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Latest Evidence: Benefits of the Patient-Centered Medical Home

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Patient-Centered Medical Homes are driving some of the most important reforms in healthcare delivery today. A growing body of scientific evidence shows that PCMHs are saving money by reducing hospital and emergency department visits, mitigating health disparities, and improving patient outcomes. The evidence we present here outlines how the medical home inspires quality in care, cultivates more engaging patient relationships, and captures savings through expanded access and delivery options that align patient preferences with payer and provider capabilities. This report will be updated as new evidence of PCMH implementation is released.

NCQA first developed the PCMH recognition program at the request of, and in collaboration with, four key medical professional societies – the American Academy of Pediatrics, the American College of Physicians, the American Osteopathic Association and the American Academy of Family Physicians. Since the initial program was released in 2008, it has gone through two substantial revisions, in 2011 and 2014.

NCQA is redesigning the PCMH Recognition program and will launch the redesigned program March 31, 2017. The redesigned program incorporates feedback from practice staff, clinicians and NCQA PCMH Certified Content ExpertsTM to improve the process, cut back the paperwork and simplify reporting so practices can focus on improving care. The redesign also considers the changing payment climate, including the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The redesigned PCMH process will support the shift to value-based care, and aligns reporting requirements with expected MACRA changes to help eliminate duplication of work.

Table of Contents

NCQA Recognized Patient-Centered Medical Home Studies

NCQA Patient-Centered Medical Homes Cut Growth in Medicare Emergency Department Use: Medicare Claims & Enrollment Data. 4

NCQA Patient-Centered Medical Homes Lower Total Cost of Care for Medicare Fee-for-Service Beneficiaries: Medicare Claims & Enrollment Data. 5

NCQA Patient-Centered Medical Homes Lower Costs and Provide a High Return on Investment: Colorado Multipayer PCMH Pilot, New Hampshire Citizens Health Initiative Multi-Stakeholder Medical Home Pilot 6

NCQA Patient-Centered Medical Homes Provide More Effective Care Management and Optimize Use of Health Care Services: Empire Blue Cross and Blue Shield, New York City. 7

NCQA Patient-Centered Medical Homes Lower Medicare Spending: Medicare Claims & Enrollment Data 8

NCQA Patient-Centered Medical Homes Improve Care Management and Preventative Screenings for Cardiovascular and Diabetes Patients: Southeast Pennsylvania Multi-Payer Advanced Primary Care Practice Demonstration. 9

NCQA Patient-Centered Medical Homes Reduce Overall Health Costs; Study Reinforces Need for Reform Maturation Before Evaluation: Vermont Blueprint for Health. 10

NCQA Patient-Centered Medical Homes Drive Quality Improvement, More Effective Utilization of Primary Care and Fewer Hospital and Emergency Department Visits: Northeastern Pennsylvania Chronic Care Initiative 11

NCQA Patient-Centered Medical Homes Increase Efficient Utilization of Health Care Services: Rochester Medical Home Initiative. 12

NCQA Patient-Centered Medical Homes with Financial and Technical Support Produce Sustained Reductions in Utilization: Colorado Multi-Payer HealthTeamWorks PCMH Pilot 13

Additional Patient-Centered Medical Home Evidence

Patient-Centered Medical Homes Reduce Socio-economic Disparities in Cancer Screening: Blue Cross Blue Shield of Michigan Physician Group Incentive Program.. 14

Long-term Patient-Centered Medical Home Implementation Produces Largest Sustainable Cost Savings in Acute Inpatient Care: Geisinger Health System’s ProvenHealth Navigator 15

Patient-Centered Medical Home Initiatives Expanded Fourfold from 2009–13. 16

Medicare Beneficiaries Have Better Patient Experience in Patient-Centered Medical Homes: John A. Hartford Foundation Primary Care Poll Series. 17

Patient-Centered Medical Homes Produce Most Effective Cost Savings in Highest Risk Patients: Pennsylvania Chronic Care Initiative. 18

Patient-Centered Medical Homes Increase Rates of Quality Improvement: New York State Medicaid and the Adirondack Medical Home Multi-payer Demonstration. 19

Medicaid Patient-Centered Medical Homes Increase Patient Access and Lower Inpatient Admissions and Per Member Per Month Costs: State PCMH Initiatives. 20

Multi-payer Patient-Centered Medical Homes Reduce Preventable Emergency Department Visits: Rhode Island Chronic Care Sustainability Initiative. 21

Patient-Centered Medical Home Initiatives Produce 6 to 1 Return on Investment: UnitedHealth Center for Health Reform & Modernization. 22

Challenges and Concerns Facing Patient-Centered Medical Home Implementation

Insufficient Data and Outdated Standards. 23

Conclusions Not Supported by Demonstration Goals. 23

Non-Standard PCMH Design. 23

Summary Table of Patient-Centered Medical Home Evidence

Summary Table. 24

Evidence of NCQA Patient-Centered Medical Home Effectiveness

NCQA Patient-Centered Medical Homes Cut Growth in Medicare Emergency Department Use: Medicare Claims & Enrollment Data

NCQA PCMHs cut the growth in outpatient ED visits by 11% over non-PCMHs for Medicare patients. The reduction was in visits for both ambulatory-care-sensitive and non–ambulatory-care-sensitive conditions, suggesting that steps taken by practices to attain patient-centered medical home recognition may decrease some of the demand for outpatient ED care.

