Rethinking the medical home… again

The medical home model, seen by many as a solution to what ails primary care, continues to receive mixed reviews suggesting it may not be living up to its promise.

The latest dose of reality comes from two new studies which found that primary care medical homes 1) don’t necessarily save money; and 2) don’t increase patient satisfaction.

A little background is in order. The medical home – or, to be more complete, the patient-centered medical home – is a model developed by the National Committee for Quality Assurance to improve the delivery of primary care. Its principles are team-based care that’s coordinated, makes effective use of information technology and tracks how the patient is doing over time.

When correctly implemented, it’s supposed to improve patient care, especially for chronic conditions, by ensuring patients don’t fall through the cracks. The model also is designed to make better use of medical resources by assigning responsibility for patient care to a team that includes nurses and mid-level practitioners as well as physicians. At last count, about 4,000 medical practices in the U.S. have adopted this model.

In theory the medical home sounds terrific – the patients win, the staff wins, the practice wins. In reality the picture is less clear.

Take the study that recently appeared in the Journal of the American Medical Association, examining the relationship between quality of care and operating costs at patient-centered medical homes. Researchers at the University of Chicago found that medical homes with higher quality ratings also had higher operating costs – $2.26 more per patient per month, to be exact. This may not sound like much but over the course of a year it could add up to half a million dollars or more.

A couple of caveats are in order. First, this study only involved federally funded health centers, so the results might not apply to a privately owned medical clinic. Second, it focused primarily on cost, hence may not have fully captured the relationship between cost and value.

It provides a glimpse, however, of the fiscal dynamics that may underlie the medical home model once it’s implemented. Among policymakers who support the medical home concept, much of the emphasis has been on the cost savings that will result with fewer visits to the emergency room, fewer hospital admissions and so on. While this may save money for the system as a whole, it might not necessarily save money for the primary care clinics who are doing much of the work.

A bigger issue, at least from the public’s point of view – and one I’ve blogged about before – is whether patients like the primary care medical home.

Some of the early results aren’t encouraging. At the handful of demonstration sites that piloted the medical home model, patient satisfaction actually declined. And a new study, published last month in the Health Services Research journal, reached a similar conclusion: When 1,300 patients were surveyed about their experience at practices that had adopted the medical home model, they weren’t more satisfied.

American Medical News offered this take on the findings: Perhaps the medical home model is more about policy wonkery and behind-the-scenes restructuring than about improving the patient’s actual experience of care.

Most of the process “has been focused on talking with researchers and with academics and with clinic executives, and looking to see what makes a clinic effective, what makes the processes efficient and what makes them better able to track patients,” Dr. Robin Clarke, an assistant clinical professor at the University of California in Los Angeles, told American Medical News. “We haven’t spent a lot of time talking to patients about what they perceive to be patient-centered care and what they want to see in a primary care practice.”

Exactly.

Some months ago I was conversing with a health insurance executive when the topic turned to the medical home model. He was enthusiastic about how wonderful it was for patients. But when I pointed out that some surveys showed a decline in patient satisfaction, his response was, “Oh, people just don’t like seeing someone different,” i.e. a nurse or physician assistant instead of the doctor.

I can think of many reasons why team care might be problematic for patients, not least because of the potential for poor communication or fragmentation of care. Maybe patients instinctively sense this, or maybe they’ve actually experienced it. Either way, why wouldn’t their perspective matter?

Regardless of whether people know or care about the medical home model, their chances of encountering it are growing. Here in Minnesota, there are now 170 medical practices that are certified as medical homes, providing care for two million people.

If some of the early studies suggest the model isn’t all it’s cracked up to be, it doesn’t necessarily mean the concept is fatally flawed. Perhaps it just takes time to learn from mistakes and allow the model to mature. At the very least, however, we might want to proceed with caution.

4 thoughts on “Rethinking the medical home… again

  1. This piece is poorly researched (the medical home invented by NCQA?) and very selective in picking two studies citing cost issues (albeit with higher quality) and uneven patient satisfaction. The latter is a fair point, although there are many medical homes with extremely high satisfaction scores. But to suggest that patient perspectives are being fully considered and being from Minnesota doesn’t compute. The health care home program in that State is exemplary in terms pf patient and family member involvement. Do some more research, my friend.

  2. I see that you’re affiliated with a medical home newsletter for health care professionals, so I would submit we have differing perspectives – insider vs. consumer. And I’m by no means the first person to wonder if the medical home model will be able to deliver on its promise. I don’t know what the answer is but it seems to be a question that needs to be asked.

    I’ve seen some of the preliminary data suggesting outcomes for certain conditions are better for Minnesota patients in medical homes (here they’re known as health care homes), but the annual report submitted to the Legislature in May makes it clear that there’s considerable work to be done, and that consumer education and engagement has been one of the missing pieces.

    http://www.health.state.mn.us/healthreform/homes/legreport/2011HCHLegReport.pdf

  3. I am Connecticut’s first solo provider recognized by NCQA as a Patient Centered Medical Home. In my practice we have achieved statistically significant improvements in measures of preventive care and chronic disease. Through care coordination, we have been able to engage many more patients in their own care. As more resources become available for care coordination, my bet is that these measures will show further improvement. The upfront, and ongoing additional costs required for PCMH, represent the investment needed to achieve cost savings later on. My sense is that not enough time has elapsed since PCMH model inception and implementation to be able to truly quantify the econmic benefit to the health care system.

    • Thank you for commenting, Dr. Rippel, and congratulations on your accomplishment.

      I agree that we’re still learning about how this works and where the issues might lie. As one of my favorite hospital administrators used to say, “You don’t know what you don’t know.” Hopefully the studies are providing data that will enable practices to know what they should anticipate and plan for, so they can be successful at this.

Leave a Reply

Your email address will not be published. Required fields are marked *

*

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>