Currently Viewing:
The American Journal of Managed Care November 2019
Population Health Screenings for the Prevention of Chronic Disease Progression
Maren S. Fragala, PhD; Dov Shiffman, PhD; and Charles E. Birse, PhD
Comprehensive Health Management Pharmacist-Delivered Model: Impact on Healthcare Utilization and Costs
Leticia R. Moczygemba, PhD, PharmD; Ahmed M. Alshehri, PhD; L. David Harlow III, PharmD; Kenneth A. Lawson, PhD; Debra A. Antoon, BSPharm; Shanna M. McDaniel, MA; and Gary R. Matzke, PharmD
One Size Does Not Always Fit All in Value Assessment
Anirban Basu, PhD; Richard Grieve, PhD; Daryl Pritchard, PhD; and Warren Stevens, PhD
Value Assessment and Heterogeneity: Another Side to the Story
Steven D. Pearson, MD, MSc
From the Editorial Board: Joshua J. Ofman, MD, MSHS
Joshua J. Ofman, MD, MSHS
Multimodality Cancer Care and Implications for Episode-Based Payments in Cancer
Suhas Gondi, BA; Alexi A. Wright, MD, MPH; Mary Beth Landrum, PhD; Jose Zubizarreta, PhD; Michael E. Chernew, PhD; and Nancy L. Keating, MD, MPH
Medicare Advantage Plan Representatives’ Perspectives on Pay for Success
Emily A. Gadbois, PhD; Shayla Durfey, BS; David J. Meyers, MPH; Joan F. Brazier, MS; Brendan O’Connor, BA; Ellen McCreedy, PhD; Terrie Fox Wetle, PhD; and Kali S. Thomas, PhD
Cost Analysis of COPD Exacerbations and Cardiovascular Events in SUMMIT
Richard H. Stanford, PharmD, MS; Anna D. Coutinho, PhD; Michael Eaddy, PharmD, PhD; Binglin Yue, MS; and Michael Bogart, PharmD
CKD Quality Improvement Intervention With PCMH Integration: Health Plan Results
Joseph A. Vassalotti, MD; Rachel DeVinney, MPH, CHES; Stacey Lukasik, BA; Sandra McNaney, BS; Elizabeth Montgomery, BS; Cindy Voss, MA; and Daniel Winn, MD
Importance of Reasons for Stocking Adult Vaccines
David W. Hutton, PhD; Angela Rose, MPH; Dianne C. Singer, MPH; Carolyn B. Bridges, MD; David Kim, MD; Jamison Pike, PhD; and Lisa A. Prosser, PhD
Prescribing Trend of Pioglitazone After Safety Warning Release in Korea
Han Eol Jeong, MPH; Sung-Il Cho, MD, ScD; In-Sun Oh, BA; Yeon-Hee Baek, BA; and Ju-Young Shin, PhD
Currently Reading
Multipayer Primary Care Transformation: Impact for Medicaid Managed Care Beneficiaries
Shaohui Zhai, PhD; Rebecca A. Malouin, PhD, MPH, MS; Jean M. Malouin, MD, MPH; Kathy Stiffler, MA; and Clare L. Tanner, PhD

Multipayer Primary Care Transformation: Impact for Medicaid Managed Care Beneficiaries

Shaohui Zhai, PhD; Rebecca A. Malouin, PhD, MPH, MS; Jean M. Malouin, MD, MPH; Kathy Stiffler, MA; and Clare L. Tanner, PhD
The Michigan Primary Care Transformation project generated cost savings among adults in Medicaid managed care, particularly high-risk adults, while largely maintaining quality of care.

Objectives: To evaluate the effects of Michigan Primary Care Transformation (MiPCT), a statewide multipayer patient-centered medical home (PCMH) demonstration in 2012-2015, on cost, utilization, and quality among Medicaid managed care beneficiaries.

Study Design: Observational longitudinal study with comparison groups.

Methods: Difference-in-differences (DID) analyses compared changes in outcomes among beneficiaries whose primary care providers participated in MiPCT, non-MiPCT PCMH, and non-PCMH practices. Net cost savings were derived.

Results: The study included 173,179 MiPCT, 209,181 non-MiPCT PCMH, and 148,657 non-PCMH beneficiaries. Against 1 or both comparison groups relative to 2011, MiPCT adults had significant reductions in cost, emergency department (ED) visits, and hospitalization risk in 2015. Against both comparison groups, MiPCT high-risk adults showed significant cost reduction in 2014-2015, ED reduction in 2015, and reduced hospitalization risk in 2013-2015. For children, no significant relative change in cost occurred, but both ED and hospitalization risk were reduced in 2015. In 2013-2015, cumulative net cost savings were $15,569,526 (95% CI, $3,416,832-$27,722,219) (return on investment [ROI], $3.60) for adults and $23,998,180 (95% CI, $11,782,031-$36,214,347) (ROI, $10.69) for high-risk adults, and a cost increase of $16,517,948 (95% CI, $7,712,286-$25,323,609) (ROI, –$1.30) for children. Quality metrics were significantly higher in MiPCT in most years, although most DID estimates were not significant.

