Outcomes of Implementing Patient Centered Medical Home

Outcomes of Implementing Patient Centered Medical Home

Outcomes of Implementing Patient
Centered Medical Home Interventions:
A Review of the Evidence from Prospective
Evaluation Studies in the United States
U P D AT E D N O V E M B E R 1 6 , 2 0 1 0
Kevin Grumbach, MD
Center for Excellence in Primary Care
Department of Family and Community Medicine
University of California, San Francisco
Paul Grundy, MD, MPH
IBM Global Healthcare Transformation
President, Patient-Centered Primary Care
Collaborative
A
bundant research comparing nations, states
and regions within the US, and specific
systems of care has shown that health systems built on a solid foundation of primary
care deliver more effective, efficient and equitable care
than do systems that fail to invest adequately in primary
care.1,2 However, some policy analysts have questioned
whether these largely cross-sectional, observational studies are adequate for making inferences about whether
implementing major policy interventions to strengthen
primary care as part of health reform would in the relatively short term “bend the cost curve” at the same time
as improving quality of care and patient outcomes.
In October 2009, we issued a review of available
research evidence from prospective, controlled studies
of patient centered medical home interventions in
the United States designed to enhance and improve
primary care. This report updates our review of
patient centered medical home evaluations. Since
our 2009 report, findings from several additional
evaluations of patient centered medical home
interventions have been released. These include some
patient centered medical home initiatives mentioned
in our 2009 report which have released updated findings from ongoing assessments, as well as evaluations
of new patient centered medical home initiatives
not included in last year’s report. In total, the patient
centered medical home initiatives included in this
report involve more than a million patients cared for
in thousands of diverse practice settings, involving
both private and public payers.
The findings from our updated review are entirely
consistent with those of our 2009 report: Investing in
primary care patient centered medical homes results
in improved quality of care and patient experiences,
and reductions in expensive hospital and emergency
department utilization. There is now even stronger
evidence that investments in primary care can bend
the cost curve, with several major evaluations showing that patient centered medical home initiatives have
produced a net savings in total health care expenditures for the patients served by these initiatives.
Section 1 of the report provides a summary of the key
findings on cost related outcomes. Section 2 provides
more background information about each patient
centered medical home model and includes data
on quality and access in addition to costs, as well as
reference citations. The methods used in the review
are described in the Appendix.
Patient-Centered Primary Care Collaborative
/…iʜ“iÀÊՈ`ˆ˜}ÊUÊÈä£Ê/…ˆÀÌii˜Ì…Ê-ÌÀiiÌ]Ê °7°ÊUÊ-ՈÌiÊ{ääÊUÊ7>ň˜}̜˜]Ê°
°ÊÓäääxÊ
*…œ˜i\Ê­ÓäÓ®ÊÇÓ{‡ÎÎΣÊUÊ>Ý\Ê­ÓäÓ®ÊΙ·ȣ{n
www.pcpcc.net
Section 1:
-Փ“>ÀÞʜvÊ>Ì>ʜ˜Ê
œÃÌÊ"ÕÌVœ“iÃÊvÀœ“Ê*>̈i˜ÌÊ
i˜ÌiÀi`Êi`ˆV>Êœ“iʘÌiÀÛi˜Ìˆœ˜Ã
A. Integrated Delivery System
PCMH Models
Group Health Cooperative of Puget Sound
UÊ$10 PMPM reduction in total costs; total PMPM
VœÃÌÊf{nnÊvœÀÊ*
Ê«>̈i˜ÌÃÊÛðÊf{™nÊvœÀÊ
control patients (p=.076).
UÊ16% reduction in hospital admissions (p<.001);
x°£Ê>`“ˆÃȜ˜ÃÊ«iÀÊ£]äääÊ«>̈i˜ÌÃÊ«iÀʓœ˜Ì…ʈ˜Ê
*
Ê«>̈i˜ÌÃÊÛðÊx°{ʈ˜ÊVœ˜ÌÀœÃ°Êf£{Ê**Ê
reduction in inpatient hospital costs relative to
controls. 29% reduction in emergency department use (p<.001); 27 emergency department
ۈÈÌÃÊ«iÀÊ£]äääÊ«>̈i˜ÌÃÊ«iÀʓœ˜Ì…ʈ˜Ê*
Ê
«>̈i˜ÌÃÊÛðÊΙʈ˜ÊVœ˜ÌÀœÃ°Êf{Ê**ÊÀi`ÕV̈œ˜Êˆ˜Ê
emergency department costs relative to controls.
Geisinger Health System ProvenHealth
Navigator PCMH Model
UÊ£n¯ÊÀi`ÕV̈œ˜Êˆ˜Ê…œÃ«ˆÌ>Ê>`“ˆÃȜ˜ÃÊÀi>̈ÛiÊ
̜ÊVœ˜ÌÀœÃ\ÊÓxÇÊ>`“ˆÃȜ˜ÃÊ«iÀÊ£]äääʓi“LiÀÃÊ
«iÀÊÞi>Àʈ˜Ê*
Ê«>̈i˜ÌÃÊÛðÊΣÎÊ>`“ˆÃȜ˜ÃÊ
per 1,000 members per year in controls (p<.01).
7ˆÌ…ˆ˜Ê*
ÊVœ…œÀÌ]Ê>`“ˆÃȜ˜ÊÀ>ÌiÃÊ`iVÀi>Ãi`Ê
vÀœ“ÊÓnnÊ«iÀÊ£]äääʓi“LiÀÃÊ«iÀÊÞi>ÀÊ>ÌÊL>Ãiˆ˜iÊ̜ÊÓxÇÊ`ÕÀˆ˜}Ê*
ʈ˜ÌiÀÛi˜Ìˆœ˜Ê«iÀˆœ`°
UÊ7% reduction in total PMPM costs relative to
controls (p=.21).
