In a follow up to my blog last Friday on the growth of patient-centered medical homes (PCMH), there was an excellent study in last February’s Journal of the American Medical Association (JAMA) entitled, “Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care.”
The study by Dr. Mark Friedberg et al evaluated a pilot medical home program in Southeastern Pennsylvania for three years. To quote the article, “medical home initiatives have encouraged primary care practices to invest in patient registries, enhanced access options, and other structural capabilities in exchange for enhanced payments—often as per-patient per-month fees for comprehensive care services.” There were 32 physician practices that became National Committee for Quality Assurance (NCQA) designated medical homes. These practices cared for about 64,000 patients that were studies. These practices and patients were compared to a control group of 29 primary care practices that did not become medical homes. These control practices cared for about 56,000 patients. Primary care physicians in the PCMH practices received an additional $92,000 for their efforts to create a PCMH.
Only 1 out of 11 quality measures was better in the PCMH—diabetic nephropathy screening (83% vs 72% in the control group). The other 10 quality measures—related to diabetes care, high cholesterol, asthma and cancer screening—were the same in both groups.
Additionally, hospitalizations, ER visits, ambulatory care services and total costs were NO DIFFERENT between the two groups.
The goal of PCMHs is to improve outcomes and lower costs—so in short, in this pilot program—it did not work.
These results fly in the face of my blog last Friday which reported on the 4-fold increase in PCMH programs across the country.
The next question is… WHY? Why did the PCMH not work? Why are they expanding if this study found that they don’t work?
The answer may lie in the incentives. The PCMHs in the study were paid to achieve NCQA designation and that was it. They were not paid based on outcomes. They were not paid on improving quality as measured by specific metrics. They were not paid on lowering costs. As a result—for example—not a single PCMH in the pilot expanded its hours of operation into the evening or weekend, a step that may help reduce ER visits because the primary care physician is available.
Other PCMH programs specifically pay physicians based on outcomes and/or quality and/or cost reduction. Maybe these other practices are expanding their hours. Hence the reason for the expansion of PCMHs by 4X—the overall idea is a good one and the incentives just have to be structured right.
Again, I have to quote Charlie Munger from Berkshire Hathaway… “Incentives are Superpowers.” You get what you incentivize. If you incentivize NCQA designation, then you get NCQA designation.
Perhaps, if we want improved quality and lowered costs, we need to specifically create incentive programs that measure and reward these things.
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