The CareFirst Patient-Centered Medical Home Program: Cost and Utilization Effects in Its First Three Years

Abstract

BackgroundEnhanced primary care models have diffused slowly and shown uneven results. Because their structural features are costly and challenging for small practices to implement, they offer modest rewards for improved performance, and improvement takes time.ObjectiveTo test whether a patient-centered medical home (PCMH) model that significantly rewarded cost savings and accommodated small primary care practices was associated with lower spending, fewer hospital admissions, and fewer emergency room visits.DesignWe compared medical care expenditures and utilization among adults who participated in the PCMH program to adults who did not participate. We computed difference-in-difference estimates using two-part multivariate generalized linear models for expenditures and negative binomial models for utilization. Control variables included patient demographics, county, chronic condition indicators, and illness severity.ParticipantsA total of 1,433,297 adults aged 18–64 years, residing in Maryland, Virginia, and the District of Columbia, and insured by CareFirst for at least 3 consecutive months between 2010 and 2013.InterventionCareFirst implemented enhanced fee-for-service payments to the practices, offered a large retrospective bonus if annual cost and quality targets were exceeded, and provided information and care coordination support.MeasuresOutcomes were quarterly claims expenditures per member for all covered services, inpatient care, emergency care, and prescription drugs, and quarterly inpatient admissions and emergency room visits.ResultsBy the third intervention year, annual adjusted total claims payments were $109 per participating member (95 % CI: −$192, −$27), or 2.8 % lower than before the program and compared to those who did not participate. Forty-two percent of the overall decline in spending was explained by lower inpatient care, emergency care, and prescription drug spending. Much of the reduction in inpatient and emergency spending was explained by lower utilization of services.ConclusionsA PCMH model that does not require practices to make infrastructure investments and that rewards cost savings can reduce spending and utilization.Electronic supplementary materialThe online version of this article (doi:10.1007/s11606-016-3814-z) contains supplementary material, which is available to authorized users.

Medical Home Implementation in Small Primary Care Practices: Provider Perspectives

“…As part of an evaluation that included a claims analysis of the effects of the PCMH program on total cost of care, 14 all qualitative data collection instruments in this study received prior approval by the institutional review board at George Mason University. Information on provider attitudes and awareness of the PCMH program was collected from 2 data sources.…”

Key Design Considerations When Calculating Cost Savings for Population Health Management Programs in an Observational Setting

“…; Cuellar et al. ). This method estimates the pre‐post difference for the intervention group and compares it to the pre‐post difference for a similar group not exposed to the intervention.…”

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

“…PCMH programmes typically took a few years to reach maturity and produce measurable effects. 70 In the USA, time was required to obtain 'bureaucratic' approvals and check conformity with antitrust regulations. 11 Similarly, in Australia, the planning stage of HealthOne ) report substantial ACO start-up costs.…”

“…72 'Technical support' (character unstated) was also required. 72 Conversely, another study 70 noted as unusual that the 'CareFirst' PCMH project did not require 'up-front investment'. When that investment has to come from the participating provider organisations themselves, smaller organisations are at a disadvantage.…”

“…When that investment has to come from the participating provider organisations themselves, smaller organisations are at a disadvantage. 70 To address that obstacle, the ACO Investment Model programme provided initial investment capital and variable monthly payments to ACO participants in rural and underserved areas that might not otherwise have access to the capital needed for successful ACO formation and operation. CMMS also contracted 32 organisations under a special 'Pioneer ACOs' demonstration project.…”