Study Demonstrates Value of Practice Supports During PCMH Transition Process

STORY HIGHLIGHTS

• A new study says small and solo primary care practices are more likely to achieve improvements in efficiency and quality of care, as well as cost savings, while transitioning to the patient-centered medical home if they have access to key practice support.
• When given this support, small and medium-sized primary care practices in the study achieved notable improvements in hypertension control and breast cancer screenings while also reducing emergency department visits.
• Other nonsupported practices failed to achieve significant improvements, the study found.

Small and solo primary care practices are more likely to achieve improvements in efficiency and quality of care, as well as cost savings, when transitioning to the patient-centered medical home (PCMH) model if they have access to care-management services and other key practice support during the transition process. That's according to a new study conducted by researchers at the University of Connecticut's Health Center (UCHC) and published in a recent online edition of the Journal of General Internal Medicine.

The study evaluated 32 primary care practices during a two-year period and randomized them into two groups: an intervention and a control group. The intervention group, made up of 18 physician-led primary care practices, received a three-part support package that included practice redesign support, embedded care managers and a revised payment plan to help them achieve PCMH recognition status. It also included per-member, per-month pay-for-performance incentives. The remaining 14 control-group practices received only yearly payments for participating in the study. 

All of the physician practices participated with EmblemHealth, a health insurance plan in New York that provided the support package for the intervention practices. The size of the practices varied from solo to medium-sized practices with as many as 10 physicians.

The study found that the intervention practices achieved statistically significant improvements in two of 11 quality indicators: hypertension control and breast cancer screenings, as well as in one of 10 efficiency indicators: reduced emergency department (ED) visits. Practices without support failed to achieve significant improvements. "For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial," according to the study.

Judith Fifield, Ph.D., director of the TRIPP Center at UCHC, is convinced that the study has enormous policy implications. "Providing these kinds of supports will enhance the ability of practices to make the transition (to the PCMH model) and to show quality and efficiency improvements in a short time frame," said Fifield, who also serves as a professor of family medicine at UCHC. 

Within the intervention practices, hypertension control increased 23 percent, and breast cancer screenings improved by 3.5 percent. Moreover, the intervention practices saw a drop of 3.8 fewer ED visits per physician per year, which corresponds to savings of $1,900 per physician per year.

Still, said the study authors, "Despite these improvements, we did not observe significant cost savings, and ED costs continued to rise over time, even with the significant reduction in visits observed." They attributed this "to the rising cost of ED visits reported by EmblemHealth and the relatively modest reduction in ED visits."

On the other hand, said the study, although not dramatic, the savings achieved have a cumulative effect, which could result in significant cost savings in certain circumstances. For example, although the fewer number of ED visits in the intervention group was modest, it would be substantial when applied to a large number of physicians.

"For instance, if panels were similar in size and complexity across the 142,000 in-network physicians in EmblemHealth's Group Health Incorporated plan, a supported PCMH transition across all physicians would be expected to save $270 million each year from ED visit reductions alone," said the study.

Fifield also pointed out that primary care practices in the study provided care to a general adult population rather than a specialty population, such as high-risk elderly patients. As a result, the savings and cost improvements achieved by the intervention practices are modest compared to what likely could be achieved in practices with high-cost patients.

The UCHC researcher speculated that case management was the single biggest factor in driving cost and quality improvements. For example, the case managers worked with hypertensive patients on a regular basis and helped them adhere to their medication and food regimens, which played a major role in improving hypertension control rates, Fifield said. "This study points to the improvements that can result from care management and coordination. The changes could probably be larger with more intensive efforts."

The findings represent the second part of a two-part study. The first part of the study, which also was published in the Journal of General Internal Medicine, showed that small and solo practices can achieve PCMH status within a relatively short time with practice redesign support, embedded care managers and a revised payment plan to help them achieve PCMH recognition status. 

In fact, most of the supported practices in the earlier study became recognized medical homes within a year when given access to these practice support features, the study found.