This post by Richard A. Cooper, FACP, appeared at Better Health.
Group Health has published two papers recently, one in Health Affairs and the other in JAMA, both extolling the virtues of its medical home. These follow their brief report last fall in the NEJM and the lengthy description of their model in the American Journal of Managed Care. Their model has been promoted by the Commonwealth Fund, and it is cited in the current issue of Lancet.
The big news is that costs were a full 2% lower than conventional care, hardly a great success--it wasn't even statistically significant. But was even this small difference due to the medical home, or was it because the medical home patients were less likely to consume care?
Group Health assured us that the 7,000 patients still enrolled in their medical home were the same as the 200,000 controls because "burden of disease, as measured by Diagnostic Cost Groups (DxCGs), was similar." But while the DxCG system adjusts for diagnoses, age and sex, it does not adjust for sociodemographic factors, the strongest determinant of utilization. Nor does it appear to have accounted for health status. The chart below, from the AJ Managed Care publication, shows just how different these two groups are. Sadly, these differences are not described in papers in the NEJM, JAMA or Health Affairs, which are read more widely.
Anyone should be able to get better outcomes with patients who are more highly educated (and presumably higher income), who are more often white and whose baseline health status is better. Indeed, it's remarkable that the DxCGs could have been so similar, since health status was so much better among medical home patients. What's most amazing is that this favorable group consumed only 2% less resources. I would have expected at least 20% less.
But even if the model were valid, it's important to recognize the practical limitations in generalizing from it. It took eight physicians to constitute the six FTE physicians who provided medical home care, and these physicians had patient panels that were almost 25% smaller than Group Health's usual clinics.
Nonetheless, medical home patients were more frequently referred to specialists (and that was statistically significant). Not surprisingly, physicians in the medical home had less stress. Patients were more satisfied, too. But there are not 25% more primary care physicians available (really 50% more, when their part-time nature is considered) to allow all of the primary care physicians in America to reduce their panels and work part-time as these eight did, nor will there be enough specialists for them to refer to if the nation doesn't train more (see: No One is Home in the Medical Home).
Beyond all of this, I'm left with two nagging questions. Why, if the Medical Home is patient-centered, did it start with 9,200 patients in 2006, decline to 8,094 by the end of 2007 and fall further to 7,018 by the end of 2009, a loss of 24% of the patients in less than three years? Where did they go? And why?
And why, if Group Health's Medical Home is to be a model for the nation, does Group Health accept commercially-insured patients from eighteen counties (top panel) but Medicaid patients from only three (bottom panel)?
If we want high-performance primary care, it will have to be delivered in high-performance systems that use scarce physician resources more efficiently. Panel size will have to be increased, not decreased, as physicians defer more care to others. And physician satisfaction will have to increase not because of less stress but because physicians are rewarded for exercising the complex knowledge that they worked so hard to attain.
Most of all, if we want to decrease health care spending, we will have to recognize that the major remedial costs are associated with the added care that is provided to low-income patients. It is time to stop talking about wasteful medical homes for college grads and start talking about safe neighborhoods, high-quality schools and workable systems of care for a diverse and needy nation.
This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.