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Will the PatientCentered Medical
Home Improve
Efficiency and Reduce
Costs of Care?
A Measurement and
Research Agenda
Elbert S. Huang MD MPH
University of Chicago
PCMH Evaluators Collaborative
Efficiency Workgroup
June 29, 2010
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Reference
 Meredith
B Rosenthal, Howard B Beckman, Deb
Dauser Forrest, Elbert S Huang, Bruce E Landon,
S h Lewis
Sarah
L i
 Medical
Care Research and Review, published
p
online June 2nd, 2010
 PMID: 20519426
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Outline
 Logical
L i l
framework
f
k off costt and
d efficiency
ffi i
workgroup
 What
are we trying to measure?
 What
are the common outcome measures that
pilot studies?
could be shared across p
 Describe
evaluation plan for PCMH
intervention in safety net clinics sponsored
by Commonwealth
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A Comment on Perspective
 Health
economic evaluations must begin by
establishing the perspective of the analysis
 Societal
 Payer*
 Health
clinic)
 Patient
 Choice
 What
care provider (integrated health system,
of perspective determines
y measure
you
 Time frame for analysis
 Conclusion
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A Comment on Perspective
 Diabetes
Health Disparities Collaborative
Experience
 Societal/payer
/
perspective
 Intervention
highly cost-effective over time
 Huang et al. Health Services Research. 2007; 42 (6
Part 1): 2174-2193.
 Health
care provider perspective (outpatient
clinics)
 Intervention
is a new cost with no source of revenue
 Huang et al. Jt Comm J Qual Patient Saf. 2008; 34(3):
138 146
138-146.
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What Are We Trying to Measure?
 Costs

Amount an insurer pays for care
 PCMH

Costs
Practice
P
i costs to implement
i l
the
h PCMH:
PCMH for
f the
h purpose off
calculating ROI (incremental net revenues over incremental
net costs of operating as a PCMH)
 Efficiency

The extent to which resources are used to maximize health
benefits at a given cost
 In
practice we are focusing on cost and utilization
metrics that help flesh out these concepts:
substitution of equal quality; lower cost care (e.g.,
generic substitution,
substitution office visits for ED
ED, group visits
visits,
email visits)
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7
Principles of Measurement

A logical connection must exist between PCMH
elements and each cost/efficiency measure.

Cost/efficiency measures and proxies should be
evidence-based and grounded in clinical
appropriateness.
appropriateness

Not all PCMH pilot studies are the same. “Most
appropriate” measures can be selected to reflect the
appropriate
sequence of PCMH elements implemented.

Changes
ge in p
patient
e c
care
e and health
e
status take
e time
e to
o
accrue. Evaluations should identify intermediate
outcomes that demonstrate the projects are
y moving
g on the path
p
towards improved
p
successfully
outcomes and reduced spending.

Evaluations should search for unintended positive and
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Logic Model Inputs: Measurable
Elements of the PCMH
 Payment
Incentives: targeting quality and cost
measures (varies by pilot)
 Enhanced
access: new modes of communication,
expanded availability, language etc.
 Informed
Care Management: disease registries,
patient education, care management for high-risk
populations, e-prescribing
 Coordination
of Care: referral and test tracking,
management of care transitions
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Payment Incentives
 Recent
studies show modest evidence of impact, at
least one study with cost savings
 Pay
for performance (P4P), if part of the pilot,
could target cost or utilization measures directly
 Pay
for performance targeting improved care for
chronic
h
i ill
illness may save money indirectly
i di
tl
 Essentially, (1)
if cost/utilization measures are in
P4P and quality
i does not decline
i then efficiency
ffi i
may increase, (2) if over use measures are in P4P
then efficiency may increase, or (3) if chronic care
quality measures are in P4P then efficiency may
improve
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Enhanced Access
 The
effect of enhanced access will differ from the
effect of “primary care vs. no primary care”
 Access
A
to non-visit
i i based
b
d care and
d team visits
i i may
decrease primary care visits; specialty care unknown
 Potential
reductions in emergency department
utilization, hospitalization, and total costs



