VII. Key Issues: Regulation & Reform >> C. Health Reform >> Affordable Care Act (ACA) >> ACA Impact Analysis >> ACA Impact on Quality and Outcomes >> Patient-Centered Medical Homes (last updated 4.21.17)
- 1 Overview
- 2 Definitions and Function
- 3 Development
- 4 PCMH Costs
- 5 Skeptics of PCMHs
- 6 Research on PCMH Impact on Care
- 6.1 Impact on Quality, Cost and Satisfaction Measures
- 6.2 Impact on Quality and Cost Measures
- 6.3 Impact on Quality Measures
- 6.4 Impact on Patient Satisfaction
- 6.5 Impact on Cost
- 6.6 Impact on Use Of Evidence-Based Processes
- 7 News
- 8 Resources
There are several provisions in the ACA directed at the establishment and promotion of the Patient Centered Medical Home (PCMH). The ACA includes the following, among others: establishment of a Center for Medicare and Medicaid Innovation that would pilot test broad payment and practice reform in primary care, including consideration of the PCMH, a State Medicaid health (medical) home option, the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a grant program to maintain and expand primary care units in teaching programs with priority to those who educate medical students on the Patient-Centered Medical Home.
Prior to the ACA(2006-2007), the PCMH was demonstrated to improve patient satisfaction and improve staff morale in a hospital capitated fee system with employed providers. The authors note that “the applicability to fee-for-service settings is unclear.”
Definitions and Function
PCMH (aka Medical Home)
The PCMH is being tested by several public and private sector health insurance and provider organizations to coordinate care for patients with chronic illnesses. Medical homes provide care management services, make referrals to specialists, provide support services, and use electronic health records and health information technology to monitor and coordinate services/programs on behalf of the consumer.
PCMHs are similar to ACOs in that they consolidate multiple levels of care. However, in medical homes the primary care provider (MD, DO, NP, PA) leads the care delivery team in a single practice, as opposed to an ACO, which consists of many coordinated practices.
Focus on the Population At Large
According to the New York State Psychological Association, “the U.S. Agency for Healthcare Research and Quality (AHRQ) recently coined the term ‘practice-based population health (PBPH)’, in which the term ‘population’ refers to any group of people under the care of single physician, group practice, PCMH or ACO. Primary healthcare is increasingly moving in the direction of a PBPH (Practice-Based Population Health) model, which assumes that medical providers are responsible for increasing the overall health of the population they manage, and not just for treating individual patients who present in their office for care. This shift is driven primarily by financial changes in healthcare reform.”
Health Home (aka Medicaid Health Home)
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), “the terms medical home and health home may sound similar, but represent different approaches to care coordination across health care. A medical home (aka person-centered medical home or patient-centered medical home (PCMH)) is a care model that involves the coordinated care of individual’s overall health care needs (and where individuals are active in their care). The Health Home — as defined in Section 2703 of the Affordable Care Act — offers coordinated care to individuals with multiple chronic health conditions, including mental health and substance use disorders. The health home is a team-based clinical approach that includes the consumer, his or her providers, and family members, when appropriate. The health home builds linkages to community supports and resources as well as enhances coordination and integration of primary and behavioral health care to better meet the needs of people with multiple chronic illnesses.”
Health Home Requirements
Section 2703 of the Affordable Care Act indicates that eligibility for Medicaid health homes requires beneficiaries to have: At least two chronic conditions (e.g., mental health condition, substance use disorder, asthma, diabetes, heart disease, a body mass index (BMI) greater than 25); One chronic condition and the risk of a second; One serious and persistent mental health condition.
Health homes must provide all six of the following services, as appropriate based on beneficiaries’ changing needs: Comprehensive care management; care coordination; health promotion; comprehensive transitional care; individual and family support; Referral to community and support services.
The health homes statute further indicates that states should document the “use of health information technology to link services.” These six service components, together with the health IT linkage component, require that states have the capacity to manage a continuum of specialty and primary care health services and, at least, coordinate long-term care services and other supports. (SAMHSA-HRSA Center for Integrated Health Solutions (CIHS), 2013)
Number of PCMHs
- According to the Alliance for Health Reform’s 2013 book Covering Health Issues: A Sourcebook for Journalists, as of May 2013, over 27,500 clinicians and 5,700 sites were PCMH certified (p. 53).
