Saturday, April 21, 2018

Rural family physicians in practices that follow model for comprehensive, coordinated care expand patients' access to care

By Melissa Patrick
Kentucky Health News

Rural family physicians who work in patient-centered medical homes generally provide more services and procedures than those in non-PCMH practices, according to a recent study at the University of Kentucky. A PCMH is not just a place, but "a model of the organization of primary care," says the federal Agency for Health Research and Quality.

"The idea of a patient-centered medical home is that you organize your services in a way to better meet the needs of the patient, and that should include being able to do more for the patient," Dr. Lars E. Peterson, lead author of the study, said in an interview. "We've shown that there is evidence that if you are in a patient centered medical home practice, if you structure your care that way, you can actually provide even more services."

Peterson is the director of research at the American Board of Family Medicine and an associate professor of family and community medicine at UK. 

The study, published by UK's Rural & Underserved Health Research Center, used data from more than 3,000 rural family physicians and compared the results according to rurality, measured by population: "large rural" (20,000-250,000), "small" rural (2,500-19,999), and "frontier" (less than 2,500).

Considering a list of 21 clinical services, the study found that rural family physicians in both the large and small rural areas who practiced at PCMHs provided more services than those who did not work in a PCMH. It didn't find much difference in services provided by in the sparsely populated areas.

The other exceptions to the overall finding were inpatient hospital care, major surgery, and nursing home care. They were provided at about the same rate in both the large and small rural areas regardless of PCMH status. Also, physicians in "small" rural areas provided home visits at about the same rate as non-PCMH physicians.

Family physicians in the "large rural" areas didn't show any real differences in obstetrical and prenatal care, but those who practiced in a PCMH in "small" rural areas provided more obstetrical and prenatal care their non-PCMH counterparts.

The study found two areas in which "frontier" PCMH family physicians out-performed their non-PCMH counterparts: chronic disease management and preventive services. All of the frontier PCMH family physicians provided chronic disease management, and 98.3 percent provided preventive care; among non-PCMH physicians, the percentages were 89.3 and 87.4, respectively.

Peterson said it's important for rural communities to find ways to increase access to care, especially in the areas of women's health and mental health, which is often lacking. He added that even with the passage of the Patient Protection and Affordable Care Act and the expansion of Medicaid to people who earn up to 138 percent of the federal poverty line, many still struggle to find health care.

"This is just another way of expanding access to patients," he said. "Within rural areas, physicians who work in practices that have a patient-centered medical home designation tend to be able to do more for their patients than physicians who are not in practices that are organized in that way."

Comparing medical procedures, researchers found that while PCMH family physicians in "large rural" areas had higher rates for eight of 18 procedures, the only two that showed a significant dfference over their non-PCMH counterparts were for in-office skin procedures (92.6 percent and 80.4 percent, respectively) and neonatal circumcisions (33.3 percent and 22.1 percent).

"Consistent with family physicians in rural PCMHs being less likely to provide inpatient care, they were also less likely to provide hospital-based procedures . . . than family physicians in rural non-PCMHs," the study report said.

The PCMH physicians in the "small" rural areas had a higher rate for 12 of the 18 procedures, but only showed significant differences over their non-PCMH counterparts for four of them.

"Family physicians practicing in PCMHs in small rural areas reported over 10 percent higher rates of providing IUD insertion, endometrial biopsies, neonatal circumcision, and office skin procedures than those practicing in non-PCMHs," the report said.

In the sparsely populated "frontier" areas, PCMH physicians had higher rates only for cosmetic procedures, though that rate was not significantly different when compared to the non-PCMH family physicians in such areas.

The report points out that while rural health-care providers tend to offer a broader range of services than their urban counterparts because of their limited health care resources, they often lack the financial and provider infrastructure needed to offer the PCMH model of care.

To that end, the report stresses the importance of creating programs to help rural practices shift to this model of care and in finding financial incentives to encourage rural family physicians already working within the PCMH model to broaden their scope of practice.

"Supporting rural practices that wish to transform to the PCMH model to improve care and access will be essential to meeting patient needs," said the report. "With strong evidence that overall health care costs and hospitalization rates are lower when physicians have a broader scope of practice, including inpatient care, determining how to best structure care by rural family physicians in all care settings will be essential."

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