02/26/2014
Aaron CarrollFirst the study:
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.
Bottom line: the patient centered medical home failed to make improvements in 10 of 11 quality measures in three years, and it didn’t reduce utilization or costs. But the accompanying editorial is what you want to read:
This problem may be similar to that of expensive biomedical technologies that often are proven to have benefit in high-risk patient populations but then are inappropriately exported to broad, community-based, low-risk populations for which they fail. The same error may be occurring with the PCMH, a different type of expensive technology. The PCMH has been promoted for widespread adoption, using a fairly generic and fixed set of structural practice features, even before being fully developed in targeted high-risk populations or before clearly understanding which features or combination of features are most effective with which patients. It is time to replace enthusiasm and promotion with scientific rigor and prudence and to better understand what the PCMH is and is not. Widespread implementation of the PCMH with limited data may lead to failure.
The critical characteristic of the US health care system that defines how the PCMH will best be deployed is the skewed distribution of health care utilization across the population. Nearly a quarter of all medical care is consumed by 1% of the patient population, nearly half by just 5%. The healthy half of the population uses nearly no medical care and therefore has essentially no opportunity to benefit from any restructuring of health care delivery, however robust. The methods by which health care is delivered need to be adjusted similarly to how health care is utilized. Insurers, both private and government, and employers should be providing substantial support to health service investigators and primary care physicians to assess and then implement features of the PCMH that work best for different strata of patient risk and health care utilization, but with a particular focus on the most expensive and complex patients. The identification of target populations should not be defined by disease, as was the case with failed disease management programs of the past that focused on a single disease, but by the simple measures of utilization and cost. This approach can be linked with other aspects of health care reform, such as accountable care organizations, in which both primary care and specialty physicians are held jointly accountable for cost and outcomes.
We keep assuming that the health care system will improve things for everyone. Even the OHIE was guilty of this misconception. We need to get better about realizing that not everyone needs the same thing, and that not all interventions are necessary for all patients.
You really should go read the whole thing.
