Can more coordinated delivery of primary care make a difference in health care quality and costs? It may depend on who the patients are.
There is tremendous interest in revamping the way Americans get health care, with reform of the primary care system viewed by many as the best opportunity to improve the quality of care, while also driving down its costs.
Two recent studies seem to send mixed messages on that effort, but their findings may not really be at odds with each other when the results are considered more carefully. Both of the studies looked at the impact of patient-centered medical homes, a highly coordinated system that has been touted as an innovative – and potentially cost-saving – approach to delivering primary care.
Under the medical home model, patients are cared for by not only doctors and nurses but a team that might include a nutritionist, a social worker, and other professionals that take a comprehensive approach to their care. They enjoy quick access to providers for urgent matters, 24-hour telephone or electronic access to a clinician, and better coordination of transitions such as the return home following a hospitalization.
In a study reported in late February in the Journal of the American Medical Association, involving about 120,000 patients in 32 primary care practices, on only one of 11 quality measures did those getting care through a patient-centered medical home show better outcomes than those getting care through standard practices. Meanwhile, there were no differences in health care utilization or overall health care costs between the two primary care groups.
A second study, however, published in late March in the American Journal of Managed Care, found that patient-centered medical homes were associated with significantly lower health care costs than standard care practices for the 10 percent highest-need patients. For these patients, costs were about $75 to $100 per month lower, a savings achieved mostly through significantly fewer inpatient hospital stays. For the overall study population – about 7,000 patients each in the patient-centered medical homes and standard practices – as in the study reported in February, there were no differences in health care utilization or costs.
A key difference was the separate analysis the second study did that looked only at the subgroup of patients with high health care needs. That finding points to a crucial issue that was highlighted in CommonWealth’s look in the current issue at two big primary care innovations being led by Massachusetts physicians.
Bob Master directs the Commonwealth Care Alliance, which provides coordinated care similar to that of a patient-centered medical home to some of the state’s highest-need patients – those eligible for both Medicare and Medicaid. Meanwhile, Rushika Fernandopulle is developing a set of primary clinics that provide more intensive, coordinated primary care to general populations of patients. Through Iora Health, the company he founded three years ago, Fernandopulle has set up clinics in conjunction with various employer and union groups, including a Boston clinic opened recently in partnership with the New England Carpenters Union.
As is often pointed out, a very small proportion of patients account for a very large portion of health care spending. This is sometimes referred to as the “80/20 rule,” since about 20 percent of patients are responsible for 80 percent of health care spending. As few as 5 percent account for half of health care spending, while just 1 percent are responsible for about a quarter of health care costs.
Master and his colleagues work with these high-need patients, some of whom suffer from severe, chronic conditions and disabilities that lead them to incur costs of as much as $5,000 per month. It is easy to see how a better coordinated system of care in this population, at least in theory, could make a real dent in health care spending. It’s analogous to the old saw about why bandit Willie Sutton said he chose to rob banks: It’s where the money is.
There are some studies showing that this model can yield cost savings in these high-need patients, though success is far from assured.
Fernandopulle faces an even steeper challenge, as Stanford health policy expert Arnold Milstein told CommmonWealth. “Iora is a completely different kettle of fish that focuses on a much harder problem,” he said of the effort to provide more primary care and reduce spending in a more mainstream population. “The evidence to show that it can be done is much less well established.” Healthier populations, by definition, use fewer health care resources, so wringing savings through a more comprehensive primary care model with these patients will be more difficult.
The new studies seem to underline that challenge. As the Project Millennial health care policy blog pointed out in writing about the recent findings, “Essentially all of the cost savings and avoided hospitalizations came from the top 10 percent high-risk patient cohort. This doesn’t mean that other patient-care medical home models couldn’t squeeze savings out of lower-risk patients. It just means that this and many existing models haven’t found out how to.”
