A Difference-in-Difference Analysis of Changes in Quality, Utilization and Cost Following the Colorado Multi-Payer Patient-Centered Medical Home Pilot.
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ABSTRACT:
SUBMITTER: Rosenthal MB
PROVIDER: S-EPMC4762834 | biostudies-other | 2016 Mar
REPOSITORIES: biostudies-other
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A Difference-in-Difference Analysis of Changes in Quality, Utilization and Cost Following the Colorado Multi-Payer Patient-Centered Medical Home Pilot.
Rosenthal Meredith B MB Alidina Shehnaz S Friedberg Mark W MW Singer Sara J SJ Eastman Diana D Li Zhonghe Z Schneider Eric C EC
Journal of general internal medicine 20160301 3
<h4>Background</h4>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.<h4>Objective</h4>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.<h4>Design</h4>We conducted difference-in-difference analyses, comparing changes in utilization, costs, and qualit ...[more]
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Project description:BackgroundThe literature on patient-centered medical homes (PCMHs) and patient experience is somewhat mixed. Government and private payers are promoting multi-payer PCMH initiatives to align requirements and resources and to enhance practice transformation outcomes. To this end, the multipayer Michigan Primary Care Transformation (MiPCT) demonstration project was carried out.ObjectiveTo examine whether the PCMH is associated with a better patient experience, and whether a mature, multi-payer PCMH demonstration is associated with even further improvement in the patient experience.DesignThis is a cross-sectional comparison of adults attributed to MiPCT PCMH, non-participating PCMH, and non-PCMH practices, statistically controlling for potential confounders, and conducted among both general and high-risk patient samples.ParticipantsResponses came from 3893 patients in the general population and 4605 in the high-risk population (response rates of 31.8% and 34.1%, respectively).Main measuresThe Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey, with PCMH supplemental questions, was administered in January and February 2015.Key resultsMiPCT general and high-risk patients reported a significantly better experience than non-PCMH patients in most domains. Adjusted mean differences were as follows: access (0.35**, 0.36***), communication (0.19*, 0.18*), and coordination (0.33**, 0.35***), respectively (on a 10-point scale, with significance indicated by: *= p<0.05, **= p<0.01, and ***= p<0.001). Adjusted mean differences in overall provider ratings were not significant. Global odds ratios were significant for the domains of self-management support (1.38**, 1.41***) and comprehensiveness (1.67***, 1.61***). Non-participating PCMH ratings fell between MiPCT and non-PCMH across all domains and populations, sometimes attaining statistical significance.ConclusionsPCMH practices have more positive patient experiences across domains characteristic of advanced primary care. A mature multi-payer model has the strongest, most consistent association with a better patient experience, pointing to the need to provide consistent expectations, resources, and time for practice transformation. Our results held for a general population and a high-risk population which has much more contact with the healthcare system.
| S-EPMC5653555 | biostudies-literature
Project description:BackgroundEnhanced 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.ObjectiveTo 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.DesignWe 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.ParticipantsA 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.InterventionCareFirst 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.MeasuresOutcomes 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.ResultsBy 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.ConclusionsA PCMH model that does not require practices to make infrastructure investments and that rewards cost savings can reduce spending and utilization.
