Currently Viewing:
The American Journal of Managed Care January 2015
Disease-Modifying Therapy and Hospitalization Risk in Heart Failure Patients
Fadia T. Shaya, PhD, MPH; Ian M. Breunig, PhD; and Mandeep R. Mehra, MD, FACC, FACP, FRCP
Frequency and Costs of Hospital Transfers for Ambulatory Care-Sensitive Conditions
R. Neal Axon, MD, MSCR; Mulugeta Gebregziabher, PhD; Janet Craig, PhD, RN; Jingwen Zhang, MS; Patrick Mauldin, PhD; and William P. Moran, MD, MS
Celebrating Our 20th Anniversary
A. Mark Fendrick, MD, and Michael E. Chernew, PhD Co-Editors-in-Chief, The American Journal of Managed Care
Value-Based Insurance Design: Benefits Beyond Cost and Utilization
Teresa B. Gibson, PhD; J. Ross Maclean, MD; Michael E. Chernew, PhD; A. Mark Fendrick, MD; and Colin Baigel, MBChB
Changing Physician Behavior: What Works?
Fargol Mostofian, BHSc; Cynthiya Ruban, BSc; Nicole Simunovic, MSc; and Mohit Bhandari, MD, PhD, FRCSC
State of Emergency Preparedness for US Health Insurance Plans
Raina M. Merchant, MD, MSHP; Kristen Finne, BA; Barbara Lardy, MPH; German Veselovskiy, MPP; Casey Korba, MS; Gregg S. Margolis, NREMT-P, PhD; and Nicole Lurie, MD, MSPH
Relationship of Diabetes Complications Severity to Healthcare Utilization and Costs Among Medicare Advantage Beneficiaries
Leslie Hazel-Fernandez, PhD, MPH; Yong Li, PhD; Damion Nero, PhD; Chad Moretz, ScD; S. Lane Slabaugh, PharmD, MBA; Yunus Meah, PharmD; Jean Baltz, MMSc, MSW; Nick C. Patel, PharmD, PhD; and Jonathan R. Bouchard, MS, RPh
Revisiting Hospital Length of Stay: What Matters?
Mollie Shulan, MD; and Kelly Gao
Currently Reading
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
New Start Versus Continuing Users on Aripiprazole: Implications for Policy
Rashid Kazerooni, PharmD, BCPS; Joseph B. Nguyen, PharmD, BCPS; Mark Bounthavong, PharmD, MPH; Michael H. Tran, PharmD, BCPS; and Nermeen Madkour, PharmD, CSP
Multiple Chronic Conditions in Type 2 Diabetes Mellitus: Prevalence and Consequences
Pei-Jung Lin, PhD; David M. Kent, MD, MSc; Aaron Winn, MPP; Joshua T. Cohen, PhD; and Peter J. Neumann, ScD
Prognostic Factors of Mortality Among Patients With Severe Hyperglycemia
Ya-Wun Guo, MD; Tzu-En Wu, MD, MS; and Harn-Shen Chen, MD, PhD
Survey Nonresponders Incurred Higher Medical Utilization and Lower Medication Adherence
Seppo T. Rinne, MD, PhD; Edwin S. Wong, PhD; Jaclyn M. Lemon, BS; Mark Perkins, PharmD; Christopher L. Bryson, MD; and Chuan-Fen Liu, PhD
Using Financial Incentives to Improve the Care of Tuberculosis Patients
Cheng-Yi Lee, MS; Mei-Ju Chi, PhD; Shiang-Lin Yang, MS; Hsiu-Yun Lo, PhD; and Shou-Hsia Cheng, PhD

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.


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.


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:
1. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. Review.

2. Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Aff (Millwood). 2004;Suppl Web Exclusives:W4-184-197.

3. American College of Physicians. Reform of the dysfunctional healthcare payment and delivery system: a position paper. Published April 2006. Accessed November 2012.

4. Moore G, Showstack J. Primary care medicine in crisis: toward reconstruction and renewal. Ann Intern Med. 2003;138(3):244-247.

5. Bodenheimer T, Berry-Millett R. Follow the money—controlling expenditures by improving care for patients needing costly services. N Engl J Med. 2009;361(16):1521-1523.

6. Margolius D, Bodenheimer T. Transforming primary care: from past practice to the practice of the future. Health Aff (Millwood). 2010;29(5):779-784.

