Better Primary Care and Health Spending

Primary care providers have been invested with the power to control the quality and cost of all health care in new models, including the medical home.  A number of programs have attempted to encourage or mandate use of this model.  The research results in regard to costs, and sometimes in regard to quality, have been disappointing.  The latest piece of research comes from Canada and is reported in the Journal of Health Economics.   (JHE Article)   The province of Quebec established Family Medicine Groups, which were paid some extra funding in return for functioning in a manner similar to US medical homes.  Beginning in 2009 providers could organize themselves as one of these groups and patients could register to be cared by them.  By 2014 there were 258 FMGs, accounting for 60% of general practitioners and 41% of patients.  Payment to the doctors remained largely fee-for-service, except for the additional payments to fund the cost of being an FMG, and patients were not “locked” to the FMG.  So a fairly weak system, but most patients for the groups participating did largely use the FMG physicians for primary care.

Relative utilization and costs were compared for patients registered in the FMG groups with patients outside that model.  The usual patient demographic and health status adjustments were made to try to control for various potential confounders.  57% of the FMG patients were women, they tended to be older and they tended to not come from the highest income quintile.  The two groups of patients had basically similar rates of chronic conditions.  The FMG physicians were more likely to be female and younger.  Over the study period, 2010 to 2014, outpatient visits decreased in the FMG patients compared to the control group, while hospitalizations and ER use was the same.  Both primary care and specialty visits decreased, by around 11% and 6% respectively.  Total costs declined by a statistically insignificant less than 1% per patient per year and were basically identical after considering the costs of the model.  The intensity of services was similar.  There may have been more use of nurses, and the decline in primary care utilization was largely for less complex visits.

The researchers did not look extensively at health outcomes or status changes.  That to me is very important, because even if a different primary care model costs the same or even slightly more, if its outcomes for patients are better, that is worth a lot.  And the complete lack of financial incentives for either doctors or patients to change behaviors makes the model largely voluntary and much less likely to be effective.