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The Impact of Patient-Centered Medical Homes on Safety Net Clinics
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The Impact of Patient-Centered Medical Homes on Safety Net Clinics

Li-Hao Chu, PhD; Michael Tu, MS; Yuan-Chi Lee, MS; Jennifer N. Sayles, MD; and Neeraj Sood, PhD
Adopting a patient-centered medical home model in safety net practices can effectively reduce emergency department use and increase the use of office visits among Medicaid patients.
Study Population

This study was based on a local MMP that initiated a PCMH pilot project. Participation in this initiative was voluntary to safety net clinics. The eligibility criteria included: 1) being located within Los Angeles county, 2) being a safety net provider, 3) being part of contracted provider network, and 4) not participating in another externally led PCMH program. The detailed selection criteria can be found in eAppendix A (eAppendices available at
Among 11 PCMH-certified safety net clinics in the greater Los Angeles area in early 2012, 7 clinics were included in the study because they contracted with at least 300 of the plan’s members.12 The comparison group was 110 safety net clinics with at least 300 of the plan’s members; these clinics were located in Los Angeles County, but prior to 2013, were not recognized as PCMHs by the National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Committee, and Joint Commission.
We focused on the non-SPD population younger than 65 years old, given that the SPD population did not complete the transition to an MMP until mid-2012. In addition, we excluded patients who switched between the PCMH and comparison group during the study. Lastly, we required a 10-month minimum Medicaid eligibility during each study year for both groups to ensure sufficient exposure or interaction between patients and their primary care physicians. The study cohort derivation flow is provided in eAppendix B.
Data Source
We used a local MMP’s administrative claims data from January 1, 2011, through December 31, 2013, in the analysis. The study timeframe spanned pre- and post-PCMH transformation. Under an MMP, all members are required to select, or are otherwise assigned to, a primary care physician. The PCMH cohort included members served by a primary care provider affiliated with a PCMH clinic, and the non-PCMH cohort included those served by a primary care provider affiliated with non-PCMH clinics. We also included data on the members’ demographics (age, gender, race/ethnicity, and enrollment history); service dates; episodes (hospital admission and ED visit); International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes; procedure codes; and pharmacy claims.
We identified comorbidities using the Medicaid Rx model, a pharmacy-based risk adjustment model to adjust capitated payments to health plans that enroll Medicaid beneficiaries.13
Outcome of Interest
Hospital admissions, ED visits, and office visits were measured using NCQA standard definitions.14 To more thoroughly examine the impact of PCMHs on ED visits, we also included avoidable ED visits, as defined by the California Department of Health Services Collaborative.15 All utilization rates are presented as per 1000 members per year (PTMPY).
Statistical Analysis
Observable characteristics between the PCMH and non-PCMH groups were compared using the Kruskal-Wallis and χ2 tests for continuous and categorical variables, respectively. For the main outcomes of interest, difference-in-differences (DID) analyses were conducted by fitting generalized estimating equations with negative binomial distributions and robust standard errors to account for heteroscedasticity and clustering of patients within practices.16 Independent variables included indicators for years 2012 and 2013 (with 2011 serving as a reference), members’ demographics and comorbidities, and interactions between time periods and PCMH/non-PCMH status. A 2-tailed P value <.05 was treated as significant in all statistical tests. All the data management and analyses were conducted using SAS version 9.3 (SAS Institute, Cary, North Carolina).
Semi-Structured Interviews

We met with leaders of 3 PCMH and 3 non-PCMH clinics (ie, chief executive officer, chief medical officer, and medical directors) and collected their feedback on PCMH models with in-depth, semi-structured interviews. The leaders were asked about clinic operations and their approaches to patient care, including the use of health IT, involving patients in decision making, disease management, measurement of quality, and access to care. The goal was to identify differences in attributes between the 2 cohorts, as well as to seek the opinion of clinic leaders on the plausibility of our study findings and the potential differences in clinic attributes that might explain the study results. The detailed survey questions are presented in eAppendix C. This study was approved by the Institutional Review Board at the University of Southern California. 

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