What Do Medical Home Studies Indicate?

Another publication, this time from Pediatrics, indicates the value of a medical home. But is this value about the term “medical home” or is this value about the concepts that are associated with “medical home”- concepts that any number of providers and clinics can address.

In addition, this is a poorly conceived study with a major failure to consider the real reasons for differences - social determinants that shape access, continuity, and better outcomes.
What Do Medical Home Studies Indicate?
  • Associations and researchers are willing to use data sources that are not from “official medical homes” to indicate medical home value.
  • Concepts are considered more important than the primary care people who deliver the care. Of course those who cut primary care funding fail to understand they are cutting the experienced people needed to deliver primary care. Primary care is about people – repeat often, especially when examining studies about primary care. 
  • Methods that select patients with better social determinants will have better outcomes. Methods tha select patients with higher levels of continuity will have better social determinants and better outcomes as well as better access to care. Substantially more is also invested in health care for those who have greater access and higher social determinant levels. One would also have to ask how many criteria were needed by researchers to demonstrate a difference. 
  • In the study, those of advantage were more likely to have continuity home experiences. In almost every instance of lower probability of preventive visits (age less than 1, single mom, lower income, lack of health insurance, less educated parents), those that preserved continuity had greater proportional improvement (close to 2 to 1). In other words those that somehow bucked social determinants had better care. The continuity home definition did little for those with social determinant advantages and did the most for those that managed to have a continuity home despite odds against. 
  • In the study the differences are significant, but the differences are so small as not to be relevant.
  • Children with a medical home were more likely to receive higher health ratings (excellent or very good) as compared to those without that were lower rated (good, fair or poor). Many would consider the noted outcomes as a matter of differences in health status.
  • As with other pediatric studies, the experts consider near universal access to pediatric care. They have of course overlooked the problem of maldistribution and limited access for over half of children due to workforce limitations in 30,000 zip codes with low or lower health workforce concentrations.
  • Then the study considers a 30% decreased ER utilization discussed in association with a continuity home.
At this point I just have to stop looking. This is a poor study by any number of measures. These are good people that are well intentioned. Some if not most have delivered care where needed. Sadly there is a loss of perspective.

There are significant investments of time and effort by associations and this is a likely reason why such studies are published. What is obvious from this and other studies is that changes in social determinants are required as a top priority with reorganizations of care way down the list.

The current pediatric study does not prove the value of the Medical Home as headlines indicate in Medscape – proof is almost impossible to prove in medical studies. What the Medscape headlines do indicate is poor understanding of medical studies by the medical media (or at least dramatization that is deceptive).

The investment in medical home terminology is so high that family medicine leaders have protested when studies fail to show the expected benefit. After devoting substantial funding to this area, perhaps objectivity is lost. Does Family Medicine Need New Leaders?

I am certainly for the concepts of team care, continuity of care, integration of information, and other aspects that are considered medical home concepts. These are obvious to those who have experienced the great pleasure of delivering challenging care with a supportive team. Who would be against such a design?

The problem remains that continuity home interventions are not going to solve primary care woes or the associated social determinant maldistributions.

Diverting a Nation from Real Solutions

The continuity home has been touted as a solution for the primary care woes of the nation. In fact, the Continuity Home will not improve the major health access problems of the nation. When providers present “cures” that do not work and distract patients from treatments that do work, this is considered a serious offense.

Offensive Literature and Offensive to Dedicated Primary Care Practices

It is hard not to find much of the literature developing around the medical home concept to be “offensive.”

I will continue to assert first that social determinants are far more important and that any primary care practice that has dedicated health professionals that function together as a team to provide health care, that stay together as a team, that keep the same patients, that keep the same location for care, and that have sufficient funding to accomplish the above – will have the optimal care with or without medical home designation.

If the cost of a medical home designation impedes care, medical home designation will not improve the care and may damage care.

If the medical home designation comes with more funding, the care may improve but this is likely the result of the additional funding rather than a medical home focus (beware government promises of more funding as this may not materialize).

If sites receive continuity home grants, then they will have better care because the additional funding is likely to give them an advantage in recruiting and retaining the best primary care personnel. Continuity care is clearly more likely with those that are easiest to care for, as demonstrated in the study.
Of course a real design for the care of all Americans provides sufficient primary care spending across the nation, not just for those who have grants or cost-based reimbursement.

Quality Arises from People and Relationships from the Ground Up, Not from Concepts Thrust on People from Above

Quality is the result of reflective process by dedicated team members with objective consideration of all relevant aspects of care – especially very basic awarenesses and understandings of the patients served. This process does not require certain terms such as continuity home, stroke center, chest pain centers, etc. Continuity home focus can improve care and can raise awareness of methods that can improve care, but a continuity home itself will not be the reason for change.
But if you desire a nice name or certification there are numerous places to contact, meetings to attend, and others willing to take money away from delivery of primary care. Your choice of the following or dozens of others.
On-Site Certification. The Mark of Quality that Sets Your Medical Home Above the Rest. The Joint Commission: Primary Care Medical Home 2011 StandardsAccess and Continuity in the Medical Home SettingBlueprints for Building a Medical Home

The Problem Facing Primary Care
The problem facing primary care remains the same. The problem is that revenue derived from primary care services is insufficient to keep up with rapidly rising costs. When the cost of delivering care is insufficient, the result is cuts in personnel, less experienced personnel, fewer personnel, and decrease in the ability to deliver more care and better care.
When the costs of delivering care are increased due to various innovations and reorganizations without increasing the revenue, it is possible to also result in less primary care delivery.
If a national focus on higher quality (by less volume, more costly technology, fewer personnel) results in less primary care delivered per primary care provider, the nation will have much greater problems with cost, quality, and access because the missing link is primary care personnel of all types.

The Problem of Social Determinants Ignored

If primary care experts ignore social determinants, then they do not understand the most important variables regarding cost, quality, and access. If Pay for Performance pays more for “quality,” relatively less will be paid to practices that have lower and middle income patients. This is because practices that are more likely to care for those in need of care will have lower quality ratings because of the patients that they care for. Higher quality ratings and greater pay will go to those who have better quality because of who they are.

The authors of this Pediatrics article have built another very good case for social determinants yet they have claimed that the reason is the continuity home. This is a quite serious problem for Pediatrics, for primary care, and for most Americans in need of real solutions for health access.

Better Ratings with Better Pay, or Care Delivered Where Needed?

To get lower quality ratings and less pay, continue to care for underserved, poor, near poor, rural, disadvantaged, and lower income patients.
To get better quality ratings and better pay, be sure you care for less complex people. The nation will overall have lower health care quality, higher costs, and declining access to care – but you and your practice will do better.
Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D.        Basic Health Access Web    Basic Health Access Blog

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies


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