Key Study Characteristics

Size

Variables of Interest

Findings

· 308 NCQA recognized practices

· 1,906 control practices

· 146,410 beneficiaries in PCMHs and 446,273 beneficiaries in comparison practices

· Rate of growth in Emergency Department (ED) use

· Rate of growth in costs of ED visits for all causes and ambulatory-care-sensitive conditions

· The rate of growth in ED payments per beneficiary was $54 less for 2009 patient-centered medical homes and $48 less for 2010 patient-centered medical homes relative to non–patient-centered medical home practices

· The rate of growth in all-cause and ambulatory-care-sensitive condition ED visits per 100 beneficiaries was 13 and 8 visits fewer for 2009 patient-centered medical homes and 12 and 7 visits fewer for 2010 patient-centered medical homes, respectively.

Pines J.M., Martijn van Hasselt & Nancy McCall (2015). Emergency Department and Inpatient Hospital Use by Medicare Beneficiaries in Patient-Centered Medical Homes. Annals of Emergency Medicine.

http://www.annemergmed.com/article/S0196-0644(15)00003-7/pdf

Evidence of NCQA Patient-Centered Medical Home Effectiveness

NCQA Patient-Centered Medical Homes Lower Total Cost of Care for Medicare Fee-for-Service Beneficiaries: Medicare Claims & Enrollment Data

Medicare fee-for-service beneficiaries receiving care in NCQA-recognized PCMH practices had lower total annual Medicare spending than beneficiaries in comparison practices. Medical home implementation resulted in lower payments to acute care hospitals and fewer emergency department visits. The declines were larger for practices with sicker than average patients, primary care practices, and solo practices.

Key Study Characteristics

Size

Variables of Interest

Findings

· 308 NCQA recognized PCMH practices

· 1906 control practices

· 146,410 beneficiaries in PCMHs and 446,273 beneficiaries in comparison practices

· Average Medicare payments

· Inpatient costs

· Emergency Department visits

· PCMH recognition was associated with $265 lower average annual total Medicare spend per beneficiary (4.9%) 

· Lower acute care hospital spending of $164 (62%)

· Fewer emergency department visits – 55 per 1000 beneficiaries for all causes and 13 for ambulatory-care-sensitive conditions

Van Hasselt, M., McCall, N., Keyes, V., Wensky, S. G., & Smith, K. W. (2014). Total Cost of Care Lower among Medicare Fee-for-Service Beneficiaries Receiving Care from Patient-Centered Medical Homes. Health Services Research.

Evidence of NCQA Patient-Centered Medical Home Effectiveness

NCQA Patient-Centered Medical Homes Lower Costs and Provide a High Return on Investment: Colorado Multipayer PCMH Pilot, New Hampshire Citizens Health Initiative Multi-Stakeholder Medical Home Pilot

NCQA PCMH recognition is associated with lower inpatient hospitalizations and lower utilization of both specialist and emergency services. Pilot programs in Colorado also produced an estimated return-on-investment (ROI) between 2.5 and 4.5 to 1.

Key Study Characteristics

Size

Variables of Interest

Findings

· Overall pilot included 16 practices, over 100K patients

· 8,200 were WellPoint Members

· Inpatient hospitalizations

· ER utilization

· Specialist utilization

· Health plan return on investment

· Admissions per 1,000 went down 18% vs. 18% increase in control group

· 15% drop in ER utilization vs. 4% increase in control group

· Specialists visits remained flat, but 10% increase in control group

· WellPoint estimates ROI of between 2.5 to 1 and 4.5 to 1.

Harbrecht, M, Latts, L. (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

Raskas, et al. (2012). Early Results Show WellPoint’s Patient-Centered Medical Home Pilots Have Met Some Goals For Costs, Utilization and Quality. Health Affairs. http://content.healthaffairs.org/content/31/9/2002.abstract

Evidence of NCQA Patient-Centered Medical Home Effectiveness

NCQA Patient-Centered Medical Homes Provide More Effective Care Management and Optimize Use of Health Care Services: Empire Blue Cross and Blue Shield, New York City

Patients treated within NCQA PCMH practices had equal or better care management, fewer inappropriate prescriptions as well as avoidable emergency department visits and hospitalizations.

