Remodeling required?

A primary-care milestone was reached last month with announcements by insurers Aetna and WellPoint that they would both start paying more money to primary-care physicians whose practices qualify as patient-centered medical homes.

In its announcement, Indianapolis-based WellPoint cited research from its Colorado medical-home programs that found the practice model led to an 18% decrease in hospital admissions and a 15% drop in emergency department visits. In the announcement from Hartford, Conn.-based Aetna, the company said providers that have been recognized as medical homes will receive a quarterly care coordination payment.

The patient-centered medical home, a business model of sorts for physician practices, grew from concept to movement mostly as a leap of faith with very little hard data backing up proponents' claims of better outcomes at lower cost. Now research findings are pouring in from a multitude of demonstration and pilot projects, but—even as payers are taking notice and starting to hand out rewards—some researchers are questioning the value of the studies and are trying to steer it into other directions. And at least one critic is questioning the findings of a seminal report that helped lay the foundation for the movement itself.

“The idea that good primary care works is known,” says Debbie Peikes, a senior health researcher at Mathematica Policy Research. “It's how do you transform practices and what features are best?”

Peikes adds that the medical home model—which involves increased patient access to physicians, coordinated care and a focus on information technology-assisted continuous improvement in quality and safety—is still evolving, so what is being studied are actually “precursors” to medical homes.

Even among these precursors, however, Peikes says there is evidence of improvement and alignment with the CMS “triple aim” goals of safe, timely, patient-centered care for individuals, better population health and lower per-capita costs. “We've seen enough studies to know good coordinated care can reduce hospital readmissions—and initial hospitalizations as well,” she says.

(While the numbers steadily increase, there are still only about 3,700 physician practices that have been officially recognized by the National Committee for Quality Assurance, the Joint Commission or the Accreditation Association for Ambulatory Health Care as medical homes.)

Dr. David Meyers, director of the Center for Primary Care, Prevention, and Clinical Partnerships at HHS' Agency for Healthcare Research and Quality, says the early studies were helpful in offering “proof of concept,” but now it's time to move on.

“Do we need studies showing the effectiveness of parachutes?” Meyers asks. “I don't think we need to prove that well-coordinated primary care is a good thing. We need studies that show how to get there.”

Meyers and Peikes worked on an AHRQ decisionmaker brief titled “Improving Evaluations of the Medical Home,” which noted some of the shortcomings of available medical home research and suggested what is needed are strong evaluations for finding ways to refine, improve and customize what works and then to disseminate that information. A more comprehensive systematic evidence review is scheduled to be published in the Feb. 28 issue of the American Journal of Managed Care.

“We recognized that people were making overly optimistic interpretations of the earlier studies and we wanted to give an antidote to that,” Meyers says.

The AHRQ brief notes that the best studies have randomized controls, the next-best have matched comparisons and the not-so-good studies are the “pre-post evaluations,” which compare measures before and after an intervention but do not include a comparison group, which makes it difficult to say with certainty that the interventions are responsible for any changes.

Two early studies helped launch medical-home pilot projects when there was not much more to go on. The first was a 2008 report in the journal Health Affairs, which found that the Danville, Pa.-based Geisinger Health System reduced hospital admissions by 20% and cut medical costs by 7% at two early medical-home pilot sites launched in 2006.

The other was a report by the Mercer consulting firm, which found that by investing $10.2 million in 2003 to implement its Community Care of North Carolina medical-home network, North Carolina's Medicaid program saved $244 million in 2004. A follow-up report released in December by the Milliman actuarial firm found that the program saved $984 million between fiscal years 2007 and 2010.

Meyers says the research on those two programs was instrumental to creating the current high profile medical homes are enjoying. “Without them, the momentum for this model of care would have been much slower to get going,” he says. “They really ignited this interest.”

