First national medical home pilot yields lessons for the future
The first national medical home demonstration has come to a close, and the 36 practices who put two years into transforming toward the model deliver somewhat discouraging news. Despite their intense efforts to implement same-day appointments, optimized office design, electronic prescribing, electronic health records, practice websites and more, the participating family practices registered modest improvements in quality-of-care measures but backslid in terms of how patients rated them, according to a set of eight articles in a special supplement of the Annals of Family Medicine.
The major problem: Unlike other pilots, the practices in the National Demonstration Project did not receive extra compensation from payers for their "feverish" efforts to be a medical home, but continued to get paid on a fee-for-service basis from June 2006 to May 2008. "Given that primary-care doctors are already overwhelmed and underpaid, expecting them to transform their practices without additional funding is unrealistic," said Ann O'Malley, MD, of the Center for Studying Health System Change.
Quantitatively, both the "facilitated" (which received consultant and HIT vendor help) and "self-directed" groups of practices posted roughly a 5 percent gain on the scorecard of the Ambulatory Care Quality Alliance for managing chronic disease and a 2 percent increase in terms of patient empowerment and self-rated health status. However, throughout all 36 practices, patients rated access to care, care coordination, comprehensive care, and service relationship satisfaction slightly lower.
According to the authors, the practices threw so much time and energy into implementing HIT (more heavily emphasized at the outset of the project) and adopting other components of the medical home, that they had little interpersonal service left to give patients once they got in the door.
The disappointing data, coupled with the fact that few of the practices, even among the half that got extensive help, completed the transformation within the two years, led the report's authors to conclude: "The jury is still out on the actual impact on quality of care and patient outcomes. It is apparent that for most practices, the process will take a high degree of motivation, communication and leadership; considerable time and resources; and probably some outside facilitation."