Why the medical home may not save primary care money

When the Disease Management Care Blog saw the flurry of news reports about the Patient Centered Medical Home (PCMH) “saving money,” it couldn’t wait for the full print version of Health Affairs to arrive at the DMCB World Headquarters.

The DMCB had previously reviewed Group Health’s negative “no statistically significant…. cost differences” one year study and was looking forward to seeing researchers Robert Reid et al’s reportedly positive two year follow-up.

Here’s what the DMCB found out when it lifted the abstract gown and examined the patient-manuscript itself.

The authors reported the outcomes of a single clinic with a “stable workforce, strong leadership and history of successful quality improvement” that cared for about 9200 patients and which was selected to pilot a “prototype” medical home. This clinic’s results were compared to 19 other Group Health primary care clinics without a medical home approach to patient care. Investing in the medical home was not cheap, because the prototype clinic had to hire additional physicians, medical assistants, licensed practical nurses, physician assistants, nurse practitioners, registered nurses and pharmacists. It also appears that the clinic “downsized” its primary care patient panels to reduce physician workloads.

Using vigorous statistical methods to neutralize baseline differences, the authors compared over 200,000 usual care patients to the medical home’s 7,000 continuously enrolled patients. The medical home was associated with fewer emergency room visits and inpatient admissions with greater numbers of specialty physician visits. When the costs were added up, this is what the authors found:

When costs are totaled across all types of care and adjusted for case-mix and baseline costs, we estimate a total savings of approximately $10.30 per member per month, a result that approaches statistical significance, p=.08, meaning that the difference could still be due to chance.

In other words, the savings failed to meet the conventional threshold for statistical significance.

Despite the negative finding, the authors forged on and added up the cost of the program and compared it to the savings: “… we can estimate return on investment associated with the prototype at 21 months at 1:51″

In addition to its failure to achieve statistical significance, there are several possible weaknesses with the study that went unmentioned in the “Lessons Learned” and Policy Implications” sections of Reid et al’s Health Affairs publication:

1) the authors chose their strongest clinic (making its generalizability to other Group Health clinics suspect)

2) it’s not clear which patients were dropped from the panel prior to institution of the PCMH

3) despite statistical attempts to neutralize any known sources of bias, this was a non-randomized study and could have been influenced by unknown or unreported factors

4) what works at Group Health – an integrated delivery system in the Northwest – isn’t necessarily going to work in any primary care clinic in Dade Country Florida, McAllen Texas or Mobile Alabama.

The DMCB wonders why its friends in policy circles and academia continue give the PCMH a pass. Based on these data, the PCMH is still not ready for prime time and should be confined to pilot testing. The DMCB is not the only curmudgeon that feels that way: check out this thorough review of the possible sources of bias and the testy response of the study’s lead author.

Speaking of pilots, check out what Rhode Island Blue Cross Blue Shield is up to. The insurer is directly paying for the salaries of nurses that are being dropped into network primary care physicians’ offices.

While the Group Health article preaches about investing in primary care, clinical leadership, change management, electronic records, transformation, educational reform and the like, the folks in Ocean State have come up an approach that is a quadruple threat: it’s 1) generalizable (could work in multiple settings), 2) adaptive (care management nurses are a supremely flexible species) 3) probably cheaper than “redesigning” primary care sites and 4) preserves the core value of non-physician coaches dedicated to engaging patients in their own care.

That used to be called disease management, but it’s really become a hybrid “2.0″ version of the medical home that, if it works, may also deserve the attention of Health Affairs.

Jaan Sidorov is an internal medicine physician who blogs at the Disease Management Care Blog.

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  • http://www.drdialogue.com Juliet K. Mavromatis, MD

    Thanks for your discussion of the Group Health findings, which really are the main findings to date that “support” the potential for cost savings to this approach. Having participated in a practice redesign of an 18-member academic practice applying the “Chronic Care Model” a precursor of the Medical Home Model, I too am somewhat skeptical about the prospect of cost savings. Have you read the recent TransforMED findings from the Medicare pilots? http://www.aafp.org/online/en/home/publications/news/news-now/practice-management/20100607tmedndpfindings.html They are not as promising. This transformation process will be very difficult. The support required exceeds what most primary care practices can afford. The goals are lofty and many of the features of the model are certainly worth striving for, but the NCQA certification process will be a bear to deal with.

    • MB

      I was a patient in one of the TransforMED clinics. For one of the medical issues I had during that time, I saw 5 different providers, three of them were physicians assistants. The care was fragmented and I never had any sort of relationship with my former primary care physician. When I got a copy of my EMR for the next provider, he said my chart was difficult to read. To save time, the staff categorized questions into standard issues instead of listening to the actual question. I don’t know how many times my question was not answered but some other question was. Fees for office visits increased and it was cheaper to follow up with a specialist instead my PCP, and the specialist provided me that doctor-patient relationship that was lacking with the TransforMED clinic.

