Benefits of implementing the primary care patient centered medical 2012
Benefits of Implementing the Primary Care Patient- Centered Medical Home:A Review of COST & QUALITY RESULTS, 2012 Prepared by: Marci Nielsen, PhD, MPH Barbara Langner, PhD Carla Zema, PhD Tara Hacker, MPH Paul Grundy, MD, MPH | Funding provided by Millbank Memorial Fund |
Patient-Centered Primary Care Collaborative | 1Dear Colleagues,On June 28, 2012, the United States Supreme Court ruled to uphold the vast majority of the federal healthreform law passed in 2010. The Patient-Centered Primary Care Collaborative believes this ruling recognizesa fundamental value about health care delivery: A health care system built upon a strong primary care foun-dation, supported by the patient-centered medical home (PCMH), is critical to achieving the Institute forHealthcare Improvement’s Triple Aim of better health, better care and lower costs.(1)Efforts to transform primary care at the practice level—as with the PCMH—have gained tremendousmomentum and broad support from both the private and public sectors. The number of primary care clini-cians who have redesigned their practices has grown, and millions of American families are benefiting throughaccess to better coordinated care, which leads to improved outcomes. More and more practices and healthsystems are creating partnerships to develop medical homes with the patients and families they serve. Majorinsurers are driving primary care transformation through payments for patient-centered services nationwideas a means to increase access to care, control costs, improve patient satisfaction and make Americans healthier.A mounting body of evidence demonstrates the patient-centered medical home is an effective means ofdelivering patient-centered health care to children and adults.It is becoming increasingly imperative to collect and review relevant data about patients and patientpopulations in order to continue the transformation that moves the U.S. health care system toward team-based, coordinated and accessible care through the patient-centered medical home.As this report demonstrates, the public and private sectors have both demonstrated their commitment toadvance these team-based, patient-centered transformation efforts. We fully expect the primary care deliverysystem to embrace full implementation of the medical home. With the historic Supreme Court rulingbehind us, it is now full speed ahead—as we seek to continue supporting these efforts.We would like to extend our thanks to the Milbank Memorial Fund for its generous sponsorship of thisreport and for Carmen Hooker Odom and Mark Benton’s thoughtful input and ideas. We also thank theCollaborative’s Board of Directors, especially Douglas Henley, MD, FAAFP, executive vice president andchief executive officer, American Academy of Family Physicians, and Beverley H. Johnson, president andCEO, Institute for Patient- and Family-Centered Care, who offered helpful insights and input. Additionalcomments and improvements were provided by the PCPCC’s Executive Committee; Tracey Moorheadand Jeanette May of the Care Continuum Alliance; Melinda Abrams of The Commonwealth Fund andKatherine H. Capps of Health2 Resources. Their assistance helped make this report possible and anyomissions or errors are ours alone. Every member of the Collaborative staff assisted in the development ofthis report and we appreciate their enthusiasm and commitment to all that they bring to the PCPCC.Sincerely, Paul GrundyMarci Nielsen, PhD, MPH Paul Grundy, MD, MPH, FACOEM David Nace, MDPCPCC Executive Director PCPCC President PCPCC Chair Global Director of IBM Healthcare Vice President and Medical Director Transformation of Clinical Development IBM Corporation McKesson Corporation
2 | Benefits of Implementing the PCMH: A Review of Cost & Quality Results, 2012Executive SummaryF ounded in 2006, the Patient-Centered of care, and reduces expensive, unnecessary hospital Primary Care Collaborative (PCPCC or and emergency department utilization. The results Collaborative) is a large coalition of more meet the goals of the Institute for Healthcare than 1,000 organizations and individuals— Improvement’s Triple Aim for better health out-comprised of employers, physicians and other health comes, better care, and lower costs.(2) The momen-professionals, consumer and patient/family advocacy tum for transforming the U.S. health system is reach-groups, patient quality organizations, health plans, ing the tipping point, and the PCMH and primaryhospitals and unions—who have joined together care are central to this goal. The current fragmentedto advance an effective and efficient health system health system that pays for volume over value isbuilt on a strong foundation of primary care and the riddled with inefficiencies, has highly variable healthpatient-centered medical home (PCMH). The Col- outcomes, is not financially sustainable, and is nolaborative serves as a broad-based national advocacy longer acceptable.organization for the primary care patient-centeredmedical home, providing timely information and This paper, in reviewing data from PCMH initiativesnetworking opportunities to support transformation nationwide, has a two-fold goal. First, it provides aof the U.S. health system. summary of new and updated results from PCMH initiatives from the past two years, including costThis report updates our earlier reviews of the cost and quality outcomes data. The results provideand quality data from 2009 and 2010, and the substantial empirical support for the PCMH andfindings are clear, consistent, and compelling: Data the health care professionals, health plans, employersdemonstrates that the PCMH improves health out- and policymakers who are adopting it, as well ascomes, enhances the patient and provider experience the patients and their families receiving this care. Second, it defines the features of a PCMH and provides data to demonstrate how each feature of a PCMH contributes to lower costs, improved care and better health outcomes. Introduction. The patient-centered medical home is not limited to a single place or location: It is best described as a model of primary care that is patient- centered, comprehensive, team-based, coordinated, accessible and focused on quality and safety.(3) It is supported by robust health information technol- ogy (health IT), provider payment reform focused on patient outcomes and health system efficiencies, and team-based education and training of the health professions workforce.(4) Growing support for the PCMH has arisen across the vast majority of the U.S.
