The American Journal of Managed Care August 2010
Value and the Medical Home: Effects of Transformed Primary Care
A patient-centered medical home with intensive case management and a payer partner can significantly improve hospital utilization and may decrease total medical costs for a Medicare population.
Background: The primary care medical home has been promoted to integrate and improve patient care while reducing healthcare spending, but with little formal study of the model or evidence of its efficacy. ProvenHealth Navigator (PHN), an intensive multidimensional medical home model that addresses care delivery and financing, was introduced into 11 different primary care practices. The goals were to improve the quality, efficiency, and patient experience of care.
Objective: To evaluate the ability of a medical home model to improve the efficiency of care for Medicare beneficiaries.
Study Design: Observational study using regression modeling based on preintervention and postintervention data and a propensity-selected control cohort.
Methods: Four years of claims data for Medicare patients at 11 intervention sites and 75 control groups were analyzed to compute hospital admission and readmission rates, and the total cost of care. Regression modeling was used to establish predicted rates and costs in the absence of the intervention. Actual results were compared with predicted results to compute changes attributable to the PHN model.
Results: ProvenHealth Navigator was associated with an 18% (P <.01) cumulative reduction in inpatient admissions and a 36% (P = .02) cumulative reduction in readmissions across the total population over the study period.
Conclusions: Investing in the capabilities of primary care practices to serve as medical homes may increase healthcare value by improving the efficiency of care. This study demonstrates that the PHN model is capable of significantly reducing admissions and readmissions for Medicare Advantage members.
(Am J Manag Care. 2010;16(8):607-614)
ProvenHealth Navigator (PHN), a multidimensional medical home model, was introduced into 11 Geisinger Health System primary care practices with the goal of improving the quality, efficiency, and patient experience of care for Medicare Advantage patients.
- This transformed primary care model resulted in significantly fewer hospital admissions (18%) and readmissions (36%) when measured across the entire population.
- Total care costs for the entire PHN population decreased 7%, but this decrease did not achieve statistical significance.
- Medical home models seeking to change cost trends require a multidimensional transformation of primary care practice with intensive case management and a payer partnership.
Elements of and antecedents to the current concept of the medical home have been shown to be associated with higher quality of care and patient experience.5-8 Closely related work on Wagner’s Chronic Care Model suggests the potential of this approach to improve the quality of care for patients with chronic conditions and prevent costly acute care.9-11 However, empirical evidence is scant about whether efforts to transform practices into medical homes will improve quality or yield healthcare cost savings. Two recent studies demonstrate both the challenges of practicing transformation in primary care and the potential benefits in terms of patient and provider experience as well as preventable acute care utilization.12,13
In this study, we evaluate the impact of a medical home model, Proven-Health Navigator (PHN), introduced for Medicare Advantage enrollees in 11 practices owned by Geisinger Health System (GHS) in Pennsylvania. ProvenHealth Navigator is a new model of care designed to improve the quality, efficiency, and patient experience of care. It functions as a partnership between participating primary care practices and Geisinger Health Plan (GHP). Central to the model is the transfer of population management capabilities, including nurse case managers, from the health plan to the practice sites. This report focuses on the impact of the PHN on hospitalization and healthcare spending compared with a matched set of practices, using 2 years of preintervention and 2 years of postintervention data.
We assembled medical claims data for services provided from January 1, 2005, through December 31, 2008,and paid through June 30, 2009, and demographic information for 15,310 members of GHP’s Medicare Advantage product. Using these data, we identified all claims for enrollees who were cared for by physician practices that implemented the PHN model and enrollees who were cared for by matched physician practices during the study period. Enrollees who switched physician practices during the study period were excluded from the analyses. Continuous enrollment was not required for inclusion in the study sample; analyses conducted on the continuously enrolled subpopulation yielded qualitatively similar results.
This analysis was approved by the GHS institutional review board.
Located in rural northeastern and central Pennsylvania, GHS is a not-for-profit, integrated healthcare organization comprised of the Geisinger Clinic, which has nearly 800 employed physicians; 2 acute tertiary/quaternary care hospitals; GHP, which serves 190,000 commercial and 38,000 Medicare Advantage members; and numerous other clinical programs and facilities. Geisinger Health Plan also utilizes a network of more than 18,000 non-GHS providers and 80 non-GHS hospitals.
Geisinger Health System has an electronic health record (EHR) implemented systemwide for all ambulatory and inpatient care. This EHR also is used by GHP case managers and patients. These EHR capabilities were operational in all participating practices for several years prior to the launch of the PHN. All Geisinger-owned primary care practices, including the PHN sites, participated in a preexisting, EHR-enabled quality initiative to improve preventive, diabetes, and coronary artery disease care.14
Implementation of ProvenHealth Navigator
The PHN model has 5 functional program components: (1) Patient-Centered Primary Care Team Practice, (2) Integrated Population Management, (3) Micro-delivery Systems, (4) Quality Outcomes Program, and (5) Value Reimbursement System (Table 1). A more detailed description of each component, with a comparison to the National Committee for Quality Assurance (NCQA) Physician Practice Connections and Patient-Centered Medical Home (PPC-PCMH)standards, can be found in the eAppendix at www.ajmc.com.
