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Medical home pilot fails to reduce cost, utilization.


In a 3-year pilot study, small- and medium-sized primary care practices that had created patient-centered medical homes were not successful in reducing costs or curbing hospital and emergency department visits.

The 32 Pennsylvania practices also had a limited effect on quality of care, improving nephropathy monitoring in diabetes patients, but showing no significant improvement on 10 other quality metrics.

The results come from the south eastern region of the Pennsylvania Chronic Care Initiative, a multipayer pilot study that provided technical assistance and financial incentives to internal medicine, family medicine, and pediatric practices, as well as some nurse-managed health centers that were seeking patient-centered medical home (PCMH) recognition from the National Committee for Quality Assurance (NCQA).

The findings were published in JAMA (JAMA 2014;311:815-25).

Dr. Mark W Friedberg, of the RAND Corporation in Boston, and his colleagues compared the performance of the 32 pilot practices to that of 29 similar practices in Pennsylvania. Each of the pilot sites achieved NCQA recognition as a PCMH by the third year of the study, with half achieving level 3 status. They earned performance bonuses averaging $92,000 per physician and were successful in making structural changes to their practices, including using patient registries and electronic prescribing.

But the pilot practices fell short in significantly improving quality, cost, and utilization compared with the practices that did not receive technical assistance and bonuses.

One reason that the pilot sites did not see improvements is that the bonus payments, which were tied to achieving NCQA recognition, might have distracted the practices from other activities that could have improved the quality and efficiency of care, Dr. Friedberg and his colleagues wrote. The pilot sites also had no direct incentives to contain costs, and they didn't get any information on how their patients were utilizing care.

"Possibly as a consequence of these features of pilot design, we found that few pilot practices increased their night and v/eekend access capabilities, which could, in theory, have produced short-term savings by offering patients an alternative to more expensive sites of care (such as hospital emergency departments)," they added. On the quality side, the researchers suggested that the pilot practices, which were all volunteers, may have been performing at a high level at the start, creating a "ceiling effect" that made it hard to achieve significant improvements over the 3year study period.

But the real problem, according to the NCQA, is that the pilot practices were using outdated standards.

The pilot ran from June 1, 2008, to May 31, 2011, and used the NCQA's initial recognition standards for the patient-centered medical home, which were released in 2008. The NCQA said those standards were updated in 2011 and will be updated once again in March.

"In effect, we have already--twice-done the 'further refinement' the study recommends. Our standards will also continue to evolve," NCQA officials said in a statement. The officials pointed out that other studies have demonstrated cost and quality improvements from using the organization's medical home standards.

"The preponderance of evidence supporting medical homes is why most states and many private and commercial insurers support PCMHs with financial or technical support," according to the statement.

The American Academy of Family Physicians also cautioned physicians and policy makers not to put too much stock in the study results, saying that they do not reflect improvements that have been made to the medical home model since 2008, including the emphasis on after-hours care that could keep more patients out of the emergency department.

Additionally, the Pennsylvania practices participating in the pilot project were functioning in the traditional fee-for-service payment model, despite the availability of bonus payments, rather than using alternative payment models that don't emphasize the volume of care, said Dr. Reid Blackwelder, AAFP president.

"Every study that's done is useful. It's another piece of the puzzle," Dr. Blackwelder said.

"I think we have a lot of other evidence that shows we are definitely on the right track," according to Dr. Blackwelder.



Major finding: Primary care practices in the medical home pilot performed significantly better on only 1 of 11 measures.

Data source: Researchers analyzed claims data, survey responses, and performance on NCQA recognition by the 32 primary care practices in the medical home pilot. They compared their performance to that of 29 practices not in the study.

Disclosures: The study was sponsored by the Commonwealth Fund and Aetna. They had no role in the design or conduct of the study. The investigators reported no relevant conflicts of interest.


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Author:Schneider, Mary Ellen
Publication:Family Practice News
Geographic Code:1U2PA
Date:Mar 1, 2014
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