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Transforming practices into medical homes has limited impact

Saturday March 1, 2014
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One of the largest and longest-running multipayer trials of patient-centered medical home medical practices in the U.S. was associated with limited improvements in quality and no reductions in use of ED or ambulatory care services or total costs over a three-year period.

The patient-centered medical home is a team-based model of primary care practice intended to improve the quality, efficiency and patient experience of care, according to background information in the study, which was published in the Feb. 26 issue of the Journal of the American Medical Association. Professional associations, payers, policymakers and other stakeholders have advocated for the patient-centered medical home model.

In general, medical home initiatives have encouraged primary care practices to invest in patient registries, enhanced access options and other structural changes that might improve patient care in exchange for enhanced payments. Dozens of privately and publicly financed trials of the medical home model are underway. “Interventions to transform primary care practices into medical homes are increasingly common, but their effectiveness in improving quality and containing costs is unclear,” the authors wrote.

Mark W. Friedberg, MD, MPP, of the RAND Corporation in Boston, and colleagues measured associations between participation in the Southeastern Pennsylvania Chronic Care Initiative, a multipayer medical home program, and changes in the quality, utilization and costs of care. Pilot practices could earn bonus payments for achieving patient-centered medical home recognition by the National Committee for Quality Assurance. The pilot program included 32 volunteering primary care practices between June 2008 and May 2011.

Using claims data from four participating health plans, the researchers compared changes in care — in each year, relative to before the intervention — for 64,243 patients who were attributed to pilot practices and 55,959 patients attributed to 29 comparison practices. Measured outcomes included performance on 11 quality measures for diabetes, asthma and preventive care; utilization of hospital, ED and ambulatory care; and standardized costs of care.

Pilot practices successfully achieved NCQA recognition and reported structural transformation on a range of capabilities, such as use of registries to identify patients overdue for chronic disease services (an increase from 30% of pilot practices to 85%) and electronic medication prescribing (an increase from 38% to 86%). Pilot practices accumulated average bonuses of $92,000 per primary care physician during the three-year intervention.

Of the 11 quality measures evaluated, pilot participation was significantly associated with greater performance improvement, relative to comparison practices, only on monitoring for kidney disease in patients with diabetes. There were no other statistically significant differences in measures of utilization, costs of care or rates of multiple same-year hospitalizations or ED visits.

The authors conclude that “a multipayer 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 three 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.”

The authors add that their “findings suggest that medical home interventions may need further refinement.”

In a separate news release, Bruce A. MacLeod, MD, president of the Pennsylvania Medical Society, noted the initiative in the study has evolved since the pilot program began in 2008. Future research should examine later models, he said.

“Part of providing the best care to patients that we can involves learning from what works, and what doesn’t work,” MacLeod said. “This study adds to that knowledge but we aren’t giving up on medical homes as an important tool for managing the care of our patients. We look forward to further research which will help guide our public policy decisions.”

Study abstract: http://jama.jamanetwork.com/article.aspx?articleid=1832540


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