The American Journal of Managed Care June 2015
Impact of the Patient-Centered Medical Home on Veterans' Experience of Care
In our analysis, we controlled for patient-level covariates (ie, age, gender, income, ethnicity, race, and DCG risk score). In addition, we included PCP fixed effects (controlling for time-invariant differences across providers, allowing us to identify the effect of providers changing PACT status and allowing each PCP to serve as a control for him or herself), 6-month time period fixed effects (controlling for secular changes in the outcomes that are common to PACT and non-PACT providers), and a mean 0 random error component. All standard errors were adjusted for clustering within PCP using Huber-White estimators of variance.29,30
Between July 2010 and September 2012, 30,849 patient experience surveys were completed in VISN 4 that were linked to a provider and clinic site. Descriptions of the patient characteristics are shown in Table 1. A majority of our cohort of veterans were white males 65 years and older. The overall results of the SHEP survey demonstrate that veterans had a favorable patient experience of care in 3 domains: overall rating of VHA healthcare, overall rating of personal doctor/nurse, and how well doctor/nurse communicates (Figure 1).
During the 2.5-year study period of PACT implementation, there was a 10-fold increase in veterans who had a PACT provider (Figure 2). In addition, the percentage of PCPs who implemented specific elements of the PACT model increased in 8 of 9 measures (Table 2). For example, the percentage of PCPs who adopted high-risk registries increased from nearly 7% in the first time period to 64% in the last period. In contrast, we did not see an increase in the use of nurse medication protocols. During the study period, we also found that the quality of PACT implementation increased from 1 to 14 among PCPs in the cohort.
Our regression models examined the effect of PACT implementation measured in the 3 different ways on 5 domains of patient experience of care. Although we saw a substantial increase in the number of veterans with a PACT provider, in the PACT quality level, and in the adoption of PACT structural measures, we find little impact of PACT implementation on patient experience of care (Table 3). For example, having a PACT provider did not have an effect in any of the 5 patient care experience domains. In these models, the adjusted percentage-point difference in positive responses to patient experience of care between having a PACT provider and not having a PACT provider was less than 1 percentage point and not statistically significant. Similarly, there was no effect of a 10-point increase in the PCP PACT quality scale on any patient care experience measures.
Finally, we found that the effect of specific structural changes on patient care experience was generally small and not statistically significant. For 2 structural measures—alternative to face-to-face visits, and team communication and functioning—we found inconsistent results. We found that having alternatives to face-to-face visits was associated with a nearly 7-percentage-point (95% CI, –14.6 to –0.6; P = .03) worse rating in getting care needed, but we also discovered that policies related to team communication and functioning were associated with a 4-percentage-point (95% CI, 0.2-9.5; P = .04) higher rating in overall rating of the VHA.
A key foundation of the PCMH is improving patient experiences of care. However, despite wide adoption of the PCMH, there is little evidence of the impact of medical home transformation on patient experience of care.
We examined the impact of medical home implementation in the VHA on patient experiences of care. Over a 2.5-year time period, we found that there were significant structural changes made to improve primary care delivery. In a majority of structural measures of PACT implementation, primary care providers increased their adoption of these PCMH elements more than 7-fold. However, in our primary analysis, having a PACT provider or having PACT more effectively implemented was not associated with evidence of higher ratings in 5 major domains of patient care experience. We also found that a majority of structural measures were not associated with patient care experience; 2 cases were exceptions. Because we had multiple comparisons, these exceptions may in part be due to chance alone.
Our results represent an important contribution to the evidence on PCMH implementation and patient care experience. First, we provide evidence from one of the largest PCMH implementation initiatives in the country using a large cohort of patients. Second, we did not measure medical home implementation simply as an on-off switch; we also evaluated whether there was a dose effect of medical home on patient care experiences. By using qualitative data, we not only evaluated if successful implementation matters, but also which structural changes to support the medical home matter, if any. Although we did not find an association with medical home implementation on patient experience, this may simply represent the complexity required to measure and implement the medical home in practice.
