Measuring medical homes
Medical-home demos advance, but questions persist over performance data
Aprimary-care milestone was reached last month with announcements by insurers Aetna and Wellpoint that they would both start paying more money to primary-care physicians whose practices qualify as patient-centered medical homes.
In its announcement, Indianapolisbased Wellpoint cited research from its Colorado medical-home programs that found the practice model led to an 18% decrease in hospital admissions and a 15% drop in emergency department visits. In the announcement from Hartford, Conn.based Aetna, the company said providers that have been recognized as medical homes will receive a quarterly care coordination payment.
The patient-centered medical home, a business model of sorts for physician practices, grew from concept to movement mostly as a leap of faith with very little hard data backing up proponents’ claims of better outcomes at lower cost. Now research findings are pouring in from a multitude of demonstration and pilot projects, but—even as payers are taking notice and starting to hand out rewards—some researchers are questioning the value of the studies and are trying to steer it into other directions. And at least one critic is questioning the findings of a seminal report that helped lay the foundation for the movement itself.
“The idea that good primary care works is known,” says Debbie Piekes, a senior health researcher at Mathematica Policy Research. “It’s how do you transform practices and what features are best?”
Piekes adds that the medical home model—which involves increased patient access to physicians, coordinated care and a focus on information technology-assisted continuous improvement in quality and safety—is still evolving, so what is being studied are actually “precursors” to medical homes.
Even among these precursors, however, Piekes says there is evidence of improvement and alignment with the CMS “triple aim” goals of safe, timely, patient-centered care for individuals, better population health and lower per-capita costs. “We’ve seen enough studies to know good coordinated care can reduce hospital readmissions—and initial hospitalizations as well,” she says.
(While the numbers steadily increase, there are still only about 3,700 physician practices that have been officially recognized by the National Committee for Quality Assurance, the Joint Commission or the Accreditation Association for Ambulatory Health Care as medical homes.)
Dr. David Meyers, director of the Center for Primary Care, Prevention, and Clinical Partnerships at HHS’ Agency for Healthcare Research and Quality, says the early studies were helpful in offering “proof of concept,” but now it’s time to move on.
“Do we need studies showing the effectiveness of parachutes?” Meyers asks. “I don’t think we need to prove that well-coordinated primary care is a good thing. We need studies that show how to get there.”
Meyers and Piekes worked on an AHRQ decisionmaker brief titled “Improving Evaluations of the Medical Home,” which noted some of the shortcomings of available medical home research and suggested what is needed are strong evaluations for finding ways to refine, improve and customize what works and then to disseminate that information. A more comprehensive systematic evidence review is scheduled to be published in the Feb. 28 issue of the American Journal of Managed Care.
“We recognized that people were making overly optimistic interpretations of the earlier studies and we wanted to give an antidote to that,” Meyers says.
The AHRQ brief notes that the best studies have randomized controls, the next-best have matched comparisons and the not-so-good studies are the “pre-post evaluations,” which compare measures before and after an intervention but do not include a comparison group, which makes it difficult to say with certainty that the interventions are responsible for any changes.
Two early studies helped launch medical-home pilot projects when there was not much more to go on. The first was a 2008 report in the journal Health Affairs, which found that the Danville, Pa.-based Geisinger
Dr. Chuck Willson says he is pleased with the results of a medical-home program in North Carolina.