- By 5.7.15, the total number of PCMH sites with NCQA recognition stood at 10,098 with 48,617 recognized clinicians in 50 states, the District of Columbia and Puerto Rico. “Government and private sector initiatives in 38 states have used the NCQA model to support the spread of medical homes.”
- Patient-centered Primary Care Collaborative. Mapping the Medical Home Movement. This map includes a diverse range of programs using patient-centered medical homes (PCMH) and enhanced primary care models.
- As of 5.20.15, there were 156 accredited health homes.
Certification and Accreditation
There are a number of voluntary PCMH certification criteria that currently exist, including those from the National Committee for Quality Assurance, the Accreditation Association for Ambulatory Health Care and The Commonwealth Fund.
- Accreditation & Certification Programs For Medical Homes & Health Homes: Where Are We Now, & Where Are We Headed In The Future? “Why Pursue Accreditation/Certification? Many states require accreditation/certification as a condition of operating a health home/medical home through Medicaid; One of the key benchmarks for measuring the quality of a health care organization; Establishes your organization’s commitment to being a provider of choice; Helps ensure your patients are receiving the best care possible; Helps strengthen consumer confidence in your organization, and the quality of services you provide; Assists organizations to document and communicate efficiency, fiscal health, service delivery and national benchmarking; Builds foundation for continuous quality improvement and consumer satisfaction; Positions the organization to be seen as higher quality than non-accredited organizations; Represents agencies as credible and reputable organizations dedicated to ongoing and continuous compliance with the highest standard of quality.” (The 2015 OPEN MINDS Strategy & Innovation Institute, Wednesday, June 17, 2015)
- Medical Home & Health Home Accreditation – What Are The Options? “Even newer than the proliferation of medical homes and health homes is the accreditation of these program models. There are five organizations – The Accreditation Association for Ambulatory Health Care (AAAHC), CARF International, the Joint Commission, the National Committee for Quality Assurance (NCQA), and URAC – that offer some type of accreditation. And, on the payer side, requirements for accreditation are on the increase. For example, of the 20 state Medicaid plans that have medical home initiatives, eight of these states require patient-centered medical home (PCMH) accreditation… CARF International offers behavioral health home accreditation… the Joint Commission, which offers both PCMH and behavioral health home certification. CARF certifies programs and service lines, not organizations. Therefore, it is possible to achieve behavioral health home accreditation without being accredited in other programs or having organizational accreditation…The Joint Commission takes a slightly different approach to PCMH and health home accreditation. The Joint Commission accredits an entire organization; an organization must first receive organization accreditation and then add-on the optional PCMH or behavioral health home certification.” (Open Minds, 8.7.15)
Recognition and Accreditation Resources
- Medical Group Management Association. Comparison of the AAAHC (Accreditation Association for Ambulatory Health Care), Joint Commission, NCQA (National Committee for Quality Assurance), and URAC Patient-Centered Medical Home Recognition and Accreditation Programs to The Guidelines for the Patient-Centered Medical Home Recognition and Accreditation Programs [American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP) and American Osteopathic Association (AOA)]. (MGMA, 1.30.14)
- The cost of certification, which involves purchasing survey tools, consultations and site visits, vary but are conservatively $550 per clinician and between $275-$2,200 per site. Nationwide, those costs for accreditation translate into $15.125 million to certify clinicians and $8.55 million for sites (using an estimated $1,500/site and not including the jump in participants from 7/13-1/14) (Jan Gurley, 2.17.14).
- “The process to become a PCMH is also so onerous that, even with this much money on the table, only 34% of New York Medicaid clinicians were willing to participate” (Jan Gurley, 2.17.14).
Maintenance of Certification
Jan Gurley observes “a glance over what’s required leads one to believe that at least one staff member must be dedicated to compliance with all the compiling and reporting of these PCMH requirements.”
- Maintaining PCMHs Will Cost $105,000 Per Physician Per Year. “Providing the staffing necessary to deliver required patient-centered medical home (PCMH) functions for even partial implementation will cost about $105,000 for each full-time physician per year, researchers have found… ‘Unless there is reform across commercial [payers], Medicaid, and Medicare, [PCMHs] won’t work for small practices.’ With any medical home, ‘someone’s got to pay the rent,’ and that includes up-front costs to organize these models and train people to make the transition. Although some payers may pay the costs this study describes, he explains, practices have multiple payers, and if reimbursement is not consistent, it will be difficult for practices to manage…Moreover, none of the study practices had fully implemented all of the PCMH functions, so costs for maintaining a fully implemented PCMH may be understated, according to the authors.” (Medscape Medical News, 9.21.15)
- The Commonwealth Fund has released a summary of the operating costs of federally funded PCMHs. The study showed shows that “the more regulatory PCMH rules are met, in general, the higher the operating cost.”
