ACA Reform and the Medical Home: The Newest Primary Care Initiative

Part of the ACA’s success hinges on its ability to reduce the cost of medical care by better managing chronic illness and by averting hospitalization. Ten billion dollars has been invested in new projects through Medicare’s Innovation Center, much of the money flowing through hospitals and large organizations. In a previous blog we discussed how an expensive program financed by the Innovation Center, designed to reduced hospital readmissions, has not shown any progress after its first year. Of the 48 centers enrolled in the program, 29 dropped out or were terminated due to poor results, and only 4 achieved any drop in readmissions. As with much of the ACA’s top-down expert-driven philosophy, this program failed because it did not meaningfully alter the landscape at the ground level. As with many ACA programs, practicing primary care doctors did not take a central role in its design.

Now we have learned about another endangered program from the Innovation Center, this one touted to be primary care focused, although again without significant primary care input. Medical home models are a concept that the ACA had stated will be crucial to improving health care outcome and decreasing cost. In fact, according to a recent announcement from Medicare, starting in 2016 much of primary care income will be derived from participation in medical homes and in accountable care organizations, which have a similar dynamic. Put simply, through medical homes, patients identified to be at high risk for poor health outcomes, including those with chronic disease, will receive extra medical services such as nursing calls/visits and education. These nurse educators will work with primary care physicians to identify problems and fix them before they deteriorate sufficiently to mandate hospitalization. I am joining a medical home in my county, and I applaud its overall goals and methods. It will help us take care of an ill group of patients. But, as we will discuss, it will not enable us to curtail excessive hospitalization and overuse of services for a variety of reasons, despite what the experts state.

A Kaiser Health News report by Jay Hancock, who writes excellent articles about ACA reforms, looks at the ACA’s $322 million experiment with medical homes, called the Comprehensive Primary Care Initiative. After one year, the program did cut expenditures by $168/participant due to a small drop in hospitalization, but this came at a cost of $240/participant to cover the additional services. In other words, it lost money, and averted only a small number of hospital visits. As is true with far too many ACA programs, they also measured their success by assessing “quality” indicators, although those results are not yet available. Some quoted in the article believe that quality indicators are essential to measuring actual quality, a concept that I have repeatedly debunked in both my book and in these blogs; in fact, as my book demonstrates, quality indicators are great time wasters that frequently detract from true geriatric quality. Also, primary care doctors were paid to coordinate care, something that is very promising and, if not straddled by too many rules and regulations and quality indicators, may allow doctors to spend more time with patients and to keep them out of the hospital. Eventually the program will offer primary care doctors shared savings, which means that if costs drop then primary care doctors will reap some of that financial benefit. But it is too early to know if that will work. The one year disappointing results mirror a host of other studies demonstrating that medical homes do not cut cost.

Why? Without a doubt, the medical home has worthy goals and will help many people with chronic illness, while allowing primary care doctors to have eyes in the community to enable improved care. I am excited to be joining Healthy Howard, a medical home in Howard County. But the problem is not with medical homes, rather it is with the belief that medical homes are sufficient to curb hospitalization, and that the quality gained through medical homes can be measured by using metrics. The bottom line is that if doctors are judged by quality indicators, if we are forced to type copious notes and fill out piles of forms as is the case with other ACA reforms, if we are vulnerable to audits that will squander time and money, very few of us will participate, despite the often elusive promise of shared savings. A top-down approach that forces clinically irrelevant quality measures on us and our patients, and straddles us with very restrictive rules is bound to fail. Again, this is a program designed to help primary care doctors, but created without sufficient practicing primary care input.

An even more salient reason that medical homes are not going to achieve the success that their supporters are proclaiming is that they do not provide sufficient tools to really keep people out of the hospital and away from over-testing and over-treatment. The very concept of controlling diabetes, congestive heart failure, and chronic bronchitis very aggressively is not one that has been proven to reduce hospital stays, prolong life, or save money. In fact, just the opposite is true. Also, patients will still have ample access to specialty care and testing, and can go to the hospital whenever they wish. While doctors are going to benefit if patients stay out of the hospital, patients derive no similar rewards. To them it is far less expensive go to the hospital and ER than to try to stay home, where they may have to hire home health aides, be left alone, and have less access to the aggressive care many think is life-saving. If they go to the hospital and stay three nights, they will be rewarded with 100 days of inpatient rehabilitation, something again not covered by Medicare should they stay home. They can get IV treatments in the hospital, but not at home. Tests are easier to arrange at hospitals. The list goes on. The bottom line is that unless you incent patients to stay home by making it cheaper and easier, then the hospital express will not be slowing down. No amount of primary care incentives, nurse educators, quality indicators, and wishful thinking changes that reality. In fact, most studies of medical homes show very little impact on hospitalization or reduction of cost. Other programs, such as certain HMO’s that give doctors and patients meaningful tools to provide home care, do cut hospital rates and increase patient/doctor satisfaction. But that is not what the Innovation Center is scripting for our future.

Bottom line, medical homes are a very worth adjunct to what should be a more comprehensive primary care program that allows doctors to treat their patients at home. By removing quality indicators, excessive regulations, and template note taking; by giving doctors both control over their practice and time to take care of their patients; and by incenting both patients and their doctors to treat people at home, then true reform will be born. The question is, when, if ever, will the ACA get to that point?