Health Policy$ense

Patient-Centered Medical Homes: The Next Generation

An Idea That Seems Too Good Not To Work But Actual Evidence is Disappointing

The ugly truth is that health care is often inefficient, costly, and does not meet the needs of its principal constituent -- the patient. This realization has led many physicians and health systems to enthusiastically turn to a new model for delivering primary care, the patient-centered medical home. The patient-centered medical home is a simple idea. It reorganizes care around the needs of the patient, emphasizing coordinated, accessible, and efficient care. In short, it reimagines the health care delivery system in the best image of itself.

Rachel Werner
Rachel Werner writes that despite recent disappointing evidence about the success of the patient-centered medical home concept, it should not be viewed as a failure.

Becoming a medical home has been a rather straightforward (though at times costly) process for most primary care practices. According to the NCQA, the organization that certifies most medical homes in this country, practices must invest in infrastructure to support this new delivery model -- by using patient registries to easily identify patients who might benefit from coordinated care, increasing doctors’ accessibility for their patients through extended hours, same-day appointments, or secure messaging, and making other changes to the structure of delivery to support the goals of the medical home. Physician practices often make these changes in exchange for increased payments, which may also be tied to metrics to ensure that high-quality care is delivered.

Disappointing evidence
The idea seems too good to not work. Yet the evidence to date is disappointing. Studies often find that when practices adopt the patient-centered medical home there is little change in the quality or costs of care. Another such study was published last week in JAMA, a study that I helped conduct. The study found that a large medical home demonstration project in Pennsylvania had little-to-no effect on quality, costs, or health care utilization. While virtually all of the participating practices made the requisite structural changes to become certified as a medical home, over the following three years quality improved on only one of eleven measure of care (screening for kidney disease among patients with diabetes) and there was no change in health care utilization or costs of care. This study is important because it evaluates the largest and longest multipayer medical home demonstration to date, and it confirms what many smaller studies have found.

Participants in this pilot who I have heard from are disappointed and discouraged by these findings. Through numerous in-depth interviews with participants in this demonstration we know that practices devoted significant time and resources to this effort to ensure a successful transformation to a medical home. We have also heard anecdotal reports of improvements from those involved. After all of that, to find out that it didn’t seem to change patient care can be both surprising and frustrating.

However, my experience in evaluating this medical home demonstration and several others has taught me several lessons that might be useful in implementing the next generation of medical home transformation efforts.

Complete culture change
First, it has become increasingly obvious that transforming a primary care practice into a medical home takes more than simply adopting structural capabilities such as electronic health records and patient registries. True transformation requires a complete culture change where the emphasis is on managing patient health across the continuum of care, both inside and outside of the health care system. Successful medical homes must consist of team members who work as a well-coordinated team, with individuals taking on new roles and responsibilities that at times feel uncomfortable in their newness and out of the bounds of what a person was trained to do. The typical primary care practice may be ill-equipped to make this transformation to team culture and current medical home certification programs do not provide guidance in this regard.

Payment system reform
Second, the payment system underlying the medical home should be reformed to support the goals of the medical home. Medical homes are often adopted in the setting of a more traditional fee-for-service payment system. While some demonstrations (including the Pennsylvania demonstration recently evaluated in JAMA) provide financial incentives for adopting medical home structural capabilities (usually in the form of a per-member-per-month add-on), the underlying payment systems continues to reimburse physicians in a more traditional way—based on the office visit. Meanwhile, patients’ health (and health care use) is largely determined by what happens outside of doctor’s office. For the medical home to be truly transformational, its incentives must be directed toward managing population health, not patient health. This includes providing incentives to move care from the face-to-face office visit to managing health between office visits and providing direct incentives to reduce unnecessary utilization of care.

Appropriate patient targeting
Third, the medical home must target those patients it will benefit most. For someone like me, a well-educated, healthy, and savvy health care consumer, the medical home will be of little benefit. While it might be nice to have a medical home, having one is unlikely to change my health or my health care utilization. On the other hand, a well-executed medical home could have tremendous success among chronically ill patients with few resources and high health care expenditures -- but only by targeting efforts at the patients with the highest utilization. Indeed, the success of the medical home may depend on its ability to serve as a medical home for those who need it most, rather than for everybody.

Despite recent disappointing evidence about the success of the medical home, it should not be viewed as a failure. Rather, it is a work in progress and an important first step in reforming a dysfunctional health care system that has been decades in the making. The most important lesson for us is that change is not easy. However that does not mean it is not worth pursuing.