Key Study Characteristics

Size

Variables of Interest

Findings

· 31,032 NCQA PCMH patients

· 350,015 Non-PCMH patients

· Care for patients with diabetes, cardiovascular disease

· Resource use: inappropriate antibiotic use

· Resource use: ED and hospital utilization, total costs

· Higher A1C testing in PCMH patients: 82.11% vs. 77.7%

· LDL screening higher in PCMH patients: 75.9% vs. 73.5%

· LDL control (<100) better in PCMH patients: 64.7% vs. 57.3%

· Antibiotic use in children was lower for PCMH patients: 27.5% vs. 35.4% (lower is better)

Lower risk-adjusted ED use and hospitalizations for adults in PCMH:

· 11% reduction ED services

· 12% fewer hospitalizations

· Total costs 409$ PMPM for patients in PCMH-$484 PMPM costs for non-PCMH patients

DeVries, A, Chia-Hsuan W, Sridhar G, Hummel J, Breidbart S., Barron J. (2012) Impact of Medical Homes on Quality Healthcare Utilization and Costs. The American Journal of Managed Care.http://www.ajmc.com/publications/issue/2012/2012-9-vol18-n9/Impact-of-Medical-Homes-on-Quality-Healthcare-Utilization-and-Costs#sthash.vuXFYJRA.dpuf

Evidence of NCQA Patient-Centered Medical Home Effectiveness

NCQA Patient-Centered Medical Homes Lower Medicare Spending: Medicare Claims & Enrollment Data

Beneficiaries enrolled in an NCQA PCMH showed lower rates of utilization and Medicare payments across many types of services than comparison practices, particularly with regard to ambulatory-care-sensitive condition ER visits.

Key Study Characteristics

Size

Variables of Interest

Findings

· 312 NCQA PCMH practices

· 312 control practices

· 190,000 Medicare beneficiaries

· Average Medicare payments

· PCMH resulted in $1,099 lower average per-patient total Medicare spending 

Perry R, McCall N, Goodwin S. Examining the Impact of Continuity of Care on Medicare Payments in the Medical Home Context. Presented at the AcademyHealth Annual Research Meeting, Orlando, FL, June 24, 2012.

http://www.academyhealth.org/files/2012/sunday/perry.pdf

Evidence of NCQA Patient-Centered Medical Home Effectiveness

NCQA Patient-Centered Medical Homes Improve Care Management and Preventative Screenings for Cardiovascular and Diabetes Patients: Southeast Pennsylvania Multi-Payer Advanced Primary Care Practice Demonstration

NCQA PCMH programs demonstrated significant improvements in receiving evidence-based screenings and treatment for diabetes as well as modest improvements in clinical outcomes, such as blood pressure and cholesterol.

Key Study Characteristics

Size

Variables of Interest

Findings

· 25 practices

· 143 providers

· Care for cardiovascular disease and diabetes

· 8.5% increase in % of patients with LDLc<130

· 4% increase in % of patients with BP<140/90

· 2.5% decrease in % of patients with A1C>9

Gabbay RA, Bailit MH, Mauger DT, Wagner EH and Siminerio L. (2011). Multipayer Patient-Centered Medical Home Implementation Guided by the Chronic Care Model. The Joint Commission Journal on Quality and Patient Safety. http://www.bailit-health.com/articles/062211_bhp_mpcmhi.pdf

Evidence of NCQA Patient-Centered Medical Home Effectiveness

NCQA Patient-Centered Medical Homes Reduce Overall Health Costs; Study Reinforces Need for Reform Maturation Before Evaluation: Vermont Blueprint for Health

When compared with patients in traditional primary care practices, PCMH patients had lower overall health care costs driven by fewer inpatient and outpatient expenditures. They also had increased use of non-medical support services. The Blueprint’s findings over 6 years of implementation highlight the importance of providing sufficient time for complex delivery system reforms to mature. 

Key Study Characteristics

Size

Variables of Interest

Findings

· 123 PCMH recognized practices; 236,229 patients

· ~60 comparison practices; 81,648 patients

· Total health care expenditures per-capita

· Utilization patterns

· Use of non-medical support services by Medicaid beneficiaries

· Reduced total annual health care expenditures per capita by $482.40

· Reduced inpatient discharges and days by 8.8 and 49.6 per 1000 members, respectively

· Significantly decreased use of outpatient hospital facility services such as advanced imaging

· $57 more spending per capita on non-medical support services by Medicaid beneficiaries

Department of Vermont Health Access / Vermont Blueprint for Health http://blueprintforhealth.vermont.gov/sites/blueprint/files/BlueprintPDF/AnnualReports/Vermont-Blueprint-for-Health-2015-Annual-Report-FINAL-1-27-16.pdf

Evidence of NCQA Patient-Centered Medical Home Effectiveness

NCQA Patient-Centered Medical Homes Drive Quality Improvement, More Effective Utilization of Primary Care and Fewer Hospital and Emergency Department Visits: Northeastern Pennsylvania Chronic Care Initiative

NCQA PCMHs that included shared savings for practices performed better on four process measures related to diabetes and breast cancer screening. They also increased primary care utilization and lowered the use of emergency departments, hospital, and specialty care.

