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-------- Original Message --------
Subject: qotd: "Medical home" proponents should focus on specific
services for specific patients
Date: Wed, 19 Mar 2014 11:29:35 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>
Commonwealth Fund Blog
February 25, 2014
Medical Home: An Evolving Model of Primary Care
By Melinda K. Abrams
Today, the Journal of the American Medical Association (JAMA) released a
study, cofunded by The Commonwealth Fund, evaluating a three-year
medical home pilot in Pennsylvania. The study, led by RAND's Mark
Friedberg and colleagues, found the program was not associated with
significant improvements in quality of care or cost reductions. ….
While some may be ready to hand medical homes a failing grade, the
study's findings underscore what we already knew about this team-based
model of primary care: we need to continue to improve how care is
delivered, how providers are paid, and how the model is implemented in
different settings.
Since the Pennsylvania initiative was launched in 2008, we have learned
more about how best to implement an effective patient-centered medical
home. For example, it's become clear that the payment model needs to
reward cost savings as well as quality improvement. ….
In addition, evidence suggests that sites targeting patients with
complex medical conditions are more likely to see an impact on outcomes
and utilization than those serving patients with more routine needs. ….
But this study also raises questions about whether recognition criteria
used by NCQA and other accrediting organizations need to better reflect
meaningful practice transformation….
http://www.commonwealthfund.org/Blog/2014/Feb/Medical-Homes-Evolving-Primary-Care.aspx
==
Comment by Kip Sullivan, JD
The February 25 edition of JAMA published a study of "patient-centered
medical homes" (PCMH) by Mark Friedberg et al. The authors reported that
PCMHs had no effect on costs and almost no effect on quality (PCMHs
outperformed the control clinics on only one of 11 quality measures). In
fact, it appears that PCMHs raised costs when the costs associated with
setting up PCMHs and rewarding PCMH doctors is taken into account.
The PCMH may not survive much longer if research continues to show that
it cannot cut costs. The loss of the "medical home" metaphor will be
inconsequential, but if the termination of the PCMH experiment sets back
the campaign to strengthen the primary care sector, that will be a
significant loss. To avoid that outcome, PCMH proponents should cease
hyping the PCMH as a cost containment device applicable to entire
"populations" and instead focus on specific services for specific patients.
Cutting costs has always been one of the primary goals of PCMH
advocates. For private insurers, it is not merely a goal – it is a
precondition. Unless it is ordered to do otherwise by state legislatures
or Congress, the American insurance industry will not, over the long
haul, subsidize clinics to provide "home" services if those services do
not reduce the industry's net costs – their subsidies to PCMHs plus
their expenditures on claims. Nor will clinics certified as PCMHs
provide, over the long term, the services PCMHs are expected to provide
if insurers refuse to compensate them for those services. And if
insurers and PCMHs refuse to pay for those services, it is extremely
unlikely patients can be persuaded to pay for them.
The "medical home" label was originally coined to refer to clinics which
held all the records of children with special needs. But in 2007 the
concept was greatly expanded by the American Academy of Family
Physicians and three other primary care specialty groups and promoted as
a means to bring more resources into the entire primary care sector
while simultaneously cutting costs
http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf.
As Robert Berenson et al. put it in a 2008 paper, "[T]he medical home
can be viewed as an alternative way to recognize and support primary
care activities, particularly those that are not considered to be part
of evaluation and management service codes...."
http://content.healthaffairs.org/content/27/5/1219.abstract As Ed Wagner
and other PCMH advocates put it in a 2012 paper for the Commonwealth
Fund, "Among the experts, stakeholders, and patients consulted for this
report, there was broad agreement that … sustaining the PCMH model and
making the case for increased primary care payments hinge on success in
reducing health care costs."
http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2012/Feb/1582_Wagner_guiding_transformation_patientcentered_med_home_v2.pdf
Promoting the "medical home" as a cost-containment tool rather than
simply calling for more resources for primary care may turn out to have
been a mistake. It is becoming increasingly apparent that the
cost-cutting prowess of the "home" was vastly exaggerated by its
proponents. It should have been described only as an approach or model
that might cut costs if applied to specific categories of chronically
ill patients. Thanks to research like the paper by Friedberg et al.,
that realization seems to be dawning on PCMH advocates. The comment on
the Commonwealth Fund blog quoted above is one example. An editorial
accompanying the JAMA paper, aptly entitled "One size does not fit all,"
is another. Even the ever-optimistic Patient-Centered Primary Care
Collaborative (which last year added Liz Fowler to its board
http://www.pcpcc.org/2013/07/23/liz-fowler-jill-hummel-hal-lawrence-and-adrienne-white-faines-join-pcpcc-board-directors)
said of the JAMA paper, "There was no targeting and/or analysis of
chronically ill patients."
http://www.pcpcc.org/2014/02/26/pcpcc-leadership-responds-jama-article-medical-home-pilot-study
The "medical home" movement would be well advised to stop exaggerating
the cost-containment powers of the PCMH and instead call for
experimentation and research on specific services for specific types of
chronically ill patients. Let me offer one example suggested by the
Friedberg paper. The PCMH model studied by Friedberg et al. focused on
diabetes care – six of the 11 quality measures measured some aspect of
diabetes treatment. The one measure at which the PCMH clinics excelled
turned out to be a diabetes measure (kidney exams). How did the PCMH
clinics achieve this laudable outcome? We don't know, but it is
reasonable to infer that the high percentage of diabetes measures in the
quality measurement set caused the clinics to "teach to the test" – to
concentrate resources on diabetes patients, possibly at the expense of
patients without diabetes. Did they use some or all of the diabetes
disease management techniques that have been shown to improve the health
of diabetics and pre-diabetics? We don't know.
If instead of testing the impossibly amorphous, one-size-fits-all "home"
concept, the PCMH clinics had tested their ability to improve the health
of diabetics with specific treatments and interventions, we might now be
reading a paper with useful information about what treatments work for
diabetics and whether those treatments cost more to deliver than they
saved in future medical costs. Instead we are left to scratch our heads
about why the latest over-hyped managed care fad with the saccharine
name isn't working.
The AAFP and other proponents of the "medical home" should never have
burdened the concept with the expectation of cost containment. If they
were serious about cost containment, they should have endorsed
single-payer legislation. If they were serious about strengthening the
primary care sector, they should have called for more money for primary
care, period.
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