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The patient-centered medical home has become a prominent model for reforming the way health care is delivered to patients. The model offers a robust system of primary care combined with practice innovations and new payment methods. But scant information exists about the extent to which typical US physician practices have implemented this model and its processes of care, or about the factors associated with implementation. In this article we provide the first national data on the use of medical home processes such as chronic disease registries, nurse care managers, and systems to incorporate patient feedback, among 1,325 small and medium-size physician practices. We found that on average, practices used just one-fifth of the patientcentered medical home processes measured as part of this study. We also identify internal capabilities and external incentives associated with the greater use of medical home processes.T he patient-centered medical home model of health care delivery system reform was featured prominently in the Affordable Care Act of 2010. The model was developed by the primary care specialty societies in 2007. It has been endorsed by a broad coalition of purchasers, payers, providers, consumers, and other health care stakeholders. It emphasizes a robust system of primary care combined with practice innovations and new payment models.

The patient-centered medical home is taking center stage in discussions of primary care innovation as a new delivery model that provides comprehensive, coordinated care across the lifespan. Although the medical home is widely discussed by policymakers, payers, and other stakeholders, the extent to which physician practices have the infrastructure in place to function as medical homes is not known. Using data from the 2006-07 National Study of Physician Organizations, we examine the extent of adoption of medical home infrastructure components among large primary care and multispecialty medical groups and their association with medical group size and ownership.

Nearly two-thirds of US office-based physicians work in practices of fewer than seven physicians. It is often assumed that larger practices provide better care, although there is little evidence for or against this assumption. What is the relationship between practice sizeand other practice characteristics, such as ownership or use of medical home processes-and the quality of care? We conducted a national survey of 1,045 primary care-based practices with nineteen or fewer physicians to determine practice characteristics. We used Medicare data to calculate practices' rate of potentially preventable hospital admissions (ambulatory care-sensitive admissions). Compared to practices with 10-19 physicians, practices with 1-2 physicians had 33 percent fewer preventable admissions, and practices with 3-9 physicians had 27 percent fewer. Physician-owned practices had fewer preventable admissions than hospital-owned practices. In an era when health care reform appears to be driving physicians into larger organizations, it is important to measure the comparative performance of practices of all sizes, to learn more about how small practices provide patient care, and to learn more about the types of organizational structures-such as independent practice associations-that may make it possible for small practices to share resources that are useful for improving the quality of care.

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Objective. To validate physicians' self‐reported intentions to leave clinical practice and the American Medical Association (AMA) Masterfile practice status variable as measures of physician attrition, and to determine predictors of intention to leave, and actual departure from, clinical practice. Data Sources. Survey of specialist physicians in urban California (1998); the AMA Physician Masterfile (2001); and direct ascertainment of physician practice status (2001). Study Design. Physicians' intention to leave clinical practice by 2001 (self‐reported in 1998) was tested as a measure of each physician's actual practice status in 2001 (directly ascertained). Physician practice status according to the 2001 AMA Masterfile was also tested as a measure of physicians' actual practice status in 2001. Multivariate regression was used to predict both physicians' intentions to leave clinical practice and their actual departure. Data Collection/Extraction Methods. AMA Masterfile data on 2001 practice status were obtained for 967 of 968 physician respondents to the 1998 survey. Actual practice status for 2001 was directly ascertained for 957. Principal Findings. The sensitivity of Masterfile practice status as a measure of actual departure from clinical practice was 9.0 percent, and the positive predictive value was 52.9 percent. Allowing for a two‐year reporting lag did not change this substantially. Self‐reported intention to leave clinical practice had a sensitivity of 73.3 percent and a positive predictive value of 35.4 percent as a measure of actual departure from practice. The strongest predictor of both intention to leave clinical practice and actual departure from practice was older age. Physician dissatisfaction had a strong association (OR=5.6) with intention to leave clinical practice, but was not associated with actual departure from practice. Conclusions. Our findings call into question the accuracy of both AMA Masterfile data and physicians' self‐reported intentions to leave as measures of physician attrition from clinical practice. Research using these measures should be interpreted with caution. Self‐reported intention to leave practice may be more of a proxy for dissatisfaction than an accurate predictor of actual behavior.

The use of evidence-based care management processes (CMPs) in physician practice is an important component of delivery-system reform.The authors used data from a 2006-2007 national study of large physician organizations—medical groups and independent practice associations (IPAs) to determine the extent to which organizations use CMPs, and to identify external (market) influences and organizational capabilities associated with CMP use. The study found that physician organizations use about half of recommended CMPs, most commonly disease registries, specially trained patient educators, and performance feedback to physicians. Physician organizations that reported participating in quality improvement programs, having a patient-centered focus, and being owned by a hospital or health maintenance organization used more CMPs. IPAs and very large medical groups used more CMPs than smaller groups. Organizations externally evaluated on quality measures used more CMPs than other organizations. These findings can inform efforts to stimulate the adoption of best practices for chronic illness care.

The effective management of patients with chronic illnesses is critical to bending the curve of health care spending in the United States and is a crucial test for health care reform. In this article we used data from three national surveys of physician practices between 2006 and 2013 to determine the extent to which practices of all sizes have increased their use of evidence-based care management processes associated with patient-centered medical homes for patients with asthma, congestive heart failure, depression, and diabetes. We found relatively large increases over time in the overall use of these processes for small and medium-size practices as well as for large practices. However, the large practices used fewer than half of the recommended processes, on average. We also identified the individual processes whose use increased the most and show that greater use of care management processes is positively associated with public reporting of patient experience and clinical quality and with pay-for-performance.