Dataset Information

The CareFirst Patient-Centered Medical Home Program: Cost and Utilization Effects in Its First Three Years.

ABSTRACT:

Background

Enhanced primary care models have diffused slowly and shown uneven results. Because their structural features are costly and challenging for small practices to implement, they offer modest rewards for improved performance, and improvement takes time.

Objective

To test whether a patient-centered medical home (PCMH) model that significantly rewarded cost savings and accommodated small primary care practices was associated with lower spending, fewer hospital admissions, and fewer emergency room visits.

Design

We compared medical care expenditures and utilization among adults who participated in the PCMH program to adults who did not participate. We computed difference-in-difference estimates using two-part multivariate generalized linear models for expenditures and negative binomial models for utilization. Control variables included patient demographics, county, chronic condition indicators, and illness severity.

Participants

A total of 1,433,297 adults aged 18-64 years, residing in Maryland, Virginia, and the District of Columbia, and insured by CareFirst for at least 3 consecutive months between 2010 and 2013.

Intervention

CareFirst implemented enhanced fee-for-service payments to the practices, offered a large retrospective bonus if annual cost and quality targets were exceeded, and provided information and care coordination support.

Measures

Outcomes were quarterly claims expenditures per member for all covered services, inpatient care, emergency care, and prescription drugs, and quarterly inpatient admissions and emergency room visits.

Results

By the third intervention year, annual adjusted total claims payments were $109 per participating member (95 % CI: -$192, -$27), or 2.8 % lower than before the program and compared to those who did not participate. Forty-two percent of the overall decline in spending was explained by lower inpatient care, emergency care, and prescription drug spending. Much of the reduction in inpatient and emergency spending was explained by lower utilization of services.

Conclusions

A PCMH model that does not require practices to make infrastructure investments and that rewards cost savings can reduce spending and utilization.

SUBMITTER: Cuellar A

PROVIDER: S-EPMC5071295 | biostudies-literature | 2016 Nov

REPOSITORIES: biostudies-literature

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Publications

The CareFirst Patient-Centered Medical Home Program: Cost and Utilization Effects in Its First Three Years.

Cuellar Alison A Helmchen Lorens A LA Gimm Gilbert G Want Jay J Burla Sriteja S Kells Bradley J BJ Kicinger Iwona I Nichols Len M LM

Journal of general internal medicine 20160729 11

<h4>Background</h4>Enhanced primary care models have diffused slowly and shown uneven results. Because their structural features are costly and challenging for small practices to implement, they offer modest rewards for improved performance, and improvement takes time.<h4>Objective</h4>To test whether a patient-centered medical home (PCMH) model that significantly rewarded cost savings and accommodated small primary care practices was associated with lower spending, fewer hospital admissions, an ...[more]

PMID: 27473005

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Project description:Research on the effects of patient-centered medical homes on quality and cost of care is mixed, so further study is needed to understand how and in what contexts they are effective.We aimed to evaluate effects of a multi-payer pilot promoting patient-centered medical home implementation in 15 small and medium-sized primary care groups in Colorado.We conducted difference-in-difference analyses, comparing changes in utilization, costs, and quality between patients attributed to pilot and non-pilot practices.Approximately 98,000 patients attributed to 15 pilot and 66 comparison practices 2 years before and 3 years after the pilot launch.Healthcare Effectiveness Data and Information Set (HEDIS) derived measures of diabetes care, cancer screening, utilization, and costs to payers.At the end of two years, we found a statistically significant reduction in emergency department use by 1.4 visits per 1000 member months, or approximately 7.9 % (p?=?0.02). At the end of three years, pilot practices sustained this difference with 1.6 fewer emergency department visits per 1000 member months, or a 9.3 % reduction from baseline (p?=?0.01). Emergency department costs were lower in the pilot practices after two (13.9 % reduction, p?<?0.001) and three years (11.8 % reduction, p?=?0.001). After three years, compared to control practices, primary care visits in the pilot practices decreased significantly (1.5 % reduction, p?=?0.02). The pilot was associated with increased cervical cancer screening after two (12.5 % increase, p?<?0.001) and three years (9.0 % increase, p?<?0.001), but lower rates of HbA1c testing in patients with diabetes (0.7 % reduction at three years, p?=?0.03) and colon cancer screening (21.1 % and 18.1 % at two and three years, respectively, p?<?0.001). For patients with two or more comorbidities, similar patterns of association were found, except that there was also a reduction in ambulatory care sensitive inpatient admissions (10.3 %; p?=?0.05).Our findings suggest that a multi-payer, patient-centered medical home initiative that provides financial and technical support to participating practices can produce sustained reductions in utilization with mixed results on process measures of quality.

Project description:The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices' internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare. The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care. The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change. Measuring the PCMH involves the following: Giving primacy to the core tenets of primary care. Assessing practice and system changes that are hypothesized to provide added value Assessing development of practices' core processes and adaptive reserve. Assessing integration with more functional healthcare system and community resources. Evaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspects. Recognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings. Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.

Dataset Information

The CareFirst Patient-Centered Medical Home Program: Cost and Utilization Effects in Its First Three Years.

Background

Objective

Design

Participants

Intervention

Measures

Results

Conclusions

Publications

The CareFirst Patient-Centered Medical Home Program: Cost and Utilization Effects in Its First Three Years.

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