Key Study Characteristics

Size

Variables of Interest

Findings

· 27 NCQA PCMH practices; 17, 921 attributed patients

· 29 control practices; 12, 894 attributed patients

· 4 process measures related to diabetes care quality

· 1 process measure related to breast cancer screening

· Utilization of hospitals and emergency departments

· Utilization of primary vs. specialty care

· NCQA PCMHs outperformed control group on all 4 diabetes measures:

o 4.2-8.3% better on HbA1c testing

o 4.3-8.5% better on LDL-C testing

o 15.5-21.5% better on nephropathy monitoring

o 9.7-15.5% better on eye examinations

· PCMHs produced an average of 4.1-6.8% more breast cancer screenings

· PCMHs produced 1.7 fewer all-cause hospitalizations and 4.7 fewer ED visits per 1000 patients per month

· PCMHs produced 77.5 more primary care visits and 17.3 fewer ambulatory-care-sensitive specialist visits per 1000 patients per month

Friedberg MW, Rosenthal MB, Werner RM, Volpp KG, Schneider EC. (2015). Effects of a Medical Home and Shared Savings Intervention on Quality and Utilization of Care. Journal for the American Medical Association Internal Medicine. http://archinte.jamanetwork.com/article.aspx?articleid=2296117

Evidence of NCQA Patient-Centered Medical Home Effectiveness

NCQA Patient-Centered Medical Homes Increase Efficient Utilization of Health Care Services: Rochester Medical Home Initiative

NCQA PCMH practices participating in the Rochester Medical Home Initiative reported decreased use of expensive imaging tests as well as reduced drug spending and ambulatory-care-sensitive ED visits. The practices also saw increased primary care visits, laboratory tests and life-saving cancer screening rates.

Key Study Characteristics

Size

Variables of Interest

Findings

· 7 NCQA PCMH practices

· 61 comparison practices

· Prescription drug spending

· Ambulatory-care-sensitive ED visits

· Use of imaging tests

· Primary care visits

· Use of laboratory tests

· Breast cancer screenings

· $11.75 lower drug spending by per patient per month

Per 1000 member months, NCQA PCMHs produced:

· 2 fewer ACSD ED visits

· 400 fewer imaging tests

· 30 more PCP visits

· 70 more lab tests

· 20 more breast cancer screening tests

Rosenthal MB, Sinaiko AD, Eastman D, Chapman B, Partridge G. (2015). Impact of the Rochester Medical Home Initiative on Primary Care Practices, Quality, Utilization, and Costs. Medical Care. http://www.ncbi.nlm.nih.gov/pubmed/26465125

Evidence of NCQA Patient-Centered Medical Home Effectiveness

NCQA Patient-Centered Medical Homes with Financial and Technical Support Produce Sustained Reductions in Utilization: Colorado Multi-Payer HealthTeamWorks PCMH Pilot

A study of Colorado’s HealthTeamWorks PCMH pilot found meaningful reductions in ED utilization that were sustained into the third year of the pilot. These reductions translated to nearly $5 million per year in savings for the approximately 100,000 patients touched by the pilot.

Key Study Characteristics

Size

Variables of Interest

Findings

· 15 NCQA PCMH practices

· 66 comparison practices

· ED utilization

· Cancer screening rates

· HbA1c testing rates

· Ambulatory-care-sensitive inpatient admissions

· Primary care utilization

After third year of PCMH pilot:

· 9.3% reduction in ED utilization (resulting in approx. $5 million in savings per year)

· 9% increase in cervical cancer screenings; 18.1% reduction in colon cancer screenings

· 0.7% reduction of HbA1c testing in patients with diabetes

· 10.3% reduction in ambulatory-care-sensitive inpatient admissions for patients with two or more comorbidities

· 1.5% reduction in primary care visits

Rosenthal MB, Alidina S, Friedberg MW, Singer SJ, Eastman D, Li Z, Schneider EC. (2015). A Difference-in-Difference Analysis of Changes in Quality, Utilization and Cost Following the Colorado Multi-Payer Patient-Centered Medical Home Pilot. Journal of General Internal Medicine. http://www.ncbi.nlm.nih.gov/pubmed/26450279

Additional Studies Showing Effectiveness of PCMH Model

Patient-Centered Medical Homes Reduce Socio-economic Disparities in Cancer Screening: Blue Cross Blue Shield of Michigan Physician Group Incentive Program

PCMHs increase highly-recommended cancer screening rates, especially for people with lower socioeconomic status, thereby reducing disparities in care.

Key Study Characteristics

Size

Variables of Interest

Findings

· 2218 Michigan primary care practices that participated in the Blue Cross Blue Shield of Michigan (BCBSM) Physician Group Incentive Program (PGIP)

· Breast, cervical, and colorectal cancer screening rates for practices’ BCBSM patients

· Socioeconomic context of each practice (the geographic environment in which its patients reside)

· PCMH are associated with higher breast, cervical, and colorectal cancer screening rates for most socioeconomic groups

· However, the increase is greatest for lower socio-economic groups

· For example, the disparity in breast cancer screening was cut in half, from a 6% to a 3% difference

Markovitz AR, Alexander JA, Lantz PM, Paustian ML (2015). Patient-Centered Medical Home Implementation and Use of Preventive Services: The Role of Practice Socioeconomic Context, Journal for the American Medical Association Internal Medicine. http://archinte.jamanetwork.com/article.aspx?articleid=2110999

Additional Studies Showing Effectiveness of PCMH Model

Long-term Patient-Centered Medical Home Implementation Produces Largest Sustainable Cost Savings in Acute Inpatient Care: Geisinger Health System’s ProvenHealth Navigator

Geisinger Health System PCMHs produced greatest savings through reduced acute inpatient care, which increased over time and with further implementation of PCMH reform.

