Do medical homes cut costs, raise quality? Study casts doubts

RAND researcher suggests ambitious goals may be to blame

A new JAMA study raises questions about the ability of patient-centered medical homes (PCMHs) to reduce health care spending and improve quality.

The study—conducted by the RAND Corporation and funded by Aetna and the Commonwealth Fund—evaluated 32 physician practices and four insurance plans between 2008 and 2011 while they participated in the Southeastern Pennsylvania Chronic Care Initiative, one of the first PCMH pilot programs in the country.

In order to participate in the program, the practices were required to receive accreditation from the National Committee for Quality Assurance. Each participant was eligible for a $20,000 bonus support payment during the first year and between $28,000 and $95,000 in annual bonus payments.

Related: Is the patient-centered medical home a Neanderthal?

The researchers compared data on 64,000 patients who received care from the 32 participating providers with data on about 56,000 patients who received care from 29 comparison medical practices. They found:

  • The 32 participating practices delivered improvements for just one of 11 quality measures outlined for the PCMH model.
  • The practices showed modest improvements in monitoring patients with diabetes for kidney disease and certain other aspects of diabetic care—but there were no reductions in emergency department visits, hospitalizations, or overall costs of care over the three-year time period.
  • In addition, health care costs actually increased, from $389 per 1,000 patients per month prior to the study, to $430 per 1,000 patients per month in the study's third year.

Perspectives on the findings

Mark Friedberg, the study's lead author, said that the findings do not indicate "the medical home model is doomed," but rather that the effort to "produce better and lower-cost health care ... is a challenge."

For example, Friedberg noted that the participating practices did not have financial incentives to reduce costs and only a few of the practices increased night and weekend hours, which could have helped curb unnecessary ED visits and hospitalizations.

Friedberg said that RAND is continuing its research into the PCMH model, which has been deployed for other pilot programs and in other regions of Pennsylvania, and noted that those might provide additional insight into whether the model is successful. He added that the model also needs to be evaluated to identify elements that are useful so that it can be refined for future adoption.

Separately, NCQA President Margaret O'Kane criticized the study, noting that the Pennsylvania pilot program was based on standards implemented in 2008—not the revised 2011 standards, which are scheduled to be implemented in 2014. "It feels like being judged on old data," she said (Steenhuysen, Reuters, 2/25; Carrns, New York Times, 2/25; Pittman, "The Gupta Guide," MedPage Today, 2/26).

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