The latest patient-centered medical home study suggests that cost and utilization reductions are noticeable for only the highest-risk patients – a boon for payers. But there are pluses for providers too, including better patient and clinician satisfaction, more roles for specialty care and a roadmap for accountable care.
Researchers at the Philadelphia-based insurer Independence Blue Cross tracked 700 commercial HMO members with multiple chronic conditions treated at patient-centered medical home primary care practices between 2009 and 2011 and compared them to 300 members with analogous health problems treated in regular practices.
Of the 700, those with the highest risk had "significantly reduced costs and utilization" stemming in large part from avoided hospital admissions, wrote IBC informatics researcher Susannah Higgins and colleagues in a study published in the American Journal of Managed Care.
The researchers found that the highest-risk members treated in PCMH practices had an average of 12 percent fewer admissions over the three years, with 11.2 percent lower inpatient treatment costs in 2009 and 7.9 percent lower inpatient costs in 2010 (the study did not have inpatient cost results for 2011).
The researchers also found there were increases in specialty care utilization for a range of chronic conditions, including heart failure, asthma and COPD – a result consistent with the concept of the model, as Higgins and colleagues noted. "As providers gain access to better quality information about patient needs through improved medical record-keeping and care is coordinated across multiple sites, the patients with the highest medical risk may be appropriately directed to more frequent contact with specialists."
Even with increases in specialty care visits and spending, the reductions in inpatient care led to aggregate savings of $107 per member per month in 2009 and $75 per member per month in 2010.
Those findings deviate a bit from a recent Rand Corp. evaluation of a large PCMH pilot in southeastern Pennsylvania, in which little correlation between PCMHs and quality and cost was detected in a three-year analysis.
The Independence Blue Cross study actually examined members from some of the same practices as the Rand study. Of the 700 members enrolled in one of 17 PCMH practices, 15 were from the 32 practices in the Pennsylvania Chronic Care Initiative pilot also studied by Rand.
The difference in the studies' findings largely stems from the fact that the IBC study honed in on the highest-risk patients in the cohort, said Don Liss, MD, the insurer's senior medical director of clinical programs and policy.
"If we look at the 10 percent most costly, most at risk, we can see a pretty significant difference," Liss said.
For patients at modest risk and for the general population, PCMH is a better way to deliver primary care, Liss said. "We know patients and doctors like it better."
One of several founding payers in the Pennsylvania Chronic Care Initiative, IBC has been trying to expand PCMH models across its network, offering enhanced payments to any practice recognized as a PMCH.
Over 30 percent of the primary care physicians in the insurer's network are part of PCMHs, and of those PCMH practices, over half are owned by or tightly affiliated with health systems.
"I think the more forward-thinking health systems consider the PCMH practices to be a foundation for their ACOs," said Liss.
"Every health system is in some stage of developing its ACO plans and they're going to need a strong base for this. The medical home practices are the likely candidates," he said.