  • ninguem

    Group Health’s PCMH was run in a yuppie suburb of Seattle. Pampering a bunch of yuppies, yuppie-puppies, and yuppie mommies and daddies.

    I’d say it’s an accomplishment that costs weren’t markedly higher in such a PCMH.

    I get refugees from all those big box clinics to my solo practice, because the families are sich and tired of seeing a different face each time, and that different face is hardly ever a physician.

  • Chris

    “Negative” findings are tricky aren’t they? The interpretation of the P-value in the manuscript is poorly stated. A “significant” P-value of .05 certainly does not mean that the findings could NOT be due to chance, it simply means if you did the same experiment ad infinitum approximately 5% of the time you’d see a larger cost savings than $10.30. Period. So a P-value of .08 just means that 8% of the time there’d be a larger cost savings than $10.30. It’s a small point but deserves mention. The arbitrary .05 cutoff is just that: arbitrary.

  • Primary Care Internist

    excellent point chris. Non-statistical people tend to take that arbitrary cutoff as meaning that something is CLINICALLY significant, when it is not necessarily. A good example is in oncology, where many chemo drugs that provde e.g. 24 weeks of survival, instead of the old drug’s 22 weeks, thus a 2-week advantage. But for that advantage the drug company spent millions of dollars to fund a huge study to show a “statistical significance” – what bullshit.

    but all that aside, ninguem you are absolutely right. If one is so inclined, he/she could be quite “successful” picking up the disgruntled patients from transforMED-type practices in the future. Unfortunately since we have no control over our rates, this is not a financially viable model. Same goes for today with small office PCPs versus hospital-based clinics – they get hefty gov’t funding and we get screwed, but patients uniformly HATE those clinics.

  • jsmith

    The PCMH is a desperate ploy that internist and FP leaders have come up with in an attempt to have the government throw more money at them. Of course I don’t blame them–any port in a storm. The likelihood that it will save money is low, the likelihood that it will save primary care is low, the likelihood that pts will buy into the idea of getting most of their care from para-professionals is low.
    Junk the PCMH. Pay primary care a lot more, pay sub-specialists less. You’ll be amazed with the results.

    • r watkins

      The PCMH is a misbegotten vision of patient care, burdened under an excessive load of administrative and bureaucratic chores.

      In the original model, the obvious question of “how to pay for all this” was not even addressed. When this was pointed out, the AAFP came out with the truly hilarious “Future of Family Medicine Paper Number Six,” which claimed to prove that primary care docs would see their income sky-rocket due to all the generous payments from insurance companies for tasks like e-mail consults, group visits, patient registries, and care coordination.

      To the surprise of no one in touch with reality, it ain’t working out like that. This is a terrible plan for the future of primary care, and needs to be ditched immediately.

  • ninguem

    I just had such a refugee, hating the big box clinic, and particularly hated the rather inattentive care. Daughter brining in very elderly parent.

    So parent, frail elderly, got the attention, saw the same face, a physician, no mid-levels, a receptionist who recognizes their voice on the phone and all that.

    So of course they complain about the Medicare copays. Now these are Medicare primary care copays, someone seen maybe every other month. Frail elderly person with a raft of problems.

    So they complain about that, and want “I’m tired” and pain complaints handled over the phone.

    I had to invite them to return to the big box.

    Some have unrealistic expectations.

    But that’s the advantage as well. I can choose who I will see.

  • ninguem

    The patient-centered-medical-home.

    You know what a success the “gatekeeper” concept was, back in the 1990′s.

    They have a bridge for sale, too.

  • http://www.healthecommunications.wordpress.com Stephen Wilkins

    A couple of facts not mentioned by Dr. Sidorov that I find interesting about the Group Health Factoria Clinic pilot are these:

    1) They estimate that they saved about $2 million dollars a year on physician recruitment as a result of increased staff satisfaction and retention. I understand from Claire Trescott, Dir. of Primary Care at Group Health that they have a waiting list for physicians who want to work for Group Health.

    2). Again according to Dr. Trescott and Dr. Handley they put the patient – not the provider or system – at the center of their primary care redesign initiative. Duh…what a novel concept. While there is much about the Group Health pilot that is not easily replicated elsewhere, putting patient at the center of health care is replicable. Oh that’s right…physicians “don’t have the time and aren’t paid” to do that.

    I think the fact that Group Health has committed to role their new primary care model to the entire membership based upon the Factoria pilot speak volumes about Group Health faith in their model.