Pa. Chronic Care Initiative pilot program makes little difference to costs, quality

A new study found that primary care practice reforms resulted in virtually no change—in costs or the quality of care delivered to patients.

Several years ago, a string of Southeastern Pennsylvania primary care practices transformed they way they do business, this week a study found that the reforms resulted in virtually no change — in costs or the quality of care delivered to patients.

The Pennsylvania Chronic Care Initiative pilot program which began in 2008 and ended 2011, offered bonus payments to doctors’ offices that became certified as a Patient-Centered Medical Home.

The medical home approach strives to better coordinate health services—especially for patients who have a chronic condition such as diabetes.

“People have made the analogy, that changing into a patient-centered medical home is like rebuilding your airplane while you are in flight,” said Mark Friedberg, who led the study from the RAND Corp.

Friedberg’s team surveyed medical practices to determine if they set up electronic health records, established registries of patients with certain chronic illnesses—or whether they had special outreach to keep track of people with complex medical conditions. Information on costs and how frequently patients used health services was pulled from health insurance claims data.

The number of patient emergency room visits and hospital admissions did not drop.

If driving down costs is a goal, Friedberg says “something more might be needed” than what was done in the medical home pilot.

The participating doctors offices were mostly small, mostly independent.

“Some folks are very disappointed with the results,” Friedberg said.

The RAND study measured the early days of the pilot program, and Friedberg says the health system is still experimenting. It’s a mistake, he said, to consider the pilot a failure. By contrast, he said, the experiment was a good investment of time and money.

William Sonnenberg, presidents of the Pennsylvania Academy of Family Physicians, says he’s waiting for a different side-by-side comparison.

The RAND study measures the effectiveness of the medical home model by comparing the primary care practices before–and after–the medical model overhaul.

Sonnenberg wonders if some of the practices were already, ‘unofficially’ doing much of the care coordination and patient tracking tasks that are codified in the patient-centered medical home model.

“It’s the elements you’d see in any good family practice, maybe it’s not much of a comparison,” he said.

“I would really to love to do something comparing a good patient centered medical home, to a fragmented system where, people just go to specialty, to specialty, to specialty—where there’s not coordination of care, and I think you’d see rich differences if you did that,” Sonnenberg said.

Feedback varies when Sonnenberg speaks with physician colleagues who earned the medical home certification–and resulting bonus payments.

“Some people say it takes a lot of time and lots of paperwork to document. Others say it’s made me a better doctor,” Sonnenberg said.

Emergency room physician Bruce MacLeod is president of the Pennsylvania Medical Society–the state’s doctors group. He says the RAND study is an early snapshot of an evolving program.

“It’s changed since then. People who were actually involved in the project said we have to improve it, we have to focus it,” MacLeod said.

“What we found is that if you are a healthy person you probably don’t need much coordination, however people with chronic conditions—diabetes, severe asthma, COPD—do,” MacLeod said.