Patient-Centered Primary Care Collaborative | 3health care delivery system to include more than Horizon Blue Cross Blue Shield in New Jersey,90 commercial insurance plans, multiple employers, Blue Cross Blue Shield of North Dakota (13)42 state Medicaid programs, numerous federal agen- and many others. More than 4 million Bluecies, the Department of Defense, hundreds of safety Cross Blue Shield members in 39 states arenet clinics, and thousands of small and large clinical currently participating in some version of apractices nationwide. (5) PCMH initiative. (14)Private sector support. Major health plans and • Integrated health plans, such as Kaiser Perman-industry partners are embracing the PCMH model ente which serves more than 8.8 million people,with enthusiasm by creating insurance plans and have also long been committed to offeringdeveloping tools and resources contributing to comprehensive primary care services and havethe implementation of medical homes. embraced the PCMH model of care delivery. • WellPoint, a private health insurer covering Federal support. Federal health reform has made 34 million Americans with a network of advancing primary care and the PCMH a top health 100,000 primary care doctors, publicly an- policy priority. The Affordable Care Act (ACA) nounced in January 2012 its decision to invest builds on the efforts of numerous states, health in the medical home across its entire network.(6) plans, medical practices, federally qualified health centers and multi-stakeholder initiatives that have • Aetna, another large private health plan insuring spearheaded medical home care delivery. Because more than 18 million Americans with a network the PCMH is foundational to Accountable Care of 55,000 primary care doctors, also recently an- Organizations (ACOs)(15)—with ACOs often nounced a PCMH rollout in Connecticut and described as the “medical neighborhood”—the New Jersey, with expectations to begin expand- PCMH is likely to gain even greater prominence ing the program nationally in 2012.(7) as ACOs continue to develop in the marketplace. Delivery system reform and the potential for shared • Humana, serving 11.8 million medical members savings available through programs championed by and 2.2 million Medicare Advantage beneficia- the Center for Medicare & Medicaid Innovation ries, now offers medical home services in ten (e.g., the Comprehensive Primary Care initiative, the states providing enhanced care for more than Advanced Primary Care Practice Demonstration and 70,000 Medicare Advantage and more than the Advance Payment ACO Model) hold the prom- 35,000 commercial health insurance members.(8) ise to further expand access to PCMHs for patients, specifically for elderly, chronically ill and low income • UnitedHealthcare, insuring 34 million populations across the country. The Department of Americans, announced in February 2012 Defense, Department of Veterans Affairs and the an expansion of its value-based payment model, federal Office of Personnel Management (OPM) are which supports PCMH, and is estimated to implementing versions of the PCMH and experienc- impact between 50 to 70 percent of their ing impressive results, described in this report. (16) customers.(9) State and local support. Many of these federal • Numerous Blue Cross Blue Shield plans have efforts build from PCMH initiatives that began with demonstrated leadership in driving PCMH state and local communities taking the lead. (17) efforts in their local communities, to in- clude Blue Cross Blue Shield of Michigan,(10) As of May 2012, the vast majority of states are CareFirst BlueCross BlueShield (Virginia, making efforts to advance the medical home in Maryland and the District of Columbia), (11, 12) their Medicaid or Children’s Health Insurance
4 | Benefits of Implementing the PCMH: A Review of Cost & Quality Results, 2012Program (CHIP).(18) This work has been supported palliative care providers. Many of these healthby the National Academy for State Health Policy, professional organizations are members of thewhich has a major initiative focused on supporting Patient-Centered Primary Care Collaborative.(24)state PCMH activity. (19) Recently announced bythe Center for Medicare & Medicaid Innovation, Patient and family engagement. Increasingly,the Comprehensive Primary Care initiative PCMH and other health reform initiatives are(CPC)(20) adds to the PCMH momentum by conveying the expectation for authentic patientfostering collaboration between public and and family engagement. This engagement occursprivate health care payers along with health care at multiple levels:consumers in order to strengthen primary carein seven selected marketplaces across the U.S. • At the clinical encounter—patient and family engagement in direct care, care planning, andInternational outcomes. Across the globe, re- decision-making;search from a recent large study of 11 industrializedcountries demonstrates that adults with complex • At the practice or organizational level—patientcare needs who had a medical home reported bet- and family engagement in quality improvementter coordinated care, fewer medical errors and test and health care redesign;duplication, better relationships with their doctorsand greater satisfaction with care.(21) When com- • At the community level—bringing togetherparing care delivered in a medical home (to care not community resources with health caredelivered in a medical home) within each country organizations, patients, and families; andsurveyed, researchers found a difference of between18 to 39 percentage points on questions such as • At the policy level—engaging policymakerswhether their doctor spends enough time with locally, regionally, and nationally.them, encourages them to ask questions, explainsthings clearly and engages patients in managing Patient and family engagement is an important con-their chronic conditions.(22) sideration within the work of the CMS Innovation Center, National Priorities Partnership, and policyBroad health care professions support. organizations such as the Robert Wood JohnsonKey to the PCMH is strong support among pri- Foundation, the California Healthcare Foundation,mary care physician and other health professional Maine Health Access Foundation and the Coloradoorganizations. In February 2007, four primary Health Foundation. These agencies and foundationscare physician societies—the American Academy are supporting the development of meaningfulof Family Physicians, American Academy of partnerships with patients and families in thePediatrics, American College of Physicians and the redesign of primary care.American Osteopathic Association—developedthe Joint Principles (23) for the Patient-Centered Based on the results to date and current marketMedical Home, which have been highly influential factors that will continue to affect health carein advancing this model of care delivery. Since that delivery, we identify three broad conclusionstime, 18 more physician membership organizations about PCMH outcomes:have endorsed the Joint Principles. Multiple otherhealth professionals have embraced the PCMH • As medical home implementationwith its emphasis on team-based care, including increases, the Triple Aim outcomes ofnurse practitioners, physician assistants, psycholo- better health, better care and lower costsgists, social workers, nutritionists, pharmacists, are being achieved. The number of medi-physical, occupational, and speech therapists and cal home providers has grown to the tens of
Patient-Centered Primary Care Collaborative | 5 thousands, serving millions of Americans. • Investment in the medical home offers Momentum for the model is rapidly increasing both short- and long-term savings for with public and private sector investment. The patients, employers, health plans and concept of the PCMH is evolving to include policymakers. In the current economic the medical neighborhood, especially with the environment, controlling the rising cost of growth of ACOs. As the PCMH expands, the health care is paramount. Although imple- need to continue cataloging the outcomes of menting the many features of a PCMH takes the PCMH is vital for ongoing engagement time, the long-term cost savings of the PCMH from employers, purchasers, policymakers, are impressive, as demonstrated by mature patients and their families. As the information PCMH initiatives such as the Geisinger in this report illustrates, a mounting body of Health System.(27) By providing high qual- data demonstrates that the PCMH is an effec- ity health care to Americans that results in tive means of delivering primary care to achieve fewer unnecessary emergency room visits and the Triple Aim outcomes (25) and transform the inpatient hospital admissions, as well as better U.S. health system. care coordination, this report demonstrates that PCMHs can achieve cost-savings in the• Medical home expansion has reached short-term as well. Continued focus on health the tipping point with broad private and information technology diffusion, primary public sector support. There is far-reaching care payment reform, education and train- interest across the health care industry in the ing for a robust primary care workforce, and PCMH delivery model. Major insurers are improving patient experience are critical to the driving PCMH efforts nationwide as a means PCMH’s long-term success. In addition, effec- to control costs, improve patient satisfaction tive collaboration with patients and families in and make Americans healthier. Federal health all aspects of primary care redesign and evalu- reform has prompted expansion of the PCMH ation will be essential. Efforts to measure the in Medicare, Medicaid and federally qualified effectiveness of the PCMH are ongoing (28) health centers, in addition to leveraging inno- and continue to be a high priority for entities vations from commercial insurers. The Office such as the Agency for Healthcare Research of Personnel Management, the U.S. military and Quality (AHRQ) and the Milbank and the Department of Veterans Affairs are all Memorial Fund, which funded this report. In committed to expanding primary care through addition to supporting a number of PCMH medical homes. In addition to these federal pilots nationwide, The Commonwealth Fund’s efforts, ongoing and successful initiatives at the Patient-Centered Medical Home Evaluators’ state level continue to expand. The majority of Collaborative has recently recommended core state Medicaid programs are initiating or ex- measures for PCMH evaluation that include panding their PCMH programs.(26) We believe both cost and quality care measures to ensure the combined result of these public and private standardized metrics for effective care. (29) initiatives propels the PCMH to the tipping point for the care delivery system to embrace full implementation of the PCMH. Conse- quently, more patients than ever will receive care from PCMHs.
