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

February 25, 2014

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

  1. Thomas L. Schwenk, MD

Intense case management directed at the most complicated patients might be a better approach.

  1. Thomas L. Schwenk, MD

The team-based, comprehensive case management approach to primary care, called the patient-centered medical home (PCMH), has been advocated as the foundation for achieving improved access and quality of care at lower cost. Researchers used a network of primary care practices in southeastern Pennsylvania (supported by six payers) to assess its value in a community-based setting.

Thirty-two primary care practices (with about 64,000 patients) that volunteered to adopt a wide range of PCMH features — performance feedback, disease-management registries and protocols, reminder systems for delivering preventive services, and electronic health records — were compared with 29 control practices (with about 56,000 patients). Intervention practices achieved “medical home-ness” by the end of the 3-year study, as measured by standardized national criteria; control practices could not be assessed adequately for achieving “medical home-ness” due to a low response rate. Physicians in intervention practices earned a mean US$92,000 in performance bonuses during the 3 years.

Changes in quality-of-care and utilization measures (based on payer claims data) from baseline to the end of the study were evaluated: No difference was found between intervention and control practices 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 than in control practices.

Comment

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

Dr. Schwenk wrote the editorial that accompanied this original article in JAMA (JAMA 2014 Feb 26; 311:802).

  • Disclosures for Thomas L. Schwenk, MD at time of publication Editorial boards UpToDate

Citation(s):

Reader Comments (3)

DAVID SMITH Other, Unspecified

An interesting report. I'm age 70, retired from the airline industry and have never worked in the medical field. I read Journal Watch because I'm interested in healthcare trends. Glad to see new ideas being tested even if some of them don't immediately result in statistical improvement, like this one. Keep trying anyway. It's the only way to make meaningful progress.

George Taler, MD Physician, Geriatrics, MedStar Washington Hospital Center
Competing Interests: I am a participant in the Independence at Home Demonstration, that is actually testing Dr. Sshwenk's hypothesis.

Interested in PCMH as a policy effort to enhance payment for primary care. To that extent, the study was a success. Even proponents doubt the impact on "quality metrix" given that the numbers of ambulatory sensitive condition admissions and ED visits would likely be small in most primary care practices, even with these large numbers.

ROGER HATHARASINGHE Physician, Internal Medicine

Maybe a good thing we did not start his yet.

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