On one hand, our results may seem surprising. We expected that improvement in patient experiences of care would be a core outcome of PCMH transformation. However, improving patient experiences of care is complex and influenced by an array of patient and social factors, including previous healthcare interactions, expectations, and attitudes that exist prior to any current experience within a healthcare system.20,31 It may be difficult for medical home transformation to influence the myriad of characteristics required to impact patient experience of care, especially over a relatively short period of time.
Our study has several important limitations. First, the medical home model may have significant lag effects. PCMH, like other innovations, may take time to have significant impact on patient experiences of care. During this early phase of primary care transformation, we may be measuring the effect of unanticipated disruptions needed for practices to become functional medical homes. Second, as with most survey data, we may have response bias. For example, we had a limited sample of racial and ethnic minorities, which can influence the generalizability of our findings in this population. In addition, given the changes to primary care delivery, patients with strong opinions—positive or negative—may have undue influence on our findings. Third, this is an observational study, and as such causality cannot be inferred. Finally, while we use 3 unique measures of medical implementation, most based on qualitative data, this method has limits. For example, we assume providers become fully trained in PACT implementation on the date they became a PACT provider. However, providers may in fact take weeks to years to become proficient at implementing the principles of the medical home. While the interviewees were told about the confidentiality of the interviews, they may have overstated the positives that the clinic and providers have made in medical home transformation.
Despite several limitations, our study provides important insights on the impact of medical home implementation on patient experiences of care. Most medical home implementation efforts have focused on the establishment of key structural elements of the model without sufficient emphasis on the interpersonal aspects of primary care that contribute to improving patients’ experience of care. Increasing focus on these relational aspects around improved communication and trust may be central to improving patient care experience. As we move forward with the medical home model, it will be key to obtain more qualitative and quantitative data on what patients want in a medical home or a primary care practice more generally. As we focus on primary care transformation to improve healthcare delivery, we need to find ways to incorporate the patient’s voice and input into these transitions.
Author Affiliations: VISN 4 Center for Evaluation of PACT, Philadelphia VA Medical Center (AR, AC, RMW), Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania (AR, RMW), Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania (AR, RMW), Philadelphia, PA; Robert Wood Johnson Clinical Scholars Program, University of Pennsylvania (AR), Philadelphia, PA.
Source of Funding: This work was supported by the Robert Wood Johnson Foundation Clinical Scholars Program. Funding for the PACT Demonstration Laboratory initiative is provided by the VA Office of Patient Care Services.
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 (AR, RMW); acquisition of data (AR, AC, RMW); analysis and interpretation of data (AR, RMW); drafting of the manuscript (AR, RMW); critical revision of the manuscript for important intellectual content (AR, RMW); statistical analysis (AR, RMW); obtaining funding (RMW); administrative, technical, or logistic support (AC, RMW); and supervision (RMW).
Address correspondence to: Ashok Reddy, MD, Robert Wood Johnson Clinical Scholar, University of Pennsylvania, Perelman School of Medicine, Blockley Hall – 1303, 423 Guardian Dr, Philadelphia, PA 19104-6021. E-mail: firstname.lastname@example.org.REFERENCES
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. Bodenheimer T, Fernandez A. High and rising health care costs. part 4: can costs be controlled while preserving quality? Ann Intern Med. 2005;143(1):26-31.
3. Greenfield S, Rogers W, Mangotich M, Carney MF, Tarlov AR. Outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus treated by different systems and specialties. results from the medical outcomes study. JAMA. 1995;274(18):1436-1444.
4. Parchman ML, Culler S. Primary care physicians and avoidable hospitalizations. J Fam Pract. 1994;39(2):123-128.
5. NCQA Patient Centered-Medical Homes. Fact Sheet 2013. National Committee for Quality Assurance website. http://www.ncqa.org/Portals/0/Newsroom/2013/pcmh%202011%20fact%20sheet.pdf. Accessed May 14, 2015.
