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Patient-Centered Medical Home Features and Expenditures by Medicare Beneficiaries

Erica L. Stockbridge, MA; Lindsey M. Philpot, PhD, MPH; and José Pagán, PhD
Analysis of the impact of individual features of the patient-centered medical home care model on future healthcare expenditures among Medicare beneficiaries.
Table 2 reports the unadjusted and adjusted average expenditures associated with each of the PCMH features (see eAppendix B for CIs). Having little to no difficulty contacting the regular source of care over the telephone during regular business hours was associated with significantly lower total expenditures and inpatient expenditures. The adjusted average inpatient expenditures for individuals who had little to no difficulty contacting their regular source of care by telephone during business hours was $3230, while the adjusted average inpatient expenditures for individuals who reported difficulty was $6966, a difference of $3736 (P = .0177). Total adjusted average healthcare expenditures were also significantly lower for individuals who had no difficulty contacting their regular source of care by telephone during business hours. The adjusted average total healthcare expenditures for individuals who had little difficulty contacting their regular source of care during business hours was $10,117, while the adjusted average total expenditures for individuals who had difficulty was $12,984, a difference of $2867 (P = .031).

On the other hand, there were no significant differences in the adjusted average annual medical expenditures for outpatient services (difference of –$888, P = .0852), ED services (difference of –$59, P = .4443), pharmacy services (difference of $94, P = .6782), or other health services (difference of $195, P = .3122) depending on whether or not the patient had difficulty contacting his or her usual source of care by telephone during business hours.

Having a regular source of care with office hours at night or on the weekend was associated with significantly lower outpatient, ED, and other healthcare expenditures. The adjusted average outpatient expenditures for individuals who had a usual source of care with office hours at night or on the weekend was $2531, while the adjusted average outpatient expenditures for individuals without a usual source of care with this feature was $3066, a difference of $535 (P = .0201). The adjusted average ED expenditures for individuals who had a usual source of care with office hours at night or on the weekend was $195, while the adjusted average ED expenditures for individuals without a usual source of care with this feature was $298, a difference of $103 (P = .0234). The adjusted average for other health expenditures for individuals who had a usual source of care with office hours at night or on the weekend was $1057, while the adjusted average for other health expenditures for individuals without a usual source of care with this feature was $1386, a difference of $328 (P = .0181). However, there were no significant differences in the adjusted average annual medical expenditures in total (difference of –$1485, P = .065) or for inpatient services (difference of –$879, P = .2028) or pharmacy services (difference of $34, P = .8693) depending on whether or not the usual source of care had office hours at night or on the weekend.

Having no difficulty contacting the usual source-ofcare provider after regular hours was not associated with significant differences in total or in any individual health service category. There were no significant differences in the adjusted average annual medical expenditures for total health services (difference of $967, P = .2334), outpatient services (difference of –$84, P = .7905), inpatient services (difference of $1380, P = .0665), ED services (difference of –$15, P = .8012), pharmacy services (difference of $169, P = .3908), or other health services (difference of –$122, P = .5349) depending on whether or not the patient had difficulty contacting his or her usual source-of-care provider after regular hours.

There were no statistically significant differences in the adjusted average annual medical expenditures for total health services (difference of –$279, P = .7729), outpatient services (difference of $23, P = .9311), inpatient services (difference of –$360, P = .7068), ED services (difference of –$41, P = .5252), or other health services (difference of $141, P = .423) depending on whether or not the usual source of care asked about medications and treatments prescribed by other doctors. However, the average pharmacy expenditures differed significantly depending on whether or not the usual source of care asked about medications and treatments prescribed by other doctors. The adjusted average pharmacy expenditures for individuals whose usual source of care asked about medications and treatments prescribed by other doctors was $2735, while the adjusted average pharmacy expenditures for individuals whose usual source of care did not ask about medications and treatment prescribed by other doctors was $2372, a difference of $362 (P = .0387).

