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Medical Homes: Cost Effects of Utilization by Chronically Ill Patients

Jason Neal, MA; Ravi Chawla, MBA; Christine M. Colombo, MBA; Richard L. Snyder, MD; and Somesh Nigam, PhD
A longitudinal case-control design was used to evaluate the effects of the patient-centered medical home model on medical costs and utilization among chronically ill patients.
Although we employed the same rigorous adjustments used by the GHC study, some differences at baseline were not specifically accounted for in the regression adjustments used. For example, while all patients in the Pennsylvania study satisfied the criterion of displaying some chronic illness or illnesses, PCMH and non-PCMH practices may have had a different case mix. Though patient-level variation was accounted for, at least in part, by use of the DxCG risk score in the regression adjustments, future research might consider identifying the most useful practice changes for specified conditions or assessing whether practice case mix drives the decision to adopt PCMH innovations.

Furthermore, observed differences may be driven in part by self-selection on the part of primary care practices; practices with a trajectory toward electronic health records, enhanced case management, and so forth may have been more likely to seek NCQA certification early in the process. Future work based on finer practice-level variation could account for these baseline differences and could also assess the relative impact of higher levels of NCQA certification and within-level variation in order to distinguish the contributions of various components of the PCMH model to improving care and controlling costs and utilization. One promising method for follow-up studies would be to pair difference-in-difference regression analysis with case-control matching in order to get equal samples from PCMH and non-PCMH practices, and to achieve improved control of practice-level differences such as size and affiliation.

CONCLUSION

This study joins a growing body of research which suggests that the PCMH model offers a promising mechanism for addressing primary care’s pressing concerns with respect to delivering quality care and facing potentially unsustainable cost growth. By supporting patient self-management and improving coordination of care, practices adopting the PCMH model were able to achieve relative decreases in cost and utilization at the highest levels of care intensity (inpatient admissions) by chronically ill patients. In light of these findings, policy makers and healthcare thought leaders should continue to emphasize the PCMH as a vehicle for improving primary care, particularly for patients with complex, chronic conditions.

Acknowledgments

The authors thank Susannah Higgins, Manu Tyagi, Sara Fritz, Qiuyan Cindy Wang, Aaron Smith-McLallen, and Pam Eckardt of Independence Blue Cross, Philadelphia, for their assistance in data collection, analysis, and review. The authors acknowledge the assistance of CTI Clinical Trial & Consulting Services, Inc, Cincinnati, a paid consultant to Independence Blue Cross, for their technical support and editing during the manuscript preparation.

Author Affiliations: Independence Blue Cross (JN, RC, CMC, RLS, SN), Philadelphia, PA.

Source of Funding: This study was funded by Independence Blue Cross, an independent licensee of the Blue Cross and Blue Shield Association.

Author Disclosures: During the course of the study, all of the authors were employed by Independence Blue Cross. Physicians subject to the study are contracted as in-network by Independence Blue Cross for agreed-upon reimbursement of covered services.

Authorship Information: Concept and design (JN, RC, RLS, SN); acquisition of data (JN); analysis and interpretation of data (JN, RC, CMC, RLS, SN); drafting of the manuscript (JN, RLS); critical revision of the manuscript for important intellectual content (JN, CMC, RLS, SN); statistical analysis (JN); administrative, technical, or logistic support (RC, RLS); supervision (RC, CMC, SN).

Address correspondence to: Jason Neal, MA, Independence Blue Cross, 1901 Market St, 22nd Fl, Philadelphia, PA 19103. E-mail: Jason.Neal@ibx.com.
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