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Specialty Care and the Patient-Centered Medical Home

Hollingsworth, John M. MD, MS*†; Saint, Sanjay MD, MPH*‡§¶; Hayward, Rodney A. MD*‡¶; Rogers, Mary A. M. PhD*‡¶; Zhang, Lingling MA; Miller, David C. MD, MPH†‡**

doi: 10.1097/MLR.0b013e3181f537b0
Original Article

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.

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

Research Design: Cross-sectional.

Subjects: Physicians from the 2007 National Ambulatory Medical Care Survey.

Measures: 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.


From the *Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, MI; †Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; ‡VA Ann Arbor Health Services Research and Development Center of Excellence, Ann Arbor, MI; §VA Ann Arbor Medical Center/University of Michigan Patient Safety Enhancement Program, Ann Arbor, MI; ¶Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; ∥Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI; and **Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.

Reprints: David C. Miller, MD, MPH, Department of Urology, The University of Michigan, Room 1031, Michigan House, 2301 Commonwealth Blvd, Ann Arbor, MI 48105–2967. E-mail:

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© 2011 Lippincott Williams & Wilkins, Inc.