- “A 10-point higher overall PCMH score was associated with a $2.26, or 4.6 percent, higher operating cost per patient per month,” which translates to “$508,207 annually for the average clinic in the study…. The cost per physician time — the two subscales of ‘ability to track patients’ and ‘capacity to perform quality measurement and improvement’ were associated with an additional $27,300 per FTE physician.” (Jan Gurley, 2.17.14)
Skeptics of PCMHs
- Regina Herzlinger. “Accountable care organizations and patient-centered medical homes are unlikely to succeed. Those are two predictions from Regina E. Herzlinger, a professor at the Harvard Business School who has successfully predicted some of the most powerful trends in health care since the 1990s. Arguably, most of her predictions about health care have come true or are about to…’The reason PCMHs will not succeed is that health care follows the 80/20 rule — 20 percent of patients generate 80 percent of the costs,’ she says. ‘Those 20 percent are the chronically ill, and I don’t see how primary care physicians serving these patients add value to their care.’” (Managed Care Magazine, April, 2012)
- Jan Gurley, M.D. “The data on the much-lauded PCMH approach, a cornerstone of ACA, shows that it is expensive, onerously bureaucratic, a drain on health care resources, especially for primary care providers, and a distraction from health care delivery. And, if cost savings ultimately materialize, they are likely to go to large health systems, and not to sustaining, much less expanding, primary care.” (Jan Gurley, 2.6.14)
- PCMH’s “are generally acknowledged to be an improvement for families” based on “numerous opinion and consensus/expert panel papers.” However “it is surprisingly hard to find any randomized comparison data to support PCMH efficacy.”
- “New York Medicaid hospitalization rates, including for preventable hospitalizations, appear to have gone up for patients in PCMHs, compared to those not in PCMHs.”
- Glancey, Kelley K., M.D. and Kennedy, James G., MD, MBA. Achieving PCMH Status May Not Be Meaningful for Small Practices. “We started our idealized micro practice (a practice with no nonprofessional employees) using the tenets set out by the Institute of Medicine report that has become the basis of the patient-centered primary care (PCMH) movement… First, we believe that the question is not whether small practices are missing out on the new methods of reimbursement, but whether the reimbursement models are correct. PCPCC data does not conclusively show an improvement in the Triple Aim by a movement to PCMH, and we may be driving already high-quality small practices to consolidate… we should resist the idea that PCMH will improve practice. In our small practice, this has not been the case, and the costs will not be reimbursed to us for doing all the quality work. The unintended consequence of using poorly conceived surrogate measures may be that more individual practices are forced into larger institutions. Second, family medicine and other primary care organizations need to be drivers of correct quality measures that make sense. Lastly, it appears to us that a return to transparency and a free market model (for all medical care) such as direct primary care (DPC) is a better solution for small practices than joining larger groups or participating in externally driven quality programs. In DPC, the consumer judges quality and cost directly and will reward or punish the provider of care in a timely manner.” (Annals of Family Medicine, January/February, 2016)
Research on PCMH Impact on Care
Impact on Quality, Cost and Satisfaction Measures
- Group Health Cooperative (2009): Patient-centered Medical Home Demonstration: A Prospective, Quasi-experimental, Before and After Evaluation. “At 12 months, there were no significant differences in overall costs.” However “PCMH patients reported higher ratings than controls on 6 of 7 patient experience scales” and “PCMH patients also had gains in composite quality between 1.2% and 1.6% greater than those of other patients.”
- In 2012, when analyzing PCMHs’ impact on their patients who were seniors, the researchers found that while “seniors in the PCMH clinic reported higher ratings than controls on 3 of 7 patient experience scales,”… “at 1 and 2 years, the PCMH and control clinics did not differ significantly in overall costs.”
