Community​ health​ centers​ still​ believe​ medical​ home​ model​ delivers​ value

For instance, most of the community health centers studied were not officially certified as a patient-centered medical home by the National Committee for Quality Assurance until toward the end of the demonstration.

Previous studies have shown that savings under the models don't kick in until four or five years after certification, according to Strothers.

It can take that long to truly affect healthcare utilization for people with severe chronic conditions such as diabetes, Strothers said. Also, Medicare patients tend to make up a small amount of a health center's patient population, averaging less than 20%. Most of their patients tend to be Medicaid beneficiaries.

The study also didn't take into account that there were more baby boomers joining Medicare each year of the experiment, and that this population tends to have a high level of social determinants impacting their health, according to Brian Toomey, CEO of Piedmont Health Services, a system of 10-community health centers based in North Carolina.

Piedmont Health participated in the demonstration studied by RAND and has continued the medical home model not only for its Medicare patients, but for everyone it sees.

"When you have only fee-for-service, then the whole focus is on increasing revenue," Toomey said. "This approach ensures that the focus is on the care of the patient."

Sticking with the model has actually led to savings for Medicare even though Piedmont no longer receives a case management fee from the CMS. In 2016, eight of the system's health centers that have patient-centered medical home certification had a per member per year cost of $9,189, nearly $700 less than the national fee-for-service cost of $9,875.

Community health centers are playing an important role in the national health system. In 2015, 1,375 health centers provided care to 24.3 million patients, including 1 in 12 U.S. residents and nearly 1 in 6 Medicaid enrollees, according to research by the Kaiser Family Foundation.

Velma Hendershott, CEO of InterCare, a Michigan-based network of community health centers, said she is also sticking by the model after being involved in the demonstration because she sees that it is especially beneficial for the type of patients that come to centers like hers.

More than 90% of health center patients have income at or below 200% of the federal poverty level, which is $40,180 for a family of three, according to the Kaiser Family Foundation study of 2015 data.

Community health center patients also tend to have an array of chronic illnesses and behavioral health conditions, Hendershott said. These patients often don't know the best way to navigate all their care needs. To that end, her facilities work to have providers that address primary-care needs as well as some specialty services.

"It's kind of like one-stop shopping," Hendershott said. "Now, when we need to refer a patient to someone else, they can go right to that person and that doctor doesn't have to worry if that patient got the care they needed or not."

While RAND's study indicated no savings were harvested from the model, evaluations and case studies for other payer and provider settings have shown some savings were achieved for other patient types treated in medical homes, according to Cristina Boccuti, an associate director of the program on Medicare policy at the Kaiser Family Foundation.

A July 2017 analysis by the Patient-Centered Primary Care Collaborative (See sidebar, p. 22) found that a medical home overseen by Blue Cross and Blue Shield of Michigan did indeed reduce spending. Its program began eight years ago and includes 4,534 primary-care doctors at 1,638 practices.

Since the model's launch, practices participating have generated savings of $26.37 per member per month in adult medical costs. "The medical home model of care can work," Boccuti said.

As healthcare spending continues to skyrocket, medical home models could be key to reversing the trend, according to Dr. Robert Winn, who oversees the University of Illinois Hospital & Health Sciences System's 13 federally qualified health centers.

In 2015, U.S. healthcare spending rose 5.8% to $3.2 trillion, or $9,990 per person. That trend was likely driven in part by millions of people who gained coverage under the Affordable Care Act but didn't know how to properly navigate their care options.

A medical home helps people figure out what services they actually need, Winn said, and who can best provide them. "The best person to help you get to the ideal health outcomes is a doctor who you trust."

Related story: "Medical homes need time to deliver results"