6 | Benefits of Implementing the PCMH: A Review of Cost & Quality Results, 2012Section OneSummary of PCMH: Newly-reported and updatedresults since the 2010 reportR oughly 30 percent, or approximately $700 This section of the paper provides a summary of billion, of the $2.5 trillion in annual health numerous PCMH results published since the last care spending in the U.S. is estimated to be PCPCC 2010 Outcomes Update, primarily focused unnecessary. (30) The marketplace recog- on cost and quality.(33) It highlights outcomes fromnizes the potential for return on investment in the peer-reviewed research as well as industry-reportedmedical home, in the form of both quality and cost outcomes. Although the initiatives described belowimprovements. Success of previous PCMH demon- differ from one another in scope and implementa-strations across the U.S. has prompted investments tion, each incorporates features of a PCMH in orderin publicly and privately funded PCMH programs, to improve health outcomes, improve health carewith anticipation of future savings and better patient delivery and/or lower overall health care costs.care. For example, WellPoint predicts that its new These features are described in greater detail inPCMH program could reduce its projected medical section two of the report.costs in 2015 by up to 20 percent based on analysisof its current medical home pilot projects.(31) The initiatives that follow also use different methodsUnitedHealthcare estimates that its new efforts of analysis to determine cost savings or quality im-will save twice as much as they cost.(32) provement. Some come from academic peer-reviewed journals, while others are industry generated. It is im- portant to note that academic research versus industry analysis often serves distinct purposes. Academia’s goal is to build a body of knowledge over time that is generalizable and of suitable quality for publication, a generally slow and deliberate process. In contrast, industry uses actuarial analysis and other statistical tools consistent with proprietary business practices that generally moves more quickly—with a focus on the financial bottom line. Other methods to evaluate the PCMH, such as rapid-cycle innovation, are being used with success.(34) It is important to acknowledge that regardless of approach, thorough and thoughtful analysis of the PCMH and the outcomes it produces will lead to improvement of health care delivery for patients and their families. Ongoing evaluation is es- sential as the model evolves.(35) Uniform methods to evaluate the PCMH are being developed by a team of more than 75 researchers under the leadership of The Commonwealth Fund, with the objective of support- ing improvements in policy and practice.(36)
Patient-Centered Primary Care Collaborative | 7 Results of Patient-Centered Medical Home Initiatives, by State or AgencyInitiative Health Care Cost & Acute Health Outcomes & Years of Data Report Type Care Service Outcomes Quality of Care Results Review • 14% fewer emergency • 77% of diabetic patients 2009–2011 Agency department (ED) and had improved glycemic Congressional urgent care visits control at Hill Air Force Base testimonyAir Force (2011) (37) • Hill Air Force Base (Utah) saved $300,000 annually through improved diabetes care management • 50% reduction in urgent 10-year span IndustryAlaska: care and ER utilization (years not report via publicAlaska Native • 53% reduction in hospital specified) presentationMedical Center admissions(2012) (39) • 65% reduction in specialist utilization • 15% fewer hospital 2010 BCBS industry readmissions report • 15% fewer inpatientCalifornia: hospital staysBCBS of California • 50% fewer inpatientACO Pilot (2012) (40) stays of 20 days or more • Overall health care cost savings of $15.5 million • $215 lower per member • Increased provider 2007–-2009 Peer-reviewed per year for children participation in CHIP article:Colorado: program from 20% to 96% Health AffairsColorado Medicaid • Increased well-care visitsand SCHIP (41) for children from 54% in 2007 to 73% in 2009 • 40% lower inpatient • 250% increase in primary 2003–2011 Institute forFlorida: hospital days care visits HealthcareCapital Health Plan, • 37% lower ED visits Improvement(Tallahassee, Fla.) • 18% lower health care report2012 (42) claims costsIdaho: • $1 million reduction in Years not BCBS industryBCBS of Idaho single year medical claims provided reportHealth Service • ROI of 4:1 for disease(2011)(40) management programs • 4.2% average reduction in 2011 BCBS industry expected patient’s overall reportMaryland: health care costs among 60%CareFirst BCBS of practices participating for(2011) (43) six or more months • Nearly $40 million savings in 2011 (continued)
8 | Benefits of Implementing the PCMH: A Review of Cost & Quality Results, 2012Initiative Health Care Cost & Acute Health Outcomes & Years of Data Report Type Care Service Outcomes Quality of Care Results Review • 13.5% fewer ED visits • 60% better access to care BCBS industry among children in PCMH for participating practices report, factsheet (vs. 9% non-PCMH) that provide 24/7 access • 10% fewer ED visits (as compared to 25% in Michigan: among adults in PCMH non-participating sites)(40) BCBS of Michigan (vs. 6.5% non-PCMH) (44) 2008–2011 (Physician Group • 7.5% lower use of Incentive Program) high-tech radiology (45) (2011) • 17% lower ambulatory-care sensitive inpatient admissions • 6% lower 30-day readmission rates(40) • 39% lower ER visits Improved quality of services: 2004–2009 Industry report • 24% fewer hospital • Reduced appointment admissions wait time by 350% from • 40% lower readmission 26 days to 1 day rates • 129% increase in optimal • 30% lower length of stay diabetes care • 20% lower inpatient costs • 48% increase in optimalMinnesota: due to outpatient case heart disease care.HealthPartners (46) management program for Changed provider behavior(Bloomington, Minn.) behavioral health • 10% decrease in diagnostic • Overall costs decreased imaging scans in first year to 92% of state average in 2008(47) • Reduced outpatient costs of $1,282 for patients using 11 or more medications (48)Nebraska: • 10% fewer hospitalizations 2011 BCBS industryBCBS of Nebraska (49) • 27% fewer emergency visits report(2012) • 10% lower per member Better diabetes care: 2011 BCBS industry per month (PMPM) costs • 8% improvement in report, press • 26% fewer ED visits HbA1c levels release • 25% fewer hospital • 31% increase in ability New Jersey: readmissions to effectively self-manage BCBS of New Jersey • 21% fewer inpatient blood sugar (Horizon BCBSNJ) admissions Better prevention: 2012 (50, 51) • 5% increase in use of • 24% increase in generic prescriptions LDL screening • 6% increase in breast and cervical cancer screening • 24% lower hospital 2008–2010 Industry report, New York: admissions press release Capital District • 9% lower overall medical Physicians’ Health cost increases resulting in Plan (Albany, N.Y.) (52) savings of $32 PMPM New York: • Cost savings of 11% 2010 Press release Priority Community overall in first 9 months of Healthcare Center approximately $150,000 Medicaid Program • Reduced hospital spending (Chemung County, by 27% and ER spending N.Y.) 2011(53) by 35%