Impact on Quality and Cost Measures
- The Medical Home’s Impact on Cost & Quality: An Annual Update of the Evidence, 2012-2013. “This annual report highlights recently published clinical, quality, and financial outcomes of patient-centered medical home (PCMH) initiatives from across the United States. Profiling a showcase of PCMH initiatives, this report focuses on studies released between August 2012 and December 2013… Although the evidence is early from an academic perspective, and this report does not represent a formal peer-reviewed meta-analysis of the literature, the expanding body of research provided here suggests that when fully transformed primary care practices have embraced the PCMH model of care, we find a number of consistent, positive outcomes.” Nielsen, M. Olayiwola, J.N., Grundy, P., Grumbach, K. (ed.) Shaljian, M. Patient-Centered Primary Care Collaborative (January, 2014)
- Game Changing Idea: Specialty Intensive Medical Home. “Back in September 2014, Blue Cross and Blue Shield of Illinois (BCBSIL) announced the first specialty IMH (intensive medical home) in the state, with the Illinois Gastroenterology Group (IGG), the state’s largest independent gastroenterology practice. Participating patients have Crohn’s disease, a high-risk chronic inflammatory bowel disease that causes a high incidence of complications. Today, nearly 350 patients are in the specialty IMH, according to Donna Levigne, divisional senior vice president, Illinois Health Care Delivery, BCBSIL. ‘Recent results show that for Crohn’s specific costs and utilization—the IGG population is out-performing in all areas: hospital admissions, emergency room [ER], outpatient visits and office visits,’ says Levigne. ‘We will be adding three more gastro IMHs this year.’… In March 2016, it announced the first oncology IMH pilot program in Illinois with Illinois Cancer Specialists. To qualify, patients must be receiving chemotherapy or hormone therapy, with a cancer diagnosis of breast, colon, lung, pancreatic, prostate and any non-Hodgkin’s lymphoma. The program intends to enroll 150 to 200 patients per year.” (Modern Medicine Network, 4.12.17)
- Friedberg Study (2014)
- Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Cost of Care. “Pilot participation was associated with statistically significantly greater performance improvement, relative to comparison practices, on 1 of 11 investigated quality measures: nephropathy screening in diabetes… A multipayer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement.” Friedberg, M.W., Schneider, E.C., Rosenthal, M.B., Volpp, K.G., Werner, R.M. (JAMA, 2014; 311:815-825, 2.26.14)
- Medical Home Pilot Study: Little Benefit in Quality or Cost. “Dr. Friedberg emphasized that the study results should not be seen as an argument to start from scratch on the medical home model. ‘One study of one pilot should not be taken by anybody that as a concept the medical home cannot work,’ he told Medscape Medical News. In an accompanying editorial, Thomas L. Schwenk, MD, from the Department of Family Medicine, University of Nevada School of Medicine, Reno and Las Vegas, notes that a limitation of the study was that a 3-year time frame may not be long enough to assess the outcomes of chronic disease management that evolve over decades. However, lack of improvement on 10 of 11 quality measures is still disappointing, he said. Dr. Schwenk suggests the study shows that a one-size-fits-all approach to the PCMH may not be the answer.” (Medscape Medical News, 2.25.14)
- Financial Incentives = Change. “This reminds me of last year’s Medicare Demonstration Project results – the only demonstration project (among a number of disease management, care coordination, and value-based payment models) that saved money was the one that was competitively bid and involved some degree of provider organization risk-sharing (see Medicare Demonstration Project Results Are In – Only Winner Was Bundled Payments). “I think the implications are clear. Putting a new model in place in the midst of the current fee-for-service reimbursement system is a waste of time. Without financial incentives and a more flexible reimbursement system, expecting a change in outcomes is a bit fanciful. For service provider organizations to change, they need a reimbursement model that allows flexibility in service delivery and the financial incentives to make change happen. This study – and the reporting aftermath – remind me of the Einstein quote. “Insanity is doing the same thing over and over again and expecting different results.’” Oss, Monica (Open Minds, 3.4.14)
- Medical Homes: Are They Making a Difference? “At the end of 3 years, the only significant difference among 11 quality measures was nephropathy screening, which was 82.7% for pilot sites (baseline, 72.8%) and 71.7% for the comparison practices (baseline, 72.8%). Other measures, such as A1c and low-density lipoprotein (LDL) cholesterol testing and control; eye examinations; appropriate pediatric asthma medications; and screening for breast cancer, cervical cancer, chlamydia, and colorectal cancer, were similar in the pilot and comparison groups. Utilization, measured as all-cause hospitalization (including multiple visits for the same patient), emergency department visits (including multiple visits for the same patient), primary care visits, and specialist visits, did not significantly differ between pilot and comparison sites. Total costs also did not significantly differ between the groups. This particular study does not show the robust changes that many hoped for with medical homes over a 3-year period. We must be cautious not to allow the momentum of ‘healthcare reform’ to take us down a road that leads to simply checking off boxes to gain higher reimbursement.” (Medscape Medical News, 4.2.14)