6. Baron RJ. New pathways for primary care: an update on primary care programs from the innovation center at CMS. Ann Fam Med. 2012;10(2):152-155.
7. 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.
8. 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.
9. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49:796-804.
10. Roter DL. Observations on methodological and measurement challenges in the assessment of communication during medical exchanges. Patient Educ Couns. 2003;50(1):17-21.
11. Post DM, Cegala DJ, Miser WF. The other half of the whole: teaching patients to communicate with physicians. Fam Med. 2002;34(5):344-352.
12. Pignone M, Bucholtz D, Harris R. Patient preferences for colon cancer screening. J Gen Intern Med. 1999;14(7):432-437.
13. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152(9):1423-1433.
14. Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989;27(3 suppl):S110-S127.
15. Record JD, Rand C, Christmas C, et al. Reducing heart failure readmissions by teaching patient-centered care to internal medicine residents. Arch Intern Med. 2011;171(9):858-859.
16. Meterko M, Wright S, Lin H, Lowy E, Cleary PD. Mortality among patients with acute myocardial infarction: the influences of patient-centered care and evidence-based medicine. Health Serv Res. 2010;45(5, pt 1):1188-1204.
17. Reid RJ, Fishman PA, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009;15(9):e71-e87.
18. Heyworth L, Bitton A, Lipsitz SR, et al. Patient-centered medical home transformation with payment reform: patient experience outcomes. Am J Manag Care. 2014;20(1):26-33.
19. Kern LM, Dhopeshwarkar RV, Edwards A, Kaushal R. Patient experience over time in patient-centered medical homes. Am J Manag Care. 2013;19(5):403-410.
20. Martsolf GR, Alexander JA, Shi Y, et al. The patient-centered medical home and patient experience. Health Serv Res. 2012;47(6):2273-2295.
21. Jaén CR, Ferrer RL, Miller WL, et al. Patient outcomes at 26 months in the patient-centered medical home National Demonstration Project. Ann Fam Med. 2010;8 (suppl 1):S57-S67;S92.
22. Rosland AM, Nelson K, Sun H, et al. The patient-centered medical home in the Veterans Health Administration. Am J Manag Care. 2013;19(7):e263-e272.
23. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med. 2003;348(22):2218-2227.
24. Kizer KW. The “new VA”: a national laboratory for health care quality management. Am J Med Qual. 1999;14(1):3-20. Review.
25. Nelson KM, Helfrich C, Sun H, et al. Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use. JAMA Intern Med. 2014;174(8):1350-1358.
26. Wright SM, Craig T, Campbell S, Schaefer J, Humble C. Patient satisfaction of female and male users of Veterans Health Administration services. J Gen Intern Med. 2006;21(suppl 3):S26-S32.
27. Hausmann LR, Gao S, Mor MK, Schaefer JH Jr, Fine MJ. Understanding racial and ethnic differences in patient experiences with outpatient health care in Veterans Affairs Medical Centers. Med Care. 2013;51(6):532-539.
28. Werner RM, Canamucio A, Shea JA, True G. The medical home transformation in the Veterans Health Administration: an evaluation of early changes in primary care delivery. Health Serv Res. 2014;49(4):1329-1347.
29. Huber PJ. The behavior of maximum likelihood estimates under nonstandard conditions. Proceedings of the Fifth Berkeley Symposium on Mathematical Statistics and Probability. 1967;1(1):221-233. http://projecteuclid.org/euclid.bsmsp/1200512988.
30. Halbert W. A heteroskedasticity-consistent covariance matrix estimator and a direct test for heteroskedasticity. Econometrica: Journal of the Econometric Society. 1980;48(4):817-838.
31. Rodriguez HP, von Glahn T, Rogers WH, Safran DG. Organizational and market influences on physician performance on patient experience measures. Health Serv Res. 2009;44(3):880-901.