Patient-Centered Primary Care Collaborative | 9Initiative Health Care Cost & Acute Health Outcomes & Years of Data Report Type Care Service Outcomes Quality of Care Results ReviewNorth Carolina: • 52% fewer visits to 2011 BCBS industryBlue Quality specialists report, pressPhysician’s Program • 70% fewer visits release(BCBSNC) 2011(54) to the ER • 23% lower ED utilization Improvements in asthma 2003–2010 Peer reviewed and costs care: journals: Health • 25% lower outpatient • 21% increase in asthma Affairs; Annals of care costs staging Family Medicine;North Carolina: • 11% lower pharmacy costs • 112% increase in influenza agency reportCommunity Care Estimated cost savings of: inoculationsof North Carolina • $60 million in 2003(Medicaid)(55) • $161 million in 2006 • $103 million in 2007 • $204 million in 2008 • $295 million in 2009 • $382 million 2010 (56) • 6% lower hospital Better diabetes care: 2005–2006 BCBS industry admissions • 6.7% improvement in report • 24% fewer ED visits BP control • 30% lower ED use among • 10.3% improvement in patients with chronic disease cholesterol control • 18% lower inpatient • 64.3% improvement in hospital admission rates optimal diabetes care.North Dakota: compared to general N.D. Better coronary arteryBCBS of North population disease management:Dakota— • 8.6% improvement inMediQHome Quality BP controlProgram 2012(51) • 9.4% improvement in cholesterol control • 53.8% improvement in optimal diabetes control Better care for hypertension • 8% improvement in blood pressure controlOhio: • 34% decrease in ER visits • 22% decrease in patients 2008–2010 Industry reportHumana Queen City with uncontrolled bloodPhysicians (2012) (57) pressure • Reduced per capita Improved access over one 2008–2010 Industry report member costs by year period: $29 per year • Reduction from 1,670 toOklahoma: 13 patient inquiries relatedOklahoma Medicaid to same-day/next-day(2011)(58) appointment availability • 8% increase in patients “always getting treatment quickly.” (continued)
10 | Benefits of Implementing the PCMH: A Review of Cost & Quality Results, 2012Initiative Health Care Cost & Acute Health Outcomes & Years of Data Report Type Care Service Outcomes Quality of Care Results Review Lower hospital 2010 Press release admission rates:Oregon: • 231.5 per 1000 beneficiari-Bend Memorial es (compared to state/Clinic & Clear One national averages of 257 andMedicare Advantage 351 per 1000, respectively).(PacificSource Lower ER visit ratesMedicare • 242 per 1000 beneficiariesAdvantage) 2012 (59) (compared to state/national averages of 490 and 530 per 1000, respectively).Oregon: • 9% lower PMPM costs (60) Better disease management 2007–2009 CommonwealthCareOregon • Reduced PMPM costs among diabetics in one clinic: Fund, pressMedicaid and by $89)(61) • 65% had controlled HbA1c releaseDual Eligibles levels vs. 45% pre-PCMH(62)(Portland, Ore.) • Reduced hospital length Improved quality of care: 2005–2010 Congressional of stay by half a day • 74% for preventive care testimony, • 25% lower hospital • 22% for coronary artery PCPCC admissions care Outcomes • 50% lower readmissions • 34.5% for diabetes care Report, peerPennsylvania: following discharge reviewed journal:Geisinger Health • 18% reduced inpatient American JournalSystem Proven- admissions of Managed CareHealth Navigator • 7% lower cumulative totalPCMH model spending(65) (from 2005(Danville, Penn.),(63, 64) to 2008)2010, 2012 Longer exposure to medical homes resulted in lower health care costs: • 7.1% lower cumulative cost savings (from 2006 to 2010) with an ROI of 1.7 • 13% fewer hospitalizations Improved patient outcomes 2009 Press interview by 2009 for diabetics: • Medical costs nearly • Increases in eye examsPennsylvania: 4% lower from 50% to 90%UPMC(68) • 20% long-term improve-(Pittsburgh, PA) ment in control of blood2011 sugar • 37% long-term improve- ment of cholesterol control Better diabetes care: 2008–2011 BCBS industry • Increased diabetes reportPennsylvania: screenings from 40% to 92%Independence Blue • 49% improvement inCross—Pennsylvania HbA1c levelsChronic Care • 25% increase in bloodInitiative (Southeast pressure controlPennsylvania) • 27% increase in2012(51) cholesterol control • 56% increase in patients with self-management goals
Patient-Centered Primary Care Collaborative | 11Initiative Health Care Cost & Acute Health Outcomes & Years of Data Report Type Care Service Outcomes Quality of Care Results Review • 0% 30-day hospital 2011 Industry report,Pennsylvania: readmission rate for PCMH press releasePinnacleHealth patients vs. 10-20% for(2012) (69) non-PCMH patients • 17-33% lower health care Improved quality of care 2008–2011 BCBS industry costs among PCMH patients measures: reportRhode Island: • 44% for family &BCBS of Rhode children’s healthIsland (2012) (51) • 35% for women’s care • 24% for internal medicineSouth Carolina: • 14.7% lower inpatient 2008–2011 BCBS industryBCBS of South hospital days reportCarolina (Palmetto • 25.9% fewer ED visitsPrimary Care • 6.5% lower total PMPMPhysicians) 2012 (51) medical and pharmacy costs Increased screening rates: 2009–2012 BCBS industry • 3% for diabetes exams report • 7% for diabetes retinal examsTennessee: • 14% for diabetesBCBS of Tennessee nephropathy exams(2012) (51) • 4% for lipid exams Increased prescription rates: • 6% for coronary artery disease medications • 23% lower readmission 2009 BCBS industryTexas: rates reportBCBS of Texas • $1.2 million estimated(2012) (40) health care cost savings (continued)
12 | Benefits of Implementing the PCMH: A Review of Cost & Quality Results, 2012Initiative Health Care Cost & Acute Health Outcomes & Years of Data Report Type Care Service Outcomes Quality of Care Results Review Improved disease 2000–2008 Peer review management: journal: • Increased control of HbA1C Journal of levels from 81% to 93% of Ambulatory Care diabetes patients Management • Increased LDL levels under control, from 51% to 95%, for heart disease patients • Increased control of BP levels from 67% to 90% Improved preventive care • Increased screening rates for mammography from 19% to 40% • Increased screening rates for colon cancer from 11%Texas: to 50%WellMed Inc.(70) • Improved diabetes HbA1c(San Antonio, Tex.) testing from 55% to 71% • LDL screenings for all patients increased from 47% to 70% • LDL screenings for diabetic patients increased from 53% to 78% • LDL screenings for ischemic heart disease patients increased from 53 to 76%. • BP screening rates for all patients increased from 38 to 76% • BP screenings for high BP patients increased from 46 to 88%. • 27% reduction in projected 2010–2012 Industry reportVermont: cost avoidance across its as part of publicVermont Blueprint commercial insurer presentationfor Health (2012) (71) population • 21% decreased inpatient 2008–2010 Industry report utilizationVermont: • 22% lower PMPMVermont Medicaid (72) inpatient costs • 31% lower ED use • 36% lower PMPM ED costs • 8% lower urgent care visits 2007–2009; 2011 Press interview • 4% lower acute admissionVeterans Health rates by 4%(73)Administration • 27% lower hospitalizationsand VA Midwest and ED visits among chronicHealthcare Network disease patients(VISN 23) 2012 • $593 per chronic disease patient cost savings (74)