| S-EPMC5071295 | biostudies-literature
Project description:PurposeTo identify components of the patient-centered medical home (PCMH) model of care that are associated with lower spending and utilization among Medicare beneficiaries.MethodsRegression analyses of changes in outcomes for Medicare beneficiaries in practices that engaged in particular PCMH activities compared with beneficiaries in practices that did not. We analyzed claims for 302,719 Medicare fee-for-service beneficiaries linked to PCMH surveys completed by 394 practices in the Centers for Medicare & Medicaid Services' 8-state Multi-Payer Advanced Primary Care Practice demonstration.ResultsSix activities were associated with lower spending or utilization. Use of a registry to identify and remind patients due for preventive services was associated with all 4 of our outcome measures: total spending was $69.77 less per beneficiary per month (PBPM) (P = 0.00); acute-care hospital spending was $36.62 less PBPM (P = 0.00); there were 6.78 fewer hospital admissions per 1,000 beneficiaries per quarter (P1KBPQ) (P = 0.003); and 11.05 fewer emergency department (ED) visits P1KBPQ (P = 0.05). Using a patient registry for pre-visit planning and clinician reminders was associated with $29.31 lower total spending PBPM (P = 0.05). Engaging patients with chronic conditions in goal setting and action planning was associated with 4.62 fewer hospital admissions P1KBPQ (P = 0.01) and 11.53 fewer ED visits P1KBPQ (P = 0.00). Monitoring patients during hospital stays was associated with $22.06 lower hospital spending PBPM (P = 0.03). Developing referral protocols with commonly referred-to clinicians was associated with 11.62 fewer ED visits P1KBPQ (P = 0.00). Using quality improvement approaches was associated with 13.47 fewer ED visits P1KBPQ (P =0.00).ConclusionsPractices seeking to deliver more efficient care may benefit from implementing these 6 activities.
| S-EPMC7708292 | biostudies-literature
Project description:BACKGROUND: The patient-centered medical home (PCMH) model aims to provide patient-centered care, lower costs, and improve health outcomes. Medical students have not been meaningfully integrated in this model. AIM: To test the feasibility of a longitudinal clerkship based on PCMH principles and anchored by PCMH educational objectives. SETTING: Two community-based family medicine clinics, one academic internal medicine clinic, and one pediatric clinic affiliated with an urban medical school. PARTICIPANTS: 56 medical student volunteers. PROGRAM DESCRIPTION: We embedded student teams in existing faculty practices and recruited a high-risk patient panel for each team. Clinical education occurred through a traditional clinic preceptor model and was augmented by 3rd and 4th year students directly observing 1st and 2nd year students. Didactic content included monthly Grand Rounds conferences. PROGRAM EVALUATION: Students attended 699 clinics, recruited 273 continuity patients, and participated in 9 Grand Rounds conferences. Student confidence with PCMH principles increased and attitudes regarding continuity were highly positive. "Continuity," "early clinical exposure," and "peer teaching" were the most powerful themes expressed by students. Faculty response to the pilot was highly positive. DISCUSSION: An Education-Centered Medical Home (ECMH) is feasible and is highly rated by students and faculty. Expansion of this model is underway.
| S-EPMC3710377 | biostudies-other
Project description:ObjectiveTo examine the relationship between practices' reported use of patient-centered medical home (PCMH) processes and patients' perceptions of their care experience.Data sourcePrimary survey data from 393 physician practices and 1,304 patients receiving care in those practices.Study designThis is an observational, cross-sectional study. Using standard ordinary least-squares and a sample selection model, we estimated the association between patients' care experience and the use of PCMH processes in the practices where they receive care.Data collectionWe linked data from a nationally representative survey of individuals with chronic disease and two nationally representative surveys of physician practices.Principal findingsWe found that practices' use of PCMH processes was not associated with patient experience after controlling for sample selection as well as practice and patient characteristics.ConclusionsIn our study, which was large, but somewhat limited in its measures of the PCMH and of patient experience, we found no association between PCMH processes and patient experience. The continued accumulation of evidence related to the possibilities of the PCMH, how PCMH is measured, and how the impact of PCMH is gauged provides important information for health care decision makers.
| S-EPMC3523375 | biostudies-literature
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.