New modes of access (after hour calls)(Lattimer 2000)
Expanded primary care hours (De Maeseneer 2003, Billings
1996)
Enhanced language access services (Hampers and McNulty
2002)
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Informed Care Management
 Chronic
Care Model (CCM) (Pawlson 2009)
 May
increase or decrease primary care or
specialty
p
y care
 Prescription
drug utilization and possibly costs
might increase if PCMH successful
 Test
utilization may also increase
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Informed Care Management
 Systematic
reviews of CCM (Bodenheimer 2002;
Coleman 2009)
 Bodenheimer
review: 18/27 studies ((CHF,, asthma,,
diabetes) studies showed reductions in utilization
and costs with CCM
 Numerous
more studies have found improvements
in p
processes of care and intermediate health
outcomes (Homer 2005; Asch 2005; Chin 2007;
Vargas 2007)
 Others
have found no effect on intermediate health
outcomes ((Landon 2007))
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Care Coordination
 Geisinger
medical home model with practicebased care managers and focus on care transitions
for Medicare patients showed ~20% reduction in
all-cause
all
cause readmissions (Paulus, Davis, and Steele
2008)
 Coleman
et al.
al 2006 find reductions in
readmissions with independent coaches that serve
patients immediately post
post-discharge
discharge
 Other
non-practice based coordination efforts
have been less successful
 Medicare
Health Support demonstrations had little
effect on health care spending (Peikes 2009)
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Logic Model Outputs:
Measurable Effects that Relate
to Costs and Efficiency
 Reasonable
R
bl



Admissions (ambulatory-care sensitive)
Readmissions
ED visits (ambulatory-care sensitive)
 No



degree
d
off evidence/support
id
/
t
evidence or cross-sectional only
Lab tests and imaging (speculative)
R f
Referrals
l (b
(based
d on cross-sectional
ti
l evidence
id
only)
l )
Generic prescribing
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Utilization and Cost Measures
 Primary
care visits
 Specialist
visits
 Screening
and diagnostic tests
 Prescription
P
i ti
 Emergency
g
y
d
drugs
department
p
visits (all
( and ambulatoryy
sensitive)
 Hospitalizations
 Re-admissions
(all and ambulatory-sensitive)
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Utilization and Cost Measures
 Many
stakeholders will be interested in dollar
dollardenominated effects
 Using
U i
actual
t l dollars
d ll
paid
id (“allowed
(“ ll
d amount”)
t”) may
be simplest approach for evaluators but paid
amounts vary
 Recommend
using a common fee schedule as
yardstick
d ti k or use average rates
t from
f
all-payers,
ll
allll
provider data
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Summary Measures
 Cost
per case (episode) – calculated using
standard episode grouper software
 Costs
per member per month – has the advantage
of simplicity but requires risk adjustment
 Summary
measures should be calculated for entire
enrolled population as well as subsets of patients
(patients with diabetes, heart failure)
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Practice and Plan
Implementation Costs
 We
recognize that implementation and
transformation costs should be counted in the full
assessment of the policy
 Incremental
outlays of resources for the pilot?
Fixed and variable costs of PCMH
 Unclear
whether evaluations are collecting these:
what are likely to be key costs that are feasible to
estimate that we could ask for in site visits, phone
calls?
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Evaluation of the
Commonwealth Fund’s
Safety-Net Medical Home
I iti ti
Initiative
Principal Investigator:
Marshall Chin
Chin, MD MPH
University of Chicago
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Study overview
 68
Safety Net Clinics
 Federally-qualified
 Non-FQHCs
5
states
 Colorado
 Oregon
 Idaho
 Massachusetts
 Pennsylvania
community health centers
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Evaluation Goals
 Evaluate
intervention to inform health care organizations
policymakers
y
and p
 Patient
 Economic
 Clinical
 Implementation
 Collect
data that will be useful to participating clinics and
the Qualis
Q ali / MacColl intervention
i te e tio team
tea
 Evaluate
the PCMH initiative as a whole, and not to rate
individual clinics
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3 Questions
 Do
the clinics become PCMHs?
 What
are the outcomes?
 Clinical
Cli i l quality
lit
 Patient experience
 Staff experience
 Efficiency
 Utilization and charges
 Business Case
 What
is associated with successful
implementation?
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Business Case
 PCMH
administrative costs and revenues
 Disease
Disease--specific
clinical costs and revenues
 Overall
costs and revenues
 Indirect
costs and benefits
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Medicaid Analysis
 Utilize
Utili
d
data
t across 6 states
t t
 Compare
health care cost/efficiency measures of
patients enrolled in PCMH clinics and non-PCMH
clinics
 Match
patients by age, gender, race, zip code,
clinical case mix
 Ambulatory
 Laboratory
 Total
sensitive hospitalizations, ED visits
testing, specialist referrals
costs – PMPM
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Study Team

Marshall Chin, MD MPH: Principal Investigator

Deborah Burnet, MD: Pediatric and CommunityCommunity-Based Research

Lawrence Casalino, MD PhD: Structure, Quality, and Efficiency

Melinda Drum,
Drum PhD: Biostatistician

Elbert Huang, MD MPH: Cost and Efficiency
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S h Lewis,
Sarah
L i MSPH
MSPH: P
Project
j
M
Manger

Michael Quinn, PhD: InIn-depth Interviews / Experience Questionnaires

Thomas Summerfelt, PhD: Medicaid Analysis

Hui Tang, MS: Programmer / Statistician

Anusha Vable, MPH: Project Manager