Mathematica Policy Research: Mixed Results For Obamacare Tests In Primary-Care Innovation. “Medical homes are a simple, compelling idea: Give primary-care doctors resources to reduce preventable medical crises for diabetics, asthmatics and others with chronic illness — reducing hospital visits, improving lives and saving money. But it’s not so easy in practice. New reports show that two big experiments run by the health law’s innovation lab, known as the Center for Medicare & Medicaid Innovation, delivered mixed early results in enhancing primary care. The programs reduced expensive hospital visits in some cases but struggled to show net savings after accounting for their cost…Nor was there a big change in quality-of-care indicators, such as follow-up visits after a hospital discharge and making sure patients got recommended diabetes tests…But those who believe medical homes, also known as patient-centered medical homes, are one answer to America’s expensive, uncoordinated health system found encouraging spots in the evaluation.” (Kaiser Health News, 1.30.15)
Evaluation of CMS FQHC APCP Demonstration: Second Annual Report. “CMS recognizes as advanced primary care (APC) the type of care that is offered by FQHCs that have achieved Level 3 recognition as a patient-centered medical home (PCMH) from the National Committee for Quality Assurance (NCQA)…. In summary, relative to four baseline quarters, claims-based analyses across nine quarters show significantly more utilization and costs for demonstration FQHCs than comparison FQHCs for total Medicare payments (four quarters), hospital admissions (two quarters), readmissions (one quarter), and ED visits (six quarters). Standard claims-based process measures characterizing utilization among Medicare beneficiaries with diabetes or ischemic vascular disease show improvements in process for demonstration FQHC users compared with comparison FQHC users after considering baseline differences. Most beneficiary survey analyses show no difference in cross-sectional analyses, but longitudinal beneficiary analyses will not be available until the final report. (RAND Corporation, July, 2015)
- Commonwealth Fund Study (2015). Analysis of Changes in Quality, Utilization and Cost Following the Colorado Multi-Payer Patient-Centered Medical Home Pilot. “To date, research on the effects of the care model has yielded mixed results. Few studies, however, have evaluated outcomes beyond two years, even though evidence suggests that transforming practices into fully functioning PCMHs can take years. Researchers supported by The Commonwealth Fund evaluated a pilot program involving 15 PCMH practices in Colorado serving approximately 98,000 patients both prior to the program’s launch and then again at two and three years. (The Commonwealth Fund, 10.23.15)
- No Net Cost Savings. A multipayer medical home program piloted in Colorado led to a sustained reduction in emergency department use and costs over three years, although there were no overall cost savings for practices or patients.
- Reduced Primary Care. Primary care visits also decreased.
- Mixed Effects on Quality. The impact on quality was mixed: cervical cancer screening rates improved, yet colon cancer screenings and hemoglobin testing for diabetes patients decreased.”
Impact on Quality Measures
Improvement “Incremental and Slow”
- Kern Study (2014)
- The Patient-Centered Medical Home, Electronic Health Records, and Quality of Care. “The PCMH group improved significantly more over time than either the paper group or the EHR group for 4 of the 10 measures (by 1 to 9 percentage points per measure): eye examinations and hemoglobin A1c testing for patients with diabetes, chlamydia screening, and colorectal cancer screening (adjusted P < 0.05 for each). The odds of overall quality improvement in the PCMH group were 7% higher than in the paper group and 6% higher than in the EHR group (adjusted P < 0.01 for each). Limitation: This study was observational, and the possibility of unmeasured confounders cannot be excluded. Conclusion: The PCMH was associated with modest quality improvement. The aspects of the PCMH that drive improvement are distinct from but may be enabled by the EHR. (Annals of Internal Medicine, 6.3.14)
- Is There Value in Medical Home Implementation Beyond the Electronic Health Record? [Opinion]: In the same issue, the editorialists discuss the findings and “recommend that providers consider the interplay of clinicians, staff, patients, and information systems and how each area depends on the presence of others for care outcomes to improve.” They note that although PCMHs with an EHR had better results than non-PCMH practices with EHRs, the difference across groups was small, “conﬁrming the results of others that improvement is incremental and slow.” (Annals of Internal Medicine, 6.3.14)
