Medical Homes and Cost and Utilization Among High-Risk Patients
Published Online: March 24, 2014
Susannah Higgins, MS; Ravi Chawla, MBA; Christine Colombo, MBA; Richard Snyder, MD; and Somesh Nigam, PhD
The patient-centered medical home (PCMH) has been advanced as a promising framework for transforming primary care. In 2007, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association issued the “Joint Principles of the Patient-Centered Medical Home,” which outlined the PCMH model. The medical home model emphasizes a team-based approach to primary care, in which a physician-leader coordinates care by other providers across multiple sites and specialties. It encourages increased access, both in terms of expanding practice hours and opening new channels of communication with patients. Organizations such as the Patient-Centered Primary Care Collaborative have initiated numerous pilot programs aimed at studying the impact of PCMH adoption,1 and the PCMH model was written into the Patient Protection and Affordable Care Act of 2010 as an area for study.2
A number of previous studies have shown early promise for the PCMH model as a vehicle for controlling costs and improving the quality of healthcare delivered by primary care practices,3-6 including for targeting subpopulations such as children with special health needs.7 However, reviews often point to the incomplete nature of this work, citing methodological concerns,5,7,8 insufficient time for practices to implement reforms, and inadequate policy support beyond the level of individual practices.4 This study aims to contribute to this literature by comparing the effects of adopting the PCMH model on the healthcare cost and utilization in the nonpediatric population, using propensity score matching in order to reduce variability in the PCMH and non- PCMH groups studied. Additionally, the analysis employs difference-indifferences regression analysis in order to further control for remaining differences in patients’ characteristics as well as cost and utilization at baseline.
This study aims to assess the impact of PCMH adoption on the patients identified as having the greatest health risks. While the Joint Principles envision the PCMH model as being applicable to all patients, other pilots have targeted only high-risk patients with complex needs.9 The high cost of care associated with relatively few individuals makes such targeting a potentially powerful mechanism: one study noted that virtually all of the growth in expenditures for Medicare over the period from 1987 to 2002 occurred among beneficiaries with 5 or more chronic illnesses10; another paper noted that only 10% of Medicare beneficiaries accounted for 70% of healthcare costs.11 In order to evaluate whether the benefits of medical homes are limited to such high-risk, high-cost subpopulations, this study reports cost and utilization comparisons 2 ways: first, for all matched patients; and subsequently, limited to the patients with risk scores in the 90th percentile or above for the study population.
The majority of the PCMH practices (15/17) included in this study were part of Pennsylvania’s Chronic Care Initiative, a multi-stakeholder effort to improve primary care, which launched a 3-year pilot project that started in May 2008 in the Philadelphia area. The largest commercial health plans— led by Independence Blue Cross, all 3 Medicaid managed care plans, and 32 practices caring for 250,000 members—were convened by the governor to establish the first of several regional PCMH programs. Practices received significant additional payments to participate in a learning collaborative which supported practice transformation and provided the care management and coordination services required by patients with chronic conditions. The learning collaborative was based on Wagner’s Chronic Care Model12 and led by the MacColl Institute, with Edward H. Wagner, MD, MPH, facilitating the first session.
Practices were required to send a physician and a practice support leader to 7 days of sessions. Practice coaches provided ongoing support and education on installing and using a registry to track and monitor patients and implementing a team-based approach involving care managers, health educators, and other nonphysician healthcare personnel to promote self-management skills and patient engagement.13 Additionally, clinical guidelines were used to create evidence-based standing orders to optimize patient care. Practices used their electronic systems to identify and stratify patients in need of care management, selfmanagement support, and goal monitoring. Patient engagement was promoted through the use of report cards, on which concrete data from each visit are logged for patients so they can monitor their progress.
To provide a definition of the PCMH model, the authors employed the recognition standards published by the National Committee for Quality Assurance (NCQA). These standards list 9 categories encompassing 30 possible practice improvements (including 10 “must pass” items), each of which has a point value. Three levels of certification are possible, with each defined by a minimum number of “must pass” items achieved and specified point totals. The full list of recognition criteria appears in Table 1.14 Practices qualified for PCMH status by achieving NCQA Level 1 recognition or higher during 2009, and the control group was limited to practices which did not receive recognition until 2011 or later.
Study Population and Design
This study employs a longitudinal, case-control design to compare members of commercial health maintenance organizations (HMOs) enrolled in nonpediatric PCMH and non-PCMH practices with respect to healthcare costs and utilization during the period from 2009 to 2011. All figures are reported first for the full matched cohort of cases and controls (N = 6940 cases and 6940 controls), and then using the 10% of patients with highest risk scores, drawn from the pooled population of cases and controls (N = 654 cases and 734 controls).
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