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Project description:BACKGROUND:Through the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration, Medicare, Medicaid, and private payers offered supplemental payments to 849 primary care practices that became patient-centered medical homes (PCMHs) in eight states; practices also received technical assistance and data reports. Average Medicare payments were capped at $10 per beneficiary per month in each state. OBJECTIVE:Since there was variation in the eight participating states' demonstration designs, experiences, and outcomes, we conducted a qualitative multi-case analysis to identify the key factors that differentiated states that were estimated to have generated net savings for Medicare from states that did not. PARTICIPANTS:States' MAPCP Demonstration initiatives were comprehensively profiled in case studies based on secondary document review, three rounds of annual interviews with state staff, payers, practices, and other stakeholders, and other data sources. APPROACH:Case study findings were summarized in a case-ordered predictor-outcome matrix, which identified the presence or absence of key demonstration design features and experiences and arrayed states based on the amount of net savings or losses they generated for Medicare. We then used this matrix to identify initiative features that were present in at least three of the four states that generated net savings and absent from at least three of the four states that did not generate savings. RESULTS:A majority of the states that generated net savings: required practices to be recognized PCMHs to enter the demonstration, did not allow late entrants into the demonstration, used a consistent demonstration payment model across participating payers, and offered practices opportunities to earn performance bonuses. Practices in states that generated net savings also tended to report receiving the demonstration payments and bonuses they expected to receive, without any issues. CONCLUSIONS:Designers of future PCMH initiatives may increase their likelihood of generating net savings by incorporating the demonstration features we identified.
| S-EPMC6025664 | biostudies-literature
Project description:Introduction:Like most patient-centered medical home (PCMH) models, Oregon's program, the Patient-Centered Primary Care Home (PCPCH), aims to improve care while reducing costs; however, previous work shows that PCMH models do not uniformly achieve desired outcomes. Our objective was to describe a process for refining PCMH models to identify high value elements (HVEs) that reduce cost and utilization. Methods:We performed a targeted literature review of each PCPCH core attribute. Value-related concepts and their metrics were abstracted, and studies were assessed for relevance and strength of evidence. Focus groups were held with stakeholders and patients, and themes related to each attribute were identified; calculation of HVE attainment versus PCPCH criteria were completed on eight primary care clinics. Analyses consisted of descriptive statistics and criterion validity with stakeholder input. Results:2,126 abstracts were reviewed; 22 met inclusion criteria. From these articles and focus groups of stakeholders/experts (n = 49; 4 groups) and patients (n = 7; 1 group), 12 HVEs were identified that may reduce cost and utilization. At baseline, clinics achieved, on average, 31.3 percent HVE levels compared to an average of 87.9 percent of the 35 PCMH measures. Discussion:A subset of measures from the PCPCH model were identified as "high value" in reducing cost and utilization. HVE performance was significantly lower than standard measures, and may better calibrate clinic ability to reduce costs. Conclusion:Through literature review and stakeholder engagement, we created a novel set of high value elements for advanced primary care likely to be more related to cost and utilization than other models.
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Project description:OBJECTIVE:To evaluate impact of the Maryland Multipayor Patient-centered Medical Home Program (MMPP) on: (1) quality, utilization, and costs of care; (2) beneficiaries' experiences and satisfaction with care; and (3) perceptions of providers. DESIGN:4-year quasiexperimental design with a difference-in-differences analytic approach to compare changes in outcomes between MMPP practices and propensity score-matched comparisons; pre-post design for patient-reported outcomes among MMPP beneficiaries. SUBJECTS:Beneficiaries (Medicaid-insured and privately insured) and providers in 52 MMPP practices and 104 matched comparisons in Maryland. INTERVENTION:Participating practices received unconditional financial support and coaching to facilitate functioning as medical homes, membership in a learning collaborative to promote education and dissemination of best practices, and performance-based payments. MEASURES:Sixteen quality, 20 utilization, and 13 cost measures from administrative data; patient-reported outcomes on care delivery, trust in provider, access to care, and chronic illness management; and provider perceptions of team operation, team culture, satisfaction with care provided, and patient-centered medical home transformation. RESULTS:The MMPP had mixed impact on site-level quality and utilization measures. Participation was significantly associated with lower inpatient and outpatient payments in the first year among privately insured beneficiaries, and for the entire duration among Medicaid beneficiaries. There was indication that MMPP practices shifted responsibility for certain administrative tasks from clinicians to medical assistants or care managers. The program had limited effect on measures of patient satisfaction (although response rates were low) and on provider perceptions. CONCLUSIONS:The MMPP demonstrated mixed results of its impact and indicated differential program effects for privately insured and Medicaid beneficiaries.
| S-EPMC5882272 | biostudies-literature