A more welcoming model for care

Medical homes, such as Union Square Family Health in Somerville, aim to provide more satisfying care for patients, doctors. (Pat Greenhouse/Globe Staff)

The future of primary care medicine is taking shape in Somerville's Union Square.

Doctors quickly answer patients' questions by e-mail and phone.

Visits are available from early morning into the evening and Saturdays.

The medical team tracks patients' needs so closely that they know when a diabetic misses a critical blood test or an asthmatic needs a new inhaler.

Across the nation, patients are so frustrated by lack of access to their doctors that they are going to drug-store clinics for basic care. And primary care doctors are so harried that they are abandoning their practices in droves.

The "medical home" being created at Union Square Family Health and at many doctors' offices across the nation is an attempt to provide an alternative. Such a doctor or nurse-practitioner-led team practice is designed to offer patients care when and where they want it and to give the team the money, the tools, and the time to do more than triage.

What distinguishes a medical home from a conventional practice is a comprehensive approach to care from prevention through hospitalization that provides as many services as possible in one location and coordinates all other care, using both a personal touch and electronic medical records. In addition, the medical home provides easy access to medical staff through same-day office appointments, weekend and evening hours, e-mail, and phone.

Whether this approach will rescue primary care and whether insurers, including the government, will pay for it is still unclear.

A number of pilot projects are underway locally, although few practices have all the elements in place.

Cambridge Health Alliance is funding the enhanced care, including a fully computerized medical record system, at Union Square and some of its other outpatient clinics. A group of physicians affiliated with Tufts Medical Center last month launched a medical home in Plymouth aimed at diabetes patients and funded by Harvard Pilgrim Health Care.

In addition, the state Senate passed a bill last month that would establish medical homes in up to 10 communities to serve low-income patients with chronic or severe illnesses through the Medicaid program.

The medical home concept is also being tested nationally, including in the Medicare program, which will launch a demonstration project early next year in eight states yet to be chosen.

The goal is to determine if investing more in primary care will improve patients' health, increase doctors' and patients' satisfaction, and curb costs in the long run.

At the Union Square office, doctors offer one-stop shopping for physical and mental care, provide group as well as individual visits, and recently began encouraging patients to e-mail their doctors and view portions of their computerized medical record through a secure website.

Cidalia Moura, a 57-year-old Somerville factory worker, learned about the computer access from her doctor last month. The convenience of renewing prescriptions online is very appealing, she said, as are the evening hours. But what matters most, she said, is the time with her doctor and nurse, and feeling truly cared for.

"I know everybody, and I feel at home when I come here," she said, as Dr. Rachel Wheeler took her blood pressure. It showed no sign of her hypertension or the rise in pressure that often accompanies the stress of a doctor's visit. "That's proof," she said, "of how comfortable I feel."

At Massachusetts General Hospital, Dr. Allan Goroll is raising private money to test a medical home model where doctors are paid per patient, instead of per visit, to encourage comprehensive care and ease the pressure on physicians.

"Doctors now are on a hamster treadmill," said Goroll, an internist who cofounded a primary care training program at Mass. General decades ago. "They have to maximize visits to keep the lights on in a practice. There isn't much pay for thinking, talking to patients, and coordinating, just for doing things."

"Patients have the sense that the doctor is rushed, not available. Physicians feel poorly and patients are unhappy. It's a downward spiral."

"What we need is concierge care for everyone at Wal-Mart prices," he said.

For a total cost to the healthcare system of just $500 to $800 per patient each year, he said, doctors could run an office that included a nurse practitioner, nurse, medical assistant, receptionist and part-time social worker and nutritionist. Patients would not have to pay extra, he said. To discourage the team from withholding care, a portion of the fee would be paid only if quality goals were met.

Other models keep the existing system in which doctors are paid per visit, but add some extra money for coordination.

Some newly minted doctors who are being trained to work in a medical home are seeing benefits.

"I'm more satisfied working in a situation like this where more people are helping me and we have the electronic medical record," said Dr. Lenard Lesser, who is training at the Malden Family Medicine Center. "It's a happier environment."

It's also more efficient for many patients.

When Andy Misiura needs a specialist appointment, the 66-year-old retired electrician gets it within days because of the center's commitment to coordinating all his care. "The coordination is tremendous," he said, and helps keep his multitude of medical problems from festering.

And his doctor, Michael Doupé takes time to provide a personal touch, regularly calling Misiura at his Malden home to check on him. "It's like he's part of my family," Misiura said.

When the medical home was first conceived by pediatricians about four decades ago, doctors thought it would most help patients with complex or chronic problems. Tests in several practices nationwide found that these patients treated in medical homes more often got needed care promptly, hospitalization rates dropped and patient satisfaction rose.

Still, the concept didn't gain much traction until the last four years, when organizations representing 333,000 doctors, including many of the nation's primary care physicians, endorsed the medical home for all patients. As dissatisfaction with the primary care system grew, the movement got a big boost from a national coalition of employers, insurers, and doctors. And in January, the National Committee for Quality Assurance set out standards to measure medical homes, giving more structure to the effort.

A two-year pilot in 36 practices nationwide - none in Massachusetts - is just wrapping up. Preliminary reports on the effort, supported by the American Academy of Family Physicians, found the culture change difficult, particularly for small practices, and many had trouble affording the switch to electronic medical records.

At a recent national conference, Dr. Elliott Fisher, director of the Dartmouth Center for Healthcare Research and Reform, laid out other obstacles. "Patients have to be convinced this is really a gateway and not a gatekeeper. Some providers see it as a threat. Politicians see a lack of evidence on costs."

Some early examples did show cost savings - from keeping people out of the emergency room, reducing unnecessary imaging and smarter use of medicines. North Carolina saved $231 million over two years in Medicaid spending, according to one assessment, after enrolling 725,000 patients in a network of hospitals and specialists built around a medical home. The Commonwealth Fund, a private foundation focused on healthcare access and quality, estimated last year that Medicare could save $194 billion over 10 years if all its fee-for-service patients were enrolled in medical homes.

But the movement has also brought hype, as many medical practices claim to be a medical home without putting all the elements in place.

"It's become a phenomenal marketing term," said Dr. Chuck Kilo, a Portland, Ore., medical home pioneer.