Currently Viewing:
The American Journal of Managed Care August 2015
Differential Impact of Mental Health Multimorbidity on Healthcare Costs in Diabetes
Leonard E. Egede, MD, MS; Mulugeta Gebregziabher, PhD; Yumin Zhao, PhD; Clara E. Dismuke, PhD; Rebekah J. Walker, PhD; Kelly J. Hunt, PhD, MSPH; and R. Neal Axon, MD, MSCR
Clinical Efficacy: A Cost Containment Weapon for the 21st Century
Lonny Reisman, MD, Chief Executive Officer, HealthReveal
Opportunity Costs of Ambulatory Medical Care in the United States
Kristin N. Ray, MD, MS; Amalavoyal V. Chari, PhD; John Engberg, PhD; Marnie Bertolet, PhD; and Ateev Mehrotra, MD, MPH
A Comparison of Relative Resource Use and Quality in Medicare Advantage Health Plans Versus Traditional Medicare
Bruce E. Landon, MD, MBA, MSc; Alan M. Zaslavsky, PhD; Robert Saunders, PhD; L. Gregory Pawlson, MD, MPH; Joseph P. Newhouse, PhD; and John Z. Ayanian, MD, MPP
Medicare Shared Savings Program: Public Reporting and Shared Savings Distributions
John Schulz, BA; Matthew DeCamp, MD, PhD; and Scott A. Berkowitz, MD, MBA
Global Payment Contract Attitudes and Comprehension Among Internal Medicine Physicians
Joshua Allen-Dicker, MD, MPH; Shoshana J. Herzig, MD, MPH; and Russell Kerbel, MD, MBA
Addressing the Primary Care Workforce Crisis
Zirui Song, MD, PhD; Vineet Chopra, MD, MSc; and Laurence F. McMahon, Jr, MD, MPH
Currently Reading
The Association Among Medical Home Readiness, Quality, and Care of Vulnerable Patients
Lena M. Chen, MD, MS; Joseph W. Sakshaug, PhD; David C. Miller, MD, MPH; Ann-Marie Rosland, MD, MS; and John Hollingsworth, MD, MS
Feasibility of Integrating Standardized Patient-Reported Outcomes in Orthopedic Care
James D. Slover, MD, MS; Raj J. Karia, MPH; Chelsie Hauer, MPH; Zachary Gelber, DDS; Philip A. Band, PhD; and Jove Graham, PhD
A Randomized Controlled Trial of Co-Payment Elimination: The CHORD Trial
Kevin G. Volpp, MD, PhD; Andrea B. Troxel, ScD; Judith A. Long, MD; Said A. Ibrahim, MD, MPH; Dina Appleby, MS; J. Otis Smith, EdD; Jane Jaskowiak, BSN, RN; Marie Helweg-Larsen, PhD; Jalpa A. Doshi, PhD; and Stephen E. Kimmel, MD, MSCE
A Randomized Controlled Trial of Negative Co-Payments: The CHORD Trial
Kevin G. Volpp, MD, PhD; Andrea B. Troxel, ScD; Judith A. Long, MD; Said A. Ibrahim, MD, MPH; Dina Appleby, MS; J. Otis Smith, EdD; Jalpa A. Doshi, PhD; Jane Jaskowiak, BSN, RN; Marie Helweg-Larsen, PhD; and Stephen E. Kimmel, MD, MSCE

The Association Among Medical Home Readiness, Quality, and Care of Vulnerable Patients

Lena M. Chen, MD, MS; Joseph W. Sakshaug, PhD; David C. Miller, MD, MPH; Ann-Marie Rosland, MD, MS; and John Hollingsworth, MD, MS
The characteristics of patients who visit practices that are ready versus unready for the patient-centered medical home differ in important ways.

RESULTS
We examined 17,358 visits, representing 341 million adult outpatient visits to general practitioners and internists during the study interval. Nearly three-fourths occurred at practices ready for the PCMH (Table). Compared with patients seen at visits to unready practices, patients seen at visits to ready practices were more likely to have 3 or more comorbid conditions (25% of visits to PCMH-ready practices vs 17% of visits to other practices; P = .001). However, visits to both types of practices were similar with respect to race/ethnicity and socioeconomic status. Practice characteristics of both types of visits were also similar except for physician ownership and rural location, although this latter finding was not statistically significant (P = .058). In sensitivity analyses with broader categories, 2 findings became statistically significant. When we compared visits in the South with all other practices, visits in the South were less likely to occur at PCMH-ready compared with unready practices (36% vs 52%; P = .049). Similarly, when we compared privately insured visits with all other visits, privately insured visits were more likely to occur at PCMH-ready compared with unready practices (57% vs 51%; P = .047).

Visits to PCMH-ready practices were generally more likely to meet the medication and counseling/screening quality indicators, although this difference reached statistical significance for only 3 indicators (Figures 1 and 2). For example, 18% of visits to ready practices included diet counseling, compared with 12% of visits to unready practices (P = .018). Similarly, exercise counseling occurred at 14% of visits to ready practices, but at only 5% of visits to unready practices (P <.001). For medication quality indicators, at visits to ready practices (vs unready ones), 41% (vs 32%) of patients were prescribed a diuretic or beta-blocker for hypertension (P values for difference = .031).

