February 26, 2014

NCQA Responds to Study:
Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care

(JAMA. 2014;311(8):815-825) 

Although NCQA regards this study as a good-faith effort to advance understanding of the medical home model, and has great respect for the researchers who led it, the Pennsylvania program analyzed and the study itself are unusual in important ways.

About the Pennsylvania program:
The Pennsylvania Chronic Care Initiative (PACCI) lacked two common features of current PCMH pilot programs: cost reduction incentives and a high proportion of Level 3 medical homes.

PACCI included incentives to earn PCMH recognition, but not to reduce costs. Cost savings would have been more likely if practices had incentives to reduce costs.

Half the NCQA-Recognized medical homes in the PACCI earned the highest level of recognition (Level 3), compared to 75% nationally. A higher (and more typical) concentration of high-capability medical homes would probably have produced better outcomes.  

About the study:
The study is based on outdated NCQA PCMH standards and contradicts several other studies that have shown improvement in cost, quality, access and patient experience.

The study is based on the earliest version of our PCMH program (2008). We updated the standards in 2011 and will update them again March 24, 2014. In effect, we will have twice performed the “further refinement” the study recommends. Our standards will also continue to evolve. 

As a recent NCQA white paper shows, other studies have found that NCQA PCMHs improve quality, patient experience, continuity, prevention and disease management.

Various studies show lower costs from reduced emergency department visits and hospital admissions.1–8 Other research shows reduced income-based disparities in care and provider burnout.9,10 At the same time the study reported in JAMA was underway, Vermont’s Blueprint for Health was having success with PCMH.

The preponderance of evidence supporting medical homes is why most states, and many private and commercial insurers, support PCMHs with financial or technical support.

Journalists and others interested in the latest generation of medical home standards are welcome to attend a preview of the PCMH 2014 standards on March 10. Highlights of the new standards include:

  • Alignment with Meaningful Use Stage 2 (MU2).
  • Enhanced emphasis on team-based care.
  • Care management focus on high-need populations.
  • Alignment of quality improvement with all three facets of the triple aim.
  • Emphasis on sustained transformation.
  • Integration of behavioral healthcare.

 

1 Perry, R., et al. June 24, 2012. Examining the Impact of Continuity of Care on Medicare Payments in the Medical Home Context, Presented at the AcademyHealth Annual Research Meeting, Orlando, FL. http://www.academyhealth.org/files/2012/sunday/perry.pdf

2 Gabbay, R.A., et al. 2011. Multipayer patient-centered medical home implementation guided by the chronic care model. Jt Comm J Qual Patient Saf. 37(6):265-73. http://ww.bailit-health.com/articles/062211_bhp_mpcmhi.pdf

3 Maeng, D.D., et al. 2011. Can a Patient-Centered Medical Home Lead to Better Patient Outcomes* The Quality Implications of Geisinger’s Proven Health Navigator. Am J Med Qual. epub ahead of print Aug 18. http://ajm.sagepub.com/content/27/3/210.abstract?patientinform-links=yes&legid=spajm;27/3/210

4 DeVries, A., et al. 2012. Impact of Medical Homes on Quality Healthcare Utilization and Costs. AMJC. http://www.ajmc.com/publications/issue/2012/2012-9-vol18-n9/Impact-of-Medical-Homes-on-Quality-Healthcare-Utilization-and-Costs#sthash.vuXFYJRA.dpuf

5 Takach, M. July 2011. Reinventing Medicaid: State Innovations To Qualify And Pay For Patient-Centered Medical Homes Show Promising. Health Affairs. http://content.healthaffairs.org/content/30/7/1325.abstract

6 Harbrecht, M., et al. September 2012. Colorado’s Patient-Centered Medical Home Pilot Met Numerous Obstacles, Yet Saw Results Such as Reduced Hospital Admissions. Health Affairs. http://content.healthaffairs.org/content/31/9/2010.abstract

7 Patient Centered Primary Care Collaborative. January 2014. The Medical Home's Impact on Cost & Quality An Annual Update of the Evidence, 2012-2013.www.pcpcc.org/resource/medical-homes-impact-cost-quality#sthash.EJoswJug.dpuf

8 Department of Vermont Health Access/Vermont Blueprint for Health. http://hcr.vermont.gov/sites/hcr/files/pdfs/VTBlueprintforHealthAnnualReport2013.pdf

9 Berenson, J., et al. May 2012. Achieving Better Quality of Care for Low-Income Populations: The Role of Health Insurance and the Medical Home for Reducing Health Inequities, Commonwealth Fund, May 2012.

10 Soman, et al. May 2010. The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction and Less Burnout For Providers. Health Affairs.

11Christensen EW1, Dorrance KA, Ramchandani S, Lynch S, Whitmore CC, Borsky AE, Kimsey LG, Pikulin LM, Bickett TA.  Impact of a patient-centered medical home on access, quality, and cost. Mil Med. 2013 Feb;178(2):135-41.

12 Lebrun-Harris LA1, Shi L, Zhu J, Burke MT, Sripipatana A, Ngo-Metzger Q. Effects of Patient-Centered Medical Home Attributes on Patients' Perceptions of Quality in Federally Supported Health Centers. Ann Fam Med. 2013 Nov-Dec;11(6):508-16.

13 Savage A, Lauby T, Burkard JF. Examining Selected Patient Outcomes and Staff Satisfaction in a Primary Care Clinic at a Military Treatment Facility After Implementation of the Patient-Centered Medical Home. Mil Med. 2013 Feb;178(2):128-34.

14 Rosenberg CN1, Peele P, Keyser D, McAnallen S, Holder D. Results from a Patient-Centered Medical Home Pilot at UPMC Health Plan Hold Lessons for Broader Adoption of the Model. Health Aff (Millwood). 2012 Nov;31(11):2423-31. doi: 10.1377/hlthaff.2011.1002.

15 Liss DT1, Fishman PA, Rutter CM, Grembowski D, Ross TR, Johnson EA, Reid RJ. Outcomes among Chronically Ill Adults in a Medical Home Prototype. Am J Manag Care. 2013 Oct 1;19(10):e348-58.

16 Reid RJ1, Johnson EA, Hsu C, Ehrlich K, Coleman K, Trescott C, Erikson M, Ross TR, Liss DT, Cromp D, Fishman PA. Spreading a Medical Home Redesign: Effects on Emergency Department Use and Hospital Admissions. Ann Fam Med. 2013 May-Jun;11 Suppl 1:S19-26.

17 Raskas RS, Latts LM, Hummel JR, Wenners D, Levine H, Nussbaum SR. Early Results Show Wellpoint's Patient-Centered Medical Home Pilots Have Met Some Goals for Costs, Utilization, and Quality. Health Aff (Millwood). 2012 Sep;31(9):2002-9.

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