7. Weiss LJ, Blustein J. Faithful patients: the effect of long-term physician-patient relationships on the costs and use of health care by older Americans. Am J Public Health. 1996;86(12):1742-1747.

8. Flocke SA, Frank SH, Wenger DA. Addressing multiple problems in the family practice office visit. J Fam Pract. 2001;50(3):211-216.

9. Thorpe KE, Howard DH. The rise in spending among Medicare beneficiaries: the role of chronic disease prevalence and changes in treatment intensity. Health Aff (Millwood). 2006;25(5):w378-w388.

10. Higgins S, Chawla R, Colombo CM, Snyder RL, Nigam S. Medical homes and cost and utilization among high-risk patients. Am J Manag Care. In press.

11. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home. Published February 2007. Accessed November 2012.

12. Berenson RA, Hammons T, Gans DN, et al. A house is not a home: keeping patients at the center of practice redesign. Health Aff (Millwood). 2008;27(5):1219-1230.

13. Peikes D, Zutshi A, Genevro JL, Parchman ML, Meyers DS. Early evaluations of the medical home: building on a promising start. Am J Manag Care. 2012;18(2):105-116.

14. Reid RJ, Coleman K, Johnson EA, et al. The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29(5):835-843.

15. Harbrecht MG, Latts LM. Colorado’s patient-centered medical home pilot met numerous obstacles, yet saw results such as reduced hospital admissions. Health Aff (Millwood). 2012;31(9):2010-2017.

16. DeVries A, Li CH, Sridhar G, Hummel JR, Breidbart S, Barron JJ. Impact of medical homes on quality, healthcare utilization, and costs. Am J Manag Care. 2012;18(9):534-544.

17. Flottemesch TJ, Scholle SH, O’Connor PJ, Solberg LI, Asche S, Pawlson LG. Are characteristics of the medical home associated with diabetes care costs? Med Care. 2012;50(8):676-684.

18. Jackson GL, Powers BJ, Chatterjee R, et al. Improving patient care. The patient centered medical home: a systematic review. Ann Intern Med. 2013;158(3):169-178.

19. Hoff T, Weller W, DePuccio M. The patient-centered medical home: a review of recent research. Med Care Res Rev. 2012;69(6):619-644.

20. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311(8):815-825.

21. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288(14):1775-1779.

22. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001;20(6):64-78.

23. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74(4):511-544.

24. Fiscella K, Williams DR. Health disparities based on socioeconomic inequities: implications for urban health care. Acad Med. 2004;79(12):1139-1147. Review.

25. Eberhardt MS, Pamuk ER. The importance of place of residence: examining health in rural and nonrural areas. Am J Public Health. 2004;94(10):1682-1686.

26. National Committee for Quality Assurance. Standards and Guidelines for Physician Practice Connections—Patient-Centered Medical Home (PPC-PCMH). Washington, DC: National Committee for Quality Assurance; 2008.

27. Verisk Health Inc. Sightlines DxCG Risk Solutions: Concepts and Methodologies Guide for UNIX. Waltham, MA: Verisk Health, 2010.

28. Fortney JC, Steffick DE, Burgess JF Jr, Maciejewski ML, Petersen LA. Are primary care services a substitute or complement for specialty and inpatient services? Health Serv Res. 2005;40(5 Pt 1):1422-1442.

29. Wang QC, Chawla R, Colombo CM, Snyder RL, Nigam S. Patient-centered medical home impact on health plan members with diabetes. J Public Health Manag Pract. 2014;20(5):E12-E20.

30. Rittenhouse DR, Casalino LP, Gillies RR, Shortell SM, Lau B. Measuring the medical home infrastructure in large medical groups. Health Aff (Millwood). 2008;27(5):1246-1258.

31. Rosenthal MB, Friedberg MW, Singer SJ, Eastman D, Li Z, Schneider EC. Effect of a multipayer patient-centered medical home on health care utilization and quality: the Rhode Island Chronic Care Sustainability Initiative pilot program. JAMA Intern Med. 2013:173(20):1907-1913.

32. Zuckerman S, Merrell K, Berenson R, et al. Incremental Cost Estimates for the Patient-Centered Medical Home. New York: The Commonwealth Fund; 2009.
Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up