Rand Study Finds Limited Improvement In Care In Medical Homes
The Medical Home concept was developed to reconstitute the structure and operation of the physician office, such that care outcomes, rather than care output could be the focus of a medical practice. With this alternative focus a medical practice would achieve better care, and lower utilization and costs. To date, the evidence to support that medical homes have actually accomplished this aim has been limited. The common complaint of medical homes is that despite the fact that they “re-structure” to become medical home accredited, they are underfunded to ultimately achieve their goals of improved care and decreased costs.
The RAND Corporation hypothesized that in a longer-term, more well-funded effort medical homes might be able to achieve their care and cost goals. Evaluators from RAND explored the effect of medical home efforts in the Pennsylvania Chronic Care Initiative (PACCI). The PACCI, lead by the Govenor’s Office of Health Care reform, designed a statewide effort in conjunction with a coalition of payers and clinicians. The PACCI initiated a pilot consisting of thirty-two volunteer primary care practices. Pilot practices received disease registries and technical assistance and could earn bonus payments for achieving patient-centered medical home recognition by the National Committee for Quality Assurance (NCQA).
The RAND analysis evaluated this pilot from June 1, 2008 to May 31, 2011. The structural capabilities of the pilot practices were evaluated and each practice successfully achieved NCQA recognition and adopted new structural capabilities such as registries to identify patients overdue for chronic disease services. In return, pilot practices received bonuses of (on average) $92, 000 per primary care physician (over the 3-year intervention).
In addition, claims data from 4 participating health plans, were evaluated to assess the quality, utilization, and costs of care delivered to 64,243 patients who were attributed to pilot practices (the evaluation used a control population of 55,959 patients attributed to 29 comparison practices of similar size, specialty, and location to the pilot practices). The claims evaluation reviewed 11 quality measures (for diabetes, asthma, and preventive care), utilization of hospital, emergency department and ambulatory care and cost of care. Pilot participation was associated with statistically significantly greater performance improvement in only one of the quality measures (nephropathy screening in diabetes), no improvement in utilization or cost of care could be identified.
The evaluation concluded that effecting structural changes sufficient to achieve medical home accreditation “was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement”.
The RAND group drew some specific conclusions as to what these refinements might be:
- Incentives for the practices focused on achieving accreditation. No incentives were actually provided for achieving better quality or reduced cost.
- The practices received no feedback throughout the year regarding quality or utilization trends
In summary, the practices were incentivized to and, in fact, focused exclusively on structural transformation. Little effort was focused on process transformation. The authors specifically cited a number of works which demonstrated little relationship between structural capabilities, NCQA recognition and performance with regard to quality and utilization.
This evaluation was published in: JAMA. 2014;311(8):815-825.
James Notaro, RPh, PhD