PCPCC Statement on Veterans Affairs PACT Health Affairs Article

Statement Attributable to:

Marci Nielsen, PhD, MPH
Chief Executive Officer, Patient Centered Primary Care Collaborative

Health Affairs recently released a study entitled, Patient-Centered Medical Home Initiative Produced Modest Economic Results For Veterans Health Administration, 2010–12, authored by Paul Hebert and colleagues from the Veterans Affairs (VA) Health Services Research and Development Center for Veteran-Centered, Value-Driven Health and the University of Washington School of Public Health.  

The abstract is provided here:

Abstract: In 2010 the Veterans Health Administration (VHA) began a nationwide initiative called Patient Aligned Care Teams (PACT) that reorganized care at all VHA primary care clinics in accordance with the patient-centered medical home model. We analyzed data for fiscal years 2003–12 to assess how trends in health care use and costs changed after the implementation of PACT. We found that PACT was associated with modest increases in primary care visits and with modest decreases in both hospitalizations for ambulatory care–sensitive conditions and outpatient visits with mental health specialists. We estimated that these changes avoided $596 million in costs, compared to the investment in PACT of $774 million, for a potential net loss of $178 million in the study period. Although PACT has not generated a positive return, it is still maturing, and trends in costs and use are favorable. Adopting patient-centered care does not appear to have been a major financial risk for the VHA.

Although some media reports are focused on the early findings that a positive financial return has not yet been achieved, the PCPCC is encouraged at the authors’ conclusion that trends are moving in the right direction.  Specifying that most of the investment thus far has focused on hiring and training health professionals, the authors acknowledge that this  study examines the short term impact of the PACT program.

• “After two and a half years, the PACT initiative appears to have had a modest effect on three categories of utilization within the VHA: Hospitalizations for ambulatory care-sensitive conditions and specialty mental health visits decreased slightly, while outpatient primary care visits by patients ages sixty-five and older increased slightly.”
• “The VHA is a very large and complex system in which large-scale change requires prolonged effort. Implementation of PACT was still progressing during our study period, and a more conclusive analysis must await the initiative’s full implementation. Studies are currently under way to determine whether the utilization changes in the post-PACT period are correlated with degrees of implementation at the facility level. Our analysis also does not account for any long-term cost implications of improvements in population health, such as diabetes control, that have been found in other studies of patient-centered medical homes.”
• ”Our analysis suggests that the PACT initiative has not yielded a positive return on investment. However, the initiative was still in its formative stages during our study period, and trends in use and costs appear to be in a favorable direction. This suggests that an organization’s decision to adopt the patient-centered medical home model should be based not upon unrealistic expectations of substantial cost savings but upon expected benefits, such as improved quality of care and high satisfaction with care. Over time, however, there may well be incremental savings.”
• “The discounted investment in PACT through FY 2012 was $774 million. The investment was overwhelmingly in hiring new personnel to staff the primary care teams. In addition, approximately $23 million was spent on training.”

Even in the short time period examined after implementation of PACT, the PCPCC notes that three important outcomes were statistically significant, using a sound methodological approach to the analysis.

• Outpatient visits with mental health specialists decreased significantly (7.3 percent)  
  • “These savings may have been facilitated by the initiative to integrate primary care and mental health.  When mental health care was made more accessible within primary care, the need for PACT teams to refer patients for specialty mental health care may have been reduced. Because the integration initiative predated the PACT initiative, the savings that were related to mental health care may augur well for the future: Additional savings may be realized if, as planned, other components of PACT become equally well integrated into primary care.”
• Primary care visits increased significantly among patients ages sixty-five and older ( 1.0 percent)
  • “This utilization increase may reflect PACT’s focus on population health management. For example, PACT nurse care managers engage in telephone counseling of patients with complex chronic conditions.”
• Hospitalizations for ambulatory care–sensitive conditions among all patients (4.2 percent)
  • “The fact that we detected the effect in the younger cohort is important because this is the age group and category of utilization in which we would most expect to see a beneficial effect of PACT if one existed.”

Not all outcomes measures, however, resulted in statistically significant findings and there were some limitations in the study. Authors noted that they may not have had enough data to find differences in some of the outcomes, specifically, emergency department and urgent care clinic use – both important utilization measures that other PCMH studies have been found to impact.

• “Previous studies have observed reductions in visits to the ED and urgent care clinics after the implementation of a patient-centered medical home, but we did not observe this effect within the VHA. This is likely because of the unique characteristics of VHA emergency care, which is provided at only 111 of the 908 VHA sites of care included in our study.”
• “Many VHA patients use non-VHA emergency care that is paid for by the VHA. However, claims for these non-VHA visits through FY 2012 are incomplete, so they could not be included in our analysis.”
• “Only thirty-seven facilities with an ED (out of the 111 facilities that had an ED at some time during the study period) had sufficient data to contribute to our models.”

Finally, even with the positive trends noted above, the PCPCC recognizes that the population studied may not be generalizable to general public, given that patients receiving care at community VA clinics are mostly male, white, and older.  Additionally,  the authors  found wide variation by clinic.

• “For the five million patients enrolled in primary care at the beginning of PACT, patients’ mean age was 63.5 years, 72.4 percent of patients were white, and 93.6 percent were male.”
• “There was substantial heterogeneity in utilization trends across VHA clinics. Some facilities may be yielding a higher return on investment than others. Ongoing studies are addressing the extent to which the degrees of PACT implementation at the facility level are correlated with changes in utilization.”

Access original study here.