Key Study Characteristics

Size

Variables of Interest

Findings

· 86 PCMH practices

· Total cost of care, defined as PMPM payments. Costs were further broken down into inpatient, outpatient, professional and prescription drug components

· Total costs savings of about 7.9% - largest savings was in acute inpatient care ($34 PMPM, or 19% savings)

· Savings increased the longer a clinic was exposed to PCMH transformation

Maeng, Daniel D., Nazmul Khan, Janet Tomcavage, Thomas R. Graf, Duane E. Davis, and Glenn D. Steele. (2015). Reduced Acute Inpatient Care Was Largest Savings Component of Geisinger Health System's Patient-Centered Medical Home. Health Affairs. 

Additional Studies Showing Effectiveness of PCMH Model

Patient-Centered Medical Home Initiatives Expanded Fourfold from 2009–13

Programs that promote Patient-Centered Medical Home transformation with payment reform incentives continue to rapidly expand across the United States. Private and public payer initiatives together have grown from 18 states in 2009 to 44 states in 2013, and now cover almost 21 million patients. These heterogeneous initiatives overall are becoming larger, paying higher fees, and engaging in more risk sharing with practices.

Key Study Characteristics

Size

Variables of Interest

Findings

· In 2009, 26 PCMH initiatives, including over 14,000 providers serving almost 5 million patients

· In 2013, 114 PCMH initiatives, including over 63,000 providers serving almost 21 million patients

· Growth in number of initiatives as well as the number of patients served by them

· Payment models as well as payment reform incentives within each initiative

· There has been fourfold growth nationally in the number of PCMH initiatives as well as the number of patients served by them, including expansion from only 18 states in 2009 to 44 states in 2013.

· The initiatives that included payment reform incentives have evolved from mostly small and time-limited demonstration programs to larger, more open-ended efforts.

Edwards Samuel T, Asaf Bitton, Johan Hong, and Bruce E. Landon (2014). Patient-Centered Medical Home Initiatives Expanded In 2009–13: Providers, Patients, and Payment Incentives Increased, Health Affairs. http://content.healthaffairs.org/content/33/10/1823.full

Additional Studies Showing Effectiveness of PCMH Model

Medicare Beneficiaries Have Better Patient Experience in Patient-Centered Medical Homes: John A. Hartford Foundation Primary Care Poll Series

Surveys of Medicare beneficiaries found that they want PCMH care and believe it is improving their health.

Key Study Characteristics

Size

Variables of Interest

Findings

· Survey of 1,107 adults ages 65 and older

· Perceptions of PCMH care

· 73% said they want PCMH-style care, 61% said it would improve their health, but only 27% said they receive such care.

Of those receiving PCMH care:

· 83% say it improved health, 51% can get same-day appointments vs 13% of those not, and 30% vs. 21% said their PCP is available on weekends/evenings via phone.

When asked about care plans:

· 86% said they were not sure or do not have them, 56% want them, 48% said it would improve health, and 78% of the 14% who were sure they have them said it improved health.

Langston C, Undem T, Dorr D. (2014). Transforming Primary Care What Medicare Beneficiaries Want and Need from Patient ‐Centered Medical Homes to Improve Health and Lower Costs. Hartford Foundation.

Additional Studies Showing Effectiveness of PCMH Model

Patient-Centered Medical Homes Produce Most Effective Cost Savings in Highest Risk Patients: Pennsylvania Chronic Care Initiative

PCMH practices had significantly reduced costs and utilization for the highest risk patients, particularly with respect to inpatient care. As high-risk members represent a high-cost group, the most benefit can be gained by targeting these members.


Key Study Characteristics

Size

Variables of Interest

Findings

· 6940 cases and 6940 controls, then using the 10% of patients with highest risk scores (654 cases and 734 controls)

· Costs for high-risk patients

· Total cost decreased significantly for the PCMH group than for controls in the high-risk group in years 1 and 2 (reductions of $107 and $75 PMPM), driven by lower inpatient costs.

· The PCMH group experienced a significantly greater reduction in

inpatient admissions in all 3 years (61, 48, and 94

hospitalizations per 1000).

Higgins S, Chawla R, Colombo C, Snyder R, & Nigam. (2014). Medical Homes and Cost and Utilization Among High-Risk Patients, American Journal of Managed Care.http://www.ncbi.nlm.nih.gov/pubmed/24773328


Additional Studies Showing Effectiveness of PCMH Model

Patient-Centered Medical Homes Increase Rates of Quality Improvement: New York State Medicaid and the Adirondack Medical Home Multi-payer Demonstration

New York State reported to the legislature in April 2013 that PCMH practices in the state have higher rates of quality performance, as defined by national standardized measures, than non-PCMH practices for a majority of measures.

