Medical Home: An Evolving Model of Primary Care

By Melinda K. Abrams
Commonwealth Fund Blog, February 25, 2014

Today, the Journal of the American Medical Association (JAMA) released a study, cofunded by The Commonwealth Fund, evaluating a three-year medical home pilot in Pennsylvania. The study, led by RAND’s Mark Friedberg and colleagues, found the program was not associated with significant improvements in quality of care or cost reductions. ….

While some may be ready to hand medical homes a failing grade, the study’s findings underscore what we already knew about this team-based model of primary care: we need to continue to improve how care is delivered, how providers are paid, and how the model is implemented in different settings.

Since the Pennsylvania initiative was launched in 2008, we have learned more about how best to implement an effective patient-centered medical home. For example, it’s become clear that the payment model needs to reward cost savings as well as quality improvement. ….

In addition, evidence suggests that sites targeting patients with complex medical conditions are more likely to see an impact on outcomes and utilization than those serving patients with more routine needs. ….

But this study also raises questions about whether recognition criteria used by NCQA and other accrediting organizations need to better reflect meaningful practice transformation….

http://www.commonwealthfund.org/Blog/2014/Feb/Medical-Homes-Evolving-Primary-Care.aspx

Comment:

By Kip Sullivan, JD

The February 25 edition of JAMA published a study of “patient-centered medical homes” (PCMH) by Mark Friedberg et al. The authors reported that PCMHs had no effect on costs and almost no effect on quality (PCMHs outperformed the control clinics on only one of 11 quality measures). In fact, it appears that PCMHs raised costs when the costs associated with setting up PCMHs and rewarding PCMH doctors is taken into account. 

The PCMH may not survive much longer if research continues to show that it cannot cut costs. The loss of the “medical home” metaphor will be inconsequential, but if the termination of the PCMH experiment sets back the campaign to strengthen the primary care sector, that will be a significant loss. To avoid that outcome, PCMH proponents should cease hyping the PCMH as a cost containment device applicable to entire “populations” and instead focus on specific services for specific patients. 

Cutting costs has always been one of the primary goals of PCMH advocates. For private insurers, it is not merely a goal – it is a precondition. Unless it is ordered to do otherwise by state legislatures or Congress, the American insurance industry will not, over the long haul, subsidize clinics to provide “home” services if those services do not reduce the industry’s net costs – their subsidies to PCMHs plus their expenditures on claims. Nor will clinics certified as PCMHs provide, over the long term, the services PCMHs are expected to provide if insurers refuse to compensate them for those services. And if insurers and PCMHs refuse to pay for those services, it is extremely unlikely patients can be persuaded to pay for them.

The “medical home” label was originally coined to refer to clinics which held all the records of children with special needs. But in 2007 the concept was greatly expanded by the American Academy of Family Physicians and three other primary care specialty groups and promoted as a means to bring more resources into the entire primary care sector while simultaneously cutting costs http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf. As Robert Berenson et al. put it in a 2008 paper, “[T]he medical home can be viewed as an alternative way to recognize and support primary care activities, particularly those that are not considered to be part of evaluation and management service codes….” http://content.healthaffairs.org/content/27/5/1219.abstract As Ed Wagner and other PCMH advocates put it in a 2012 paper for the Commonwealth Fund, “Among the experts, stakeholders, and patients consulted for this report, there was broad agreement that … sustaining the PCMH model and making the case for increased primary care payments hinge on success in reducing health care costs.” http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2012/Feb/1582_Wagner_guiding_transformation_patientcentered_med_home_v2.pdf

