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Almost No Benefit of Medical Home Interventions in Community-Based Practices — Physician’s First Watch

Medical News |
February 26, 2014

Almost No Benefit of Medical Home Interventions in Community-Based Practices

By Thomas L. Schwenk, MD

The patient-centered medical home approach to primary care did little to improve utilization or quality-of-care measures in a JAMA study.

Thirty-two primary care practices in Pennsylvania who adopted a wide range of medical home features (e.g., performance feedback, disease-management registries) were compared with 29 control practices. Intervention practices achieved "medical home-ness" by the end of the 3-year study, as measured by standardized national criteria.

By study's end, intervention and control practices did not differ in ambulatory care-sensitive hospitalizations, emergency department use, primary care or specialist visits, or total cost of care. Only 1 of 11 quality-of-care measures (monitoring for diabetic nephropathy) was better in intervention practices.

These results will be discouraging to patient-centered medical-home advocates, but they might simply mean that the medical home is best deployed in a more concentrated approach for patients with costly conditions and high use and not as a generic way to care for broad populations of community-based primary care patients.

Dr. Schwenk is deputy editor of NEJM Journal Watch General Medicine, from which this story is adapted.

Reader Comments (9)

Beth Sirr NP Other, VA

I wish the standard for any regulation was that after accounting for the total cost in time and dollars there was a net outcome benefit for patients.
Time for the patient has proven to be the MOST important determinant of patient outcomes.
Any requirement that takes time from patients is the #1 threat to the patients.
Until Joint Commission and others are held to standard of producing a quantifiable net benefit to patients, they will continue to suck time from patient care, for their burgeoning bureaucracies.

Parr, Jesse MD Physician, Pediatrics/Adolescent Medicine, Texas

We are a PCMH but it is not the record keeping and minutiae entered in the electronic health record that has made a difference. It is being open on weekends and early evenings and preaching to our patients to stay away from the ERs and UCs that has made a difference. Our patients health status has improved and our hospitalization rate is very low. Oh, I forgot to mention. We are not hospital owned. I think the idea of integration of care by hospital owned practices has been hijacked to meet the needs of hospitals and we are now marketing that we are not part of an integrated network. Also, whether we click on tobacco status for every patient over 14 or not does not improve health care.

SIDNEY YASSINGER Physician, Gastroenterology, Carmichael, CA

Another example of academia and government foisting upon practicing physicians an unproven idea before the concept has been adequately tested. In addition, the idea that "managing populations" rather than dealing w/ individual patients and truly getting to know them is the way to render quality care, has also not been proven. Rushing patients through every 10-15 minutes and then spending an equal or greater amt. of time documenting minutiae on EMR for insurance and government bureaucrats has also been a bust. For us seasoned (?old) docs who took good care of our pts and kept good dictated although they were paper records are getting mighty discouraged.

Dennis Novak Physician, Family Medicine/General Practice, office

I participate in a similar effort which is under way. I feel the effort has been effective in creating a network of practices who have the infra-structure to improve the true quality of care, however it will take more than 2 or 3 years to influence the behavior of populations.

We may reach the highest risk patients sooner, but they are by definition already the ones who need the most care and all we can do is try to organize and direct the flow. We cannot change decades of processes in a few years. Patients will still use ERs more than medically required, ECFs will bounce patients back and forth to hospitals, specialists will send patients to other specialists and hospitals will create "centers of Excellence" that feed their beds.

I believe we are on the right track, though bogged down in excessive reporting for the present. I hope we can overcome the short term mentality and support Primary Care initiatives long enough to be able to show a true difference.

Maureen Nash, MD Physician, Geriatrics

It is way to early to tell if there is benefit. Most chronic health conditions like diabetes, ASCVD, htn take many years or decades for the full effect to emerge. One would need at least 10 years of data to actually have a guess about either quality or cost changes driven by this intervention.

That being said, it is also easy to believe that the people who are most likely to benefit are those who have the most complex problems. But only time and more data will tell.

Jared Ellis Physician, Family Medicine/General Practice, University of Alabama Family Medicine Residency Program

I note the comment "better product at a lower cost" which works well for manufacturing, but a number of patients don't want a better product-they want their shot of decadron and a zpak, not our EBM, PCMH, etc. And if they are paying their $1 or $25 copay with their government or employer sponsored healthcare regardless, why would they care that the insurance company saves money? I suspect they want their salt and large soft drinks too. NeverTheLess,my job is to do my job well and hope it makes an impact somehow.

Michael P Dailey MS MD FACP Physician, Infectious Disease, Hospital/ Infusion Center

In order to improve medical care you need a better product at less cost. You need a community center of excellence near most hospitals that can do IV therapy 7 days a week and be available by cell phone to other critical MDs. This most likely has to be ID doctors but they are trained these days with shrinking vision and clinical competence in a "broad spectrum" way. The training programs must integrate infusion pracice in OP areas. There are a few barriers from insurers but most can be overcome with persistence. Personal Income is not a barrier. Unfortunately only real doctors should apply.

danny lancaster Physician, Infectious Disease, retired

Another fad supported by activists/enthusiasts with no data to justify utility but widely embraced. Yes it might simply mean...then again it might not.

nomi crnp Other, Geriatrics, ccrc

cannot believe the outcomes.
i was doing home care with the county and was able to cut ER visits hospitalization.

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