- PCMH Tied to Better Adherence for Chronic Disease Medication. “Patients with chronic conditions who received care in patient-centered medical homes (PCMHs) had 2% to 3% better medication adherence than patients in other practices, new nationwide data show. But the study is limited in the conclusions it can draw about whether the 2% improvement in adherence rates is clinically significant, she says, because the optimal threshold for adherence and the percentage increase needed to show clinical improvement are not well established for many medications… [S]uccess must be measured beyond adherence, she writes.” (Medscape Medical News, 11.14.16)
Impact on Patient Satisfaction
• Shared Medical Appointments in the PCMH: A Retrospective 3-Year Study of Patient Satisfaction. “Shared medical appointments (SMAs) are becoming popular, but little is known about their association with patient experience in primary care. We performed an exploratory analysis examining overall satisfaction and patient-centered care experiences across key domains of the patient-centered medical home among patients attending SMAs vs usual care appointments… SMA patients rated their care as more accessible and more sensitive to their needs, whereas usual care patients reported greater satisfaction with physician communication and time spent during their appointment…Our study confirms and extends prior literature demonstrating that patient satisfaction outcomes are often mixed despite concerted efforts geared toward improving the patient experience.” (Annals of Family Medicine, July/August 2014 vol. 12 no. 4 324-330)
Impact on Cost
• Total Cost of Care Lower among Medicare Fee-for-Service Beneficiaries Receiving Care from Patient-Centered Medical Homes. In this study, the researchers compared Medicare claims filed over three years by 308 PCMHs to claims from nearly 2,000 primary-care practices in the same ZIP codes. “Relative to the comparison group, total Medicare payments, acute care payments, and the number of emergency room visits declined after practices received NCQA PCMH recognition. The decline was larger for practices with sicker than average patients, primary care practices, and solo practices.” (Health Services Research, 7.30.14)
- PCMH Electronic Messaging and Telephone Encounters With Patients Increased Number of Office Visits. “In an adult patient population with diabetes, proportional increases in telephone encounters and, to a lesser extent, secure message threads, were associated with proportional increases in primary care office visits. In an interaction model, results varied modestly across selected patient characteristics, and the positive association between log-transformed numbers of office visits and telephone encounters attenuated over time. Although unadjusted office visit use declined by 8% in the study population, patient-level regression analyses demonstrated that a proportional increase in patients’ telephone encounters or secure messaging was associated with additional office visits for all study periods and patient subpopulations.” (Annals of Family Medicine, July/August 2014 vol. 12 no. 4 338-343)
- Experiment In Coordinated Care For Medicare Failed To Show Savings. “A $57 million experiment to provide better, more efficient care at federally funded health centers struggled to meet its goals and is unlikely to save money, says a government report on the project… As the trial wound down last fall, 69 percent of the clinics that hadn’t dropped out had obtained full accreditation as so-called medical homes. Those are primary care practices that coordinate care across the maze of specialists, hospitals and emergency rooms. HHS had hoped for 90 percent. Another project goal was to cut unnecessary hospital visits. But admissions and emergency room care rose in centers that were part of the experiment compared with results in those that weren’t. So did expenses. ‘It appears that the demonstration will not achieve cost savings,’ concluded the RAND Corp., an independent research group, in the study commissioned by HHS’ Centers for Medicare and Medicaid Services, or CMS. HHS recently posted the report on its website. There had been talk of extending the three-year demonstration. But the health law requires HHS to stop experiments that don’t show signs of saving money or improving care. The program ended in October.” (National Public Radio, 7.27.15)
- Early Impact Of CareFirst’s Patient-Centered Medical Home With Strong Financial Incentives. “In 2011 CareFirst BlueCross BlueShield, a large mid-Atlantic health insurance plan, implemented a payment and delivery system reform program. The model, called the Total Care and Cost Improvement Program, includes enhanced payments for primary care, significant financial incentives for primary care physicians to control spending, and care coordination tools to support progress toward the goal of higher-quality and lower-cost patient care. We conducted a mixed-methods evaluation of the initiative’s first three years. Our quantitative analyses used spending and utilization data for 2010–13 to compare enrollees who received care from participating physician groups to similar enrollees cared for by nonparticipating groups. Savings were small and fully shared with providers, which suggests no significant effect on total spending (including bonuses).” (Health Affairs, March 2017)
