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The American Journal of Managed Care May 2019
Evaluation of Value-Based Insurance Design for Primary Care
Qinli Ma, PhD; Gosia Sylwestrzak, MA; Manish Oza, MD; Lorraine Garneau; and Andrea R. DeVries, PhD
The Presurgical Episode: An Untapped Opportunity to Improve Value
Erika D. Sears, MD, MS; Rodney A. Hayward, MD; and Eve A. Kerr, MD, MPH
Clarification of References to Medication Adherence Scale
Open Doors to Primary Care Should Add a “Screen” to Reduce Low-Value Care
Betsy Q. Cliff, MS; and A. Mark Fendrick, MD
From the Editorial Board: Daniel B. Wolfson, MHSA
Daniel B. Wolfson, MHSA
Cost-Effectiveness of DPP-4 Inhibitor and SGLT2 Inhibitor Combination Therapy for Type 2 Diabetes
Manjiri Pawaskar, PhD; S. Pinar Bilir, MS; Stacey Kowal, MS; Claudio Gonzalez, MD; Swapnil Rajpathak, MD; and Glenn Davies, DrPH
Improving Provider Directory Accuracy: Can Machine-Readable Directories Help?
Michael Adelberg, MA, MPP; Austin Frakt, PhD; Daniel Polsky, PhD; and Michelle Kitchman Strollo, DrPH, MHS
Electronic Consults for Improving Specialty Care Access for Veterans
David E. Winchester, MD, MS; Anita Wokhlu, MD; Juan Vilaro, MD; Anthony A. Bavry, MD, MPH; Ki Park, MD; Calvin Choi, MD; Mark Panna, MD; Michael Kaufmann, MD; Matthew McKillop, MD; and Carsten Schmalfuss, MD
Potential Impact of Pharmaceutical Industry Rebates on Medication Adherence
Leah L. Zullig, PhD; Bradi B. Granger, PhD; Helene Vilme, DrPH; Megan M. Oakes, MPA; and Hayden B. Bosworth, PhD
Producing Comparable Cost and Quality Results From All-Payer Claims Databases
Maria de Jesus Diaz-Perez, PhD; Rita Hanover, PhD; Emilie Sites, MPH; Doug Rupp, BS; Jim Courtemanche, MS; and Emily Levi, MPH
Beyond Satisfaction Scores: Exploring Emotionally Adverse Patient Experiences
Laura M. Holdsworth, PhD; Dani L. Zionts, MScPH; Karen Marie De Sola-Smith, PhD; Melissa Valentine, PhD; Marcy D. Winget, PhD; and Steven M. Asch, MD
Currently Reading
Patient-Centered Medical Homes and Preventive Service Use
Joel F. Farley, PhD; Arun Kumar, PharmD, MS; Benjamin Y. Urick, PharmD, PhD; and Marisa E. Domino, PhD

Patient-Centered Medical Homes and Preventive Service Use

Joel F. Farley, PhD; Arun Kumar, PharmD, MS; Benjamin Y. Urick, PharmD, PhD; and Marisa E. Domino, PhD
Preventive service use was better in patients with a usual source of care but little improved by patient-centered medical home status.
ABSTRACT

Objectives: Despite data suggesting that patient-centered medical homes (PCMHs) improve preventive service use, limited nationally representative evidence exists. This study compared preventive service use between patients with and without a usual source of care (USC) and, of the patients with a USC, between those in practices with and without PCMH status.

Study Design: This study used a cross-sectional study design.

Methods: We constructed general and disease-specific preventive service indicators using the 2015 Medical Expenditure Panel Survey. Preventive service rates were compared between patients reporting a USC versus no USC and between patients whose USC practices were PCMH certified versus not PCMH certified. Unadjusted outcomes were tested using χ2 tests. Multivariable logistic regression was used to test differences between groups, controlling for predisposing, enabling, and need variables.

Results: Using multivariable logistic regression, respondents with a USC reported higher rates of screening for breast cancer (odds ratio [OR], 2.40; 95% CI, 1.81-3.17) and cervical cancer (OR, 1.99; 95% CI, 1.61-2.47) than respondents with no USC. Diabetes respondents with a USC had higher odds of an annual eye exam (OR, 2.05; 95% CI, 1.26-3.33) than respondents with no USC. Diabetes respondents with a USC that was PCMH certified reported higher rates of annual foot screenings (OR, 2.01; 95% CI, 1.31-3.08) and lower rates of annual cholesterol screenings (OR, 0.30; 95% CI, 0.11-0.83) than those with a USC that was not PCMH certified.

