Patient-centered medical home program results in little improvement in quality

The patient-centered medical home is a team-based model of primary care practice intended to improve the quality, efficiency, and patient experience of care. Professional associations, payers, policy makers, and other stakeholders have advocated for the patient-centered medical home model. In general, medical home initiatives have encouraged primary care practices to invest in patient registries, enhanced access options, and other structural changes that might improve patient care in exchange for enhanced payments, according to background information in the article. Dozens of privately and publicly financed trials of the medical home model are under way. "Interventions to transform primary care practices into medical homes are increasingly common, but their effectiveness in improving quality and containing costs is unclear," the authors write.

Mark W. Friedberg, M.D., M.P.P., of the RAND Corporation, Boston, and colleagues measured associations between participation in the Southeastern Pennsylvania Chronic Care Initiative, a multipayer medical home program, and changes in the quality, utilization, and costs of care. Pilot practices could earn bonus payments for achieving patient-centered medical home recognition by the National Committee for Quality Assurance (NCQA). Thirty-two volunteering primary care practices participated in the pilot (conducted from June 2008 to May 2011). Using claims data from 4 participating health plans, the researchers compared changes in care (in each year, relative to before the intervention) for 64,243 patients who were attributed to pilot practices and 55,959 patients attributed to 29 comparison practices. Measured outcomes included performance on 11 quality measures for diabetes, asthma, and preventive care; utilization of hospital, emergency department, and ambulatory care; standardized costs of care.

Pilot practices successfully achieved NCQA recognition and reported structural transformation on a range of capabilities, such as use of registries to identify patients overdue for chronic disease services (increased from 30 percent to 85 percent of pilot practices) and electronic medication prescribing (increased from 38 percent to 86 percent). Pilot practices accumulated average bonuses of $92,000 per primary care physician during the 3-year intervention.

Of the 11 quality measures evaluated, pilot participation was significantly associated with greater performance improvement, relative to comparison practices, on only l measure: monitoring for kidney disease in diabetes. There were no other statistically significant differences in measures of utilization, costs of care, or rates of multiple same-year hospitalizations or emergency department visits.

The authors conclude that "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."

"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."

The authors add that their "findings suggest that medical home interventions may need further refinement."

Editorial: The Patient-Centered Medical Home -- One Size Does Not Fit All

"Before confidently promoting the patient-centered medical home (PCMH) as a core component of health care reform, it is necessary to better understand which features and combination of features of the PCMH are most effective for which populations and in what settings," writes Thomas L. Schwenk, M.D., of the University of Nevada School of Medicine, Reno, in an accompanying editorial.

"The identification of specific PCMH features for various risk strata will likely have significant influence on the work patterns of physicians, who may be responsible for a larger panel of patients than currently but for whom only routine care is needed, often by other members of the health care team. The physician's time and expertise will be best focused on a relatively small number of the most complex and expensive patients."