Many of the elements required under the PPC-PCMH standards are provided in the Patient-Centered Primary Care Team Practice component. Access criteria are met through close monitoring of performance on appointment standards (NCQA standard 1). Tracking and registry capabilities for several chronic diseases are embedded into the Primary Care Team Practice component’s EHR (NCQA standard 2). Reminders for preventive and chronic disease care are part of the quality improvement initiative described above (NCQA standards 3 and 8). Self-management support has been a central theme in the team-based care approach the practices use; disease and case management were added as part of the PHN model (NCQA standard 4). Electronic prescribing as well as test and referral tracking also are available in the EHR (NCQA standards 5, 6, and 7). Advanced communication capabilities for patients and providers are available through the electronic portals portion of the EHR system (NCQA standard 9).
Although the PHN model was created prior to the publication of NCQA’s PPC-PCMH standards, it does address all of the capabilities described in those standards. However, because our goal was to impact the quality, patient experience, and efficiency of care across the full continuum of care, not just in the office of the primary care physician (PCP), we believed that additional components and activities were necessary. The activities included in the 5 components are described further in Table 1. Several are worth noting. First, many of GHP’s population management activities were moved to the practice site. Geisinger Health Plan provided case managers for each practice at a ratio of 1 nurse for every 800 Medicare patients to serve as the hub for population-based activities. Second, the model explicitly calls for the PCPs to develop systems of care for their patients when they are seen by other physicians or in other settings. Third, additional financial support was provided by GHP to pay for new services in the PCP office. An example is dedicated phone lines to allow high-risk patients to contact their case managers directly. Fourth, performance reports documenting the quality, utilization, and overall cost-of-care results were provided to the practice. Finally, we added a shared savings incentive model to the GHP reimbursement arrangement. Qualityoutcomes were aligned with preexisting preventive and chronic disease care quality initiatives. Shared savings incentive payments then were based on improvement in bundled metrics for these services and other agreed-upon metrics.
Implementation was focused on the GHP Medicare Advantage population because the high prevalence of chronic illnesses and the resource use of this population provide the best opportunity to demonstrate and evaluate the impact of the interventions. In October 2006 and January 2007, the PHN model was introduced into 2 pilot GHS practice sites selected because of their large GHP Medicare Advantage population and because their locations made them easily accessible for our PHN management team. During 2007 and January of 2008, the PHN model was expanded to include the Medicare Advantage members in 9 additional practices (Table 2). Prior to implementation at each site, all practice staff were trained on the core components of the model.
Initially, the PHN teams focused on improving the management of the highest risk patients. The GHP-embedded case managers were integrated as part of the practice care team. They were provided with utilization and predictive modeling reports derived from GHP claims data. For the first time, these reports gave the practice teams a systematic way to identify relative risk for their GHP patients. The case managers then met with the highest risk patients to design patient-specific care plans. They also provided close follow-up for patients transitioning from hospital to home.This activity focused on reaching out to the patient within 48 hours of discharge, medication reconciliation, appropriate resources and social supports in the home, and timely follow-up with the patient’s PCP. Monthly team meetings that included PCPs, office staff, case managers, and GHP staff were held to evaluate results, discuss practice workflow and care access, and review hospital admissions for missed opportunities.
The case managers also formed partnerships with preferred home health agencies and nursing homes. Outreach and education regarding the PHN strategy were provided to these agencies. Pharmacy management initiatives were developed to improve generic utilization, assist members approaching the Medicare Part D coverage gap, and provide members with acute care protocols for treating exacerbations of chronic conditions.
As progress was made, expanded strategies focused on members at moderate and low risk. Patients with gaps in preventive or chronic care were identified by EHR registries and health plan claims tools. Health plan nurses with training in disease management targeted moderate-risk members with hypertension, coronary artery disease, and diabetes for selfmanagement education; worked with providers to ensure appropriate screenings; and assisted in optimizing medications. Site-based practice staff reached out to low-risk members to coordinate preventive care screenings such as mammograms, colorectal screening, and influenza vaccinations.
Measures of Impact
Because we hypothesized that opportunities to reduce total healthcare spending through this model would relate to the ability of the practice to prevent hospitalizations and readmissions, we constructed monthly series of these events for each patient. Readmissions were defined as all medical–surgical patients admitted to acute care within 30 days from time of discharge for primary admission. Total healthcare spending (plan payment plus copayment) was computed for each member for each month by summing the allowed amount on medical claims. Pharmacy claims were not included in total spending because of variability in prescription drug coverage among members and over time because of the introduction of Medicare Part D in 2006. To protect the confidentiality of GHP payment information, we indexed spending so that the mean for patients in the nonintervention practices in January 2005 was set to $100.