Promoting the “medical home” as a cost-containment tool rather than simply calling for more resources for primary care may turn out to have been a mistake. It is becoming increasingly apparent that the cost-cutting prowess of the “home” was vastly exaggerated by its proponents. It should have been described only as an approach or model that might cut costs if applied to specific categories of chronically ill patients. Thanks to research like the paper by Friedberg et al., that realization seems to be dawning on PCMH advocates.  The comment on the Commonwealth Fund blog quoted above is one example. An editorial accompanying the JAMA paper, aptly entitled “One size does not fit all,” is another. Even the ever-optimistic Patient-Centered Primary Care Collaborative (which last year added Liz Fowler to its board http://www.pcpcc.org/2013/07/23/liz-fowler-jill-hummel-hal-lawrence-and-adrienne-white-faines-join-pcpcc-board-directors) said of the JAMA paper, “There was no targeting and/or analysis of chronically ill patients.” http://www.pcpcc.org/2014/02/26/pcpcc-leadership-responds-jama-article-medical-home-pilot-study

The “medical home” movement would be well advised to stop exaggerating the cost-containment powers of the PCMH and instead call for experimentation and research on specific services for specific types of chronically ill patients. Let me offer one example suggested by the Friedberg paper. The PCMH model studied by Friedberg et al. focused on diabetes care – six of the 11 quality measures measured some aspect of diabetes treatment. The one measure at which the PCMH clinics excelled turned out to be a diabetes measure (kidney exams). How did the PCMH clinics achieve this laudable outcome? We don’t know, but it is reasonable to infer that the high percentage of diabetes measures in the quality measurement set caused the clinics to “teach to the test” – to concentrate resources on diabetes patients, possibly at the expense of patients without diabetes. Did they use some or all of the diabetes disease management techniques that have been shown to improve the health of diabetics and pre-diabetics? We don’t know.  

If instead of testing the impossibly amorphous, one-size-fits-all “home” concept, the PCMH clinics had tested their ability to improve the health of diabetics with specific treatments and interventions, we might now be reading a paper with useful information about what treatments work for diabetics and whether those treatments cost more to deliver than they saved in future medical costs. Instead we are left to scratch our heads about why the latest over-hyped managed care fad with the saccharine name isn’t working.

The AAFP and other proponents of the “medical home” should never have burdened the concept with the expectation of cost containment. If they were serious about cost containment, they should have endorsed single-payer legislation. If they were serious about strengthening the primary care sector, they should have called for more money for primary care, period.

Medical Home: An Evolving Model of Primary Care

By Melinda K. Abrams
Commonwealth Fund Blog, February 25, 2014

Today, the Journal of the American Medical Association (JAMA) released a study, cofunded by The Commonwealth Fund, evaluating a three-year medical home pilot in Pennsylvania. The study, led by RAND’s Mark Friedberg and colleagues, found the program was not associated with significant improvements in quality of care or cost reductions. ….

While some may be ready to hand medical homes a failing grade, the study’s findings underscore what we already knew about this team-based model of primary care: we need to continue to improve how care is delivered, how providers are paid, and how the model is implemented in different settings.

Since the Pennsylvania initiative was launched in 2008, we have learned more about how best to implement an effective patient-centered medical home. For example, it’s become clear that the payment model needs to reward cost savings as well as quality improvement. ….

In addition, evidence suggests that sites targeting patients with complex medical conditions are more likely to see an impact on outcomes and utilization than those serving patients with more routine needs. ….

But this study also raises questions about whether recognition criteria used by NCQA and other accrediting organizations need to better reflect meaningful practice transformation….

http://www.commonwealthfund.org/Blog/2014/Feb/Medical-Homes-Evolving-Pri…

The February 25 edition of JAMA published a study of “patient-centered medical homes” (PCMH) by Mark Friedberg et al. The authors reported that PCMHs had no effect on costs and almost no effect on quality (PCMHs outperformed the control clinics on only one of 11 quality measures). In fact, it appears that PCMHs raised costs when the costs associated with setting up PCMHs and rewarding PCMH doctors is taken into account.

The PCMH may not survive much longer if research continues to show that it cannot cut costs. The loss of the “medical home” metaphor will be inconsequential, but if the termination of the PCMH experiment sets back the campaign to strengthen the primary care sector, that will be a significant loss. To avoid that outcome, PCMH proponents should cease hyping the PCMH as a cost containment device applicable to entire “populations” and instead focus on specific services for specific patients.

