The Patient-Centered Medical Home

So far, the research evidence suggests that the patient-centered medical home, available in a number of iterations, is not meeting expectations proponents set for  cost-savings and/or quality improvement.  A new study published at the National Bureau of Economic Research attempts to disentangle various attributes of medical homes and determine if various subsets of medical homes have more or less success.   (NBER Paper)   The certifying bodies for medical homes have laid out a number of criteria and alternatives to be considered an “official” medical home model.  If research doesn’t account for this variation in characteristics, the results may mask better or worse performance by certain types of medical homes.  The researchers examined a medical home model used by an insurer in Pennsylvania which covered about 152,000 patients in 104 medical home certified practices.  The insurer paid the practices an extra few dollars pmpm, presumably because it believed that medical home certified practices would reduce overall costs.  The authors identified around 127 implementation factors which might vary across medical homes.  They grouped practices across three models: a basic one; one that focused on enhanced population health management and one that focused on enhanced access, decision support and data reporting.

The primary analysis was to compare patient utilization, cost and quality outcomes before and after a practice became a medical home, and to look at both all patients treated by the practice and just those that had a chronic illness.  Overall, the study finds little effect of medical home certification.  In the population health and “analytics” cluster, there was limited evidence for some lowered cost.  This indicates there is value in trying to analyze specific aspects of being a medical home to identify effects on outcomes.  My reading of the results indicates that in some cases, however, the more intensive clusters actually had increased costs and utilization.  There is almost an element of randomness even in the analyses that appeared to reach statistical significance.  That suggests that factors other than being a medical home may dominate variable performance across practices.  This could be unobserved patient or practice characteristics or, again, just randomness even in apparent significance of findings.

It may be that becoming a medical home practice doesn’t show as much difference in patient cost and quality outcomes, in this study and in other prior research, for two reasons.  One is that some practices that get certified were already operating like a medical home; they didn’t actually change much, just got certified.  For these practices you wouldn’t expect to see much improvement after the certification.  The other reason is that there are likely practices that don’t bother to go through the hassle and expense of becoming certified and changing operations, but deliver efficient, high quality care.  If you compare medical home practices to this group, you aren’t going to see much of a difference.  My current conclusion is that practices and payers are spending a lot of money and time on medical homes with very little evidence that they are changing outcomes.