Key Study Characteristics

Size

Variables of Interest

Findings

· 333,847 members in 2010 measurement year

· 653,194 in 2011 measurement year

· Adult rates of evidence-based screening

· Adult diabetes care

· Adult cardiac care

· Pediatric counseling for nutrition and physical activity

· Pediatric weight assessment

· Adolescent immunizations

· 2010 breast cancer screening (rate): 71 PCMH vs. 66 non-PCMH

· 2011 breast cancer screening (rate): 70 PCMH vs. 65 non-PCMH

· 2010 chlamydia screening (rate): 70 PCMH vs. 67 non-PCMH

· 2011 Received all recommended tests (rate): 52 PCMH vs. 45 non-PCMH

· 2011 cholesterol control (<100mg/dL): 59 PCMH vs. 47 non-PCMH

· 2011 counseling for nutrition: 84 PCMH vs. 74 non-PCMH

· 2011 counseling for physical activity: 72 PCMH vs. 64 non-PCMH

· 2011 weight assessment: 81 PCMH vs. 68 non-PCMH

· 2011 immunization combo: 76 PCMH vs. 65 non PCMH

The Patient-Centered Medical Home Initiative in New York State Medicaid: Report to the Legislature, April 2013. New York State Department of Health. http://www.health.ny.gov/health_care/medicaid/redesign/docs/pcmh_initiative.pdf

Additional Studies Showing Effectiveness of PCMH Model

Medicaid Patient-Centered Medical Homes Increase Patient Access and Lower Inpatient Admissions and Per Member Per Month Costs: State PCMH Initiatives

In a survey of a number of state initiatives, some of which use NCQA recognition, National Association for Health Policy researcher Mary Takach found evidence of improvements in quality and reduced use of emergency room and other utilization measures.

Key Study Characteristics

Size

Variables of Interest

Findings

· Multiple Medicaid pilot programs

· VT – inpatient use, total PMPM costs

· CO – expanded access to care

· 21% lower inpatient use

· 22% lower PMPM costs

· Statewide pediatrician participating in Medicaid increased from 20% to 96% after implementation

· Improved CAHPS scores on access questions, including 90% of parents reporting little or no trouble in scheduling children’s appointments when needed

Takach, M. (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

Additional Studies Showing Effectiveness of PCMH Model

Multi-payer Patient-Centered Medical Homes Reduce Preventable Emergency Department Visits: Rhode Island Chronic Care Sustainability Initiative

Rhode Island multiple-payer PCMH initiative yielded significant reduction in emergency room visits for conditions that could be treated in a doctor’s office. The five small, independent primary care practices in the program also improved their ability over two years to prospectively manage patient populations and track and coordinate care.

Key Study Characteristics

Size

Variables of Interest

Findings

· 5 practices, compared with 34 control group practices

· ER utilization

· 3 diabetes measures

· 3 preventive screening

· 11.6% reduction in ambulatory-sensitive ER utilization as compared to control

· No difference on quality measures

Rosenthal M. B., M. W. Friedberg, S. J. Singer et al. (2013). Effect of a Multipayer Patient-Centered Medical Home on Health Care Utilization and Quality: The Rhode Island Chronic Care Sustainability Initiative Pilot Program. Journal of the American Medical Association Internal Medicine. http://archinte.jamanetwork.com/article.aspx?articleid=1735895.

Additional Studies Showing Effectiveness of PCMH Model

Patient-Centered Medical Home Initiatives Produce 6 to 1 Return on Investment: UnitedHealth Center for Health Reform & Modernization

An actuarial evaluation of four medical home programs in Arizona, Colorado, Ohio, and Rhode Island, based on operation between 2009 and 2012 for 40,000 members, found average gross savings of 7.4% of medical costs compared to traditional primary care practices. Every dollar invested in care coordination activities produced $6 in savings in the third year (a return on investment of approximately 6 to 1). Including the cost of the intervention, the programs saved approximately 6.2% of medical costs on average.

Advancing Primary Care Delivery: Practical, Proven, and Scalable Approaches. (2014). UnitedHealth Center for Health Reform & Modernization.

http://www.unitedhealthgroup.com/newsroom/articles/feed/unitedhealth%20group/2014/0930practicalscalableprimarycare.aspx

Challenges and Concerns Facing PCMH Implementation

There are several common threads among studies reporting little or no benefit from the PCMH model. Some have used limited data sets or looked at outdated standards. Others drew conclusions that were not consistent with the design of the PCMH initiative in question or evaluated non-standard medical home models.