Patient-Centered Primary Care Collaborative | 13Initiative Health Care Cost & Acute Health Outcomes & Years of Data Report Type Care Service Outcomes Quality of Care Results ReviewWashington: • 20% lower health care costs • 14.8% improved patient- 2007–2009 BCBS industryRegence Blue reported physical function reportShield (Intensive and mental functionOutpatient Care • 65% reduced patientProgram with reported missed workdaysBoeing) 2012(40) • 29% fewer ED visits Improved medication • 2006–2007 The Common- • 11% fewer hospitalizations management: • 2008 (57) wealth Fund, for ambulatory care-sensitive • 18% reduction in use peer reviewed conditions of high-risk medications journal: American • Net cost savings trend of among elderly Journal of $17 PMPM (78) • 36% increase in use of Managed Care, • $4 million in transcription cholesterol-lowering drugs PCPCC cost savings through the • 65% increase in use of Outcomes Report use of EHRs generic statin drugWashington: • $2.5 million in cost savings Improved quality of care:Group Health through medical records • Composite measuresof Washington management increased by 3.7% to(Seattle, WA) (75, 76, 77) • $3.4 million in cost savings 4.4% Improved provider2009, 2010 through medication use satisfaction: management program • Less emotional exhaustion • 40% cost reduction through reported by staff (10% PCMH use of generic statin drug vs. 30% controls) Improved patient experiences in one clinic: • 83% of patient calls resolved on the first call compared to 0% pre-PCMH (79)
14 | Benefits of Implementing the PCMH: A Review of Cost & Quality Results, 2012Section TwoPCMH Definition and Selected Results byPCMH FeatureT his section of the report defines the health practitioners or behavioral health special- features of a PCMH and provides ists; social workers; care coordinators; pharmacists; specific examples from peer-reviewed palliative care providers; physical, occupational and research and self-reported data to speech therapists; community health workers; anddemonstrate how each feature contributes to others offering support services in the community.better health, improved care and/or lower cost Whereas some PCMHs provide most care in a singlewithin the PCMH model. location, others include virtual teams of profession- als who work together, depending upon the specificA. What is Comprehensive Team-Based Care? needs of the patient. Beyond the primary care setting, the PCMH also coordinates the care of Comprehensive Team-Based Care: patients in the medical neighborhood and across health care settings and transitions—including The primary care medical home is specialty care and inpatient hospital services— accountable for meeting the large majority which is vital for patients with chronic illnesses. of each patient’s physical and mental health The PCMH team includes the patients and their care needs, including prevention and families as well, as their input is a key component wellness, acute care and chronic care. of realizing the medical home. Providing comprehensive care requires a team of care providers. This team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators and care coordinators. Although some medical home practices may bring together large and diverse teams of care providers to meet the needs of their patients, many others, including smaller practices, will build virtual teams linking themselves and their patients to providers and services in their communities. (AHRQ, 2012)A key feature of the PCMH is team-based caredelivery focused on the needs of the patient and,when appropriate, the family. Depending on thepractice, the team includes primary care physicians;nurse practitioners; physician assistants; mental
Patient-Centered Primary Care Collaborative | 15Examples of comprehensive team-based care and 23.9 percent ( Johnsbury service area) torelevant key outcomes include: 15.3 percent (Burlington service area); ◊ Lower ED utilization (visits per 1,000) Vermont Blueprint for Health ranging from 33.8 percent ( Johnsbury) to 18.9 percent (Burlington) to 2.8 percentPCMH feature highlighted: Community health (Barre);teams, including nurse coordinators, behavioralhealth providers and social workers ◊ In the Burlington service area, the subset of patients that received support from theThis statewide project currently serves more than Community Health Team experienced350,000 Vermonters. In a single year (2011), the even lower rates of inpatient hospitalizationnumber of physician practices in this initiative more (25.1 percent) and ED utilizationthan tripled (from 24 to 78 practices); expansion (22.1 percent);continues with all interested practices anticipatedto participate by October 2013.(80) The Vermont ◊ Patients with chronic diseases who had beenBlueprint for Health (“Blueprint”) provides ad- seen only once a year by their primary carevanced primary care to patients, with selected pilot providers were now being seen up to foursites offering additional support services provided by times a year; anda community health team. The community healthteam differs by locality, but often includes nurse ◊ Persons referred for mental health servicescoordinators, behavioral health providers and social were more likely to obtain services becauseworkers. The Blueprint also links health care provid- the community care team included aers through centralized data systems, offers payment behavioral specialist.reforms through multiple insurers, coordinates withspecialized services (medical and otherwise) andfocuses on continuous evaluation to fuel improve- Senior Care Options program, affiliatedment.(81) In 2010, the Vermont Child Health with the Community Care AllianceImprovement Program at the University of Vermontconducted evaluations of the three Blueprint pilots PCMH feature highlighted: Community–basedand reported impressive early results to the Vermont team care including nurse practitioners and geriatricDepartment of Public Health on health care costs social workersand health outcomes, which were included in theBlueprint’s Annual Report.(82) Individuals who are elderly and have very low income qualify for both Medicare and Medicaid andKey Outcomes:(83) are referred to as being “dually eligible.” These indi- viduals benefit from care offered through a medical • When comparing care before and after the home because of their multiple chronic medical con- Advanced Primary Care pilot began in July ditions and significant need for care coordination 2008i, all three pilot communities found:(84) and social support. In addition, those who are dual eligibles are of interest to state and federal policy- ◊ Lower inpatient hospitalization rates makers who regulate the financing and management (admission rate per 1,000) ranging from of their often high-cost health care needs.(85) 39.7 percent (Barre service area) to Senior Care Options is a partnership between i data reported July 2006 to January 2010 MassHealth and Medicare and part of the
