Reinvigoration of primary care has been one health public policy goal for the last decade. The medical home concept is one way of advancing this goal. Many low-income patients receive care in federally qualified health centers and CMS ran a demonstration from 2011 to 2014 to facilitate adoption of a medical concept in some of these centers. Researchers have now evaluated certain results from this demonstration. (NEJM Article) About 500 centers participated in the demonstration and received financial and other support to become a certified medical home. The researchers compared these centers with 827 sites that did not participate in the demonstration. Treatment for Medicare patients at the medical home and comparison sites was the primary outcome, and the authors analyzed a number of utilization and quality measures. Some patients were also surveyed and leaders at a small number of the centers were interviewed. In 2011, at the start of the study, no sites had achieved level 3 medical home certification. By the end of the demonstration in 2014, 70% of the demonstration centers and 11% of the comparison sites had received such certification.
Patients at all sites had reduced rates of visits, but the decrease was slower at the medical home sites. This meant a relative improvement in eye exams and neuropathy tests for diabetic patients at these sites. Surprisingly, however, some expensive forms of utilization increased more in demonstration centers. For example use of the ER rose at a rate of 30 visits per 1000 beneficiaries per year at the medical home centers compared to the control group, and inpatient admissions rose by a relative 5.7 per 1000 patients per year. Part B expenses increased more in demonstration sites than in control ones as well. There was little difference in patient-reported outcomes. Leaders of the medical home sites said the additional funding was insufficient for the costs and effort associated with being a medical home. So one interpretation is that you can spend a lot of money and time trying to be a medical home and you get really limited at best improvements in quality and you appear to have more health care utilization and spending. That might be the case, and other medical home research supports that interpretation, but in fairness, I think these efforts to improve primary care take a much longer evaluation period. The impact from improving the health care of a patient could take many years to show up in reduced spending and better long-term health outcomes. And I think we should be most concerned about the quality impact; if we don’t see improved outcomes within 5 to 10 years than the effort is worthless regardless of whether it decreases costs.