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Popular U.S. health reform plan may not cut costs, boost quality: study

By Julie Steenhuysen

CHICAGO (Reuters) - Increased attention given to patients in primary care practices organized into so-called medical homes may not improve quality of care or reduce health costs as reformers of the U.S. healthcare system had hoped, researchers said on Tuesday.

Thousands of primary care doctors in the United States are revamping their practices based on this new medical home model.

Under this scheme, doctors and other providers receive bonuses from insurance companies for spending extra time with patients by extending office hours and providing follow-up care in hopes of keeping them healthier and out of the hospital.

In medical home practices, primary care doctors adopt a team-based care approach using patient registries, electronic health records and other tools to help identify high-risk patients and deliver more personalized care.

The thinking is that this extra attention will result in improved quality and reduced spending.

But new evidence from a large, three-year pilot study among 32 physician practices in Pennsylvania found modest improvements in quality of care and no reductions in hospitalizations, emergency department visits or total costs of care.

"The medical home has gained popularity as a new model of primary care, with the expectation that the approach will produce better and lower-cost health care," said Dr Mark Friedberg, the study's lead author and a scientist at RAND, a nonprofit research organization. "Our findings suggest that achieving all of these goals is a challenge."

The findings were published in the Journal of the American Medical Association (JAMA) on Tuesday. This adds to evidence from a study of five Rhode Island physician practices published in September in JAMA Internal Medicine that found no statistically significant improvements in quality or emergency department visits, although there were signs that ER use was declining.

Dr Thomas Schwenk of the University of Nevada School of Medicine in Reno said the findings from the Pennsylvania trial suggest that the medical home movement may not work for every patient in every practice.

"It's gotten to be almost a fad in which it is applied indiscriminately," said Schwenk, who wrote an editorial accompanying the study in JAMA.

Schwenk calls the medical home model a "powerful technology" for treating expensive, high-risk patients, but when it has been applied in broad practice settings, it "by and large has been shown not to be that effective."

Friedberg said the findings suggest it may be a little harder to achieve the goals of the medical home model than previously thought. "I would not say our findings say the medical home model is doomed." But, he added, "It's not a sure thing."

Friedberg's team evaluated practices taking part in the Southeastern Pennsylvania Chronic Care Initiative, one of the first medical home pilots in the state. In this region, 32 primary care practices and six health plans took part in the pilot between 2008 and 2011.

Practices in the pilot program were required to transform their practices into medical homes and become accredited by the National Committee for Quality Assurance or NCQA. Such practices enlist the help of everyone from nurses to front desk staff to help avoid costly and preventable complications by focusing on preventing and managing chronic disease.

To motivate doctors in the Pennsylvania study, each practice was eligible to receive a $20,000 bonus support payment in the first year and annual bonus payments, which ranged from $28,000 to $95,000, depending on the size and structure of the practice.

Using data on approximately 120,000 patients, researchers compared quality, use of medical services and costs of care between the pilot practices and 29 other practices.

But over the three-year period, researchers found rates of quality significantly improved on only one out of 11 quality measures that included asthma care, cancer screening and overall diabetes control.

They also did not find any reductions in the number of hospital visits, emergency department use or ambulatory care services, or in the total costs of medical care.

The study did not examine why the pilot failed to make a major impact. Yet, the authors said the fact that many of the practices volunteered for the study suggest they may have already been more quality-conscious than other practices even before the pilot began.

A POPULAR HYPOTHESIS

The findings contradict the hypothesis that better preventive and primary care will help patients avoid more costly medical problems down the line.

Insurance companies pay a premium to primary care practices that organize themselves into a team of professionals, including nurse practitioners and 0physician assistants.

More than 10 percent of U.S. primary care practices or about 7,000 practices, are recognized as patient-centered medical homes by the NCQA, the nation's largest group that certifies such practices.

The movement got its start with an American Academy of Family Physicians report called the 2004 Future of Family Medicine. It has since been championed in President Barack Obama's healthcare law through provisions that allow states to boost reimbursements to primary care practices designated as medical homes for Medicaid patients.

Health insurer Aetna Inc helped pay for the Pennsylvania study along with the nonpartisan Commonwealth Fund. The company said it was still convinced of the value of the medical home model, noting it has come a long way since the start of the pilot.

Elizabeth Curran, Aetna's head of National Network Strategy and Program Development, said Aetna has nearly 1 million commercial members being treated in patient centered medical homes under an estimated 5,000 primary care physicians.

She said Aetna patients treated in a medical home have a range of 3 to 13 percent fewer visits to the emergency department per 1,000 patients than patients treated in typical practices. Medical costs per patient are from $2 to $24 cheaper per month in medical homes versus typical practices.

Dr Elbert Huang, a health care policy expert at the University of Chicago Medicine who was not involved in the study, said three years may not be enough to show a significant impact in improving chronic diseases such as diabetes or asthma.

"The practices clearly changed the way they do business," he said.

(Reporting by Julie Steenhuysen; Editing by Michele Gershberg and Diane Craft)

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