16 | Benefits of Implementing the PCMH: A Review of Cost & Quality Results, 2012Community Care Alliance in Boston. The program The Improving Mood/Promotingprovides a complete package of health care and Access to Collaborative Treatmentsocial services for dual eligibles through a team of (IMPACT) Studyhealth care professionals, including physicians, nursepractitioners, geriatric social workers and communi- PCMH feature highlighted: Team-basedty-based staff. The goal of the Senior Care Options interdisciplinary primary care and behavioral healthprogram is to keep patients healthy and allow themto remain in their homes for as long as possible. Depression causes an immense burden of sufferingBy comparing costs before and after the Senior Care on both individuals and on society with a yearlyOptions program began, researchers were able to estimated cost in the U.S. (due to lost productivitydemonstrate that the team-based approach improved and increased medical expenses) of $83 billion.(88)the quality of care for chronically ill patients and The Improving Mood/Promoting Access to Collab-reduced their use of hospitals and nursing homes, orative Treatment (IMPACT) study is one of largestthus reducing overall health care costs.(86) treatment trials for adult depression in the U.S. Span- ning two years, data from the study reported hereKey Outcomes:(87) included 18 primary care clinics from eight health care organizations in four states, including two • Improvement in the quality of health care for Veterans Administration clinics. Researchers used patients included: a randomized control study design to determine whether patients who received care in a primary care ◊ Influenza immunization rates increased from practice that included a depression care manager 65 to 77 percent from 2005 to 2011; (as part of the care team) differed from care provided in a regular primary care setting. Involving more than ◊ Mammography screening rates increased 1,800 older patients with a mental health diagnosis, among women ages 65 to 69 years by this study found that using a depression care man- 75 to 79 percent from 2005 to 2011; ager in a primary care practice as part of a care team improved the symptoms of depression in patients. ◊ Colorectal cancer screening rates increased from 30 to 51 percent from 2005 to 2011; Key Outcomes:(89) ◊ Eye exams, including glaucoma testing, • At 12 months, 45 percent of the IMPACT increased from 69 to 73 percent between patients had a 50 percent or greater reduction 2008 and 2010; in depression symptoms (compared to 19 percent in the control group). ◊ Hospital readmission rates (30-day) decreased from 20.2% in 2009 to • IMPACT was more effective than usual care 18.1% in 2010; and in all of the eight different health care organiza- tions that were studied, regardless of whether ◊ Average length-of-stay in the hospital the patients had other medical conditions or decreased from 5.21 days in 2009 to anxiety disorders. 5 days in 2011. • IMPACT was equally effective across ethnic and racial backgrounds, with African American, Latino and white patients experiencing similar outcomes.
Patient-Centered Primary Care Collaborative | 17Citywide Care Management System, B. What is a Patient-Centered Orientation?Camden, N.J. A Patient-Centered Orientation:PCMH feature highlighted: Coordinating care withcommunity services and supports The primary care medical home provides primary health care that is relationship-The Camden Coalition of Healthcare Providers based with an orientation toward the whole(CCHP) developed the Citywide Care Manage- person. Partnering with patients and theirment System (CCMS) at the urging of a young families requires understanding andphysician who was frustrated with a lack of rational respecting each patient’s unique needs,health care and social services for the very high cost culture, values and preferences. The medi-“super-utilizers” of EDs and hospitals.(90) In 2005, cal home practice actively supports patientsCamden, N.J. was determined by the U.S. Census to in learning to manage and organize theirbe the poorest city in the country, with 50 percent own care at the level the patient chooses.of residents visiting a local ED or hospital in a single Recognizing that patients and families areyear.(91) More than 90 percent of the costs of care— core members of the care team, medicalmore than $460 million in 2008—was spent on just home practices ensure that they are fully20 percent of the patients. The most expensive pa- informed partners in establishing caretient had medical expenses of $3.5 million in a single plans. (AHRQ, 2012)year.(92) Jeff Brenner, MD, created the CCMS andengages a dedicated team who provide a wide varietyof health and social services to their patients. The As its name implies, a focus on the needs and prefer-team includes a family physician, a nurse practitio- ences of the patient is a key feature of the PCMH.ner, a community health worker and a social worker In contrast to a focus on a specific disease or organwho are linked through their Camden Health Infor- system, the PCMH centers on the whole person. Thismation Exchange to area hospitals. Armed with data includes physical health, but also behavioral health,to identify those who are most in need of assistance, oral health and long-term care supports. A patientthe CCMS has been successful in improving health and family-centered orientation embraces patientoutcomes and reducing use of acute care services preferences and culture, recognizes and assists withand is working with other communities to achieve health literacy, provides tools and resources for self-similar outcomes. managing chronic conditions, and is founded on trust and respect between the patient and the clinician inKey Outcomes: (93) order to develop a true partnership.(94) The Institute of Medicine defined patient-centeredness as one of • A self-reported analysis of outcomes pre- and the six key characteristics of quality care.(95) Various post-implementation of the CCMS found that organizations such as the Institute for Patient- and patients had fewer emergency visits and hospi- Family-Centered Care (96) highlight the importance talizations, resulting in a 56 percent reduction of collaboration and effective communication with in overall spending. patients and families, as well as the encouragement and support of the active participation of patients and • The first “super-utilizers” in the program had a family members in clinical care, primary care rede- 40 percent reduction in ED visits. sign, research, policy and program development. Several components of patient-centeredness have been evaluated in the peer-reviewed literature, and demonstrate the importance of this orientation.
