Mea­sur­ing med­i­cal homes

Med­i­cal-home de­mos ad­vance, but ques­tions per­sist over per­for­mance data

Modern Healthcare - - FRONT PAGE - An­dis Robeznieks

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.

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