The Rest of the Story on Medical Homes
Medical homes are the new fad. For glowing reports on how well they worked for Group Health’s 8,000 Washington patients, see articles in Health Affairs, JAMA [gated, but with abstract], NEJM, the American Journal of Managed Care, by the Commonwealth Fund, and in The Lancet. Group Health claims the distribution of illness was the same as it was in a control group and medical homes lowered costs by 2%. Here’s the rest of the story, courtesy of Buz Cooper:
Clearly, the socioeconomic characteristics of the two groups are not the same.
Cooper goes on to say that results are similar for:
Ontario’s eight year experiment with medical homes for 8,000,000 patients… Participation is skewed to healthier and wealthier patients, who, in the absence of risk adjustment, yield profitable capitation for primary care physicians. Incomes have soared an average of 25%. But while better service was promised, it hasn’t been delivered, at least not for the medical needy and not after hours. Indeed, patients who have sought such extra care (which is charged to the medical home) have been removed from the roster, further improving the risk profile of those who remained.
See JAMA commentary on Ontario here [gated, but with abstract].
In the comparison the treatment group (those in a medical home) experienced 2% lower costs compared to the control group (those not in a medical home). This finding is nothing to write home about. But after analyzing the makeup of the control group, it becomes obvious the people assigned to the medical home were far healthier to start with. This suggests the medical home probably experienced costs that were 5% to 10% HIGHER than a well-matched control rather than 2% lower.
The only reason that the medical-home concept is getting so much airtime is that it will increase doctors’ incomes. Other outcomes are irrelevent to the public debate.
It is absurd to think that a 3rd party, especially the government, can monitor and oversee the medical home, and value it appropriately.
If, on the other hand, patients controlled their health-care dollars directly, some of them might well be happy to pay for a medical home. In the same way, someone who wants to build an actual home does not hire every carpenter, painter, or electrician who participates in its construction, but hires a general contractor to manage it.
But nobody would let the federal government decide which general contractor to use, or how much to pay him!
I like this post, and would like to see more analysis like this. I especially lilke debunking orthodoxy.
I second what Ken has to say.