Advanced medical home elements didn't lead to better outcomes
■ A study looked at how community health centers fared using components such as after-hours access and test result tracking.
Community health centers that implement the most sophisticated elements of the medical home concept may not achieve superior quality outcomes compared with centers that meet basic medical home criteria, said a study published online Feb. 13 in Health Affairs.
Researchers examined 40 community health centers in the Los Angeles area that treated more than 600,000 patients in 2010. The medical director or chief executive at each clinic assessed how closely the office met the National Committee for Quality Assurance's medical home standards, although the clinics were not participating in the NCQA certification process. These are standards that the Center for Medicare & Medicaid Innovation is using as part of a separate demonstration project involving 500 FQHCs to improve care for nearly 200,000 Medicare patients, especially those with chronic diseases.
Under the NCQA system, clinics can earn up to 100 points in areas such as patient access, care management, electronic prescribing, test-tracking and performance reporting. The higher the number, the more advanced the medical home. A level 1, or basic, medical home ranges from 25 to 49 points, a level 2 home scores 50 to 74, and a level 3 -- the most advanced -- gets 75 to 100.
For example, a level 1 medical home allows patients to contact the clinic during office hours. A level 3 medical home also will provide after-hours access, email access and interpreter services for patients with limited English proficiency.
Yet researchers found no relationship between the clinics' self-assessed scores on the NCQA standards and their performance in delivering care for patients with diabetes. For example, level 1 centers tested 84% of their patients' HbA1c in the previous 12 months -- the same percentage that level 2 and 3 clinics achieved.
On some metrics, the less advanced medical homes scored better. Level 1 centers gave eye exams to 31% of patients during the prior year, compared with 21% of patients at level 2 and 3 practices. Overall, the quality results rivaled those of other high-performing practices. There was no control group of clinics that did not meet any medical home standards.
"It may be that you get all of the improvement you're going to see by becoming a level 1 medical home, and then you don't get any benefit from being a level 2 or 3," said Robin Clarke, MD, lead study author. "But that also means that we have 60 points on this 100-point scale where there's really no meaningful difference."
Limits of self-evaluation
The Health Affairs study is not a fair test of the validity of the medical home certification standards, said NCQA President Margaret E. O'Kane.
"This particular pilot did not include having NCQA evaluate the practices directly -- the usual approach -- but rather used the NCQA tool for self-assessment," she said. "The self-assessment that these centers reported is intended to show where improvement is needed."
O'Kane said that external evaluation of clinics' implementation of medical-home concepts is critical to actually improving the quality of care. "That objective review is so important," she said.
Dr. Clarke acknowledged the centers' self-evaluation as a limitation of the study but said the study may represent more of a real-world look at how the medical-home concept will be implemented.
"These are practices that weren't self-selected," he said. "All of the studies done before about the medical home always used practices that selected themselves either by applying for NCQA recognition or they probably already were the highest-performing clinics. We felt our sample was more representative of the average community health center."
FQHCs already may be engaging in population-outreach initiatives that help boost their quality scores even without being advanced medical homes, as defined by the NCQA, Dr. Clarke said. He added that better answers to how well NCQA standards match up with quality of care at community health centers will come from the Medicare demonstration project.
Advanced medical home elements such as the capacity to systematically track test results, outline and measure quality-improvement projects, and ensure that all eligible patients are receiving appropriate screening tests have been shown to improve care, said Dr. Clarke, a general internist at the Ronald Reagan University of California, Los Angeles Medical Center.
But how these concepts translate into delivering care for the low-income patients served by FQHCs may be the stumbling block, he said.
"The measurement of what makes a practice successful is very nuanced," Dr. Clarke said. "The NCQA's tool is based on a lot of evidence, and a lot of previous studies created by a lot of thoughtful people, but this is the first time it's really being investigated for the clinics that actually treat impoverished patients rather than insured patients. There may be something that's different there."