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The American Journal of Managed Care July 2018
Differences in Spending on Provider-Administered Chemotherapy by Site of Care in Medicare
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Examining Differential Performance of 3 Medical Home Recognition Programs
Ammarah Mahmud, MPH; Justin W. Timbie, PhD; Rosalie Malsberger, MS; Claude M. Setodji, PhD; Amii Kress, PhD; Liisa Hiatt, MS; Peter Mendel, PhD; and Katherine L. Kahn, MD
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Mariétou H. Ouayogodé, PhD; Ellen Meara, PhD; Chiang-Hua Chang, PhD; Stephanie R. Raymond, BA; Julie P.W. Bynum, MD, MPH; Valerie A. Lewis, PhD; and Carrie H. Colla, PhD
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Wanzhen Gao, PhD; David Keleti, PhD; Thomas P. Donia, RPh; Jim Jones, MBA; Karen E. Michael, MSN, MBA, RN; and Andrea D. Gelzer, MD, MS, FACP
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Margje H. Haverkamp, MD, PhD; David Peiris, MD, PhD; Alexander J. Mainor, JD, MPH; Gert P. Westert, PhD; Meredith B. Rosenthal, PhD; Thomas D. Sequist, MD, MPH; and Carrie H. Colla, PhD
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Ann M. Annis, PhD, RN; Marcelline Harris, PhD, RN; Hyungjin Myra Kim, ScD; Ann-Marie Rosland, MD, MS; and Sarah L. Krein, PhD, RN
Inpatient Placement: Associations With Mortality, Cost, and Length of Stay
Daniel A. Handel, MD, MBA, MPH; Zemin Su, MS; Nancy Hendry, MSN; and Patrick Mauldin, PhD

Examining Differential Performance of 3 Medical Home Recognition Programs

Ammarah Mahmud, MPH; Justin W. Timbie, PhD; Rosalie Malsberger, MS; Claude M. Setodji, PhD; Amii Kress, PhD; Liisa Hiatt, MS; Peter Mendel, PhD; and Katherine L. Kahn, MD
We examine utilization, quality, and expenditures among Medicare beneficiaries receiving care at federally qualified health centers and compare outcomes among those attributed to 1 of 3 recognition programs versus none.

Objectives: We examined differences in patient outcomes associated with 3 patient-centered medical home (PCMH) recognition programs—National Committee for Quality Assurance (NCQA) Level 3, The Joint Commission (TJC), and Accreditation Association for Ambulatory Health Care (AAAHC)—among Medicare beneficiaries receiving care at federally qualified health centers (FQHCs).

Study Design: We used data from CMS’ FQHC Advanced Primary Care Practice Demonstration, in which participating FQHCs received assistance to achieve NCQA Level 3 PCMH recognition. We assessed the impact of the 3 recognition programs on utilization, quality, and Medicare expenditures using a sample of 1108 demonstration and comparison FQHCs.

Methods: Using propensity-weighted difference-in-differences analyses, we compared changes in outcomes over 3 years for beneficiaries attributed to FQHCs that achieved each type of recognition relative to beneficiaries attributed to FQHCs that did not achieve recognition.

Results: Recognized FQHCs, compared with nonrecognized FQHCs, were associated with significant 3-year changes in FQHC visits, non-FQHC primary care visits, specialty visits, emergency department (ED) visits, hospitalizations, a composite diabetes process measure, and Medicare expenditures. Changes varied in direction and strength by recognition type. In year 3, compared with nonrecognized sites, NCQA Level 3 sites were associated with greater increases in ambulatory visits and quality and greater reductions in hospitalizations and expenditures (<.01), TJC sites were associated with significant reductions in ED visits and hospitalizations (P <.01), and AAAHC sites had changes in the opposite direction of what we anticipated.

Conclusions: Heterogeneous changes in beneficiary utilization, quality, and expenditures by recognition type may be explained by differences in recognition criteria, evaluation processes, and documentation requirements.