Having a usual source of care that always or usually asks the patient to help decide between treatments was not associated with significant differences in total expenditures or in any individual health service category. There were no significant differences in the adjusted average annual medical expenditures for total health services (difference of $3, P = .9974), outpatient services (difference of –$8, P = .978), inpatient services (difference of $151, P = .8436), ED services (difference of $64, P = .3239), pharmacy services (difference of –$337, P = .2284), or other health services (difference of –$116, P = .6173) depending on whether or not the patient was asked to help decide between treatments.

DISCUSSION

Having little to no difficulty contacting a regular source of care over the telephone during regular business hours was associated with significantly lower total healthcare expenditures as well as lower inpatient expenditures, which may be related to reduced hospitalizations. However, there were no significant differences in adjusted average annual healthcare expenditures for outpatient, ED, pharmacy, and other health services. Having a regular source of care with office hours at night or on the weekend was associated with significantly lower outpatient, ED, and other healthcare expenditures—perhaps due to a reduction in ED use—but it was not associated with significant differences in the adjusted average annual healthcare expenditures for inpatient or pharmacy services.

Having no difficulty contacting the usual source-ofcare provider after regular hours was not associated with significant differences in total expenditures or in any individual health service category. There were also no statistically significant differences in the adjusted average annual healthcare expenditures for outpatient, inpatient, ED, and other health services depending on whether or not the usual source of care asked about medications and treatments prescribed by other doctors.

Average pharmacy expenditures differed significantly depending on whether or not the usual source of care asked about medications and treatments prescribed by other doctors. This finding may be related to better medication management. For example, when a doctor asks about medication and treatments prescribed by other doctors, then this may be a marker for better medication management; the end result is that prescription expenditures will be higher, but all other expenditures may remain the same. Lastly, having a usual source of care that always or usually asks the patient to help decide between treatments was not associated with significant differences in total expenditures or in any individual health service category.

This study has several limitations. Some features of PCMHs could not be included in the current study because MEPS did not ask questions related to all the relevant PCMH features (eg, adoption of EHRs, use of evidence-based clinical protocols, degree of care coordination when transitioning between different levels of care). However, this study clearly points out the need to identify how individual PCMH features or components impact healthcare expenditures across different policyrelevant categories to better manage care. More specifically, the PCMH Recognition Program by the NCQA allows medical practices to qualify for financial incentives from health insurance plans and employers. Recognition is determined by achieving a set of standards related to, for example, patient access, communication, data tracking, and performance reporting.18 CMS also has developed programs to reward practices that fully implement PCMH models (eg, the CPC Initiative).12 Although studies have shown that PCMHs can improve care coordination and communication,1-4 this study reveals that practices that have not fully adopted a PCMH model can still make progress in improving healthcare quality while reducing or controlling costs if they adopted even some modest features of a PCMH model. For example, Medicare could consider incentivizing medical practices that adopt individual cost-saving features of PCMHs and, thus, facilitate the progression of these medical practices toward a fully implemented PCMH model. Although the precise identification of cost-saving PCMH features remains a challenge, given data constraints, this may be the only financially feasible path available for many medical practices that are unable to fully absorb the costs associated with PCMH implementation. Future research is needed to more precisely identify and track how PCMH features related to the use of EHRs and performance reporting are directly related to quality and cost over the long term.

Author Affiliations: University of North Texas Health Science Center, School of Public Health, Department of Health Management and Policy, Fort Worth, TX (ELS, LMP); Magellan Health Services, Analytic Services Department, Maryland Heights, MO (ELS); Baylor Scott & White Health, Office of the Chief Quality Officer, Dallas, TX (LMP); Center for Health Innovation, The New York Academy of Medicine, New York, NY (JAP); Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (JAP).

Source of Funding: None reported.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (ELS, LMP, JAP); analysis and interpretation of data (ELS, LMP, JAP); drafting of the manuscript (ELS, LMP, JAP); critical revision of the manuscript for important intellectual content (ELS, LMP, JAP); statistical analysis (ELS, LMP); administrative, technical, or logistic support (ELS).

Address correspondence to: Erica L. Stockbridge, Department of Health Management and Policy, School of Public Health, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX 76107. E-mail: els0127@live.unthsc.edu.
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