The difficulty in precisely measuring the benefits of the patient-centered medical home model
comes across in two new studies offering seemingly contradictory insights on the concept.
A three-year study comparing 32 Southeast Pennsylvania practices (including six nurse-managed health centers) that adopted National Committee for Quality Assurance
medical home standards with 29 that had not found significant improvement in only one of 11 quality measures—monitoring kidney disease in diabetics—and “no robust associations with utilization and or costs,” according to findings published in JAMA
. This study was done by Boston-based researchers with the RAND Corp.
There were 64,243 patients in the medical home practices and 55,959 patients in the comparison group. Researchers used claims data from four health plans and the study ran between June 1, 2008, and May 31, 2011.
In contrast, University of Minnesota School of Public Health researchers
found that practices that adopt the state's “healthcare home” model improved scores on measures related to colorectal cancer screening, asthma care, diabetes care, vascular care, and follow up care for depression.
Also, 2010-2012 healthcare costs (PDF)
for the 203,071 Medicaid enrollees receiving care at a healthcare home were 9.2% less than the costs for the 264,523 Medicaid enrollees who received care at a non-HCH clinic: $2,588 compared to $2,850, the Minnesota study found.
The medical home concept calls for delivering multidisciplinary team-based, coordinated care facilitated by health information technology tools such as patient registries while providing increased access through longer hours, same- or next-day appointments and secure electronic communication. Medical homes are touted as a method for reducing ambulatory care-sensitive hospitalizations.
But, in the RAND study's third year, these admissions were higher among the medical home-cared for patients than for those in the comparison group—83 per 1,000 patients compared to 72. The researchers noted, however, that few medical home practices increased their night and weekend hours, which is seen as a strategy to prevent these hospitalizations.
Primary-care physicians in practices achieving NCQA medical home status received bonuses of about $92,000 over the course of the study. The percentage of practices using disease registries increased from 30% to 85% and the percentage using electronic prescribing grew from 38% to 86%. But this resulted in “few statistically significant results,” the Rand researchers wrote.
They speculated that the attention the practices devoted to achieving NCQA recognition and associated bonuses could have distracted the physicians from other quality and efficiency improvement activities
“Despite widespread enthusiasm for the medical home concept, few peer-reviewed publications have found
that transforming primary care practices into medical homes (as defined by common recognition tools and in typical practice settings) produces measurable improvements in the quality and efficiency of care,” the researchers concluded.
Dr. Thomas Schwenk, dean of the University of Nevada School of Medicine, wrote an editorial accompanying the RAND study
in which he noted medical home advocates “need not be disappointed” by the results of that study—which he described as “ambitious and reasonably well-conducted.” But, he said, they should “pay close attention to its lessons.”
He adds that the RAND researchers have done a service by “effectively ending promotion” of a generic, one-size-fits-all model of the patient-centered medical home. “The next critical phase of PCMH development should focus on its strategic deployment for the care of high-utilization patients with multiple chronic comorbidities, frequently with concomitant mental illness, and often with poor social support,” Schwenk concluded.
The NCQA criticized the study
as out of date, as the practices involved were using 2008 medical home standards which were revised in 2011. Another round of revisions
is set to be released next month.Follow Andis Robeznieks on Twitter: @MHARobeznieks