Am J Manag Care. 2018;24(7):334-340
Takeaway Points

This study contributes to the literature assessing the effectiveness of medical home (MH) recognition programs on patient outcomes:
  • This analysis is the first to compare beneficiary outcomes across multiple MH recognition programs.
  • We document heterogeneity in the association between achievement of MH recognition and beneficiary outcomes among 3 MH recognition programs.
  • These study findings support the need to better understand how different components of MH recognition programs contribute to site-level changes and patient outcomes.
Many medical practices are pursuing primary care transformation using a medical home (MH) model.1,2 These models incorporate the joint principles of the patient-centered medical home (PCMH), which describe features of a strong primary care delivery system, including enhanced access, coordinated and comprehensive care, and continuous quality improvement.3-5 With time, additional administrative and financial burdens associated with primary care transformation have prompted a need to distinguish practices that systematically adhered to MH principles from those that did not.3,6-8

Over time, payers have encouraged practices to pursue MH recognition in order to codify practices’ use of PCMH principles.9,10 As of 2017, 3 organizations offer 3 common forms of MH recognition: National Committee for Quality Assurance (NCQA; 12,000 practice sites), the Accreditation Association for Ambulatory Health Care (AAAHC; 6000 practice sites), and The Joint Commission (TJC; 1400 practice sites).11-13

Despite the rapid growth of these programs, limited evidence exists on the relative effectiveness of different recognition types on patient outcomes.14-18 Although each program’s recognition standards align with core elements of the MH model, required elements vary for each program and may contribute to differences in outcomes. For example, recognition programs have differing criteria related to use of health information technology (IT), care coordination, and medication management. Additionally, each program assigns a different weight to these areas when measuring the extent of implementation of each program’s requirements.

Although descriptive work has compared recognition programs’ application procedures and recognition standards, no analyses have examined patient outcomes associated with these programs.19-23 Using data from a nationwide evaluation of an initiative to assist federally qualified health centers (FQHCs) in becoming PCMHs, we examine changes in utilization, quality, and Medicare expenditures associated with the terminal (ie, highest) MH recognition status of 3 recognition programs: NCQA 2011 Level 3 PCMH, TJC Primary Care MH, and AAAHC MH. As NCQA 2011 Level 1 and Level 2 PCMH are not terminal recognition levels, they are not included in this analysis. We hypothesized that changes in visits to FQHCs, primary care outside of FQHCs, specialists, and emergency departments (EDs); inpatient admissions; quality of care; and expenditures would vary by MH recognition type.


MH Recognition Programs

The 3 recognition programs examined differ in the content and specificity of their criteria, evaluation processes, and documentation requirements. We reviewed descriptive studies comparing these programs, as well as their online resources, to provide context for our analysis.22-26

NCQA has a practice site–level recognition program, meaning that sites affiliated with the same medical practice must individually pursue recognition. Practices pursuing recognition may achieve Level 1, 2, or 3 recognition based on the extent to which they meet specific standards.27 NCQA emphasizes meaningful use requirements; almost half of its recognition score is derived from IT capabilities.

In contrast, TJC recognition is awarded at the organizational level, meaning that a single recognition award is given to the organization spanning all of its practice sites. Practices seeking MH recognition must also meet criteria for TJC’s ambulatory care accreditation, which requires sites to implement foundational components for MH content areas; these do not disproportionately emphasize health IT capabilities. Uniquely, TJC requires sites to collect data on patient experience, which is not required for NCQA recognition.19,28

Similar to TJC, AAAHC operates an organizational-level program allowing practices to pursue MH recognition in addition to a foundational ambulatory care certification.21 Burton et al found that a large proportion of AAAHC recognition criteria require practices to develop policies related to patient care, staff development, and prevention practices. However, limited guidance is provided about the specification of these policies, which allows variance in site-level interpretation and implementation.19 Almost a quarter of the AAAHC recognition score derives from the development of these policies.

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