More reports soon followed, such as a January 2010 Commonwealth Fund report that took the opinions of more than 1,200 patients surveyed at 27 New Orleans safety net clinics operating as medical homes and compared them with 3,500 adults living elsewhere in the U.S. The findings included how only 27% of the New Orleans patients surveyed went without needed healthcare services because of cost compared to 41% for the rest of the U.S.

Melinda Abrams, vice president of the Commonwealth Fund's patient-centered coordinated-care program and a co-author of the New Orleans report, says 41 states are planning or implementing their own medical-home demonstrations, including more than 20 that are up and running and 17 involving more than one payer.

“There's an enormous amount of activity across the country,” Abrams says, including 10 Commonwealth Fund-financed demonstrations. “There are skeptics because the transformation that's required at the individual primary-care site is daunting and difficult—but those providers that have gone through it report that their staff burnout is lower, their turnover is lower and their satisfaction is higher.”

Abrams acknowledges that some of the research being generated—such as the North Carolina reports—are open to criticism because it's not published in a peer-reviewed journal. “Does that necessarily make me disbelieve the North Carolina results? No,” Abrams says.

Dr. Chuck Willson, an architect of the North Carolina program and now a clinical professor of pediatrics at East Carolina University's Brody School of Medicine in Greenville, N.C., notes that, while experimental, the medical-home initiative was not by itself an experiment.

“I think the word ‘study' is where we get into trouble a little bit,” Willson says. “It was not set up as a double-blind study. These are on-the-ground demonstrations of a different way we can practice for the future.”

He says the program originated in 1996 as a way to address double-digit rates of Medicaid-cost inflation that, if continued, threatened to consume the entire state budget by 2020, according to estimates.

The theory behind medical homes, Willson says, is to create a “continuous healing relationship” between doctor and patient that is required to address today's many “lifestyle-generated conditions.” The North Carolina Medicaid program operates on a fee-for-service basis but with physicians getting an additional $2.50 per member per month payment and another $2.50 paying for care coordinators, Willson says. “When we started out, I didn't know if it would succeed,” he adds. “But it's been successful beyond my wildest dreams.”

Al Lewis, president of the Disease Management Purchasing Consortium and contributor to the Health Care Blog, has been arguing that the North Carolina program's success has been overstated—by Mercer and Milliman—and that savings seen in reduced ER visits and hospital admissions are offset by higher costs generated by more prescriptions, tests and preventive visits, and the cost of maintaining a medical-management infrastructure.

“The actual program shows no savings, period,” Lewis argues.

Lewis will be stating his case Feb. 26 at the Fourth National Medical Home Summit in Philadelphia, and says he has invited Milliman to co-sponsor the session and make a presentation.

Lewis says utilization data on AHRQ's website contradict the findings in the Milliman report and that, after he presents his findings, other state officials will be reluctant to cite North Carolina's story to advance the medical-home cause. “Any statewide medical director who advocates this will be taking a career risk,” he says.

Robert Cosway, a Milliman principal and consulting actuary, notes that rather than have a clinic or physician group serving as a medical home, North Carolina “created a network across the state of like-minded physicians,” so its experience differs from other initiatives. He adds that he hasn't seen Lewis' findings, but he stands by his company's report. “We based our analysis on the raw claims data we received directly from the state,” Cosway says, adding that the report met the state's satisfaction and another is in the works using data through the fiscal year ending June 30.

It's noted in the report that it's difficult to link an intervention in one year with a savings a few years later, and Cosway echoes this point.

The program's “intent was to achieve improvements in healthcare efficiency and cost,” Cosway says. “So it wasn't set up under ideal scientific methods.”

Meyers at AHRQ agrees that the actuarial approach taken by Milliman differs from the numbers crunched by health service researchers, but adds that is the type of data state legislators were looking for when they had to decide whether to fund the program.

“In general, North Carolina has done cutting-edge work in the care they deliver across the state and the whole country has much to learn from them,” Meyers says.

Does Milliman intend to take Lewis up on his invitation to co-sponsor and co-present a session at the Medical Home Summit?

“He did ask us to help pay for it,” Cosway says, “so, at this point, no.”