• Patient-Centered Medical Homes In Louisiana Had Minimal Impact On Medicaid Population’s Use Of Acute Care And Costs. “We sought to evaluate the effect of patient-centered medical home certification of Louisiana primary care clinics on the quality and cost of care over time for a Medicaid population. We used a quasi-experimental pre-post design with a matched control group to assess the effect of medical home certification on outcomes. We found no impact on acute care use and modest support for reduced costs and primary care use among medical homes serving higher proportions of chronically ill patients. These findings provide preliminary results related to the ability of the patient-centered medical home model to improve outcomes for Medicaid beneficiaries.” (Health Affairs, 1.5.15)
Impact on Use Of Evidence-Based Processes
• Managing Chronic Illness: Physician Practices Increased The Use Of Care Management And Medical Home Processes. “In this article we used data from three national surveys of physician practices between 2006 and 2013 to determine the extent to which practices of all sizes have increased their use of evidence-based care management processes associated with patient-centered medical homes for patients with asthma, congestive heart failure, depression, and diabetes. We found relatively large increases over time in the overall use of these processes for small and medium-size practices as well as for large practices. However, the large practices used fewer than half of the recommended processes, on average. We also identified the individual processes whose use increased the most and show that greater use of care management processes is positively associated with public reporting of patient experience and clinical quality and with pay-for-performance.” (Health Affairs, January, 2015)
- Field Considers Use of NPs to Lead Medical Homes. “Nurse practitioners (NPs) should not supplant physicians as leaders of patient-centered medical homes because their training does not qualify them for that post, according to a report issued yesterday by the American Academy of Family Physicians (AAFP). In addition, the AAFP report warned that independent NPs should not be substituted on a wholesale basis for primary care physicians, even though the latter are in short supply. ‘Granting independent practice to NPs would be creating 2 classes of care, one with physician-led teams and one guided by less-qualified health professionals.’” (Medscape Medical News, 9.19.12)
- Task Force on Patient-centered Medical Homes: How Psychologists Enhance Outcomes and Reduce Costs. “The Task Force on Patient-centered Medical Homes was established in 2014 by APA President Nadine Kaslow, PhD. Goals of the task force include: Evaluating and communicating data demonstrating the extent to which psychologists in patient-centered medical homes are ‘value added’ vis-à-vis enhancing patient and family behavioral and physical health outcomes; enhancing patient and family satisfaction with care; ensuring more cost-effective services; improving quality of life; reducing health disparities; and improving job satisfaction for health professionals. (American Psychological Association, 2014)
- Different Definitions Muddy Measures of Medical Homes. “Researchers have found a discrepancy in the ways pediatric medical homes are defined, which may affect the perception of success. One way is at the practice level, defined by the National Committee for Quality Assurance (NCQA). According to these standards, 6700 practices nationwide qualify as medical homes. However, most of the studies on the pediatric medical home measure how they operate from the perspective of the parents or on the individual level, instead of at the practice level. Parents give responses included in the National Survey of Children’s Health (NSCH), which measures the medical home by using parental response to questions designed to assess five of the seven components defined by the American Academy of Pediatrics. Most of the studies using NSCH results show the medical home model improves health and use outcomes in the emergency department and in preventive care. That and other evidence from parent-level assessment has led to widespread promotion of the model by a number of institutional and government organizations as the best model of primary care for all children. However, parental assessments are subjective. Parents also would not be able to evaluate factors such as use of electronic medical records, which the NCQA criteria emphasize. That disconnect raises the possibility that pediatric practices could be implementing a model that may not yield the expected child health benefits.” (Medscape Medical News, 2.2.15)
- The Comprehensive Primary Care Initiative (CPCi): a federal medical home initiative in which public and private payers align with Medicare’s program model. Consists of “primary care practices committed to advancing five functions central to ‘comprehensive’ primary care (e.g., coordination across the medical neighborhood), discussed further in the practice solicitation.”
- American Academy of Pediatrics National Center for Medical Home Implementation. Overview of Data Related to the Pediatric Medical Home.
- State Delivery System and Payment Reform Map. National Academy for State Health Policy (2015). Includes state-by-state detail about both health homes and medical homes.
- Compare and Contrast: Medicaid Health Homes and Patient Centered Medical Homes.
- Behavioral Health Homes for People with Mental Health & Substance Use Conditions: The Core Clinical Features. SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) (May, 2012)
- Financing and Policy Considerations for Medicaid Health Homes for Individuals with Behavioral Health Conditions: A Discussion of Selected States’ Approaches. SAMHSA-HRSA (2013)