing care management for chronically ill patients. A full evaluation of this model’s effects on health outcomes, quality measures, and costs will be completed in 3 to 5 years. One effect that is already obvious is an increase of approximately 40% in physicians’ incomes: the average net income for a family physician has increased from $180,000 (Canadian) in 2004 to $250,000 within FHTs, but it has not risen substantially in the fee-for-service sector.'

This makes for interesting reading, but based on this article, the DMCB isn't sure that Canada's FHT is ready for prime time in the Unitied States.

For starters, according to this report, there over 11,000 family physicians in Ontario. Despite the long support of the provincial government, the endorsement of Ontario's teaching hospitals, and the allure of additional revenue, approximately 95% of these physicians have not established FHTs. Why would that be?

In addition, a quick look at the reference that purports to show that FHTs were associated with better blood pressure control seems to indicate that it's an observational study; what's more, the authors credit the control to capitation, not FHTs.

Last but not least, the DMCB isn't sure that it's realistic to believe that the U.S. is ready for 40% increase in physician incomes without more to show for it, such as better access (which was not part of FHTs), accompanying savings (which still remains elusive) or higher quality.

In the meantime, there still appears to be a dearth of data on how the U.S. medical home pilots are going. Has anyone heard anything?

No comments: