Touted Medical Homes Model Doesn’t Help Quality in StudyCaroline Chen
Medical homes, a much-touted model of patient-centered primary care that emphasizes better coordination, don’t reduce visits to hospital emergency rooms and provide limited health benefits, a study found.
Medical homes in the Southeastern Pennsylvania Chronic Care Initiative also didn’t save on costs compared with normal primary care practices. Instead, the homes accumulated bonuses of $92,000 per physician during a three-year pilot program, according to the study released today in the Journal of the American Medical Association.
Medical homes have gained popularity as health-care costs rise in the U.S. and the population ages. A physician-led team focuses on comprehensive and continuous care such as calling patients to remind them to take their medication and schedule follow-up visits. Medical homes also coordinate care among specialists, hospitals, and nursing homes.
“The findings were surprising,” Mark Friedberg, the lead study author and a scientist at the Rand Corp., a nonprofit research institute based in Santa Monica, California, said in a phone interview. “Expectations for the medical-home model were quite high and this was not consistent with previous findings.”
Today’s study involved 32 medical homes in the Pennsylvania program, one of the largest pilot projects in the U.S. with $20 million in funding during the first three years. It compared the medical homes with other provider practices from 2008-2011 and found significant improvement in one of 11 quality metrics.
Previous research of medical homes showed “modest improvements,” Friedberg wrote in today’s study, but were far smaller and shorter in duration.
The principles behind medical homes have been embraced by President Barack Obama’s administration. The Patient Protection and Affordable Care Act, known as Obamacare, set up “accountable care organizations” in the Medicare program, networks of doctors and hospitals that are rewarded if they coordinate care efficiently to keep their patients well.
“There are a lot of enthusiasts that are going to be offended,” said Thomas Schwenk, dean of the University of Nevada School of Medicine in Reno, in a telephone interview. “I do think this is an important model, but it has been spread widely and indiscriminately. It’s a powerful and expensive model that needs to be better understood.”
Critics of the study say it is outdated, as the medical home model is rapidly evolving.
‘Work in Progress’
“This has been a work in progress,” said Margaret O’Kane, president of the National Committee for Quality Assurance in Washington, D.C., which sets standards for medical homes and had recognized the ones in the Pennsylvania pilot program. “We updated our standards in 2011, and again in 2014.”
The study began in 2008, immediately after the state program started.
“I wouldn’t consider this a failure, I consider it a very good learning experience,” Marcela Diaz-Myers, director of the Pennsylvania Health Department’s Center for Practice Transformation and Innovation, said in a telephone interview. “We didn’t do enough care management in the first three years, and have put more emphasis on it since then.”
Insurer Independence Blue Cross, one of the many payers that helped support the pilot effort, said it continued to stand by the initiative.
Studies by the insurer and independent researchers show “our investment in PCMHs is producing some very positive results for chronically ill and high-risk patients who need accessible, coordinated care, and support,” Richard Snyder, chief medical officer of Philadelphia-based Independence Blue Cross, said in an e-mail.
The chronically ill are exactly the people that medical homes should focus on, says Schwenk.
“The physician’s time and expertise will be best focused on a relatively small number of the most complex and expensive patients,” he wrote in an editorial published in the journal today.
While the study only found improvement for one quality measure in diabetes patients, who are considered good candidates for medical home models due to the chronic nature of the disease, Schwenk said three years was not enough to show the benefits.
“Diabetes is a 40-year disease,” he said. “You wouldn’t see that much improvement in three years.”
Author Friedberg also says that the study doesn’t means that the medical home model should be abandoned.
“This paper says that this vision is very hard to produce in busy private care practices that are under a lot of pressures already,” he said. “But I caution against throwing out the baby with the bathwater.”