Impact of a Medical Home Model on Costs and Utilization Among Comorbid HIV-Positive Medicaid Patients

Objectives: The Pennsylvania Chronic Care Initiative (CCI) was a statewide patient-centered medical home (PCMH) initiative implemented from 2008 to 2011. This study examined whether the CCI affected utilization and costs for HIV-positive Medicaid patients with both medical and behavioral health comorbidities.

Study Design: Nonrandomized comparison of 302 HIV-positive Medicaid patients treated in 137 CCI practices and 2577 HIV-positive Medicaid patients treated elsewhere.

Methods: All patients had chronic medical conditions (diabetes, chronic obstructive pulmonary disease, asthma, or congestive heart failure) and a psychiatric and/or substance use disorder. Analyses used Medicaid claims data to examine changes in total per patient costs per month from 1 year prior to 1 year following an index episode. Propensity score weighting was used to adjust for potential sample differences. Secondary outcomes included costs and utilization of emergency department, inpatient, and outpatient/pharmacy services.

Results: We identified an average total cost savings of $214.10 per patient per month (P = .002) for the CCI group relative to the non-CCI group. This was a function of decreased inpatient medical (–$415.69; P = .007) and outpatient substance abuse treatment (–$4.86; P = .001) costs, but increased non-HIV pharmacy costs ($158.43; P = .001). Utilization for the CCI group, relative to the non-CCI group, was correspondingly decreased for inpatient medical services (odds ratio [OR], 0.619; P = .002) and inpatient services overall (OR, 0.404; P = .001), but that group had greater numbers of outpatient medical service claims when they occurred (11.7%; P = .003) and increased non-HIV pharmacy claims (9.7%; P = .001).

Conclusions: There was increased outpatient service utilization, yet relative cost savings, for HIV-positive Medicaid patients with medical and behavioral health comorbidities who were treated in PCMHs.

Am J Manag Care. 2018;24(8):368-375

Takeaway Points

The Pennsylvania Chronic Care Initiative (CCI) was a patient-centered medical home (PCMH) initiative implemented from 2008 to 2011. This study examined whether the CCI affected utilization and costs for HIV-positive Medicaid patients with both medical and behavioral health comorbidities compared with similar patients treated in non-CCI practices.

• Relative cost savings are evident for HIV-positive patients seen in PCMHs due to reduced inpatient medical and outpatient substance abuse treatment costs.
• HIV-positive patients seen in a PCMH had higher outpatient healthcare service utilization and an increased number of non-HIV pharmacy claims.
• Implementation of a PCMH for HIV-positive patients should be targeted to those with behavioral health and medical comorbidities.

Individuals with HIV have increased rates of depression, substance use, and other serious psychiatric disorders.1-4 A variety of medical comorbidities, including diabetes,5,6 heart failure,7,8 and obstructive lung disease,9,10 are also common. Moreover, recent evidence suggests that psychiatric and substance use disorders may be especially important risk factors for cardiovascular and other medical comorbidities among HIV-positive individuals.8,11

Within the general population, having more than 1 chronic disease is associated with increased mortality, poor functional status, decreased quality of life, unnecessary hospitalizations, and increased medical costs.12,13 The presence of psychiatric and substance use disorders in those with HIV has also been linked to increased healthcare utilization.14Despite the prevalence and importance of both medical and psychiatric comorbidities among HIV-positive patients, comorbid disorders often go unrecognized and untreated.10,15,16

The patient-centered medical home (PCMH) has the potential to identify and address comorbidity through core elements such as a whole-person orientation, behavioral health integration, emphasis on quality, enhanced access, use of health information technology, and coordination of outpatient care.17 Although evidence for cost savings and improved clinical outcomes has been mixed when PCMH models have been applied in the general population,18-20 implementation of a PCMH model for those with chronic diseases, such as diabetes, hypertension, and coronary heart disease, and high levels of comorbidity has been associated with relatively better clinical outcomes and reduced total healthcare costs.21

The federal Ryan White HIV/AIDS Program brings elements of a medical home to those with HIV by providing funding for primary medical care and additional support services. However, despite being targeted toward those who do not have sufficient healthcare coverage or financial resources to cope with HIV/AIDS, Ryan White funding does not apply to those with Medicaid coverage.

Beginning in 1997, Pennsylvania introduced HealthChoices, a risk-based managed care program that was initially offered in certain counties and then expanded to cover more counties and services. By mid-2009, 72% of all Pennsylvania Medicaid beneficiaries were enrolled in some form of managed care. Enrollment became mandatory for most Medicaid beneficiaries by 2013 in the counties where the program operates.

During 2008 to 2011, the state conducted one of the largest statewide multipayer PCMH experiments in the United States. This experiment, the Pennsylvania Chronic Care Initiative (CCI),22 was in place from 2008 to 2011. The Pennsylvania Department of Health provided leadership and financial support for practice transformation, requiring CCI practice managers to attend learning sessions, report monthly quality metrics, and use assigned practice coaches. These strategies were specifically based on the Chronic Care Model.23 All CCI sites received behavioral health training, integrated depression screening using validated tools, and were coached to develop a process for coordinating behavioral and medical care. Practices were selected for participation in the CCI through a voluntary application process. The PCMH model was implemented for all patients receiving services at participating practices. In total, 152 primary care practices involving 640 providers participated in the CCI, with more than 1.18 million patients receiving care.

Evaluations of the CCI using all-payer claims data have been mixed.24,25 Recent analyses found reductions in emergency department (ED) use overall, as well as reduced cost and hospitalization among high-risk patients with chronic conditions.26-28 Prior work suggests that Medicaid patients with medical and psychiatric comorbidities may benefit disproportionately from the structural advantages of the PCMH model due to the complexity of managing their illnesses, generating significantly lower costs.28-30

We previously reported that reductions in healthcare utilization and costs were evident for Medicaid patients treated with the PCMH model implemented in CCI practices.28 However, no analysis to date has determined whether such cost savings would apply to HIV-positive patients with medical and psychiatric comorbidities. Patients with HIV were a small component of the matched samples examined in the previous study of cost and utilization outcomes in the CCI,28 representing only 2.3% of that sample. A larger group of HIV-positive patients was available for analysis in the Pennsylvania Medicaid database, with 17.5% of such patients included in the previous matched sample analyses. Thus, it was not clear if findings for a non-HIV sample would generalize to an HIV-positive sample.

The current study tested the hypothesis that significant reductions in healthcare utilization and costs would be evident for HIV-positive patients with medical and psychiatric comorbidities who were treated in a CCI practice compared with similar patients treated in a non-CCI practice.

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