by Amanda A. Honeycutt, PhD
As a parent of two young children with a chronic illness, I know first-hand the importance of having a medical home that provides access to primary care doctors who coordinate testing and care across specialists, treatment facilities, pharmacies, and labs. Fortunately, our pediatrician has taken on the role of care coordinator, ensuring that my children receive the testing and treatment they need when they need it while avoiding gaps in treatment and unnecessary/duplicative testing. This type of family- and patient-centered medical home model has been recommended for the care of children with special health care needs for over 45 years (1). Thanks in no small part to its effective use, my children’s disease is being adequately managed. They are able to do ballet, play basketball and violin, and attend and fully participate in school—in other words, just be normal kids.
A similar type of patient-centered medical home (PCMH) model is now being held up as a way to improve all patients’ experiences and outcomes and reduce healthcare spending. PCMH models vary in their implementation, but generally encompass “wide-ranging team-based care, patient-centered orientation toward the whole person, care that is coordinated across all elements of the health care system and the patient’s community, enhanced access to care that uses alternative methods of communication, and a systems-based approach to quality and safety” (2; p. 2). These PCMH models build on coordinated care approaches that have worked for people with chronic conditions, such as diabetes and asthma (3, 4, 5).
A 2012 Agency for Healthcare Research and Quality (AHRQ) report identified evidence that PCMH models can improve patient experiences and the process of care for preventive services, but found insufficient evidence of an impact on clinical and economic outcomes (2). The report also noted the need to understand the effect of the PCMH model in “more broadly representative primary care samples” (2; p. 15). In a recent Medical Care article (6), researchers Meredith Rosenthal, Anna Sinaiko, and collaborators address this need through their evaluation of the Rochester Medical Home Initiative (RMHI).
RMHI was a pilot program in which 7 primary care practices in Rochester, NY, implemented a patient-centered medical home (PCMH) model beginning in 2009. The RMHI model involved implementing a coordinated clinical care approach and changing reimbursement to compensate for time spent on PCMH activities. The Rosenthal et al. (2015) analysis included patients 18 years and older who had insurance through a commercial plan or through Medicare or Medicaid HMO plans. Although many prior analyses have focused on outcomes only among Medicare or Medicaid beneficiaries or people with chronic conditions (see Damika Barr’s February 2015 blog post for examples), Rosenthal and team analyzed the impacts of PCMH for all adult patients in a primary care practice, which is important for understanding the average impact of PCMH if implemented for a broad mix of patients.
The researchers found a statistically significant, but modest, increase in breast cancer screening and LDL testing among patients with diabetes (3% to 4% higher rates than in the pre-RMHI period). They also found a significant, but very small, impact on reducing avoidable hospitalizations and no significant impact on total spending. These findings are suggestive that the PCMH model may improve health care delivery without increasing spending, but it also raises an important question of whether PCMH approaches are worthwhile for healthy adults. Should the intensive PCMH approach be used only for patients with chronic illness, where it has been shown to have desirable impacts? Rosenthal and team did not provide results for subgroups with chronic conditions or Medicaid/Medicare insurance. Yet, their finding of a limited positive effect of PCMH across all patients suggests that while PCMH approaches may significantly improve outcomes for patients with chronic conditions, they may have little impact and even raise spending for healthier patients. And because it is costly for practices to adopt a PCMH model (7), we need to ask whether the PCMH framework should be extended to all patients. For which patients is the PCMH model cost effective and how can a PCMH approach be most efficiently applied?
The ultimate goal of the PCMH approach is to improve and extend patients’ lives through providing better quality health care. Recent and ongoing research on PCMH implementation and impacts, such as the Rosenthal et al. study, are contributing to a better understanding of the broad impact of PCMH approaches. But we still have a lot to learn about which components of the PCMH model are most important for success, which patients stand to benefit the most, and under what circumstances a PCMH approach is cost effective.
Amanda A. Honeycutt, PhD, Director of the Public Health Economics Program at RTI International
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6. Rosenthal, MB, AD Sinaiko, D Eastman, B Chapman, and G Partridge. Impact of the Rochester Medical Home Initiative on Primary Care Practices, Quality, Utilization, and Costs. Medical Care. 2015. 53(11): 967-973 (http://journals.lww.com/lww-medicalcare/Abstract/2015/11000/Impact_of_the_Rochester_Medical_Home_Initiative_on.9.aspx).
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