Do Patient-centered Medical Homes Really Improve Primary Care Quality?

Robert A. Baldor, MD

and Frank J. Domino, MD

Review

Friedberg MW, Schneider EC, Rosenthal MB; Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014 Feb 26;311(8):815-25. http://jama.jamanetwork.com/article.aspx?articleid=1832540.

Study Methods

This was a comparative study to determine the influence of a patient-centered medical home pilot relative to a similar set of primary care practices without the intervention.

The 3-year medical home intervention targeted asthma management for pediatric care practices and diabetes management for adult care practices. To create monthly quality indicator reports on those conditions, the intervention used a system that relied on the Web-based Improving Performance in Practice (IPIP) disease registries. It also received assistance from IPIP practice coaches to facilitate practice transformation and achievement of National Committee for Quality Assurances (NCQA) Physician Practice Connections—Patient-Centered Medical Home (PPC-PCMH) recognition, as level 1 recognition was required by the second pilot year.

Thirty-two volunteering primary care practices participated in the Southeastern Pennsylvania Chronic Care Initiative from June 2008 to May 2011. Claims data from 4 participating health plans were used to compare changes in the quality, utilization, and costs of care delivered to 64,243 patients in those medical home pilot practices and 55,959 patients in the 29 comparison practices.

Results and Outcomes

The medical home pilot practices successfully achieved NCQA PPC-PCMH recognition and adopted new structural capabilities, such as disease registries, by the third year. However, the intervention practices only showed significantly greater performance improvement relative to the comparison practices in one of the 11 quality measures. Additionally, the medical home intervention was not associated with statistically significant changes in total costs of care or utilization of hospitals, emergency departments (EDs), and ambulatory care facilities.

Conclusion

This medical home pilot, where participating practices adopted new structural capabilities and received NCQA certification, was associated with improvement in only the measurement of microalbuminuria out of 11 quality areas, and it was not associated with reductions in hospital, ED, or ambulatory care utilization or costs of care over 3 years.

Commentary

Strictly defined, the PCMH is a philosophy of providing care that is “patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.” This team-based approach uses healthcare providers’ office staff to manage patient needs through the development of patient panels, disease registries, patient outreach, care coordination, and integrated behavioral health and social services.

This study presented initial practice data from one of the earliest multipayer PCMH pilots and then compared it to similar data from control practices, focusing on the following quality markers:

• Measurement of glycated hemoglobin (HbA1c)
• Evaluation of abnormal HbA1c
• Measurement of low-density lipoprotein cholesterol (LDL-C)
• Evaluation of abnormal LDL-C
• Measurement of diabetic nephropathy via microalbuminuria evaluation
• Diabetic eye examination
• Pediatric asthma medication use
• Breast cancer screening
• Cervical cancer screening
• Chlamydia screening
• Colorectal cancer screening

However, pilot participation improved only one of those 11 quality markers: the measurement of microalbuminuria. While determining microalbuminuria can lead to medication use that would slow the progression of renal disease in diabetic patients, it does not prevent renal insufficiency or the condition’s many complications.

This is a preliminary finding of short-term data. With the exception of appropriate use of inhaled steroids in pediatric patients with severe asthma, all of these interventions addressed intermediate outcomes. Treating a diabetic’s LDL-C or prescribing an angiotensin-converting enzyme (ACE) inhibitor for patients with diabetic microalbuminuria can take years to show an impact, if ever, and their success at preventing adverse outcomes is very dependent upon a patient’s lifestyle.

At least 3 more studies on the PCMH pilot are due to publish over the next 5 years. Although they will also be somewhat preliminary, they will offer insights into how physicians can refine the PCMH interventions to actually help patients live better and longer. In the meantime, this study serves as an initial step towards determining which aspects of the PCMH model need to be emphasized to improve patient outcomes.

The changes suggested by this paper include:

• Considering patients by multiple parameters, rather than just disease. The obese diabetic who will not alter his or her diet or exercise is very different from one who exercises and follows a nutrition plan.
• Acquiring appropriate data and following realistic outcomes. PCMH designation focuses primarily on patient registries and return visits. However, reported data is a weak measure of patient health and may differ from reality. For example, many practices under the close scrutiny of PCMH auditors will repeat blood pressures and round down. Thus, combining weak data with intermediate outcomes is unlikely to impact patient outcomes.
• Further implementing behavioral medicine and ancillary services like dietary and lifestyle counseling. This is starting to happen, and would be far more likely to improve long-term outcomes than current PCHM measures.

It is important to note incentive payments in this PCMH model were based on testing and treating intermediate measures. This should remind all family physicians that most intermediate measures are crude surrogates for healthier lives. Therefore, real patient outcomes, rather than appropriate timelines, should be the focus of future studies.

Additionally, this study was conducted in one locale with a privately insured patient population, yet most healthcare dollars are spent on high-utilizing outliers, including patients with multiple co-morbidities, those in their last 6 months of life, and individuals without access to care or medication. Addressing these outliers’ insurance and access needs is beginning to occur with the Affordable Care Act. But if the goal is to improve an entire population’s health and decrease healthcare costs, then focusing energy on the outlier subsets is more likely to improve outcomes, compared to tracking a few parameters in the insured.

The mission of the PCMH is to deliver high-quality, patient-centered, evidence-based care within a practice setting where those at greatest risk are identified and treated, and lifestyle and mental health issues are prioritized. This study is a great first step toward that goal.

About the Authors

Robert A. Baldor, MD, is Vice Chairman and Predoctoral Director for the Department of Family Medicine and Community Health at the University of Massachusetts Medical School (UMMS) and Director of Community-Based Education at the UMMS Office of Medical Education.

He was assisted in writing this article by Frank J. Domino, MD, Professor and Pre-Doctoral Education Director for the Department of Family Medicine and Community Health at UMMS and Editor-in-Chief of the 5-Minute Clinical Consult series (Lippincott Williams & Wilkins).