Medical Homes: Different Models Need Different Yardsticks

As regulators and health policy experts try to determine the effectiveness of patient-centered medical homes (PCMHs), one evaluator says they shouldn't all be judged by the same measuring stick.

Instead, those questioning the cost and quality value of PCMHs need to evaluate each model on its own terms, Asaf Bitton, MD, MPH, instructor of healthcare policy and PCMH researcher at Harvard Medical School, said here.

Despite the uptick in popularity of PCMHs, there is still vast heterogeneity in the practice of medical homes. Even more so, stakeholders are still arguing over definitions and standards, Bitton said Tuesday at the Patient-Centered Primary Care Collaborative Fall Conference.

Academic studies have questioned the difference a medical home can make in quality and costs. In an article in Annals of Internal Medicine, George Jackson, PhD, of the Duke University School of Medicine, and colleagues said "current evidence is insufficient to determine effects on clinical and most economic outcomes" of PCMHs.

Deborah Peikes, PhD, of Mathematica Policy Research, and others noted in the American Journal of Managed Care last year that medical homes have some favorable effects, "a few unfavorable effects on costs, and many inconclusive results."

While PCMHs often reduce the number of hospitalizations and emergency department visits through better care coordination and care managers, those savings to the health system are offset by additional bonus payments from payers for the extra staff and time needed to achieve those reductions.

But PCMHs shouldn't be deemed a success or failure as a group, said Bitton, who chairs the clinical quality workgroup at the Commonwealth Fund's Patient-Centered Medical Home Evaluators' Collaborative.

"Rather, ask the question as a community of concerned individuals and stakeholders, in what context, in what situations, with what support, with what payment incentives, with what transformation incentives does the medical home work over what time period?" he said. "To me, as an evaluator and as a concerned individual in this game, that is a much better question because that doesn't oversimplify the world into a yes, no. It gets us to the crux of the issue and it helps us move the path forward from an unsustainable status quo."