Conclusions: Having a USC was associated with higher rates of several preventive screening measures. However, there were fewer significant preventive screening relationships by PCMH status among individuals with a USC. Our results suggest that improving access to a USC may be as important as the application of PCMH principles to a USC practice.

Am J Manag Care. 2019;25(5):e153-e159
Takeaway Points

Our study compared preventive service use between patients with and without a usual source of care (USC) and, of the patients with a USC, between those in practices with and without patient-centered medical home (PCMH) status, using the 2015 Medical Expenditure Panel Survey database.
  • Patients with a USC had higher odds of receiving preventive services for cancer, diabetes, and asthma treatment than patients without a USC.
  • Few differences were observed in the use of preventive services among patients with a USC that was certified as a PCMH in comparison with respondents with a USC not certified as a PCMH.
Chronic disease management is a major challenge facing the US healthcare system.1-4 The majority of chronic disease management occurs in the primary care setting, which provides an opportunity for preventive screening and treatment.5 Identifying a provider or place as a usual source of care (USC) can improve preventive service use.6 However, it is suggested that primary care management is best achieved when a USC provider delivers patient-centered care and assists in care coordination across providers.7,8

The patient-centered medical home (PCMH) emphasizes the role of a primary care provider in coordinating care across settings and services.9 Under National Committee for Quality Assurance (NCQA) guidance, PCMH practices agree to adopt 6 key concepts: (1) emphasizing team-based care and practice organization, (2) knowing and managing patients through comprehensive data collection and sharing, (3) patient-centered access and continuity, (4) care management and support, (5) care coordination and care transitions, and (6) performance measurement and quality improvement.10 These key concepts emphasize provider roles and responsibilities under the team-based care model, focus on longitudinal relationships between patients and providers, highlight the delivery of evidence-based screening as measures of performance, and provide data availability to providers to identify gaps in preventive screening. Therefore, the adoption of PCMH principles has the potential to contribute to better preventive care service delivery. A 2013 systematic review of 19 PCMH studies suggests improved patient care experiences and preventive service delivery.11 A more recent systematic review of the PCMH literature in low-income patients showed improvements in clinical outcomes, increases in medication adherence, and lower emergency department (ED) utilization.12

Despite growing evidence of benefit, PCMH studies are primarily conducted as regional demonstrations. A notable exception is the Comprehensive Primary Care Plus program, which includes 2932 practices across 18 regions.13 To our knowledge, only 1 study has examined PCMH benefits across a nationally representative population in the United States.14 However, this study extrapolated the definition of a medical home practice and did not measure PCMH certification status directly. In addition, the majority of PCMH studies compare outcomes between patients enrolled or not enrolled in medical homes within a health system or health plan offering medical home services. This restricts the assessment of the potential benefit that the medical home model might have to patients who do not currently have a USC due to problems accessing insurance, financial constraints, or other burdens. The objective of this study is to compare the quality of preventive services provided to patients with and without an identified USC and to further determine whether USC practices with PCMH certification status improve the receipt of preventive services more than USC practices that are not PCMH certified in a broad representative sample of the US population.

METHODS

Study Design

This study uses a cross-sectional study design to compare receipt of preventive services in patients with no USC with that of patients with a USC that is either certified or not certified as a PCMH. Data were derived from the 2015 Medical Expenditure Panel Survey (MEPS), a national probability sample of the US civilian noninstitutionalized population.15 This study used the household component, prescribed medicines, and medical condition files, as well as the newly released Medical Organizations Survey (MOS) files, from MEPS. The MOS was first fielded in 2015 to the subset of MEPS respondents reporting a USC.16 The MOS collects information on organizational and financial characteristics of practices that respondents identified as their USC, including a question about the practice’s PCMH certification status.

Population Inclusion/Exclusion

In 2015, MEPS data were collected on 35,427 respondents. We extracted cohorts of patients according to the age, gender, and condition criteria relevant to technical specifications of each quality metric. The sample size for each measure differed according to the measure’s inclusion and exclusion criteria.


 
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