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Reform Update: Medical-home adoption growing; evidence of effectiveness still elusive


By Andis Robeznieks
Posted: August 18, 2014 - 3:45 pm ET
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Primary care is a foundation of healthcare reform efforts, and patient-centered medical homes are one of the delivery system innovations encouraged by the Patient Protection and Affordable Care Act. But recent studies present a mixed picture of the effectiveness of medical homes in improving quality and reducing costs.

Last week, the Family Medicine Clinics of the 25-bed Floyd Valley Hospital in Le Mars, Iowa, became the 8,000th patient-centered medical home recognized by the National Committee for Quality Assurance. One of 12 institutions managed by Avera Health, a 19-hospital Sioux Falls, S.D.-based system, Floyd Valley operates three clinics in the Iowa communities of Le Mars, Marcus and Remsen.

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NCQA began its recognition program in 2008, though Floyd Valley Hospital and Clinics clinic administrator Julie Sitzmann said the family medicine program adopted a care-team model in 2004. Each team includes a doctor, two nurses and a patient service coordinator who coordinates patient visits and test results. “Patients absolutely love it,” Sitzmann said. “They develop a relationship with the care team.”

Sitzmann was unaware that the Floyd Valley clinics medical home designation put NCQA past the 8,000 mark. “Did I win a car?” she quipped.

The NCQA medical home recognition process, Sitzmann said, helped formalize policies and data collection strategies that will facilitate the clinics' operation as a Medicare accountable care organization and an Iowa Medicaid Health Home. The state requires practices to obtain third-party medical home accreditation to participate in its care-coordination program for Medicaid enrollees with multiple chronic conditions. Participating practices receive a per-member per-month payment and an opportunity to receive shared savings.

But the NCQA recognition comes amid studies showing mixed measures of effectiveness for medical homes. There is criticism that physicians and other providers are more concerned with checking NCQA's boxes to document processes than with providing coordinated care and achieving better outcomes.

Sitzmann said, however, that the medical home model adds accountability, eases quality measurement and allows for better tracking of patient test results and specialist visits.

For example, the quality data now collected automatically in templates previously had to be extracted from dictated clinical notes. “We have a good total picture of what's going on with patients,” Sitzmann said. “It's not like physicians are being told how to practice or how to diagnose the patient. They just have to make a few more clicks.”

But three recent primary-care studies show a fuzzy picture of medical homes' success.

A new study in the journal Health Services Research compared cost and quality measures collected between July 2008 and June 2010 for 308 NCQA-recognized medical homes with 1,906 non-recognized practices. In the CMS-funded study conducted by RTI International researchers, it was found that after receiving NCQA recognition, total Medicare payments, acute care payments, and emergency department visits declined compared with the non-recognized practices. Declines were sharper among sicker patients and solo practices.

Small and solo practices also shined in a new Health Affairs study. Researchers at New York's Weill Cornell Medical College found one- to two-doctor practices had 33% fewer ambulatory care-sensitive hospital admissions than practices with 10 to 19 doctors. They also found that physician-owned practices had fewer preventable admissions than hospital-owned practices.

“Public policymakers and health insurance company executives might consider policies that support organizations that help small practices share resources—such as nurse-care managers for patients with chronic illnesses,” the researchers wrote. “Independent practice associations, for example, have been shown to increase the number of patient-centered medical home processes provided to patients of small and medium-size practices. These organizations might provide a viable alternative … for physicians who do not want to become employed by hospitals and do not have the desire or the opportunity to join a large medical group.”

Besides size, other practice characteristics or payment methods did not appear to make much difference in some quality measures. That led the researchers to conclude that “neither the patient-centered medical home score, nor pay-for-performance incentives, nor the acceptance of risk for the cost of hospital care for the practice's patients was significantly associated with the ambulatory care–sensitive admission rate.”

Another study, by Milbank Reports, looked at medical home programs in 17 states and concluded that payer alignment is needed to foster medical home success and the corresponding payment reforms needed for that success. “This is often because no single payer can invest enough to make transforming the entire practice cost-effective,” the Milbank researchers wrote.

AMA demands more time for review of Open Payment website

The American Medical Association repeated its call for the CMS to allow physicians more time to review and correct any inaccurate information that may be posted on its troubled Open Payments website, which tracks drug- and medical device-manufacturer payments to doctors and teaching hospitals.

The website, which was mandated by the Sunshine Act provision included in the Patient Protection and Affordable Care Act, went offline Aug. 3 to address technical problems. The issues took 11 days to fix, so the CMS extended the review time to Sept. 8, but the AMA said that is still not enough time. It's demanding that the data review and correction period be extended to March 31, 2015.

On Sept. 30, the CMS is scheduled to post payment information generated between Aug. 1 and Dec. 31, 2013. Modern Healthcare reported, however, that one-third of the records will not be posted at that time because of concern with data inconsistencies.

"In order for the Sunshine Act to be effective, physicians need enough time to review and correct any inaccurate data that may be reported," Dr. Robert Wah, president of the AMA, said in a news release. “The lack of faith physicians have in the system at this point in time, is making them wonder if taking time away from patients to go through the process is even worthwhile."

PCORI to fund studies for artery disease, hip fracture

The Patient-Centered Outcomes Research Institute will fund $90 million in comparative-effectiveness studies examining treatments for carotid artery disease, hip fracture and pelvic floor dysfunction.

PCORI will fund up to $10 million of direct costs for studies lasting up to five years. Researchers must send letters of intent by Oct. 1.

Specifically, PCORI is calling for studies that compare the effectiveness of medical treatment and invasive procedures for asymptomatic carotid artery disease, different surgical options for hip fracture and different types of surgical mesh—or no mesh at all—for pelvic floor repair.

In a notice on the PCORI website, it was stated that applications for studies looking at cost-effectiveness or evaluations of decision-support tools will not be considered.

Follow Andis Robeznieks on Twitter: @MHARobeznieks


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