Medical Home Model Helps Eliminate Health Care Disparities

The patient-centered medical home is key to eliminating racial and ethnic disparities in health care quality and access while improving the care and management of chronic conditions for all patients, according to a new report by the Commonwealth Fund.

"Closing the Divide: How Medical Homes Promote Equity in Health Care" is based on a 2006 survey of more than 2,800 adults between the ages of 18 and 64. The report gauges the level of health care access and quality, especially among minority and low-income patients. It found that linking minority patients to a patient-centered medical home -- a health care setting that ensures the provision of timely, well organized and regular care -- helps eliminate barriers to care, creates greater access to preventive care services, and leads to better management of chronic conditions, such as hypertension and diabetes. In the process, the patient-centered medical home helps eliminate racial and ethnic disparities in health care.

"I was actually very excited to see these results -- to finally see a system where we were not seeing any disparities in health care," said study co-author Anne Beal, M.D., M.P.H., assistant vice president at the Commonwealth Fund, during a June 27 press briefing here announcing the release of the report.

Although the majority of all adult survey respondents who said they had a medical home reported that they could always get the care they needed when they needed it, only 27 percent of study respondents actually reported having the indicators of a medical home. The study defines those indicators as

Based on these indicators, most health care providers were not considered medical homes because they did not provide care or medical advice after regular business hours. One-third of those surveyed who had a regular health care provider or source of care rather than a medical home said it wasn't easy to get care or medical advice after hours, a statistic that has profound implications for "inappropriate emergency room use," said Beal.

In many cases, patients have to seek care from hospital emergency rooms because their regular health care providers are unavailable, she noted. "Not every kid is to going to get an ear infection between the hours of nine and five."

African Americans were the most likely to have a medical home, according to the survey; 34 percent reported having a medical home compared with 28 percent of whites and 26 percent of Asian Americans. Hispanics were the least likely to have a medical home, at 15 percent.

However, three-fourths of the African Americans, whites, and Hispanics who said they had a medical home reported being able to get the care they needed when they needed it.

The patient-centered medical home is a "very important model that we should try to promote -- to replicate in a number of settings in order to improve health care for everyone," said Beal.

The report also found that health insurance coverage is a determining factor in accessing health care and a patient-centered medical home. Uninsured individuals are much less likely to say their regular providers function as medical homes. Only 16 percent of uninsured individuals described their regular providers as medical homes.

In addition, more than half of insured patients said they received reminders from their physician's office to schedule preventive visits compared with only 36 percent of uninsured adults.

"One of the things clearly evident is that insurance matters," said Beal. "It matters in and of itself."

But insurance alone cannot eliminate racial and ethnic disparities in health care, according to the report.

"Insurance coverage helps people gain access to health care, but the next thing you have to ask is, 'Access to what?'" said Beal.

Although the percentage of uninsured people who reported having a medical home was very small, when these patients had a medical home, there were no differences between them and insured patients in terms of receiving preventive reminders, Beal said.

"With most of the data that we look at, there are differences in quality obtained by the uninsured time and time again," Beal said. "But here is one promising model where there are often no disparities by race and ethnicity, and there are not disparities versus insured and uninsured."

This report, like other reports, cites racial and ethnic disparities in health care, pointing out, for example, that African Americans and Hispanics are less likely than nonminorities to have insurance and a regular source of care.

"These are not new findings," Beal said. "We have been able to see this for years and years."

But this report, unlike many others, essentially answered the question of whether patient-centered medical homes can resolve disparities and improve overall care. The report came to several conclusions.

Beal said the federal government should promote the patient-centered medical home through a payment system that rewards providers for meeting standards contained in a medical home model.

Dora Hughes, M.D., M.P.H., a health policy adviser to Sen. Barack Obama, D-Ill., and a speaker at the press conference, identified payment policies as the "most challenging barrier" when trying to address health care disparities.

"This federal government is going to have to step up to the plate in a major way to make sure we are aligning funding and reimbursement with health care quality," Hughes said. "Right now, we do not reimburse for coordinating and integrating care. We do not reimburse physicians to conduct those telephone consultations or to answer e-mails, to see patients in their off-hours on weekends. … and that's why we're facing the crisis that we are -- with more and more specialists and fewer and fewer generalists in every graduating medical school class."