With a new study of Independence Blue Cross members, evidence on the effectiveness of the patient-centered medical home is swinging back towards the positive.
Of 700 IBC members with multiple chronic conditions treated in patient-centered medical home practices, those with the highest-risk had "significantly reduced costs and utilization" compared to those with analogous health problems treated in regular practices, a study published in the American Journal of Managed Care found.
Those findings deviate a bit from a recent Rand Corp. evaluation of a large PCMH pilot in southeastern Pennsylvania, where little correlation between PCMHs and quality and cost was detected in a three-year analysis.
The new findings are likely to fuel more debate over the actual and perceived benefits of the PCMH, while helping create a foundation of evidence that also help tailor the way the model is used.
The IBC study actually examined members from some the of 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.
IBC researchers led by Susannah Higgins followed 700 commercial HMO members with multiple chronic conditions, including asthma, COPD, diabetes and asthma, being treated in PCMH practices from 2009 to 2011 and compared their utilization and claims to those of 300 chronically ill commercial HMO members treated at non-PCMH practices.
They found that the highest-risk members in that 700 member cohort 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).
While speciality care visits and spending did increase for those PCMH members, 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.
However, Higgins and her colleagues offer this caveat: "After controlling for baseline differences, no statistically significant differences between patients enrolled in PCMH and non-PCMH practices were observed."
The PCMH model's benefits were clear "when looking at the patients with highest risk scores in the pool of matched patients and practices," Higgins and colleagues wrote.
"This suggests that the average patient may not be the relevant unit of observation for evaluating the impact of PCMH adoption. Rather, high risk patients with multiple comorbidities are the most logical targets for interventions aimed at supporting self-management, conveying test results in a timely and clear fashion, and coordinating follow-up and specialist care," Higgins and colleagues wrote, noting that healthcare costs are mostly driven by "relatively rare events concentrated in few individuals."
The fact that PCMH-treated patients with the highest risk did see cost reductions from fewer hospital admissions suggests that the model "is having its intended effect," the researchers wrote.
"Even the observation of increased spending for specialist care can be interpreted as being consistent with this conceptualization: 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."
That, they wrote, "could drive up the cost of one component of care, while the use of appropriate early interventions helps control costs overall."
Those findings add to a growing foundation of largely mixed PCMH research.
Rand's recent study, published in the Journal of the American Medical Association, found no overall reductions in utilization or spending and only limited quality improvement at the 32 PCMH sites.
Rand researchers cautioned against drawing broad conclusions from their study and also said it was possible certain factors in the Pennsylvania PCMH pilot led to fewer reductions.
Pennsylvania's pilot emphasized quality of care for chronic conditions of diabetes and asthma, but practices did not have financial incentives to contain costs and did not receive feedback on their patients' utilization of care.
That said, IBC is still quite bullish on the model.
"If we look at the 10 percent most costly, most at risk, we can see a pretty significant difference," said Don Liss, MD, IBC's senior medical director of clinical programs and policy.
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 PCMH. Over 30 percent of the primary care physicians in the insurer's network are part of PCMHs.
"The PCMH is fundamentally a better way to deliver primary care," Liss argued. "We know patients and doctors like it better." At the same time, it seems the PCMH's financial benefits, at least for now, can only be found when looking the highest-risk patients.
"In a generally healthy population where patients aren't experiencing costly hospitalizations, you can't show a difference."