Conclusions: Evidence of cost savings exists among MiPCT Medicaid managed care adults; it was driven by high-risk adults, who also had reduced hospitalization risk. For children, no cost reductions occurred, but hospital and ED utilization were reduced in 2015. MiPCT maintained equal or higher quality of care but did not show consistent improvement.

Am J Manag Care. 2019;25(11):e349-e357
Takeaway Points

Compared with similar nonparticipating groups and relative to baseline, Medicaid managed care beneficiaries assigned to physicians in practices participating in a large statewide multipayer patient-centered medical home demonstration exhibited:
  • Significant cost savings among adults, driven by savings among high-risk adults
  • Significantly reduced risk of hospitalization among high-risk adults
  • No cost savings and utilization reductions among children until the project’s fourth year
  • Better or equal quality of care, but no improvement over time
The patient-centered medical home (PCMH) has become the standard for primary care practices in the United States. Medicaid provides health insurance for populations who may benefit from PCMH.1 More than half of US states have implemented PCMH within Medicaid.2 Findings from one study indicated that 64% of Medicaid beneficiaries report having a usual source of care with some attributes of a PCMH.3 Results have been mixed.4-7 Iowa experienced reduced healthcare spending primarily due to reductions in emergency department (ED) utilization, whereas Louisiana and Alabama experienced no reduction in overall costs.4-6 Mixed results are similarly reflected in PCMH initiatives within commercial populations.8-10 Additionally, many Medicaid PCMH evaluations have identified greater utilization of services addressing unmet socioeconomic needs of beneficiaries, often through efforts of care managers within the practices.2,9

Medicaid PCMH initiatives have often been introduced through multipayer demonstrations, such as the Multi-Payer Advanced Primary Care Program (MAPCP), Comprehensive Primary Care initiatives (CPC and CPC+), and State Innovation Model initiatives.11 Few of these have been comprehensively evaluated for Medicaid outcomes.12-15

Several payers and health systems in Michigan were early adopters in the transformation of primary care. The Blue Cross Blue Shield of Michigan (BCBSM) Physician Group Incentive Program (PGIP)’s PCMH model began in 2009 and the Priority Health PCMH pilot began in 2008.16-18

The Michigan Primary Care Transformation (MiPCT) project, the first multipayer PCMH program in Michigan, was the largest participant in MAPCP. MiPCT operated from January 2012 to December 2016.19 Michigan Medicaid, Medicare, and 3 commercial payers (BCBSM, Blue Care Network, and Priority Health) participated with up to $9.50 per member per month (PMPM) contributed from Medicare and $7.50 PMPM from the other payers, plus $0.26 PMPM for administration. Medicaid accounted for 26% of the total MiPCT population (more than 1.1 million as of 2015).

This study focuses on the Medicaid managed care population, as Medicaid fee-for-service beneficiaries were not part of MiPCT. By 2011, 88% of Michigan Medicaid beneficiaries were enrolled in managed care.20 Medicaid health plans are required to maintain certification from a national certifying body (eg, the National Committee for Quality Assurance) and provide telephonic case management. Managed care beneficiaries either self-select their primary care providers (PCPs) or accept health plan–assigned PCPs.

A key feature of MiPCT was the provision of embedded care management services, with at least 2 trained care managers per 5000 patients. Care managers, often nurses or social workers embedded within primary care practice teams, are becoming increasingly utilized in new models of primary care, as evidenced in several national and regional PCMH and primary care demonstrations.21-25 These embedded care managers have been found to be acceptable to primary care teams26 and more effective in patient engagement than traditional case management by disease management companies.27,28

MiPCT care managers were physically located within the practice, documented patients’ visits in their electronic health record, communicated directly with physicians and other care team members electronically and in person, and were provided lists of high-risk beneficiaries and encouraged to work with providers to target those who could most benefit. MiPCT provided training for care managers and facilitated learning across practices. Other MiPCT requirements were to have an all-patient registry to address gaps in care and to provide advanced access (open access scheduling and options for care outside of business hours).

Other practices in Michigan continued to build PCMH capacity throughout the study period, albeit with fewer resources and without multipayer alignment. This study compared MiPCT beneficiaries with beneficiaries served in both other PCMH and non-PCMH practices. Given the ongoing PCMH programming of key commercial payers, and mature managed care in Medicaid, a key question is whether the multipayer approach to transformation had benefits over and above existing efforts. Because care management was targeted to high-risk beneficiaries, improvements were expected to be largest for this population.

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