Results from patient-centered medical homes study ‘significant’

Little evidence exists supporting the case for patient-centered medical homes (PCMHs), leaving decision-makers’ opinions on their use mixed. A recent study, the paper for which appeared in the March issue of Health Affairs, looked at the findings from 11 major PCMH evaluations in eight states to provide estimates of PCMH impact on utilization, cost and quality. The results were “significant.”

What is a PCMH?

Also referred to as a primary care medical home, advanced primary care, or a healthcare home, the patient-centered medical home model aims to reduce spending and improve quality while emphasizing coordinated, patient-centered care. HHS’ Agency for Healthcare Research and Quality (AHRQ) provides five functions or attributes of a PCMH:

1. Comprehensive care: The PCMH must meet the needs of the large majority of a patient’s physical and mental health needs, i.e., prevention and wellness, acute care, and chronic care.
2. Patient-centered: Health care must be relationship-based with an orientation toward treating the whole person, supporting patients and their families managing and organizing their own care.
3. Coordinated care: Care must be coordinated across the broader health care system, encompassing specialty care, hospitals, home health care, and community services and supports, particularly important during transitions between sites of care.
4. Accessible services: A medical home must deliver shorter wait times for urgent needs, better in-person hours, around-the-clock access (telephone or electronic) access to a care team member, and alternative methods of communication.
5. Quality and safety: Medical homes must show a commitment to quality and quality improvement, use evidence-based medical and clinical decision-support tools to share decision-making with patients and families, engage in performance measurement and improvement, measuring and responding to patient experiences and satisfaction, and practice population health management.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-2) calls for “increased quality, efficiency, and clinical practice metrics that existing models such as the PCMH support,” according to letter to then-Acting Administrator of CMS, Andy Slavitt, when the American Academy of Family Physicians and other organizations requested that CMS affirm PCMHs as an eligible alternative payment model (APM). The study authors point to PCMHs being one of the APMs under MACRA, and specifically that MACRA’s Comprehensive Primary Care Initiative (CPCI) “will become a core feature of the Medicare payment system.”

Findings of the study

The study found that PCMH evaluations varied significantly across the 11 major evaluations studies. PCMH resulted in reduced spending (4.2 percent reduction) and improvements in breast cancer screening rates for high-needs patients (1.4 percent increase), lower use of specialist visits (1.5 percent reduction), and increased cervical screening for all patients (1.2 percent increase). The results of this study, combined with mixed results from earlier studies, the study authors note, show that how a PCMH is implemented is critical to achieving the desired impact on primary care. “PCMH initiatives are not ‘one size fits all.’”

The study authors note that while there are a wide variety of approaches to PCMH implementation today, under the CPCI, practices operating a PCMH will share a single payment models and other standard features, so there will be fewer differences. The study authors noted that “identification of the components of PCMHs likely to improve outcomes is critical to decisions about investing resources in primary care.”

Primary care reform efforts showing progress

Four out of seven regions shared in savings with CMS and nearly 95 percent of all practices met quality of care requirements in the second year of CMS’ Comprehensive Primary Care (CPC) initiative. CPC is a multi-payer program launched by the Center for Medicare and Medicaid Innovation (CMMI) in October 2012 to advance primary care by paying clinicians to deliver accessible, comprehensive, and coordinated care in seven regions across the country. Throughout 2015, CPC generated $57.7 million in gross savings in Medicare Part A and Part B expenditures, which was equivalent to the $58 million paid in care management fees to the practices involved. More than half of the participating CPC practices will also receive a share of over $13 million in earn shared savings. According to CMS, the results reflect the work of 481 practices that served over 376,000 Medicare beneficiaries and more than 2.7 million patients overall in 2015.

Four of the seven regions participating in CPC – the states of Arkansas, Colorado, and Oregon, and the Greater Tulsa region in Oklahoma – realized net savings and will share in those savings with CMS; the savings generated in these four regions covered the net losses in the other three CPC regions. In addition to the Medicare savings, CPC practices had lower than expected hospital admission and readmission rates, as well as favorable performance on patient experience.

Gross savings nearly doubled from the first performance year in 2014; practices in four regions were eligible to receive shared savings, compared to one region in 2014. CMMI’s Comprehensive Primary Care Plus (CPC+) will begin on January 1, 2017, with 14 selected regions.

Quality measures

CMS included electronic clinical quality measures (eCQM) for the first time in Medicare shared savings determinations for CPC. CMS noted that these practices with eCQM also exceeded national benchmarks; the eCQM data are recorded in the electronic health record in the routine course of clinical care, enabling real time quality improvement efforts.

The majority of CPC practices that reported eCQM surpassed the median national performance for 10 out of 11 eCQMs in the measure set, with 97 percent of CPC practices successfully reporting nine eCQMs.

CPC initiative

CPC is the largest test of advanced primary care in U.S. history, exploring the potential of primary care clinicians redesigning practices to deliver better care to patients, as well as supporting physicians’ ability to innovate and deliver care to meet patients’ needs and preferences.

Highlight on Michigan: Medicaid expansion did not cause crowding

The expansion of Michigan’s Medicaid program—the Healthy Michigan Plan—did not impede access to care, according to a University of Michigan Health System study. Despite concerns that new rules and growth would be detrimental to those signed up for both the Healthy Michigan Plan and private insurance, according to the study, there was no significant increase in wait times for either group. In addition to not hindering access, expansion improved access for some individuals. For Healthy Michigan enrollees, the odds of getting an appointment increased in the first year of expansion.

Earlier research

The study, published in the American Journal of Managed Care (AJMC), is an extension of an earlier study that examined primary care appointment availability and wait times for new patients with Medicaid and private insurance before and 4 months after Michigan’s Medicaid expansion on April 1, 2014. In those first four months, the researchers found an initial increase in primary care appointment availability for new Medicaid patients and no lengthening of wait times.

Study

The subsequent study—like the earlier research—used a simulated patient or “secret shopper” method. Trained research staff called a random sample of primary care practices, before and after Medicaid expansion, to request a new patient appointment. Wait times were calculated as the difference between the date of the call and the appointment date. The study evaluated 295 clinics.

Appointment availability

The percentage of clinics accepting new Medicaid patients increased from 49 percent, before expansion, to 55 percent 12 months after expansion. The availability of appointments for privately insured individuals fell from 88 percent of clinics before expansion to 86 percent after expansion. The number of Medicaid appointments scheduled with non-physician providers increased from 8 percent before expansion to 21 percent 12 months after expansion. For individuals with private insurance, the proportion of appointments scheduled with non-physician providers increased from 11 percent before expansion to 19 percent 12 months after expansion.

Wait times

For clinics accepting Medicaid patients, median wait times remained stable over the first year of Michigan’s Medicaid expansion. For those with private insurance, median wait times increased from 7 to 10 days in the first year after expansion. Additionally, median new patient wait times were within two weeks. According to the study, 95 percent of new patient wait times satisfied the Health Michigan Law’s requirement that Health Michigan beneficiaries have access to an initial day primary care appointment within 90 days of enrollment.

Conclusion

Medicaid expansion in Michigan had a largely positive impact on patient access to care. With the exception of small increases in wait times for some privately insured individuals, the Health Michigan Program served to improve, rather than hinder, the likelihood and timeliness of care. The researchers concluded that increases in appointment availability for new Medicaid patients was likely attributable to increases in the number of non-physician appointments. As such, the study recommended that future research should examines other team-based approaches—like the use of non-physician appointments—to further improve primary care access.