Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care
Importance Interventions to transform primary care practices into medical homes are increasingly common, but their effectiveness in improving quality and containing costs is unclear.
Objective To measure associations between participation in the Southeastern Pennsylvania Chronic Care Initiative, one of the earliest and largest multipayer medical home pilots conducted in the United States, and changes in the quality, utilization, and costs of care.
Design, Setting, and Participants Thirty-two volunteering primary care practices participated in the pilot (conducted from June 1, 2008, to May 31, 2011). We surveyed pilot practices to compare their structural capabilities at the pilot’s beginning and end. Using claims data from 4 participating health plans, we compared changes (in each year, relative to before the intervention) in the quality, utilization, and costs of care delivered to 64 243 patients who were attributed to pilot practices and 55 959 patients attributed to 29 comparison practices (selected for size, specialty, and location similar to pilot practices) using a difference-in-differences design.
Exposures Pilot practices received disease registries and technical assistance and could earn bonus payments for achieving patient-centered medical home recognition by the National Committee for Quality Assurance (NCQA).
Main Outcomes and Measures Practice structural capabilities; performance on 11 quality measures for diabetes, asthma, and preventive care; utilization of hospital, emergency department, and ambulatory care; standardized costs of care.
Results Pilot practices successfully achieved NCQA recognition and adopted new structural capabilities such as registries to identify patients overdue for chronic disease services. Pilot participation was associated with statistically significantly greater performance improvement, relative to comparison practices, on 1 of 11 investigated quality measures: nephropathy screening in diabetes (adjusted performance of 82.7% vs 71.7% by year 3, P < .001). Pilot participation was not associated with statistically significant changes in utilization or costs of care. Pilot practices accumulated average bonuses of $92 000 per primary care physician during the 3-year intervention.
Conclusions and Relevance A multipayer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement.
Professional associations, payers, policy makers, and other stakeholders have advocated the patient-centered medical home, a team-based model of primary care practice intended to improve the quality, efficiency, and patient experience of care. In general, medical home initiatives have encouraged primary care practices to invest in patient registries, enhanced access options, and other structural capabilities in exchange for enhanced payments—often operationalized as per-patient per-month fees for comprehensive care services. Dozens of privately and publicly financed medical home pilots are under way, and most use recognition by the National Committee for Quality Assurance (NCQA) to assess practice structural capabilities.
Recent evidence reviews suggest that early “medical home” interventions have yielded modest improvements at best in quality and patient experience, with little evidence of effects on costs of care. However, these reviews included studies that preceded development of NCQA medical home recognition criteria and lacked significant financial support from payers, potentially limiting their applicability to current medical home efforts. More recent evaluations have assessed medical home pilots including only 1 payer (potentially a small fraction of some practices’ patient panels) occurring over a 1- or 2-year time frame (possibly insufficient to observe effects requiring longer time frames),or within large, integrated delivery systems atypical of most primary care practices. We hypothesized that a multipayer medical home initiative involving a longer intervention period and substantial financial support would be more likely to be associated with measurable improvements in quality and efficiency.
