Patient-Centered Medical Home Evidence Increases With Time
By Paul Cotton
“Reports of my death,” Mark Twain famously wrote, “are greatly exaggerated.”
The same is true for studies that find little or no benefit with patient-centered medical homes (PCMHs). One of the most widely cited and still recalled of these appeared in the Journal of the American Medical Association (JAMA) in 2014. The study evaluated PCMHs in the first three years of the National Committee for Quality Assurance’s (NCQA) initial 2008 program and found “limited improvements in quality” with no hospital, emergency department, ambulatory care, or total cost reductions. The authors did not note that the practices back then had no financial incentives to improve cost or quality.
Those who wrote PCMHs off based on such premature evaluations need to reconsider. There is now a steadily growing body of positive PCMH evidence. Recent additions are particularly noteworthy.
The American Journal of Managed Care (AMJC) just published findings that the NCQA PCMHs saved Medicaid $214.10 per month for HIV patients with diabetes, chronic obstructive pulmonary disease, asthma, congestive heart failure, or behavioral disorders. (The study did not address costs for transforming practices to PCMHs.) The savings came from inpatient care ($415.69) and outpatient substance abuse treatment reductions ($4.86), despite higher non-HIV pharmacy costs ($158.43). Simply put, PCMHs’ focus on prevention and chronic disease management got these high-needs patients the low-cost treatments they needed to prevent high-cost care. Notably, these findings on high-needs patients come from some of the same Pennsylvania Chronic Care Initiative practices as in the 2014 JAMAevaluation.
Another AJMC RAND study found that NCQA-recognized federally qualified health center PCMHs have more ambulatory visits, better quality—especially for diabetics—and greater reductions in hospitalization and cost than non-NCQA PCMHs. Only NCQA PCMHs saw a relative decrease in specialist visits (45 fewer visits per 1,000 beneficiaries), and only NCQA PCMHs had smaller total Medicare cost growth ($300 per beneficiary). The authors note that the NCQA emphasizes electronic health records, which can improve care delivery and population health management—standards on which we have raised the bar as we updated our program.
The Patient-Centered Primary Care Collaborative also recently reported that NCQA PCMHs distinguish accountable care organizations (ACOs) that improve from those that do not. The Medicare Shared Savings Program (MSSP) ACOs with more NCQA PCMHs had greater average savings than those with fewer or zero PCMHs. For example, those ACOs with the second-lowest quartile of PCMH inclusion showed a savings of 1.9 percent compared to the lowest quartile—sizable, given MSSP’s overall 0.6 percent savings rate. More NCQA PCMHs also meant higher quality on health promotion, health status, prevention, and chronic disease management, including pneumococcal vaccinations, tobacco cessation, depression screening, and diabetic and coronary artery disease measures. The study looked at 2014 MSSP data with mature NCQA PCMHs that met more rigorous, updated standards. As part of ACOs, these PCMH practices had strong and clear incentives to improve on both cost and quality.
There are clear differences between studies that do and do not find benefits. Positive evaluations assess PCMHs on advanced standards, after up to five years of transformation and with financial incentives to improve quality and efficiency, or—like the HIV study above, the impact with high-cost, high-needs patients. Studies showing little benefit assessed practices with no financial incentives to reward improvement. They also looked at PCMHs using our initial 2008 standards that we updated in 2011, 2014, and 2017. The 2011 updates further emphasize pediatrics, health information technology, and clinician-patient collaboration. We made 2014 updates to emphasize more behavioral health care integration, team-based care, focus on high-need populations care management, and patient and family involvement. We made 2017 updates to streamline our recognition processand better support practices. And we will continue making updates in the future as we continuously listen to stakeholder feedback on how to improve this powerful program.
PCMHs do, in fact, work. That is why the Medicare Access and CHIP Reauthorization Act (MACRA), which rewards clinicians for value instead of volume, gives PCMHs automatic credit. That is why 27 public-sector initiatives across 23 states and many private insurers use the NCQA PCMH model. That is why key medical boards provide PCMH credit for Maintenance of Certification. And that is why approximately 20 percent of all primary care physicians in the US are in the NCQA-recognized PCMH practices.
This article appeared originally in Health Affairs (www.healthaffairs.org) in September 2018, and appears here with the kind permission of the author and Health Affairs. The author nor his employer, The National Committee for Quality Assurance (NCQA), endorse EAPCP, and disclaim all liability for the use and interpretation of the content.