February 25, 2014
A three-year pilot of a “medical home” model of primary care yielded few improvements in the quality of care and no reductions in hospitalizations, emergency department visits or total costs of care, according to a new RAND Corporation study.
Evaluating one of the nation's earliest and largest multipayer medical home pilots, researchers found that most participating primary care practices achieved recognition as medical homes, but the quality of care improved significantly for only one of 11 widely-used quality measures.
The findings are published in the Feb. 26 edition of the Journal of the American Medical Association.
“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 W. Friedberg, the study's lead author and a natural scientist at RAND, a nonprofit research organization. “Our findings suggest that achieving all of these goals is a challenge.”
Medical homes (also known as “patient-centered medical homes”) are primary care practices that are designed to provide comprehensive, personalized, team-based care using patient registries, electronic health records and other advanced capabilities. Recent medical home initiatives have encouraged primary care practices to invest in these new capabilities, participate in learning collaboratives and achieve medical home recognition. Health plans offer to pay more to the practices that achieve recognition.
Comprehensive primary care can improve outcomes for chronic conditions like diabetes and asthma, while lowering costs by reducing patients' needs for care from hospitals and emergency departments.
Researchers evaluated the Southeastern Pennsylvania Chronic Care Initiative, which was the first of several regional multipayer medical home pilots in the state. In this region, 32 primary care practices and six health plans participated in the pilot between 2008 and 2011. Using data on approximately 120,000 patients, researchers compared quality, utilization and costs of care between the pilot practices and 29 other practices that were not in the pilot.
The RAND study found that pilot practices successfully adopted the medical home capabilities (such as creating lists of patients overdue for needed services) and achieved recognition as a medical home from the National Committee on Quality Assurance. Rates of monitoring for kidney disease among patients with diabetes improved, and there were signs that quality improved for some other aspects of diabetes care.
However, the evaluation of the medical home pilot did not detect improvements on the quality measures that assessed asthma care, cancer screening and control of diabetes.
In addition, the medical home pilot did not show a reduction in patients' use of hospitals or emergency departments, or the total costs of medical care.
“It is possible that the pilot we evaluated had some, but not all of the ingredients necessary to produce broad improvements in quality and efficiency,” Friedberg said. “Findings from this evaluation and others should help refine the medical home model.”
Researchers say there are several possible reasons that the pilot medical home pilot did not show broader improvements on measures of cost and quality.
The pilot emphasized quality of care for diabetes and asthma, and practices did not have financial incentives to contain costs. While most participating practices adopted new capabilities that targeted quality of care, fewer increased night and weekend hours, which could have created short-term savings by reducing unnecessary visits to hospital emergency departments.
Because the pilot practices volunteered to become part of the medical home experiment, they may have been more quality-conscious than other practices even before the pilot began. This would have created a “ceiling effect” where there was less room to improve quality, researchers said.
RAND researchers also are conducting evaluations of several additional medical home primary care pilot projects, including other regions of the Pennsylvania Chronic Care Initiative.
Support for the study was provided by the Commonwealth Fund and Aetna Inc. Other authors of the study are Dr. Eric C. Schneider of RAND; Meredith B. Rosenthal of the Harvard School of Public Health; and Dr. Kevin G. Volpp and Dr. Rachel M. Werner of the Perelman School of Medicine at the University of Pennsylvania.
RAND Health is the nation's largest independent health policy research program, with a broad research portfolio that focuses on health care costs, quality and public health preparedness, among other topics.