Specialty care and the patient-centered medical home.
BACKGROUND
The medical home's success depends, in part, on the degree to which primary care physicians (PCPs) and specialists collaborate to create "medical neighborhoods" based on collective accountability. Such collaboration may require a new equilibrium in chronic disease care, with some of the routine follow-up currently provided by specialists reallocated to PCPs and their medical home teams.


OBJECTIVE
To measure the care delivered by specialists for 7 chronic conditions, and to estimate the implications associated with reallocating half among the PCP workforce.


METHODS
Cross-sectional.


METHODS
Physicians from the 2007 National Ambulatory Medical Care Survey.


METHODS
We identified adult ambulatory visits for chronic obstructive pulmonary disease/asthma, low back pain, diabetes mellitus, coronary artery disease/congestive heart failure, chronic kidney disease, and depression. We calculated the time spent by specialists in direct and indirect care for established patients with these conditions. We summed individual physician estimates across specialists and converted the total into annual work weeks. After reducing this figure by half, we divided by the number of active PCPs.


RESULTS
Most specialty visits (76.8%; 95% confidence interval [CI]: 73.6%-79.7%) were made by established patients. Specialists spent 552,844 (95% CI: 454,660-651,029) and 108,113 (95% CI: 86,103-130,122) cumulative work weeks providing direct and indirect follow-up care, respectively. Reallocating half of this care would generate 3.2 (95% CI: 2.6-3.8) additional work weeks for each PCP.


CONCLUSIONS
The cumulative time spent by specialists in routine chronic disease follow-up is nontrivial. Reallocation of this care to PCP-directed medical homes may require multidimensional efforts to expand the primary care workforce.
Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, MI 48105-2967, USA.
John M
JM
Hollingsworth
Sanjay
S
Saint
Rodney A
RA
Hayward
Mary A M
MA
Rogers
Lingling
L
Zhang
David C
DC
Miller
D000553:Ambulatory Care / Q000706:statistics & numerical data; D002908:Chronic Disease / Q000628:therapy*; D003430:Cross-Sectional Studies; D006801:Humans; D033183:Interdisciplinary Communication; D008511:Medicine / Q000458:organization & administration*; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data; D010348:Patient Care Team / Q000458:organization & administration; D018802:Patient-Centered Care / Q000458:organization & administration*; D058007:Physicians, Primary Care / Q000458:organization & administration*; D011320:Primary Health Care / Q000458:organization & administration*; D011787:Quality of Health Care / Q000458:organization & administration; D012017:Referral and Consultation / Q000458:organization & administration / Q000706:statistics & numerical data; D013997:Time Factors; D000078329:Workforce