DISCUSSION
Our study had 2 principal findings. First, while visit rates among racial minorities and patients from poorer neighborhoods did not differ based on a practice’s PCMH readiness, those most ready for this new care model have a disproportionate share of patients with multiple comorbid conditions. Second, ready practices, at baseline, delivered higher or equivalent quality care in all dimensions.

Our study must be considered in the context of prior work on the value of health information technology (IT) tools, which the NCQA PCMH standards emphasize heavily. Many of the NAMCS items that we evaluated mapped to the NCQA elements that capture health IT tools. To the extent that the use of health IT improves chronic disease management,20 our finding that visits by patients with multiple chronic conditions are more likely to occur at ready practices is reassuring. Second, evidence is still being gathered to assess whether medical homes deliver better-quality care across multiple domains (eg, patient satisfaction, clinical processes of care, patient outcomes).1,3,21 While a fully developed medical home is clearly more than the sum of its parts, our observation of modestly higher quality among visits to ready practices provides 1 piece of evidence to suggest that adoption of PCMH components may be beneficial to care quality.

Limitations
Our study has several important limitations. First, we ascertained PCMH readiness by matching survey responses about a practice’s infrastructure and processes of care to 1 standard of medical home readiness: the NCQA PCMH standard. However, prior studies have utilized this method,13,22 and the NCQA standard has been widely adopted and was developed with input from organizations such as the American College of Physicians.23 Second, because the NAMCS questions are not based on the NCQA PCMH standard, we could not perfectly match NCQA elements to NAMCS questions, nor could we match all NCQA elements to an NAMCS question. This may have resulted in some misclassification of ready practices as unready or vice versa, but the directionality of this bias is difficult to ascertain. Prior work has found the NAMCS-NCQA matching approach robust to missing data (see eAppendix 2). Third, our measures of quality were limited by the cross-sectional nature of the NAMCS survey. However, the quality measures have been validated,16-19 and one of the criteria for constructing these measures with NAMCS data was that the measures have a high likelihood of correlating with improved patient outcomes.17 Nevertheless, we cannot make conclusions about causality between medical home readiness and quality of care. Fourth, it is possible that better scores on exercise and diet counseling measures for PCMH-ready versus unready practices reflect better documentation at PCMH-ready practices, since many of the NCQA measures that we mapped to NAMCS rely on health IT tools.
 
Implications
In spite of these limitations, our findings on care quality have implications for PCMH implementation strategy. To date, policy makers have often tested these models in practices most ready for transformation into a fully recognized PCMH.12,24 For example, 2 large CMS programs provide incentives to practices that already have some medical home capabilities. Criteria for inclusion in CMS’ Comprehensive Primary Care Initiative include having some level of medical home recognition. CMS’ Multi-payer Advanced Primary Care Practice Demonstration provides a monthly care management fee for beneficiaries receiving primary care from a medical home. Moreover, programs often require that participating practices attain a certain level of medical home readiness as early as 1 year after enrollment. This too would seem to favor the participation of practices that are PCMH-ready (or nearly ready). Our data support these efforts, as they suggest that such a strategy will not leave out a disproportionate number of visits by poor or minority patients, or by patients with multiple comorbidities.1,4-7

CONCLUSIONS
While it is reasonable to design PCMH programs that may attract the most PCMH-ready practices first, policy makers should also take steps to ensure that the least ready practices are not left behind. This would also shed light on the broader generalizability of results from early implementation efforts at PCMH-ready practices. Future research should examine whether or not PCMH incentives that account for baseline levels of medical home readiness are effective in bringing along the least ready practices. For example, in the Medicare Shared Savings Program, tailored incentives exist for provider organizations at different stages of becoming an accountable care organization25; a similar approach might be utilized to support PCMH adoption by a wide range of practices. Implementation of PCMHs will require as much care as ongoing, related work that assesses the net benefits of PCMH adoption.


Acknowledgments
Michael Wu assisted with data preparation and was compensated for his work. Preliminary findings were presented as posters at the Society of General Internal Medicine Annual Meeting and the Academy Health Annual Research Meeting, both in 2012.


Author Affiliations: Division of General Medicine, Department of Internal Medicine, University of Michigan (LMC, AMR), Ann Arbor, MI; VA Ann Arbor Healthcare System (LMC), VA Center for Clinical Management Research (AMR), Ann Arbor, MI; Center for Healthcare Outcomes & Policy, University of Michigan (LMC, DCM, JH), Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan (LMC, DCM, AMR, JH), Ann Arbor, MI; Department of Statistical Methods, Institute for Employment Research (JWS), Nuremberg, Germany; Department of Sociology, University of Mannheim (JWS), Mannheim, Germany; Department of Urology, Dow Division of Health Services Research University of Michigan (DCM, JH), Ann Arbor, MI.

Source of Funding: Dr Chen is supported by K08HS020671, Dr Miller is supported by K08HS018346, and Dr Hollingsworth is supported by K08HS020927, all from the Agency for Healthcare Research and Quality (AHRQ). Dr Rosland is a VA Health Services Research and Development (HSR&D) Career Development Awardee. This material is the result of work supported with resources from the VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System.