Cutting costs has always been one of the primary goals of PCMH advocates. For private insurers, it is not merely a goal – it is a precondition. Unless it is ordered to do otherwise by state legislatures or Congress, the American insurance industry will not, over the long haul, subsidize clinics to provide “home” services if those services do not reduce the industry’s net costs – their subsidies to PCMHs plus their expenditures on claims. Nor will clinics certified as PCMHs provide, over the long term, the services PCMHs are expected to provide if insurers refuse to compensate them for those services. And if insurers and PCMHs refuse to pay for those services, it is extremely unlikely patients can be persuaded to pay for them.

The “medical home” label was originally coined to refer to clinics which held all the records of children with special needs. But in 2007 the concept was greatly expanded by the American Academy of Family Physicians and three other primary care specialty groups and promoted as a means to bring more resources into the entire primary care sector while simultaneously cutting costshttp://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiati…. As Robert Berenson et al. put it in a 2008 paper, “[T]he medical home can be viewed as an alternative way to recognize and support primary care activities, particularly those that are not considered to be part of evaluation and management service codes….”http://content.healthaffairs.org/content/27/5/1219.abstract As Ed Wagner and other PCMH advocates put it in a 2012 paper for the Commonwealth Fund, “Among the experts, stakeholders, and patients consulted for this report, there was broad agreement that … sustaining the PCMH model and making the case for increased primary care payments hinge on success in reducing health care costs.”http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report…

Promoting the “medical home” as a cost-containment tool rather than simply calling for more resources for primary care may turn out to have been a mistake. It is becoming increasingly apparent that the cost-cutting prowess of the “home” was vastly exaggerated by its proponents. It should have been described only as an approach or model that might cut costs if applied to specific categories of chronically ill patients. Thanks to research like the paper by Friedberg et al., that realization seems to be dawning on PCMH advocates.  The comment on the Commonwealth Fund blog quoted above is one example. An editorial accompanying the JAMA paper, aptly entitled “One size does not fit all,” is another. Even the ever-optimistic Patient-Centered Primary Care Collaborative (which last year added Liz Fowler to its board http://www.pcpcc.org/2013/07/23/liz-fowler-jill-hummel-hal-lawrence-and-…) said of the JAMA paper, “There was no targeting and/or analysis of chronically ill patients.” http://www.pcpcc.org/2014/02/26/pcpcc-leadership-responds-jama-article-m…

The “medical home” movement would be well advised to stop exaggerating the cost-containment powers of the PCMH and instead call for experimentation and research on specific services for specific types of chronically ill patients. Let me offer one example suggested by the Friedberg paper. The PCMH model studied by Friedberg et al. focused on diabetes care – six of the 11 quality measures measured some aspect of diabetes treatment. The one measure at which the PCMH clinics excelled turned out to be a diabetes measure (kidney exams). How did the PCMH clinics achieve this laudable outcome? We don’t know, but it is reasonable to infer that the high percentage of diabetes measures in the quality measurement set caused the clinics to “teach to the test” – to concentrate resources on diabetes patients, possibly at the expense of patients without diabetes. Did they use some or all of the diabetes disease management techniques that have been shown to improve the health of diabetics and pre-diabetics? We don’t know.

If instead of testing the impossibly amorphous, one-size-fits-all “home” concept, the PCMH clinics had tested their ability to improve the health of diabetics with specific treatments and interventions, we might now be reading a paper with useful information about what treatments work for diabetics and whether those treatments cost more to deliver than they saved in future medical costs. Instead we are left to scratch our heads about why the latest over-hyped managed care fad with the saccharine name isn’t working.

The AAFP and other proponents of the “medical home” should never have burdened the concept with the expectation of cost containment. If they were serious about cost containment, they should have endorsed single-payer legislation. If they were serious about strengthening the primary care sector, they should have called for more money for primary care, period.