Thousands of primary care doctors in the United
States are revamping their practices based on this new medical home
Under this scheme, doctors and other providers receive bonuses from
insurance companies for spending extra time with patients by
extending office hours and providing follow-up care in hopes of
keeping them healthier and out of the hospital.
In medical home practices, primary care doctors adopt a team-based
care approach using patient registries, electronic health records
and other tools to help identify high-risk patients and deliver more
The thinking is that this extra attention will result in improved
quality and reduced spending.
But new evidence from a large, three-year pilot study among 32
physician practices in Pennsylvania found modest improvements in
quality of care and no reductions in hospitalizations, emergency
department visits or total costs of care.
"The medical home has gained popularity as a new model of primary
care, with the expectation that the approach will produce better and
lower-cost health care," said Dr Mark Friedberg, the study's lead
author and a scientist at RAND, a nonprofit research organization.
"Our findings suggest that achieving all of these goals is a
The findings were published in the Journal of the American Medical
Association (JAMA) on Tuesday. This adds to evidence from a study of
five Rhode Island physician practices published in September in JAMA
Internal Medicine that found no statistically significant
improvements in quality or emergency department visits, although
there were signs that ER use was declining.
Dr Thomas Schwenk of the University of Nevada School of Medicine in
Reno said the findings from the Pennsylvania trial suggest that the
medical home movement may not work for every patient in every
"It's gotten to be almost a fad in which it is applied
indiscriminately," said Schwenk, who wrote an editorial accompanying
the study in JAMA.
Schwenk calls the medical home model a "powerful technology" for
treating expensive, high-risk patients, but when it has been applied
in broad practice settings, it "by and large has been shown not to
be that effective."
Friedberg said the findings suggest it may be a little harder to
achieve the goals of the medical home model than previously thought.
"I would not say our findings say the medical home model is doomed."
But, he added, "It's not a sure thing."
Friedberg's team evaluated practices taking part in the Southeastern
Pennsylvania Chronic Care Initiative, one of the first medical home
pilots in the state. In this region, 32 primary care practices and
six health plans took part in the pilot between 2008 and 2011.
Practices in the pilot program were required to transform their
practices into medical homes and become accredited by the National
Committee for Quality Assurance or NCQA. Such practices enlist the
help of everyone from nurses to front desk staff to help avoid
costly and preventable complications by focusing on preventing and
managing chronic disease.
To motivate doctors in the Pennsylvania study, each practice was
eligible to receive a $20,000 bonus support payment in the first
year and annual bonus payments, which ranged from $28,000 to
$95,000, depending on the size and structure of the practice.
Using data on approximately 120,000 patients, researchers compared
quality, use of medical services and costs of care between the pilot
practices and 29 other practices.
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But over the three-year period, researchers found rates of quality
significantly improved on only one out of 11 quality measures that
included asthma care, cancer screening and overall diabetes control.
They also did not find any reductions in the number of hospital
visits, emergency department use or ambulatory care services, or in
the total costs of medical care.
The study did not examine why the pilot failed to make a major
impact. Yet, the authors said the fact that many of the practices
volunteered for the study suggest they may have already been more
quality-conscious than other practices even before the pilot began.
A POPULAR HYPOTHESIS
The findings contradict the hypothesis that better preventive and
primary care will help patients avoid more costly medical problems
down the line.
Insurance companies pay a premium to primary care practices that
organize themselves into a team of professionals, including nurse
practitioners and 0physician assistants.
More than 10 percent of U.S. primary care practices or about
7,000 practices, are recognized as patient-centered medical homes by
the NCQA, the nation's largest group that certifies such practices.
The movement got its start with an American Academy of Family
Physicians report called the 2004 Future of Family Medicine. It has
since been championed in President Barack Obama's healthcare law
through provisions that allow states to boost reimbursements to
primary care practices designated as medical homes for Medicaid
Health insurer Aetna Inc helped pay for the Pennsylvania study along
with the nonpartisan Commonwealth Fund. The company said it was
still convinced of the value of the medical home model, noting it
has come a long way since the start of the pilot.
Elizabeth Curran, Aetna's head of National Network Strategy and
Program Development, said Aetna has nearly 1 million commercial
members being treated in patient centered medical homes under an
estimated 5,000 primary care physicians.
She said Aetna patients treated in a medical home have a range of 3
to 13 percent fewer visits to the emergency department per 1,000
patients than patients treated in typical practices. Medical costs
per patient are from $2 to $24 cheaper per month in medical homes
versus typical practices.
Dr Elbert Huang, a health care policy expert at the University of
Chicago Medicine who was not involved in the study, said three years
may not be enough to show a significant impact in improving chronic
diseases such as diabetes or asthma.
"The practices clearly changed the way they do business," he said.
(Reporting by Julie Steenhuysen; Editing
by Michele Gershberg and Diane Craft)
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