Association between medical home enrollment and health care utilization and costs among breast cancer patients in a state Medicaid program

Abstract

Background The patient centered medical home (PCMH) is increasingly being implemented in an effort to improve and coordinate primary care, but its effect on health care utilization among breast cancer patients remains unclear. The objective of this study was to examine health care utilization and expenditures as a function of PCMH enrollment among breast cancer patients in North Carolina's Medicaid program. Methods North Carolina Medicaid claims linked to North Carolina Central Cancer Registry records (2003-2007) were used to examine monthly patterns of health care use and expenditures. Fixed effects regression models analyzed associations between PCMH enrollment and utilization of outpatient, inpatient, and emergency department (ED) services and Medicaid expenditures during the 15-months after breast cancer diagnosis, controlling for selection bias on time-invariant characteristics. Results Among 758 breast cancer patients, 381 (50%) were enrolled in a PCMH at some time in the 15 months post-diagnosis. After controlling for individual fixed effects, PCMH enrollment was significantly associated with greater outpatient service use, but there was no difference in the probability of inpatient hospitalizations or ED visits. Enrollment in a PCMH was associated with increased average expenditures of $429 per month during the first 15 months. Conclusions Greater outpatient care utilization and increased average expenditures among breast cancer patients enrolled in a PCMH may suggest that these women have improved access to primary and specialty care. Expanding PCMHs may change patterns of service utilization for Medicaid breast cancer patients, but may not be associated with lower costs.

Alternative payment and care‐delivery models in oncology: A systematic review

“…Of the 23 articles included, 12 (52%) were published in the peer‐reviewed literature, and 13 (57%) published results and thus could be assessed for quality. Table summarizes the quality of evidence assessments conducted on the 13 studies that reported outcomes . Over one‐half (n = 7; 54%) received a weak global rating, and the remaining studies (n = 6; 46%) received a moderate global rating.…”

“…Two analyses of the impact of primary care‐focused PCMHs on cancer care reported that 1 reduced value, whereas the other was value‐neutral . Specifically, an analysis of utilization and costs associated with patients who had breast cancer in the North Carolina Medicaid PCMH indicated reduced value through increased monthly outpatient service utilization, no effect on ER visits or hospitalizations, and a $429 per month increase in expenditure for the first 15 months . Notably, this increase in cost was no longer significant at 24 to 36 months postdiagnosis.…”

“…Our systematic review included both peer-reviewed and nonpeer-reviewed literature and identified 22 interventions, including 6 bundled payments, 2 cancerspecific ACOs, 2 nonspecialty-specific ACOs, 7 oncology PCMHs, 2 primary care-focused PCMHs, and 3 noncategorized alternative payment or care-delivery models. Of the 12 interventions that reported results, the majority EBRT bundle 3 2 3 2 2 3 3 Newcomer 2014 19 UHC bundle pilot 2 2 1 2 2 3 2 Butcher 2013 20 Aetna cancer-specific ACO 3 2 3 2 3 3 3 Colla 2013 21 PGPD project 2 2 1 2 1 3 2 Herrel 2016 22 MSSP ACO analysis 2 2 1 2 1 3 2 Kohler 2015 (n 5 7; 58%) improved value, 12,[19][20][21]28,32,34 4 were value-neutral, 18,22,29,30 and 1 initially reduced value, 27 although this effect was no longer significant at the 2-year to 3-year time-point. Almost all interventions with published results that impacted value focused solely on reducing health care utilization and/or costs of care (n 5 10 of 12; 83%).…”

“…Table 3 summarizes the quality of evidence assessments conducted on the 13 studies that reported outcomes. 12,13,[18][19][20][21][22][26][27][28][29][30]32,34 Over one-half (n 5 7; 54%) received a weak global rating, and the remaining studies (n 5 6; 46%) received a moderate global rating. No studies evaluating alternative payment or care-delivery models in cancer received a strong global rating.…”

The impact of provider payment reforms and associated care delivery models on cost and quality in cancer care: A systematic literature review

“…However, according to another study, the impact of PCMH enrollment was, in some measure, associated with increased resource use and cost. A significant increase in monthly Medicaid expenditures and the number of outpatient visits for PCMH enrollees was observed over the first 15 months from diagnosis compared to non-PCMH participants (p<0.001), with no significant impact on inpatient hospitalizations or ED visits [33]. ■ ACO vs. non-ACO (FFS).…”