Wednesday, February 26, 2014

The State of the Medical Home

By Sue Bornstein, MD, FACP
Executive Director, Texas Medical Home Initiative
Governor, ACP Northern Texas

Yesterday, the Journal of the American Medical Association published a study on the patient-centered medical home that has created quite a buzz, at least in my world. The authors of the study reported on their evaluation of 32 primary care practices in southeastern Pennsylvania that participated in a medical home pilot from 2008 to 2011. A comparison group of 29 practices was also evaluated. They surveyed the practices to determine structural capabilities and evaluated claims data. The authors compared changes in the quality, utilization, and costs of care delivered to patients in the pilot practices and comparison practices.

The pilot practices all achieved National Committee for Quality Assurance (NCQA) recognition and adopted new structural capabilities such as chronic disease registries. Pilot practices accumulated average bonuses of $92,000 per primary care physician during the three-year intervention.

The pilot practices were found to have statistically significantly greater performance on 1 of 11 quality measures ― screening for diabetic nephropathy. Further, pilot practices did not show statistically significant changes in utilization or costs of care.

How is this possible? There are a number of plausible explanations. First, three years may not be enough time to measure the impact of interventions of chronic diseases. Second, an editorial on the article notes that utilization and cost data were only available to about one-half the clinicians in the pilot, and regular meetings about utilization occurred in barely one-third of the practices. Hospital discharge summaries were not uniformly available. Third, in many pilots, there was great “up-front” emphasis on achieving patient-centered medical home (PCMH) recognition by NCQA at the expense of taking the time to achieve true transformation. Fourth, the PCMH model encompasses many different practice capabilities (care coordination, population management, enhanced access to care, continuity of care, etc.), and we do not yet know which one(s) will have the greatest impact on outcomes.

At the crux of the study is the finding that where the PCMH has been adopted, it has been adopted at significant cost to the entire population of a practice. Does a healthy young person without medical problems need a medical home? One could argue that they need a minimal version (i.e., a patient registry) to keep on track with preventive care. The intensity of the intervention should increase as the complexity and utilization of medical resources increases.

“Strategic stratification” of patients is essential if the model is to fulfill its promise of helping to achieve the Triple Aim. But in order to do this, practices must have current, actionable data and the resources needed to make changes.

While many lament the implications of this study, I see it as an opportunity. A number of states and organizations are now taking a critical look at simplifying the criteria while at the same time, making them more consistent. So here's the opportunity: In Texas, we frequently hear that we do things “the Texas way.” And although there has been a fair amount of PCMH activity in our state, it is generally limited to large hospital systems; academic health centers; government entities; the military; and notably, some federally qualified health centers. Why not develop the Texas PCMH model? Let’s bring together TMA, the Texas Academy of Family Physicians, the Texas Chapter of the American College of Physicians, the Texas Pediatric Society, Medicaid and CHIP, the Texas Department of State Health Services, and the payers, and come up with a plan that is right for our great state. Let’s not let this opportunity get away!

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