Medical Homes: It’s not “Do they work?” but “How do they work?”

Earlier this year, The Journal of the American Medical Association (JAMA) published a widely publicized but limited article on medical homes in Pennsylvania that found little improvements in quality and no improvements in costs or utilization associated with medical homes. The authors concluded medical homes may generally “need further refinement” — a phrase that was taken by many in the press to mean that medical homes “don’t work.”

Subsequently, there has been much debate and little clarity around the promise of medical homes. The discussion has not been helped by the multiple definitions given to a patient-centered medical home (PCMH) — National Committee for Quality Assurance (NCQA) accreditation criteria notwithstanding (see page 27).

Despite the confusion, we know that many of our customers are pursuing medical homes and our own work indicates there is value in the idea.

Here are some key sources to help you sort out your own perspective on this topic:

1. The Patient-Centered Medical Home’s Impact on Cost & Quality: An Annual Update of the Evidence, 2012-2013

This is a meta-analysis by the Patient-Centered Primary Care Collaborative that sheds light on overall PCMH effectiveness (e.g., decreases in costs of care, reductions in avoidable services, improvements in dx specific lab values, and improvements in access and patient satisfaction) – a different perspective than that of the JAMA article.

2. Assessment and Measurement of Patient-Centered Medical Home Implementation: The BCBSM Experience

Another recent set of studies from Michigan by Alexander, et al, is useful in its attempt to step around NCQA and understand what are the key components of a medical home, how might they be measured (see Appendix 1), and what is their impact, even when partially implemented.

This Annals of Family Medicine article may be especially useful if you are working to define a medical home and do not want to burden providers with the fees and other costs associated with NCQA certification. The NCQA set of medical home measures has been criticized for its low relationship to quality and its insufficient discriminatory power to reliably identify “medical homes” that will consistently stand apart from other primary care practices not so designated.

3. The NCQA 2014 PCMH Standards

The recently released NCQA 2014 standards attempt to address some of these criticisms, but there are still opportunities for improvement, especially in the area of specifying what kinds of outcomes we might expect from medical homes. For example, the new criteria assess whether “practices make efforts to improve in patient experience, cost and clinical quality,” but there are no objective indicators of what might represent successful improvement. These kinds of objective indicators are the everyday work of 3M Treo Solutions.

I should also note a positive development in the new PCMH NCQA criteria, one that I agree with wholeheartedly:

“Focus care management on high-need populations. PCMH 4, Element A: Identify Patients for Care Management: Practices establish a systematic process and criteria to monitor the total percentage of the population identified for care management. This requires considering behavioral health needs, patients experiencing high cost/high utilization, poorly controlled or complex conditions, social determinants of health…”

This objective is solidly in the 3M Treo wheelhouse. Our basic patient segmentation tools – 3M Clinical Risk Groups — and predictive analytics can help any PCMH interested in pursuing this objective, and will give the PCMH the actionable information necessary to make a real difference with their targeted care management.

Bottom line: medical homes are just getting started and, with refined focus and supports, can be an important part of an improved health care system.

Herb Fillmore is Senior Director, Market Development for Populations and Payment Solutions at 3M Health Information Systems.@HFillmoreIII

One response to “Medical Homes: It’s not “Do they work?” but “How do they work?”

  1. Also, note two days after this blog post, CareFirst announced a third successful year of their medical home demo with more than 267 $million in savings.

    http://www.modernhealthcare.com/article/20140710/NEWS/307109936

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