Insufficient Data and Outdated Standards

Studies that reflect only marginal gains in quality and cost reduction have tended to focus on early, outdated demonstrations. One study of Pennsylvania’s Chronic Care Initiative PCMH program is an example of this.[1] It was based on NCQA’s earliest PCMH standards, and only half of its practices achieved the highest recognition level. A similar study from Louisiana used the same outdated NCQA PCMH standards.[2]

Conclusions Not Supported by Demonstration Goals

The Pennsylvania and Louisiana studies also both attempted to draw conclusions that were not supported by the goals of the demonstrations they evaluated. They found no cost savings, but neither initiative had cost savings as a goal or provided incentives to reduce spending. PCMH initiatives must provide sustained, meaningful financial incentives in order to achieve real success. 

Non-Standard PCMH Design

Many early PCMH analyses studied pilots that lacked standardized metrics and goals, and instead relied on disjointed measures, self-reporting, and “cherry-picking” of low cost patients.[3],[4] Meaningful evaluation of the PCMH model requires standardized criteria, rigorous quantitative analysis, and comprehensive and consistent PCMH implementation.

Summary Table of Patient-Centered Medical Home Evidence

Summary Table

Study

Expanding Access

Mitigating Health Disparities

Cutting Costs & Utilization

Quality & Outcomes

Improving Satisfaction

Emergency Department and Inpatient Hospital Use by Medicare Beneficiaries in Patient-Centered Medical Homes 

Published: Annals of Emergency Medicine, 2015

· The rate of growth in ED payments per PCMH beneficiary was $54 less for 2009 and $48 less for 2010 relative to non–PCMH practices

Also for PCMH practices:

· The rate of growth in all-cause ED admissions per 100 beneficiaries was 13 fewer visits in 2009 and 12 fewer in 2010

· The rate of growth in ambulatory-care sensitive condition ED admissions per 100 beneficiaries was 8 fewer visits in 2009 and 7 fewer in 2010

Total Cost of Care Lower among Medicare Fee-for-Service Beneficiaries Receiving Care from Patient-Centered Medical Homes

Published: Health Services Research, 2014

· 4.9% lower average annual total Medicare spend per beneficiary

· 62% lower acute care hospital spending

· Fewer ED visits – 55 fewer per 1000 beneficiaries for all causes and 13 for ambulatory-care-sensitive conditions

Colorado’s Patient-Centered Medical Home Pilot Met Numerous Obstacles, Yet Saw Results Such as Reduced Hospital Admissions

Published: Health Affairs, 2012

---------

Early Results Show WellPoint’s Patient-Centered Medical Home Pilots Have Met Some Goals For Costs, Utilization and Quality

Published: Health Affairs, 2012

· Admissions decreased 18% vs. 18% increase in non-PCMH group

· 15% drop in ER utilization vs. 4% increase in non-PCMH group

· Estimated ROI of between 2.5:1 and 4.5:1

· Specialists visits remained flat, but 10% increase in non-PCMH group

Impact of Medical Homes on Quality Healthcare Utilization and Costs

Published: American Journal of Managed Care, 2012

· 11% reduction ED services

· 12% fewer hospitalizations

· Total costs were $75 less PMPM for patients in PCMHs

· Higher A1C testing in PCMH patients: 82.11% vs. 77.7%

· LDL screening higher in PCMH patients: 75.9% vs. 73.5%

· LDL control (<100) better in PCMH patients: 64.7% vs. 57.3%

· Antibiotic use in children was lower for PCMH patients: 27.5% vs. 35.4% (lower is better)

Examining the Impact of Continuity of Care on Medicare Payments in the Medical Home Context

Presented: AcademyHealth Annual Research Meeting, 2012

· $1,099 lower average per-patient total Medicare payments 

Multipayer Patient-Centered Medical Home Implementation Guided by the Chronic Care Model

Published: Joint Commission Journal on Quality and Patient Safety, 2012

· 8.5% increase in percent of patients with LDLc<130

· 4% increase in percent of patients with BP<140/90

· 2.5% decrease in percent of patients with A1C>9

Vermont Blueprint for Health

Published: Department of Vermont Health Access, 2016

· $57 more in spending per capita on non-medical support services by Medicaid beneficiaries

· Reduced total annual health care expenditures per capita by $482.40

· Significantly decreased use of outpatient hospital facility services such as advanced imaging

· Reduced inpatient discharges and days by 8.8 and 49.6 per 1000 members, respectively

Effects of a Medical Home and Shared Savings Intervention on Quality and Utilization of Care

Published: Journal for the American Medical Association Internal Medicine, 2016

· 1.7 fewer all-cause hospitalizations and 4.7 fewer ED visits per 1000 patients per month

· 77.5 more primary care visits and 17.3 fewer ambulatory-care-sensitive specialist visits per 1000 patients per month

· 4.2-8.3% better on HbA1c testing

· 4.3-8.5% better on LDL-C testing

· 15.5-21.5% better on nephropathy monitoring

· 9.7-15.5% better on eye examinations

· 4.1-6.8% more breast cancer screenings

Impact of the Rochester Medical Home Initiative on Primary Care Practices, Quality, Utilization, and Costs

Published: Medical Care, 2015

· $11.75 lower drug spending by per patient per month

Per 1000 member months, NCQA PCMHs produced:

