More on the Failure of a Huge Medical Home Initiative to Reduce Health Care Costs

In this JAMA editorial, Thomas Schwenk agrees with the Disease Management/ Population Health Blog that the recent negative report on the medical home may have been the result of the lack of any risk stratification.

Recall that this negative report, Association Between Participation in a Multipayer Medical Home intervention and changes in Quality, Utilization and Costs of Care, compared three years’ worth of clinical and economic outcomes for 32 community-based medical home clinics vs. those from 29 similar non-medical home clinics.  Claims expense, ER visit frequency, hospitalization rates and 10 out of 11 HEDIS measures were no different between the two groups.

He points out that this study….

…. has done a great service for the advocates of the Patient Centered Medical Home by effectively ending promotion of this care model as a generic, low-level, unselective approach to health care delivery for all.  The next critical phase of PCMH development should focus on its strategic deployment for the care of high-utilization patients….”

The DMCB couldn’t have said it better.  The medical home should be “aimed” at patients who are most likely to benefit.

Upon further reflection, it would add two other comments:

1. Another under-recognized feature of successful population health systems is the central administration (and employment) of the non-physician care managers who are peripherally distributed throughout the primary care network.  Here’s one example as well as another that suggests the central model has a better track record.

In other words, this study showed multiple independently functioning “stand-alone” medical homes is equal to the sum of its parts.

2. The study also, by the way, calls into question the return on investment of achieving NCQA Medical Home recognition.  While it’s possible that it’s ultimately necessary, it would appear that just having it doesn’t mean a health system will save money or improve quality.

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