Patient-Centered Medical Homes: Do Subspecialist Physician Practices Measure Up?

April 28, 2010 04:55 pm Sheri Porter

Can a cardiology practice serve as a patient-centered medical home? Can patients look to an endocrinology or pulmonology practice to meet their primary health care needs? A recent telephone survey funded by The Robert Wood Johnson Foundation explores the extent to which specialist physician practices function as patient-centered medical homes, or PCMHs.

Survey results are outlined in "Specialist Physician Practices as Patient-Centered Medical Homes(," which was published in the April 29 issue of the New England Journal of Medicine.

The survey team conducted telephone interviews with leaders of 373 single-specialty practices. The survey included 207 cardiology practices, 58 endocrinology practices and 108 pulmonology practices. In addition to other questions, researchers asked, "For approximately what percentage of patients, if any, do the physicians in your practice serve as primary care physicians as well as specialists?"

Researchers found that in

  • 81 percent of practices surveyed, the physicians served as primary care physicians for 10 percent or fewer of their patients;
  • 12.5 percent of practices, the physicians considered themselves primary care physicians for more than 20 percent of their patients; and
  • only 2.7 percent of practices the physicians served as primary care physicians for more than 50 percent of their patients.

Results indicate that endocrinologists were significantly more likely to serve as primary care physicians than physicians in the other two subspecialties surveyed. In addition, in all three subspecialty groups, small practices -- consisting of no more than two physicians -- were far more likely than large group practices to consider their practice a medical home.

Researchers point out that the recently passed health care reform legislation refers to medical homes as practices that provide primary care, which is defined as "the provision of integrated accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs."

The legislation also states that medical homes must include "personal physicians," but that term is not defined, note the researchers. They point out that the law requires that medical homes meet criteria similar to those set out in the medical home model designed and described by the AAFP, the American College of Physicians, the American Academy of Pediatrics, and the American Osteopathic Association.

The authors question whether policymakers should encourage some medical subspecialty practices to serve as PCMHs. Four questions could guide that decision, according to the study authors:

  • What does it mean to provide comprehensive patient care?
  • Are certain specialists -- the specific group surveyed -- more likely than other specialists, such as urologists or neurologists, to be able to provide care for patients with a wider range of problems?
  • Will specialists be willing or able to redesign their practices to enable them to provide the services required to function as a medical home?
  • Is it a proper allocation of resources for specialists to spend time trying to function as primary care physicians?

The authors conclude that subspecialty practices that want to serve as PCMHs should be allowed to do so. However, say the authors, subspecialty practices should be held to the same standards as primary care-based medical homes, "including the requirements for providing first-contact, continuous and comprehensive care, and for using systematic processes to improve the health of the practice's patients."

The paper's lead author, Lawrence Casalino, M.D., Ph.D., worked as a family physician in private practice for 20 years before turning his attention to research. He currently serves as chief of the Weill Cornell Medical College Division of Outcomes and Effectiveness Research in New York City and is the Livingston Farrand associate professor of public health in the department of public health at the college.

Casalino told AAFP News Now that if primary care physicians are concerned about competition from specialist physician practices serving as medical homes, then the survey results should be reassuring.

"By their own statements, not very many (sub)specialists are serving as primary care physicians for their patients," said Casalino.

But he added that there are two components to being a medical home.

"One component is the kind of old-fashioned things that any good primary care physician does -- basically, being there for your patients and coordinating their care and giving comprehensive care," Casalino said.

"A lot of primary care physicians say, 'I've already been doing that for 30 years,'" Casalino added. But there's a second component to the medical home that most physicians are not familiar with, he said. It's the concept of "proactively, systematically and in an organized manner trying to improve the health of the population of patients in your practice" using health information technology, nurse care managers and other resources.

"That second component is a high bar for any practice to meet," he noted.