Study Casts Doubt on Benefits of the Medical Home

A study of one of the first, largest, and longest-running multi-payer patient-centered medical home medical pilots found little improvement in quality and no reduction in use of services or total costs.

This article published with permission from The Burrill Report.

A study of one of the first, largest, and longest-running multi-payer pilots of patient-centered medical home medical (PCHM) practices in the United States has found that quality improvements were limited, and that it didn’t save money over the 3 years of the program.

The study, recently published in the Journal of the American Medical Association, casts doubt on a transformational model of healthcare delivery that is expected to improve outcomes and reduce costs.

The PCHM has been touted as a way to deliver better healthcare at lower cost through a team-based model of coordinated primary care. Professional associations, payers, policy makers, and other stakeholders have advocated for the PCHM model and many privately and publicly financed trials of the medical home model are underway.

The study, conducted by Mark Friedberg of the Rand Corporation and colleagues, measured associations between participation in the Southeastern Pennsylvania Chronic Care Initiative, a multi-payer medical home program, and changes in the quality, utilization, and costs of care. Pilot practices could earn bonus payments for achieving PCHM recognition by the National Committee for Quality Assurance, which most of them achieved.

The researchers found that of 11 quality measures evaluated, participation in a medical home was significantly associated with greater performance improvement on only one measure: monitoring for kidney disease in diabetes. There were no other statistically significant differences in measures of utilization, costs of care, or rates of multiple same-year hospitalizations or emergency department visits.

The authors concluded that “a multi-payer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years.”

“Despite widespread enthusiasm for the medical home concept, few peer-reviewed publications have found that transforming primary care practices into medical homes produces measurable improvements in the quality and efficiency of care,” they write adding that their “findings suggest that medical home interventions may need further refinement.”

But contrary to their study, another report released in January by the Patient-Centered Primary Care Collaborative found otherwise. It analyzed studies released between August 2012 and September 2013 and found that 61% of peer-reviewed studies and 57% of industry reports of medical homes noted lower costs per member and for total cost of care, and a return on investment that was mainly due to reduced use of avoidable services. It also found improvements in population health indicators and preventive services such as screenings and immunization rates, improvements in access to care, and overall greater patient satisfaction.

“Before confidently promoting the patient-centered medical home as a core component of health care reform, it is necessary to better understand which features and combination of features of the patient-centered medical home are most effective for which populations and in what settings,” wrote Thomas Schwenk, of the University of Nevada School of Medicine, in an accompanying editorial.

“The identification of specific patient-centered medical home features for various risk strata will likely have significant influence on the work patterns of physicians, who may be responsible for a larger panel of patients than currently but for whom only routine care is needed, often by other members of the health care team,” he wrote. “The physician's time and expertise will be best focused on a relatively small number of the most complex and expensive patients.”

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