Medical Homes and Medicaid

We haven’t addressed medical homes in a while, probably because the initial hype has largely passed and because ACOs have picked up much of the fervor.  A multitude of pilots and initiatives using medical homes have been implemented both in private health insurance and in Medicaid programs.  A study published in Health Affairs evaluates one such initiative:  Louisiana’s promotion of medical homes.    (HA Article)   The patient-centered medical home is a model of intensive primary care with a large number of “standards” which a practice needs to meet to become recognized as a medical home.  Supposedly the enhanced care coordination and attention to evidence-based medicine would both reduce costs and improve quality outcomes.  Most evaluations to date have shown very limited, if any, progress on these goals.  For state Medicaid programs, particularly those expanding eligibility under the reform law, finding some way to control spending is going to be crucial.  The researchers used data from 2007 to 2010 from NCQA-certified medical home clinics in the New Orleans area and compared that data to information from similar clinics that weren’t medical homes.  The researchers attempted to match medical homes and control clinics on various demographic and other factors.  Surprisingly, primary care use was actually lower in the medical home clinics, which is counter-intuitive to the idea that in a medical home more primary care attention will occur.  Emergency room use was also higher in the medical home clinic population, which again is contrary to what is supposed to happen.  And ambulatory care-sensitive inpatient use was higher in the medical home group.  Overall significant cost savings were not achieved, although in the later years it appears that the medical homes may have lower total costs per patient.  Oh geez, another well-intentioned initiative just doesn’t seem to live up to the hype.  Nonetheless, we suspect that models that are really capable of intensive focus on a patient’s medical needs will lower overall health spending at some point, and maybe will even save more than it costs to operate that intensive focus model.