· 400 fewer imaging tests

· 30 more PCP visits

· 70 more lab tests

Per 1000 member months, NCQA PCMHs produced:

· 2 fewer ACS ED visits

· 20 more breast cancer screening tests

A Difference-in-Difference Analysis of Changes in Quality, Utilization and Cost Following the Colorado Multi-Payer Patient-Centered Medical Home Pilot

Published: Journal of General Internal Medicine, 2015

After third year of PCMH pilot:

· 9.3% reduction in ED utilization (approx. $5 million in savings per year)

· 9% increase in cervical cancer screenings

· 10.3% reduction in ambulatory-care-sensitive inpatient admissions for patients with two or more comorbidities

· 1.5% reduction in primary care visits

Patient-Centered Medical Home Implementation and Use of Preventive Services: The Role of Practice Socioeconomic Context

Published: Journal for the American Medical Association Internal Medicine, 2015

· Higher rates of cancer screenings for breast (5.4%), cervical (4.2%) and colorectal (7.0%) for the lowest socioeconomic group

· Non-significant differences in cancer screenings for breast (2.6% higher) and cervical (0.5% lower), but an increase in colorectal (4.2% higher) for the highest socioeconomic group

· Reduced disparities by producing larger increases in cancer screenings for lower socioeconomic groups

· Disparity in breast cancer screening was cut in half, from a 6% to a 3% difference

Reduced Acute Inpatient Care Was Largest Savings Component of Geisinger Health System's Patient-Centered Medical Home

Published: Health Affairs, 2015

· Total cost savings of about 7.9% - the largest savings was in acute inpatient care ($34 PMPM, or 19% savings)

Patient-Centered Medical Home Initiatives Expanded In 2009–13: Providers, Patients, and Payment Incentives Increased

Published: Health Affairs, 2014

· Private and public payer initiatives together have grown from 18 states in 2009 to 44 states in 2013, and now cover almost 21 million patients

Transforming Primary Care What Medicare Beneficiaries Want and Need from Patient ‐Centered Medical Homes to Improve Health and Lower Costs

Published: Hartford Foundation, 2014

· 83% of Medicare beneficiaries in PCMHs say it improved health, 51% can get same-day appointments vs 13% of those not, and 30% vs. 21% said their PCP is available on weekends and evenings via phone

· 73% of Medicare beneficiaries said they want PCMH-style care, 61% said it would improve their health

Medical Homes and Cost and Utilization Among High-Risk Patients

Published: American Journal of Managed Care, 2014

· Significantly decreased total costs for high-risk patients (reductions of $75-$107 PMPM)

· Significantly greater reduction in inpatient admissions (61-94 fewer hospitalizations per 1000)

The Patient-Centered Medical Home Initiative in New York State Medicaid: Report to the Legislature, April 2013

Published: New York State Department of Health, 2013

· Breast cancer screening: 70% PCMH vs. 65% non-PCMH

· Adult diabetes patients who received all recommended tests: 52% PCMH vs. 45% non-PCMH

· Cholesterol control (<100mg/dL): 59% PCMH vs. 47% non-PCMH

· Weight assessment: 81% PCMH vs. 68% non-PCMH

· Immunization combo: 76% PCMH vs. 65% non-PCMH

Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising

Published, Health Affairs, 2011

· Pediatrician participation in Medicaid grew from 20% to 96% statewide following PCMH initiative

· Children covered by Medicaid who had at least one well-care visit increased from 54% to 73%

· 21% lower inpatient admissions

· 22% lower PMPM costs

· Improved CAHPS data, including 90% of parents reporting they had little or no trouble getting appointments for children as needed

Effect of a Multipayer Patient-Centered Medical Home on Health Care Utilization and Quality: The Rhode Island Chronic Care Sustainability Initiative Pilot Program

Published: Journal of the American Medical Association Internal Medicine

· 11.6% reduction in ambulatory-sensitive ED admissions

Advancing Primary Care Delivery: Practical, Proven, and Scalable Approaches

Published: UnitedHealth Center for Health Reform & Modernization, 2014

· Average gross savings of 7.4% on total medical costs compared to traditional primary care practices

· Average of $6 saved for every $1 invested in PCMH transformation (6 to 1 Return on Investment)

[1] Friedberg, M.W., Schneider, E.C., Rosenthal, M.B., Volpp, K.G., Werner, R.M. (2014). Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care. Journal of the American Medical Association

[2] Cole, Evan S., C. Campbell, M.L. Diana, L. Webber, and R. Culbertson. (2015). Patient-Centered Medical Homes in Louisiana Had Minimal Impact on Medicaid Population’s Use of Acute Care and Costs. Health Affairs.

[3] Vest, JR, Bolin JN, Miller TR, Gamm LD, Siegrist TE, Martinez LE. (2010). Medical Homes: Where You Stand Depends on Where You Sit. Medical Care Research and Review.

[4] Jackson, George L., et al. (2013). The Patient-Centered Medical Home: A Systematic Review. Annals of Internal Medicine.