Quality and Efficiency in Small Practices Transitioning to Patient Centered Medical Homes: A Randomized Trial

Abstract

BACKGROUND: There is growing evidence that even small and solo primary care practices can successfully transition to full Patient Centered Medical Home (PCMH) status when provided with support, including practice redesign, care managers, and a revised payment plan. Less is known about the quality and efficiency outcomes associated with this transition. OBJECTIVE: Test quality and efficiency outcomes associated with 2-year transition to PCMH status among physicians in intervention versus control practices. KEY RESULTS: Compared to control physicians, intervention physicians significantly improved TWO of 11 quality indicators: hypertensive blood pressure control over 2 years (intervention +23 percentage points, control -2 percentage points, p= 0.02) and breast cancer screening over 3 years (intervention +3.5 percentage points, control −0.4 percentage points, p= 0.03). Compared to control physicians, intervention physicians significantly improved ONE of ten efficiency indicators: number of care episodes resulting in ED visits was reduced (intervention −0.7 percentage points, control+0.5 percentage points, p=0.002), with 3.8 fewer ED visits per year, saving approximately $1,900 in ED costs per physician, per year. There were no significant cost-savings on any of the pre-specified costs of care measures. CONCLUSIONS: In a randomized trial, we observed that some indicators of quality and efficiency of care in general adult primary care practices transitioning to PCMH status can be significantly, but modestly, improved over 2 years, although most indicators did not improve and there were no cost-savings compared with control practices. For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial.

Inadequate Systems to Support Breast and Cervical Cancer Screening in Primary Care Practice

“…In prior studies, the association between reported NCQA recognition and improvement in screening rates has been unclear, with some showing a positive association between PCMH practice redesign and higher screening rates, 12,14,15 while other studies have reported no change in breast or cervical cancer screening quality outcomes with medical home interventions. 11,13,16 One reason for these inconsistent findings may be a lack of uniformity in system changes required for NCQA recognition.…”

“…[11][12][13][14] As HIT and practice management are incorporated into clinical practice, often as part of establishing a patient-centered medical home (PCMH), recent studies have evaluated the relationship of practice factors and system design to cancer screening quality indicators. 12,[14][15][16] Characteristics such as the number of providers in the practice have been associated with adoption of systems and HIT in support of cancer screening. 17 However, adoption of HIT systems at the practice level does not ensure that physicians will make use of them.…”

“…Some studies have reported improvement in cancer screening rates following the adoption of a PCMH model. 12,14,15 However, others have reported no change in cancer screening quality outcomes. 11,13,16 Although adoption of the PCMH has been most prevalent in the primary care specialties of general internal medicine, family medicine, and pediatrics, other fields such as obstetrics and gynecology (OB/ GYN) may consider primary care as part of their scope of practice and may benefit from similar systems.…”

Pennsylvania’s Medical Home Initiative: Reductions in Healthcare Utilization and Cost Among Medicaid Patients with Medicaland Psychiatric Comorbidities

“…[30][31][32][33][34][35][36] Recent literature reviews, evaluating anywhere from 14-200 PCMH studies, have found that many have employed weak designs resulting in inconclusive evidence. [37][38][39][40][41] Similarly, previous work on the Pennsylvania CCI also found mixed results, although these studies were limited to smaller sample sizes.…”

Moving Ahead with the PCMH: Some Progress, but More Testing Needed

“…5 This issue of JGIM contains two manuscripts by Fifield and colleagues reporting on the results of one of the first randomized controlled trials of an implementation of the PCMH. 6,7 The PCMH experiment was implemented by Emblem Health, a large health plan in New York City, with many small practices that are quite representative of primary care practices across the US. Once practices were recruited and consented by Emblem, they were cluster-randomized by the study team to intervention or control after stratification by size, presence of an electronic health record, community health center status, and measures of their patients' socioeconomic status.…”