RAND study ignores data pointing to success of PCMH care model, say physicians

Pennsylvania's physicians say a new study by researchers at the RAND Corporation in the Journal of the American Medical Association (JAMA) ignores the wealth of recent data pointing to the success of the patient-centered medical home (PCMH) care model that gives patients more control of their health care.

"Before jumping to conclusions about medical homes and our Pennsylvania experience based upon this report," says Bruce A. MacLeod MD, president of the Pennsylvania Medical Society, "it might be best to fully understand what the report actually investigated."

According to Dr. MacLeod, the report evaluated the Southeastern Pennsylvania Chronic Care Initiative, which was one of the earliest medical home pilots in the country. As part of then-Gov. Edward Rendell's "Prescription for Pennsylvania," Phase 1 of this test kicked off in 2008. Its initial focus was on diabetes and pediatric asthma, and great emphasis was placed on gaining PCMH recognition, not necessarily the follow-up work that comes with a PCMH.

Subsequently, six other regions rolled out with variations of program models.

Based on a presentation by the former director of Gov. Rendell's Office of Health Care Reform, Ann Torregrossa, Esq., lessons were learned and changes made as the initiative moved into the next phase.

"Since the Pennsylvania initiative was launched," says William Sonnenberg, MD, president of the Pennsylvania Academy of Family Physicians, "we have learned more about how they can best be effective and certainly the model is evolving."

Dr. Sonnenberg adds, "A primary care practice needs to go through a fundamental shift in how it delivers care to become a medical home. The time frame covered by this study may be too short to detect significant change."

According to the National Academy for State Health Policy, The Commonwealth Fund funded RAND and Harvard School of Public Health to conduct an evaluation of Phase 1 of this chronic care initiative. But later phases would be researched by other groups. That research isn't available yet.

Margaret E. O'Kane, president of the National Committee for Quality Assurance (NCQA), told The New York Times that she found the RAND study frustrating because it was based on standards when the test project was in its earliest stage. Ms. O'Kane says standards were updated in 2011 and newer standards are about to be adopted once again.

"While the RAND study making headlines may accurately review the 2008 model in the Philadelphia area and the way the Southeast Pennsylvania Chronic Care Initiative was designed," says Allen Nussbaum, MD, FAAP, president of the PA Chapter American Academy of Pediatrics, "the pediatric practices involved can attest to improvements in patient care both for families and the practice staff. Pediatricians have long been committed to the medical home as the optimal care environment for children and their families."

What the study likely shows is that the Southeast Pennsylvania Chronic Care Initiative had early flaws, says Dr. Sonnenberg.

"This initial study only involved 32 practices in one area of the state," says Dr. Sonnenberg. "There is the suggestion that the patient-centered medical home shows its biggest advantage in those with chronic illnesses involving coordination of care. Studies should center on this population. Less advantage is seen treating populations requiring little care in any system."

According to Dr. MacLeod, the Pennsylvania Medical Society won't be jumping to any conclusions yet based upon this study and the organization would like to see research based upon later models.

"Part of providing the best care to patients that we can involves learning from what works, and what doesn't work," says Dr. MacLeod. "This study adds to that knowledge but we aren't giving up on medical homes as an important tool for managing the care of our patients. We look forward to further research which will help guide our public policy decisions."