Group Health’s Medical Home: Leaving the Poor Out in the Cold
Group Health recently published two papers, one in Health Affairs and the other in JAMA, both extolling the virtues of its Medical Home. These follow a brief report last fall in the NEJM and a lengthy description in the American Journal of Managed Care. In addition, Group Health’s Medical Home has been promoted by the Commonwealth Fund and others, and it is praised in an editorial in the current issue of Lancet. The big news is that costs for patients in their Medical Home were a full 2% lower than in conventional practices, 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 Medical Home patients were less likely to consume care?
Group Health’s answer is that the 7,000 patients in their Medical Home were the same as the 200,000 controls, because the burden of disease, as measured by Diagnostic Cost Groups (DvCGs), was similar in the two groups. 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 data in the AJ Managed Care publication, shows just how different these two groups are. Sadly, these data were not included in papers in the NEJM, JAMA or Health Affairs, which are read more widely.
Anyone should be able use fewer resources caring for 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 more favorable group consumed only 2% less resources. I would have expected at least 20% less.
But even if Group Health’s model of care 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 per FTE than in Group Health’s usual practices. Nonetheless, Medical Home patients were more frequently referred to specialists (and that was statistically significant). With eight Medical Home physicians providing the same care as four full-time physicians working in the usual practices, it’s not surprisingly that those in the Medical Home had less stress. Patients were more satisfied, too. But there are not 25% more primary care physicians available to allow all of the primary care physicians in America to reduce their panels, particularly with many working part-time. And when there are too few, the poor come in last (see: No One is Home in the Medical Home).
Beyond these basic concerns, 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? Not too “continuous, comprehensive and coordinated ” for them. But more important in terms of study design, where did these 2,000 patients go? And why? And how much does their care cost? And why aren’t those costs in the final calculations?
And one last question. How can Group Health be a model for the nation when, according to its Service Area Maps, it accepts 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’s 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 analysis is amazing and eye-opening. It is clear that the “Medical Home” movement will not solve the primary care problem by itself, nor the cost problems of our current system. Decreasing panel size is important if we want high-quality, patient centered care and you are correct about the type of complex, cognitive care physicians should be giving…but those factors are just part of the problem.
I have not heard of any physicians in training say they would chose primary care because of the new “medical home” concept.
Medical homes, like any new technology, are more costly in the development stages and will be initially restricted to the better-off. The fact that they don’t contain the exact correct percentages of Our Favorite Victim Groups doesn’t mean that they’re a bad idea.
To show that medical homes are failing, you’d need to show that they are failing at pushing the cost-containment/health outcomes frontier, which you have not done.
Success requires that success be demonstrated. All we have so far is claims of success for what, in fact, has failed.
Most of us were instructed on the “patient centered medial home ” years ago. I can remember going to patient’s homes, nursing homes and the other principles contained in the model. Then you leave and get into the real world and it just can’t be done and maintain the volume, especially if you are turning away patient’s everyday. If productivity and efficiency are the mantra of the future to reduce costs then medical homes will certainly not fit the task. What it will do is make PCPs more difficult to find and drive up PCP labor costs and that is exactly what it is intended to do. Medicine is practiced as much with the heart as with the mind and a new ” model” won’t change that. Especially at a time when the government is advocating placing 15-20000 PCP in community health centers making it even harder to arrange medial homes for those not recieving care at those facilities. Its just another sham, but makes the physician surplus sham of the 1990s pale incomparison.