Published 9/4/12 in Medical Home News
Never confuse motion with action.
A reporter called the other day to tell me that several local health systems now had medical homes. “I don’t think so,” I said. She was emphatic. “They just told me they do.” I asked whether their medical homes take fee-for-service reimbursement. “I guess so,” she said. “Doesn’t everyone?” “Almost everyone,” I said. “But if they do, that means they have a financial stake in delivering unnecessary care.” By definition, that’s counter to the idea of a medical home, which provides the right care at the right time in the right context. You can’t have it both ways.
Virtually every organization remotely related to primary care now wraps itself in the mantle of patient-centered medical homes (PCMH), and many flaunt their Recognition by the National Committee for Quality Assurance (NCQA) as proof that they’ve met a standard. Presumably employers and other purchasers, enthused by the buzz surrounding medical homes, assume these credentials translate organically to better care at lower cost.
But is it safe to assume that medical homes deliver measurably better results? How are they different? What does it mean to be a medical home?
At this point, these questions are unresolved, and there are embarrassing problems. First, there’s scant proof so far that medical homes, at least as they are currently configured, perform better than conventional primary care practices. Or, in the dispassionate language of an exhaustive July 2012 Agency for Healthcare Research and Quality (AHRQ) review of PCMH performance:
The PCMH holds promise for improving the experiences of patients and staff, and potentially for improving care processes. However, current evidence is insufficient to determine effects on clinical and most economic outcomes.
In other words, in theory, maybe they’ll deliver in the future. But so far there’s little evidence that medical homes actually save more money than they cost.
The Patient-Centered Primary Care Collaborative defines medical homes in terms of broadened access to comprehensive primary care and care coordination, and they provide a range of concrete examples of improved care. Medical homes should be deploying systems and programs that more fully empower primary care to help manage and advocate for individual patients and populations everywhere in the system, positively influencing health and cost. So far, few do.
Formally, in the systems theory of the medical home movement, proper PCMHs should have seven major components: team-based care, sustained partnership, reorganized care or structural changes to care, enhanced access, coordinated care, comprehensive care, and a systems-based approach to quality. Each term describes a serious and important approach, but each is also open to broad, wildly divergent interpretations. And that is how it has played out. The AHRQ report also concluded that:
Published studies of PCMH interventions often have similar broad elements, but precise components of care varied widely.
This is academic-speak for “Everybody does it differently.” That is, no operational standardization based on evidence.
Similar findings came from a March Health Affairs study of performance metrics associated with NCQA Levels I-3 medical home scoring in Federally Qualified Health Clinics (FQHCs). NCQA level 1 clinics produced clinical scores that were no different than those with level 2 or 3 designations. In other words, either the scoring was not sensitive to performance differences between the two models, or different medical home levels do not produce significant differences in clinical outcomes. (In fairness, NCQA responded that these measures were not intended to be used in a self-evaluation process, so they took issue with the findings.) Other studies have shown similar results.
All of this prompted commentator Jaan Sidorov MD to politely but pointedly address the elephant in the room. “[Why do my friends, particularly] in policy circles and academia, continue to give the PCMH a pass?”
Maybe we all hope for silver bullets. But straightforward questions seem appropriate here: Why don’t medical homes deliver better results? What other activities, skills or tools should medical homes incorporate to facilitate more consistent, high quality care at the lowest possible cost throughout the continuum?
The fact that most medical homes currently fail to get hoped-for results doesn’t mean they can’t. But getting beyond current performance first requires acknowledging that changes in the larger system are necessary. So are tools and programs that can help patients and clinicians maintain or improve health, avoid unnecessary care, ensure the appropriateness of necessary care (see the New America Foundation’s AvoidableCare site), and acquire high value health care products and services more cost effectively.
Some expectations have been overblown. The savings available from (conventional) chronic disease management – generally considered a major cost impact area of good primary care – may not be as strong as has often been represented, a point Al Lewis recently drove home in his wonderfully entertaining and enlightening book, Why Nobody Believes the Numbers. It’s worth noting that exceptional programs have obtained powerful results.
Nor will much change until medical homes are outfitted with better health information technologies. By themselves, electronic health records are merely bookkeeping systems, and it’s unlikely that they do much to improve care at the individual patient level. But accessing morerobust patient information, and bolting on clinical analytics and decision support helps clinicians more easily identify patients with chronic or acute risks. These tools let them spot gaps in care, medication dynamics, and care received outside the medical home. Clinicians also need to see aggregated statistics on their patients’ clinical outcomes, so they can see how their care compares to regional and national benchmarks.
But there’s a larger point. More fully realized medical homes must find ways to advocate for patients in the care and cost beyond primary care. This may mean re-establishing the primary-specialty care communications links that have been weakened or severed over time, to make specialty care accountable to primary care physicians again.
It can mean referring to high value specialists and services, and steering away from those with poorer outcomes and higher costs. This would require accessing data to identify and steering to clinicians and services that consistently deliver the best quality care at the lowest cost. Using narrower networks of high performance providers not only rewards excellence, but sends a signal that substandard quality, or egregious pricing, won’t be tolerated.
By extending into these kinds of arrangements, primary care becomes a platform for full continuum medical management. In turn, this requires a broad perspective that demands an appreciation of benefits, claims data, analytics, medical management, supply chain dynamics, and health information technology. In short, it requires an interdisciplinary team.
A harsh truth is that business models that support true patient-centeredness, driving appropriate care, with capabilities that optimize accountable care management from a primary care base, typically require scale. Infrastructure investments are repaid by gaining economies associated with managing process rather than by driving up product/service volumes and making big margins on each one. This is a McDonalds rather than a Ruth’s Chris model, an approach alien to the health industry in recent years, and not easily achieved.More than ever, clinical excellence is likely to be favored and strengthened by operational scale. Size matters.
Medical homes are often at odds with the incentives still driving the rest of the system, and so they have not yet reached their potential. But until incentives compel mainstream organizations to invest in and apply the tools and skills that medical homes are capable of wielding, the industry is creating much ado about very little. In the process, many health care organizations and professionals are promising results to patients and purchasers that they know – or worse, sometimes don’t know – they can’t deliver.
A very few organizations have become true medical homes, assembling the mechanisms and skill sets, and stepping out of conventional reimbursement, with documented performance that allows them to succeed in the marketplace. The credentialing metrics here should be demonstrable quality improvements and cost savings over time, not simply a process checklist.
The credentialing process can become more relevant. Even so, health care is increasingly becoming a market. Ultimately performance, rather than purchased credentials, will likely matter. Which means that, pragmatically, fully realized medical homes will become mission-critical vehicles not only for better care at lower cost, but for operational excellence and organizational competitiveness.