Medical home fails to lower cost, use

Although highly touted, the patient-centered medical home model failed to lower use of services or total costs and produced little quality improvement over three years, research in the latest Journal of the American Medical Association (JAMA) has found. The findings suggest that medical homes may need “further refinement.”

The research tracked the southeastern Pennsylvania Chronic Care Initiative in one of the first, largest and longest-running multi-payer trials of the team-based model from 2008 to 2011. The pilot included 32 primary care practices with recognition from the National Committee for Quality Assurance (NCQA) and six health plans, with two commercial and two Medicaid plans supplying claims data.

Medical home efforts have encouraged primary providers to invest in patient registries, use electronic medication prescribing, enhanced access options and other structural changes aimed at improving patient care in exchange for bonuses.

Outcomes were reported for performance on 11 quality measures for diabetes, asthma, preventive care; utilization of hospital, emergency department, and ambulatory care; and standardized costs of care. Physician practices accumulated average bonuses amounting to $92,000 per physician during the three-year pilot.

“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,” said the report authors, led by Mark Friedberg, MD, a scientist at the RAND Corp. “It is possible that the pilot we evaluated had some, but not all of the ingredients necessary to produce broad improvements in quality and efficiency.”

Some factors may have contributed to the mixed results, according to the study, which was sponsored by the Commonwealth Fund and Aetna. The pilot emphasized quality of care for chronic conditions of diabetes and asthma. Practices did not have financial incentives to contain costs and did not receive feedback on their patients’ utilization of care. Few increased night and weekend hours to help reduce emergency department visits.

Some practices may already have been highly quality conscious so had less room to improve quality. Or, the pilot practices may have been digitizing and transforming themselves to adopt electronic health records (EHRs) similar to non-pilot providers, thus weakening their ability to differentiate themselves.    

Like other experiments in healthcare, researchers are finding that one size does not fit all when it comes to medical homes. In an accompanying editorial, Thomas Schwenk, MD, a University of Nevada medical professor, recommended understanding “which features and combination of features of the PCMH are most effective for which populations and in what settings.”