Medical home success story runs counter to study findings

This week the Journal of the American Medical Association released startling results from a study on patient-centered medical homes (PCMH): The first and largest medical home pilot involving 32 primary care practices and six health plans as part of the Southeastern Pennsylvania Chronic Care initiative failed to save money over a three-year period and showed limited quality improvement.

The findings are a bit of a blow as more providers take up the team-based care model to help identify high-risk patients and deliver more personalized care. Organizations that jumped on the bandwagon aimed to reduce readmissions and spending, and ultimately improve quality. 

Although the results don't necessarily mean the model doesn't work, lead study author to Mark W. Friedberg, M.D., said it's clearly difficult to achieve cost savings and quality improvement goals. "I would not say our findings say the medical home model is doomed," he told Reuters via the Chicago Tribune. But, he added, "It's not a sure thing."

The findings surprise me because, in theory, personalized care should keep patients healthier and out of the hospital. And they contradict many of the PCMH results I recently discussed with Karen DaSilva (pictured right), deputy chief medical officer and senior medical director for healthcare delivery at Harvard Vanguard Medical Associates in eastern Massachusetts, Atrius Health's largest medical practice.

Atrius Health began a coordinated, collaborative effort to build a PCMH approximately five years ago. Prior to developing the team-based approach, the practice's fixed performance target or "gate" was 2.6 out of a possible 5.0, a number based on 33 chronic disease measures under its alternative quality contract (AQC) with Blue Cross Blue Shield of Massachusetts. But last year, Harvard Vanguard Medical Associates estimates its AQC gate score rose to 3.9 or 4.0, she said.

"In Massachusetts, we are one of the top performing groups. We have some of the best quality in the country. I was looking through literature and we are hitting some of the best blood pressure control in the country," DaSilva said in an exclusive interview with FierceHealthcare.

In addition, she said data indicates that Atrius Health has reduced hospital and skilled nursing facility admissions for its Pioneer accountable care organization (ACO) population. "At Harvard Vanguard Medical Associates we have seen, year over year, about a 9 percent decrease in hospital admits per thousand, and over the course of 2013, we are tracking toward a similar reduction in skilled nursing facility admits per thousand."

"We are really starting to hit outcomes that make a difference with people. We are keeping them healthier and out of the hospital," she added

Furthermore, she reports that year over year Atrius Health reduced its total medical expense by about 4 percent, and over the course of 2013, its trends are lower than the ACO benchmark set by Medicare.

DaSilva said part of the reason for the PCMH's success is the work they did in advance, developing clear roles for all team members and efficient work flows in order to create personalized care for each patient.

For example, if a patient with diabetes and hypertension makes an appointment for a physical, team members will review his or her care in advance to anticipate the patient's needs. If the patient is due for a mammogram, the team will make note of it in her chart, for example. If the patient is frail, elderly and homebound, the team may review his or her medications and build a model of care to help maintain the patient's current condition.

"We have different team members looking at patients," DaSilva said. "The clinical pharmacist will look at his medication, the case manager will call him to see how he is doing and we will send the nurse practitioner to his home so he doesn't have to come out to a busy office. The team can look very different, depending on the patient's need. It's very personalized."

DaSilva advises organizations thinking about forming a PCMH to make sure they obtain senior leadership support and engage front line staff in the process. She also suggested putting metrics in place to measure whether the new model is achieving better outcomes. The fact that her PCMH has access to solid data sources is important because it helps the team have a better understanding of different patient populations.

And she cautioned that PCMH means creating new roles--positions that don't necessarily produce revenue like a traditional model. Atrius Health created population managers who look at different patient populations, such as diabetic patients to make sure they have their eye exams or screening labs. "This is not someone who clearly is making money for you but they are clearly impacting the quality of the care," she said.

The PCMH has also tried health coaches and case managers who track the patients through the transition of care from home to office to hospitals. "We've taken some old roles and adapted them," she said.

She also suggests organizations look at the long-term goals and not be distracted by the short-term problems that will inevitably arise. "It's easy to become less focused and take care of that short-term problem but this involves developing a multi-year plan on chronic disease management, capacity and efficiency," she said.

Finally, she expects Atrius Health's model will evolve over time. For example, DaSilva said, the PCMH is looking at how to team up with advanced practice clinicians. "The primary care physician takes a central role in coordinating the needs of the patients. Next we need to collaborate with our specialist colleagues in a more effective and efficient way, she said.