Author Disclosures: Dr Hollingsworth has received funding from AHRQ. Drs Chen, Sakshaug, Miller, and Rosland 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 (LMC, JH, DCM, AMR); acquisition of data (JH, JWS); analysis and interpretation of data (LMC, JH, DCM, AMR, JWS); drafting of the manuscript (LMC, JH, DCM); critical revision of the manuscript for important intellectual content (LMC, JH, AMR, JWS); statistical analysis (LMC, JWS); obtaining funding (LMC, JH, DCM, AMR); and supervision (JH).

Address correspondence to: Lena M. Chen, MD, MS, University of Michigan Division of General Medicine, North Campus Research Complex, 2800 Plymouth Rd, Bldg 16, Rm 407E, Ann Arbor, MI 48109-2800. E-mail: lenac@umich.edu.

REFERENCES

1. 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.

2. 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.

3. 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. Review.

4. 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.

5. Paulus RA, Davis K, Steele GD. Continuous innovation in health care: implications of the Geisinger experience. Health Aff (Millwood). 2008;27(5):1235-1245.

6. Raskas RS, Latts LM, Hummel JR, Wenners D, Levine H, Nussbaum SR. Early results show WellPoint’s patient-centered medical home pilots have met some goals for costs, utilization, and quality. Health Aff (Millwood). 2012;31(9):2002-2009.

7. Reid RJ, Johnson EA, Hsu C, et al. Spreading a medical home redesign: effects on emergency department use and hospital admissions. Ann Fam Med. 2013;11(suppl 1):S19-S26.

8. Driscoll DL, Hiratsuka V, Johnston JM, et al. Process and outcomes of patient-centered medical care with Alaska Native people at Southcentral Foundation. Ann Fam Med. 2013;11(suppl 1):S41-S49.

9. Fifield J, Forrest DD, Burleson JA, Martin-Peele M, Gillespie W. Quality and efficiency in small practices transitioning to patient centered medical homes: a randomized trial. J Gen Intern Med. 2013;28(6):778-786.

10. 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.

11. Bitton A, Martin C, Landon BE. A nationwide survey of patient centered medical home demonstration projects. J Gen Intern Med. 2010;25(6):584-592.

12. Multi-payer Advanced Primary Care Practice (MAPCP) demonstration fact sheet. CMS website. http://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf. Updated April 5, 2012. Accessed October 26, 2012.

13. Hollingsworth JM, Saint S, Sakshaug JW, Hayward RA, Zhang L, Miller DC. Physician practices and readiness for medical home reforms: policy, pitfalls, and possibilities. Health Serv Res. 2012;47(1, pt 2):486-508.

14. About the Ambulatory Health Care Surveys. CDC website. http://www.cdc.gov/nchs/ahcd/about_ahcd.htm. Updated July 14, 2009. Accessed June 27, 2015.

15. NCQA’s patient-centered medical home (PCMH) 2011 standards. National Committee for Quality Assurance website. http://www.ncqa.org/Portals/0/Public%20Policy/PCMH_2011_fact_sheet.pdf. Accessed June 27, 2015. 

16. Chen LM, Farwell WR, Jha AK. Primary care visit duration and quality: does good care take longer? Arch Intern Med. 2009;169(20):1866-1872.

17. Ma J, Stafford RS. Quality of US outpatient care: temporal changes and racial/ethnic disparities. Arch Intern Med. 2005;165(12):1354-1361.

18. Linder JA, Ma J, Bates DW, Middleton B, Stafford RS. Electronic health record use and the quality of ambulatory care in the United States. Arch Intern Med. 2007;167(13):1400-1405.

19. Romano MJ, Stafford RS. Electronic health records and clinical decision support systems: impact on national ambulatory care quality. Arch Intern Med. 2011;171(10):897-903.

20. Rao S, Brammer C, McKethan A, Buntin MB. Health information technology: transforming chronic disease management and care transitions. Prim Care. 2012;39(2):327-344.

21. 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.

22. Zickafoose JS, Clark SJ, Sakshaug JW, Chen LM, Hollingsworth JM. Readiness of primary care practices for medical home certification. Pediatrics. 2013;131(3):473-482.

23. NCQA patient-centered medical home 2011. National Committee for Quality Assurance website. http://www.ncqa.org/Portals/0/PCMH2011%20withCAHPSInsert.pdf. Accessed May 23, 2013.

24. CMS and Center for Medicare and Medicaid Innovation. Comprehensive Primary Care (CPC) Initiative: primary care practice solicitation. CMS website. http://innovation.cms.gov/Files/x/CPC_PracticeSolicitation.pdf. Accessed June 25, 2013.

25. Berenson RA, Burton RA. Accountable care organizations in Medicare and the private sector: a status update. Urban Institute website. http://www.urban.org/uploadedpdf/412438-Accountable-Care-Organizations-in-Medicare-and-the-Private-Sector.pdf. Published November 3, 2011. Accessed June 25, 2013. 
PDF
 
Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
x
Welcome the the new and improved AJMC.com, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up