18 | Benefits of Implementing the PCMH: A Review of Cost & Quality Results, 2012 National Partnership for Women Agency for Healthcare Research and & Families (97) Quality (AHRQ)PCMH feature highlighted: Patient/consumer PCMH feature highlighted: Defining patientpreferences and communication engagementAlthough there is widespread support for the AHRQ is the federal agency tasked with improv-concept of patient-centeredness, consumers’ ing the quality, safety, efficiency, and effectiveness ofpriorities are too often perceived as peripheral in health care for all Americans.(102) To provide decisionthe U.S. health care system. The National Partner- makers and researchers with access to evidence-basedship for Women & Families (NPWF) launched the resources about the medical home and its potentialCampaign for Better Care aimed at ensuring that to transform primary care, AHRQ has developed aconsumers receive comprehensive, coordinated Patient-Centered Medical Home Resource Centercare (www.campaignforbettercare.org). Through website (www.pcmh.ahrq.gov).(103) Several resourcesthe campaign, NPWF has developed a number are available aimed at describing patient-centered-of initiatives to advocate for the needs and wishes ness. In a white paper commissioned by AHRQ,(104)of patients and their families, including a project researchers recommend that patient engagementaimed at better understanding consumer views of take place at three levels: the individual; the institu-the patient-centered medical home.(98) Through a tion; and in the development of policy and research.series of community, state and national meetings,targeted focus groups and surveys, the organization Key Findings:(105)identified the key attributes of patient-centeredcare most important to consumers. • From the individual care perspective, primary care practices can better engage their patients,Key Findings: families and caregivers by: • Consumers were most supportive of whole ◊ Communicating with them about how the person care; comprehensive communication PCMH works, defining the roles of patients and coordination between patients and and their care delivery team; clinicians; patient support and empowerment; and ready access to care.(99) ◊ Supporting patients in self-care, which includes the development of goals, care • Consumers support these attributes of patient- plans and reduction of risk factors; centered care, although many were unclear about the meaning of the term “patient- ◊ Partnering with patients in informal and centered medical home.” (100) Other researchers formal decision making (including the use of have found that patients are unclear about tools such as shared decision-making); and what the term “patient-centered medical home” means, and confuse it with a nursing home ◊ Giving patients access to their own medical or other physical location. They recommend records to improve patient safety. educational and communication initiatives to explain the medical home to consumers with • From an institutional or organizational examples that have meaning to them. The perspective, primary care practices can researchers suggest that such efforts can help engage patients and their families in quality support and improve the PCMH as patients improvement efforts by: become better informed and involved. (101)
Patient-Centered Primary Care Collaborative | 19 ◊ Soliciting regular feedback through patient care and increased family satisfaction when surveys; children with special health care needs received primary care through a medical home. One of ◊ Gathering additional patient and family the longest-running national studies measuring perspectives through the formation of children’s access to medical homes is the National patient/family advisory councils; and Survey of Children’s Health, a telephone survey conducted by the Centers for Disease Control ◊ Including patients and their families in and Prevention’s National Center for Health quality improvement efforts. Statistics.(107) This survey continues to demonstrate positive associations between access to a medical • From a policy and research perspective, home, increased likelihood to receive preventive decision makers and researchers can care and fewer unmet health care needs.(108) engage patients and their families by: Key Outcomes: (109) ◊ Ensuring that the design and study of medical homes represents patient perspectives; • In this large national survey in 2007, children without a medical home were: ◊ Requiring that practices include patient engagement in order to qualify as an ◊ Almost four times as likely to have an unmet accredited medical home; health care need as were children with a medical home; and ◊ Using payment strategies to support patient and family engagement; ◊ Three times as likely to have unmet dental needs as were children with a medical home. ◊ Providing practices with technical assistance and shared resources for patient engagement; • Although most children had one of the five and features of a medical home, just over half (56.9 percent) had a fully implemented medical ◊ Establishing requirements to ensure that home (all five features) as defined by the study. health IT promotes patient engagement. • Children whose health was reported as fair or poor were only half as likely to have a medicalHealth Resources and Services home as those whose health was rated to beAdministration (HRSA) Maternal excellent or very good.and Child Health Bureau • Hispanic children were more than three timesPCMH feature highlighted: Support for family- more likely to lack a medical home than werecentered care and the PCMH white children; African American children were more than twice as likely to lack a medicalPioneered in concept by the American Academy home than were white children.of Pediatrics, family-centered care has been acentral tenet of the medical home for more than • Children in poverty were three and half times20 years.(106) Many of the earliest studies on the more likely than non-poor children to lack amedical home were conducted in pediatric practic- medical home.es with the support of federal funding from HRSAMCHB. These studies looked at improvements in
20 | Benefits of Implementing the PCMH: A Review of Cost & Quality Results, 2012Minnesota Department of Health U.S. Department of Health and Human ServicesPCMH feature highlighted: Support for familypartnership in care planning PCMH feature highlighted: Health literacy and improved patient-provider communicationThe Medical Home Initiative for Children withSpecial Health Care Needs was first implemented Health literacy is the capacity to understand basicin 2004 by the Minnesota Department of Health health information and make appropriate health(MDH). The project’s aim is to support a commu- decisions. It ties directly to the PCMH since thenity-based system offering services to children with care delivery team is focused on improving com-special health care needs. Data from the project show munication that enhances care coordination andthat all of its providers agree that the emphasis on engages the patient and family. Researchers arecare coordination has improved their patients’ health increasingly tying health literacy to a long list ofand well-being. Analysis of MDH claims data of 500 health outcomes.(111) According to one large study,children from nine of these practices also indicates only 12 percent of U.S. adults have proficient healthincreased patient health and well-being. Three years literacy, with more than a third of U.S. adultsafter implementation, several cost savings and quality having difficulty with common health tasks suchimprovements were realized. as following directions on a prescription drug label or adhering to a childhood immunization scheduleKey Outcomes: (110) using a standard chart.(112) Major PCMH accredit- ing bodies (such as NCQA, URAC, and the Joint • ED visits and inpatient admissions decreased; Commission) have acknowledged the central role that health literacy plays within their accreditation • Dental and well-child visits increased; standards. There are several federal initiatives aimed at improving health literacy built on research that • All providers surveyed felt that care plans are has demonstrated improved health outcomes and important for families to communicate with lower costs when health literacy is improved. other providers; Key Outcomes: • All providers surveyed felt that care plans should be written in partnership with the • Improved health literacy has the capacity to family; and reduce ethnic and racial disparities in the clinical and community setting. • Parents, even those not involved directly in the medical home team, noticed improvements at • In a randomized control trial, simplified their clinics that benefited children with special hospital discharge instructions given to patients health care needs. in order to help them transition from the hospi- tal to their homes led to a 30 percent reduction in hospitalization readmission rates. (113) • Health literacy researchers found that non- print broadcast media (such as radio and televi- sion) were “as important” or “more important” than print materials for all levels of literacy (four categories: below basic, basic, intermedi- ate, proficient). For those with the lowest level
