Fwd: qotd: Is the medical home a business model or a patient-service model?

_______________________________________________
Quote-of-the-day mailing list
Quote-of-the-day@mccanne.org
http://two.pairlist.net/mailman/listinfo/quote-of-the-day

-------- Original Message --------
Subject: qotd: Is the medical home a business model or a
patient-service model?
Date: Wed, 26 Feb 2014 11:21:12 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



JAMA
February 26, 2014
Association Between Participation in a Multipayer Medical Home
Intervention and Changes in Quality, Utilization, and Costs of Care
By Mark W. Friedberg, MD, MPP; Eric C. Schneider, MD, MSc; Meredith B.
Rosenthal, PhD; Kevin G. Volpp, MD, PhD; Rachel M. Werner, MD, PhD

Abstract

Importance: Interventions to transform primary care practices into
medical homes are increasingly common, but their effectiveness in
improving quality and containing costs is unclear.

Objective: To measure associations between participation in the
Southeastern Pennsylvania Chronic Care Initiative, one of the earliest
and largest multipayer medical home pilots conducted in the United
States, and changes in the quality, utilization, and costs of care.

Design, Setting, and Participants: Thirty-two volunteering primary care
practices participated in the pilot (conducted from June 1, 2008, to May
31, 2011). We surveyed pilot practices to compare their structural
capabilities at the pilot's beginning and end. Using claims data from 4
participating health plans, we compared changes (in each year, relative
to before the intervention) in the quality, utilization, and costs of
care delivered to 64 243 patients who were attributed to pilot practices
and 55 959 patients attributed to 29 comparison practices (selected for
size, specialty, and location similar to pilot practices) using a
difference-in-differences design.

Exposures: Pilot practices received disease registries and technical
assistance and could earn bonus payments for achieving patient-centered
medical home recognition by the National Committee for Quality Assurance
(NCQA).

Main Outcomes and Measures: Practice structural capabilities;
performance on 11 quality measures for diabetes, asthma, and preventive
care; utilization of hospital, emergency department, and ambulatory
care; standardized costs of care.

Results: Pilot practices successfully achieved NCQA recognition and
adopted new structural capabilities such as registries to identify
patients overdue for chronic disease services. Pilot participation was
associated with statistically significantly greater performance
improvement, relative to comparison practices, on 1 of 11 investigated
quality measures: nephropathy screening in diabetes (adjusted
performance of 82.7% vs 71.7% by year 3, P < .001). Pilot participation
was not associated with statistically significant changes in utilization
or costs of care. Pilot practices accumulated average bonuses of $92 000
per primary care physician during the 3-year intervention.

Conclusions and Relevance: A multipayer medical home pilot, in which
participating practices adopted new structural capabilities and received
NCQA certification, was associated with limited improvements in quality
and was not associated with reductions in utilization of hospital,
emergency department, or ambulatory care services or total costs over 3
years. These findings suggest that medical home interventions may need
further refinement.

http://jama.jamanetwork.com/article.aspx?articleid=1832540

****

Patient-Centered Primary Care Collaborative
January 2014
The Medical Home's Impact on Cost & Quality
An Annual Update of the Evidence, 2012-2013
By Marci Nielsen, PhD, MPH, J. Nwando Olayiwola, MD, MPH Paul Grundy,
MD, MPH, Kevin Grumbach, MD

A summary of key points from this year's report include:

1. PCMH (Patient-Centered Medical Home) studies continue to demonstrate
impressive improvements across a broad range of categories including:
cost, utilization, population health, prevention, access to care, and
patient satisfaction, while a gap still exists in reporting impact on
clinician satisfaction.

2. The PCMH continues to play a role in strengthening the larger health
care system, specifically Accountable Care Organizations and the
emerging medical neighborhood model.

3. Significant payment reforms are incorporating the PCMH and its key
attributes.

Although the evidence is early from an academic perspective, and this
report does not represent a formal peer-reviewed meta-analysis of the
literature, the expanding body of research provided here suggests that
when fully transformed primary care practices have embraced the PCMH
model of care, we find a number of consistent, positive outcomes.

http://www.pcpcc.org/resource/medical-homes-impact-cost-quality

****


Comment by Don McCanne, M.D.

Imagine doing away with all primary care professionals. Patients would
select a specialist depending on their specific presenting symptoms: an
otolaryngologist for a cold, a surgeon for a minor laceration, a
neurologist for a headache, or a gastroenterologist for an acute
diarrhea. Of course, that's ridiculous. Primary care is not a concept
that we have to sell to the public. Virtually everyone accepts it as a
given.

So what is the Patient-Centered Medical Home (PCMH) and how does it
differ from primary care? This RAND study published in the current issue
of JAMA provides enough information that we can say that, for practical
purposes, there is no difference.

The primary care practices studied by RAND received a stamp of approval
from the National Committee for Quality Assurance (NCQA) and received
bonuses for accomplishing that goal. Other than that, when compared to
similar practices, they proved to be slightly better on only one of
eleven quality measures and showed no reductions in utilization of
hospital, emergency department, or ambulatory care services or in total
costs over the 3 years of the study.

Various commentaries on this study have suggested that the reason that
the study group did not do better was that the PCMH is more appropriate
for people with complex, chronic problems. Only then would we expect to
see improved outcomes. Really? If this effort to reinforce our primary
care infrastructure is to be designed to take care of the sickest
patents only, then where do the relatively healthy go? Directly to the
specialists?

It has also been speculated that the practices volunteering for the
study were already high-performing practices and thus did not have much
room for further improvement. If that were the case, then why did the
control practices do just as well?

Rather than criticizing the disappointing performance of the
NCQA-recognized primary care practices, we should acknowledge that the
comparison practices were providing the same efficiency and quality of
care that was being provided by these selected practices. Although some
might quibble with the terminology, our primary care practices are
already functioning as patient-centered medical homes!

It is true that we need to reinforce primary care. The latest report
from the Patient-Centered Primary Care Collaborative suggests that we
can strengthen primary care, though the improvements that they report
have not been subjected to "a formal peer-reviewed meta-analysis of the
literature." But more important, the reinforcement that we urgently need
is to expand the primary care infrastructure, both geographically to
provide better access, and through the greater use of non-physician
primary care professionals, especially nurse practitioners.

Another interesting observation about this RAND study is that it was
conducted using our multi-payer system - a system well documented to be
inefficient, and one that is driven more by business interests rather
than patient-service interests. Although we need more than just a single
payer system to improve our primary care infrastructure, it would be a
gigantic and crucially important first step in establishing a single
public system that would enable further improvements in primary care,
where patients come first.