Research Author, AAFP Agree PCMH Model a Work in Progress

Three-year Medical Home Pilot Findings Fall Short of Expectations

March 12, 2014 05:00 pm Sheri Porter

Sometimes researchers exploring a high-profile topic publish study results that seemingly contradict previous study findings. Such was the case recently when a research team released results of a three-year study that examined a large multipayer patient-centered medical home (PCMH) pilot in Pennsylvania.

"One of the first, largest and longest-running multipayer medical home pilots in the United States, in which participating practices adopted new structural capabilities and received National Committee for Quality Assurance (NCQA) certification, 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 of care of over three years," concluded the authors. "These findings suggest that medical home interventions may need further refinement."

The study, titled "Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization and Costs of Care," was published in the Feb. 26 Journal of the American Medical Association(jama.jamanetwork.com) (JAMA) and was met with some concern from the AAFP, the Pennsylvania AFP, the Patient-Centered Primary Care Collaborative (PCPCC) and other PCMH stakeholders.

Story highlights
  • Research on the patient-centered medical home model of care was recently published in the Journal of the American Medical Association.
  • Researchers conducting the three-year, 32-practice pilot found limited improvements in quality of care and no reduction in use of services or total costs.
  • The AAFP and study authors agree that medical home interventions need to be refined if better results are to be expected in the future.

AAFP President Says PCMH Model Evolving

Indeed, in a Feb. 27 statement about the newly published research, AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn., said, "We strongly caution against assuming the results of this single study of a single PCMH pilot is the final word on the efficacy of the all-payer PCMH.

"The study must be viewed within the context of ongoing current research, including that by the Patient-Centered Primary Care Collaborative, which has published multiple results from across the nation and has found significant reductions in medical interventions and costs," Blackwelder added.

He noted that the latest research represented "another piece of the health care transformation puzzle." However, to improve on an evolving PCMH model, "We must first identify weaknesses and the underlying factors contributing to those limitations."

Blackwelder called the study "a step in that direction," but pointed out that the research was conducted between 2008 and 2011. "We are at a greatly different time now in terms of the maturity and function of PCMH practices," he said.

"We have more recent data from several other studies(www.pcpcc.org) that show significant improvement in patient outcomes and access, at lower cost, which are not referenced in the article or commentary," he added.

For instance, said Blackwelder, the JAMA researchers did not reference the recent PCPCC annual report(www.pcpcc.org), which analyzed 13 peer-reviewed studies and seven industry studies and found cost savings and use reductions in more than 60 percent of the evaluations.

Even so, Blackwelder agreed with the JAMA authors that future medical home interventions need to be refined to produce better results.

Gains Seen in Use of Electronic Resources

The pilot was conducted from June 1, 2008, to May 31, 2011; 32 primary care practices participated. Researchers used claims data from four participating health plans to compare changes each year in the quality, use and costs of care delivered to 64,243 patients in the pilot practices and 55,959 patients in 29 comparison practices selected to match the size, specialty and location of the PCMH practices. Pilot practices had access to disease registries and technical assistant and were given the opportunity to earn bonuses for achieving PCMH recognition by the NCQA.

All of the pilot practices successfully achieved NCQA PCMH recognition by the third year of the pilot; half of those practices achieved level three status. Primary care physicians in the pilot practices received bonuses averaging $92,000 per physician.

As for results, researchers found, among other things, that

  • use of registries to identify patients in need of chronic care services increased from 30 percent to 85 percent among the pilot practices and
  • use of electronic prescribing increased from 38 percent to 86 percent.

In addition, participation in the pilot was significantly associated with greater performance improvement on nephropathy monitoring in diabetes (one of the 11 quality measures evaluated).

Corresponding author and researcher Mark Friedberg, M.D., is a practicing internist at a primary care practice associated with Brigham and Women's Hospital in Boston. He told AAFP News that his research team cited rigorous literature reviews(pcmh.ahrq.gov) funded by the Agency for Healthcare Research and Quality and released in the past two years.

He noted that the AHRQ evidence reviews, as opposed to some other research in the field, paid particular attention to how various researchers defined the PCMH. "It's very hard to make even a general statement about the results of different studies unless you first define the medical home," said Friedberg. "Sometimes people think they're talking about the same thing when, in fact, they're using the term 'medical home' in a very general way."

Author Calls for Continuing Research

Friedberg talked more about the study and what continuing research means for the future of the PCMH model of care.

Q: How would you respond to the AAFP and other organizations that cautioned against reading too much into the results of this one study?

A: To be honest, I don't view that sentiment as a criticism of our study at all. No one should ever attach too much importance to any study. That's generally a good piece of advice, and I agree with it.

Q: Were you surprised that your study showed limited improvements in quality and no reduction in use of services or in total costs?

A: I suppose I was. This was a relatively well-run medical home pilot with good technical assistance and run by people who really wanted it to succeed. It had good payer buy-in. So what this tells us is that it is possible for a medical home pilot not to meet its expectations. We are still figuring out how to take the vision of the medical home and translate that into a transformation process for practices.

Q: What's the most important takeaway point for family physicians?

A: We need more experimentation, and there are lots of experiments already underway. All of these pilots are going to produce nice evaluations, and each one of them is going to be different.

No two medical home pilots are alike in all respects. For instance, there are different geographic locations, local cultures, practices, payers, payment ingredients and degrees of technical assistance. Those ingredients -- and all the variation -- provide a powerful learning opportunity.

Q: Where do we go next in terms of researching the PCMH model of care?

A: Just complete all the current pilots and evaluate them using rigorous methods that will allow us to compare them in a scientifically valid manner. I think in two or three years, we'll know what works. In the meantime, people don't have to wait. It's not like physicians have to sit on their hands and ignore the medical home effort between now and then. But it should be understood that right now, this is still experimentation, and I consider that to be a good thing.


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