Patient-Centered Primary Care Collaborative | 21 of health literacy, print materials were the least CareMore Medical Group likely to be used.(114) PCMH feature highlighted: Coordinating care • Information from health professionals is one of through care transitions and good communication(118) the most important sources of information on health topics for all health literacy levels.(115) CareMore Medical Group in California, a Medicare Advantage plan, has a central focus on coordinatingC. What is Care that is Coordinated? care for patients and meeting their individual needs. CareMore patients are over the age of 65, and many Care that is Coordinated: have multiple health care needs. The CareMore Medical Group promotes a comprehensive physical The primary care medical home coordinates exam for each patient, and assigns patients to work care across all elements of the broader health with a nurse practitioner who leads the care team. care system, including specialty care, hospi- Patients engage in chronic disease management and tals, home health care, and community care coordination that is supported through health services and supports. Such coordination IT and remote monitoring to track patients’ status. is particularly critical during transitions CareMore also refers its members to several com- between sites of care, such as when patients munity-based services to supplement their medical are being discharged from the hospital. care, including transportation and fitness programs, Medical home practices also excel at build- home and respite care, and caregiver assistance. This ing clear and open communication among includes providing assistance with transportation to patients and families, the medical home physician and other health-related appointments, and members of the broader care team. offering home care visits to patients, and even (AHRQ, 2012) providing talking pill boxes that remind patients to take their prescriptions. In an effort to support patients with transitions from hospital care toThe current model of health care delivery is frag- outpatient treatment, CareMore has created anmented and difficult for patients and their families “extensivist” physician function. The founder ofto navigate. Improved care coordination is proving CareMore, Sheldon Zinberg, MD, underscores theto be an essential role of the primary care provider, importance of clear, effective communication andespecially for those patients with multiple ongoing involving patients in their own care in order tohealth care needs that cannot be met by a single cli- build their trust and program buy-in.(119)nician or organization.(116) According to the Instituteof Medicine, lack of care coordination can be unsafe, Key Outcomes:and even fatal, when abnormal test results are notcommunicated correctly, prescriptions from multiple • According to self-reported data, CareMore’sdoctors conflict with each other, or primary care innovations have resulted in lower patientphysicians do not receive hospital discharge plans hospitalization rates (24 percent below thefor their patients.(117) Moreover, uncoordinated care Medicare average), hospital stays that areadds to the cost of care due to duplicated services, 38 percent shorter and an amputation ratepreventable hospital readmissions and overuse of among diabetics that is 60 percent lowermore intensive procedures. than average (no date reported).(120) • CareMore reports an impressive 97 percent patient satisfaction rate.(121)
22 | Benefits of Implementing the PCMH: A Review of Cost & Quality Results, 2012 • In a peer-reviewed study, CareMore was • Reduced hospital admissions (from 1.46 to 1.2 found to have a 15 percent reduction in health inpatient admissions per member per year) for care costs compared with regional averages, the heart failure program (2008-2009); as well as superior diabetes control and lower re-hospitalization rates compared with • Reduced hospital admissions (from 0.41 to national averages.(122) 0.32 inpatient admissions per member per year) for the respiratory program (2008-2009); andBronx Community Accountable • Reduced readmission rate (from 21.5 percentHealthcare Network to 14 percent) for hospital follow-up program (2008-2009).PCMH feature highlighted: Coordinating careacross primary and specialty services within an ACO Institute of Medicine: Living Well withThe Bronx Community Accountable Healthcare Chronic Illness: A Call for Public HealthNetwork (BAHN) is part of the Montefiore Medical Action (metaanalysis)Center and a growing collaboration of pharmacies,hospitals, physicians, ancillary services, care man- PCMH feature highlighted: Coordinating careagement services, health plans and insurers, home with patients and families through chronic diseasecare, public health agencies, long-term care facilities self-management (CDSM)and mental health services, built on a foundation ofprimary care and a PCMH model. State-of-the-art Managing patients’ chronic illness is a criticalprimary and specialty care is provided through a feature of the PCMH. Individuals who suffer fromnetwork of nearly 100 locations across the region, chronic illnesses often experience significant chal-including the largest school health program in the lenges to their quality of life, as often do their familynation and a home health program.(123) Clinical members and caretakers. Chronic diseases accountinformation between these health care organizations for 70 percent of all U.S. deaths and represent moreis exchanged through the Bronx Regional Health than 75 percent of the $2 trillion spent annually onInformation Organization (Bronx RHIO). Aggre- health.(126) Researchers have examined ways to bettergating data from various sources, the ACO facilitates manage chronic illness, including chronic diseasecare management and coordination between special- management, education and support for caregiversty services by supporting patient use of online tools, (most of whom are unpaid), and support for sharedempowering patients to manage their own health decision making between the individual and the cli-information, and also ensures that patients are aware nician.(127) CDSM programs vary significantly; someof who has access to their personal information.(124) programs manage a specific condition (like diabetes),The Bronx Community Accountable Healthcare while others focus on risk factors for chronic diseaseNetwork was also recently selected to participate such as smoking, weight loss or stress. However, allas a Pioneer ACO and has demonstrated are focused on the ability of the patient and fam-impressive results. ily to better manage care between health care visits. Although some chronic disease management pro-Key Outcomes:(125) grams are offered directly to patients/consumers by their employer, health plan, or through a community • Reduced hospital admissions by 28 percent and agency, those that are connected to the primary reduced ER utilization by 25 percent for the care provider can be more effective in improving diabetes program (between 2008-2009); health behaviors.(128)
Patient-Centered Primary Care Collaborative | 23Key Outcomes:(129) physicians that referred their patients to a popula- tion health management program. The program • Numerous randomized controlled trials and targeted various risk factors based on the patient’s a thorough meta-analytical review of the needs (blood pressure, body mass index, choles- scientific data finds that chronic disease self- terol, HbA1c and smoking status).(133) This study management leads to better quality of life and found that patients were more likely to participate more autonomy for patients, as well reducing in population health management when they were the use and cost of health care services.(130) referred by their primary care physician. • In a large 24-year review of the scientific data Key Outcomes: (134) commissioned by the Institute of Medicine, researchers identified 15 comprehensive care • At the end of six months, physicians referred models that resulted in improvements in almost half of their eligible members to quality of life and autonomy for persons population health management (80 of 187 who were chronically ill:(131) eligible members). ◊ Nine of these models were based on either • Of those referred, slightly more than half interdisciplinary primary care teams or enrolled in the population health management community-based health-related services program (43 patients). that enhance traditional primary care. • During the six-month study period, individu- ◊ The nine models came from 106 different als who had been referred by their primary care studies—66 percent of which were found practice had a ten-fold improvement in risk to lower the use of health care services, and factor management compared to the prior six 33 percent of which lowered health care costs. month period (nine versus 96 distinct risk factor improvements).Population Health Management through D. What Does Superb Access to Care Mean?Enhanced Coordination Superb Access to Care:PCMH feature highlighted: Coordinatedpopulation health management “The primary care medical home delivers accessible services with shorter waiting timesPopulation health management programs typically for urgent needs, enhanced in-person hours,work directly with persons at high risk for chronic around-the-clock telephone or electronicillness to promote healthy behaviors or assist in access to a member of the care team, andmanaging their conditions, often without their alternative methods of communication suchphysicians’ knowledge or input. Reported by the as email and telephone care. The medicalCare Continuum Alliance, researchers tested home practice is responsive to patients’whether individuals referred to population health preferences regarding access.” (AHRQ, 2012)management programs by their primary carepractice increase their participation in diseasemanagement.(132) The study involved more than 500 Access to timely care matters a great deal to patientspatients who were at high risk for coronary artery and their families. Numerous features of a PCMHdisease (CAD), diabetes and/or hypertension and can improve access to care, including shorter wait-provided a modest “pay-for-outcomes” incentive to ing times for patients with urgent needs; extended