Saturday, June 20, 2015

Nature And Nurture: What’s Behind the Variation In Recent Medical Home Evaluations?

by  Mark FriedbergConnie Sixta, and Michael Bailit



The medical home is a relatively new term term in the golden age of health reform. It is really not a new concept.We used to call it the family physician, or primary care provider. However in today's environment it takes a village to provide the care which one provider used to be able to deliver.

In evaluating Medical Homes, it is not surprising to see significant variations in success depending on regional variations.

No two medical home interventions are exactly alike, and recent studies have demonstrated their heterogeneity. Similarly, the context and setting of medical interventions differ widely and can have significant effects on their outcomes.
Recent evaluations of two regional medical home pilots (i.e., efforts to improve the capabilities and performance of primary care practices) within the Pennsylvania Chronic Care Initiative (PACCI) have produced differing results.
In the southeast region of the state, the intervention was associated with improvements in diabetes care, but no changes in other measures of quality, utilization, or costs relative to comparison practices. By contrast, the northeast region’s intervention was associated with favorable changes, relative to comparison practices, in a wider array of quality measures as well as reductions in rates of hospital admissions, emergency department visits, and ambulatory visits to specialists.

Nature: Differences In Context

Compared to primary care practices that participated in the southeast PACCI, those in the northeast PACCI had several advantages at baseline.
First, the northeast practices may have been “right sized” for rapid transformation: not too big to change quickly, but not so small that they lacked resources to make new capital and personnel investments. And when practice sites were small, they tended to be affiliated with larger provider organizations (Intermountain, Physicians Health Alliance, and Geisinger) that could bankroll and otherwise support their transformation (e.g., through access to “back office” executive leadership with significant organizational experience in care management, which was present for six practices).
Through participation in the northeast PACCI learning collaborative, intervention conveners observed that practices lacking this expertise at baseline learned quickly from their peers. In contrast, practices in the southeast were predominantly small, independent private practices or much larger organizations (academic medical centers and community health centers) with less preexisting experience in care management.
Second, conveners observed differences in practice culture at baseline. In the northeast PACCI, physicians were more accustomed and receptive to practice transformation that was directed and facilitated by their practice leaders. In contrast, for some practices in the southeast PACCI, conveners noted initial physician non-participation in, and resistance to, new initiatives by practice leaders.
Third, the southeast regional pilot included community health centers and teaching hospitals that focused on underserved, sociodemographically vulnerable populations. The northeast region did not have the same representation of such providers, and while these practices did not serve a wealthy population, they may not have faced the same degree of sociodemographic challenges as some of the southeast practices.
Fourth, the northeast region was more rural, with few hospital options and more consistent use of the same hospital over time by patients of a given practice, facilitating hospital-primary care relationships. In contrast, the southeast region was a large metropolitan area served by numerous hospitals, complicating the task of tracking hospital and emergency department care.
Fifth, evaluations of each regional pilot found that approximately one-third of the southeast practices adopted new Electronic Health Records (EHRs) during the intervention, while all of the northeast practices already had EHRs at baseline. Adopting a new EHR can be stressful to physicians and staff, disrupt longstanding workflow, and distract from other aspects of practice transformation.
Once again studies fail to illuminate the difference between apples and oranges when describing success or failure of programs
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