Veterans Health Administration and VA Midwest
Healthcare Network, Veterans Integrated Service
Network 23 (VISN 23)
UʜÀÊ
…Àœ˜ˆVʈÃi>ÃiÊ>˜>}i“i˜Ìʓœ`iÊ*
Ê
vœÀʅˆ}…‡ÀˆÃŽÊ«>̈i˜ÌÃÊ܈̅Ê
"*]ÊVœ“«œÃˆÌiÊ
œÕÌVœ“iÊvœÀÊ>Ê…œÃ«ˆÌ>ˆâ>̈œ˜ÃʜÀÊÊۈÈÌÃÊÓǯÊ
œÜiÀʈ˜Ê̅iÊ
Ê}ÀœÕ«Ê­£Óΰnʓi>˜ÊiÛi˜ÌÃÊ
2
«iÀÊ£ääÊ«>̈i˜Ì‡Þi>ÀîÊVœ“«>Ài`Ê̜Ê̅iÊ1
Ê
}ÀœÕ«Ê­£Çä°xʓi>˜ÊiÛi˜ÌÃÊ«iÀÊ£ääÊ«>̈i˜Ì‡
Þi>ÀîʭÀ>ÌiÊÀ>̈œÊä°ÇÎÆÊä°xȇ䰙äÆʫʐÊä°ääή°Ê
/…iÊVœÃÌʜvÊ̅iÊ
ʈ˜ÌiÀÛi˜Ìˆœ˜ÊÜ>ÃÊfÈxäÊ«iÀÊ
«>̈i˜Ì°Ê/…iÊ̜Ì>Ê“i>˜Ê´Ê-Ê«iÀÊ«>̈i˜ÌÊVœÃÌÊ
̅>Ìʈ˜VÕ`i`Ê̅iÊVœÃÌʜvÊ
ʈ˜Ê̅iÊ
Ê}ÀœÕ«Ê
Ü>ÃÊf{{™£Ê´Ê{ÈÇnÊVœ“«>Ài`Ê̜Êfxän{Ê´Ê
xäÈäÊÀi«ÀiÃi˜Ìˆ˜}Ê>Êfx™ÎÊ«iÀÊ«>̈i˜ÌÊVœÃÌÊ
Ã>ۈ˜}ÃÊvœÀÊ̅iÊ
Ê«Àœ}À>“°
UÊ
œ“«>À>LiÊÀi`ÕV̈œ˜Ãʈ˜ÊÊ>˜`ʅœÃ«ˆÌ>ˆâ>tions were found for Veterans Health
`“ˆ˜ˆÃÌÀ>̈œ˜Ê*
ʈ˜ÌiÀÛi˜Ìˆœ˜ÃÊÌ>À}ï˜}Ê
other patients with chronic conditions.
HealthPartners Medical Group
BestCare PCMH Model
UÊΙ¯Ê`iVÀi>Ãiʈ˜Êi“iÀ}i˜VÞÊ`i«>À̓i˜ÌÊۈÈÌÃÊ
>˜`ÊÓ{¯Ê`iVÀi>Ãiʈ˜Ê…œÃ«ˆÌ>Ê>`“ˆÃȜ˜ÃÊ«iÀÊ
i˜ÀœiiÊLiÌÜii˜ÊÓää{Ê>˜`ÊÓä䙰
UÊOverall costs for enrollees in HealthPartners
Medical Group decreased from being equal to
̅iÊÃÌ>ÌiÊ>ÛiÀ>}iʈ˜ÊÓää{Ê̜ʙӯʜvÊ̅iÊÃÌ>ÌiÊ
>ÛiÀ>}iʈ˜ÊÓään]ʈ˜Ê>ÊÃÌ>ÌiÊ܈̅ÊVœÃÌÃÊ>Ài>`ÞÊ
well below the national average.
Intermountain Healthcare Medical Group Care
Management Plus PCMH Model
UÊ,i`ÕVi`ʅœÃ«ˆÌ>ˆâ>̈œ˜Ãʈ˜Ê*
Ê}ÀœÕ«ÆÊLÞÊ
Þi>ÀÊÓʜvÊvœœÜ‡Õ«]ÊΣ°n¯ÊœvÊ*
Ê«>̈i˜ÌÃÊ
…>`ÊLii˜Ê…œÃ«ˆÌ>ˆâi`Ê>Ìʏi>ÃÌʜ˜ViÊÛÃÊÎ{°Ç¯Ê
œvÊVœ˜ÌÀœÊ«>̈i˜ÌÃÊ­«r°Óή°Ê“œ˜}Ê«>̈i˜ÌÃÊ
܈̅Ê`ˆ>LiÌiÃ]ÊÎä°x¯ÊœvÊ̅iÊ*
Ê}ÀœÕ«ÊÜiÀiÊ
…œÃ«ˆÌ>ˆâi`ÊÛÃÊΙ°Ó¯ÊœvÊVœ˜ÌÀœÃÊ­«r°ä£®°Ê
UÊ iÌÊÀi`ÕV̈œ˜Êˆ˜Ê̜Ì>ÊVœÃÌÃÊÜ>ÃÊfÈ{äÊ«iÀÊ
«>̈i˜ÌÊ«iÀÊÞi>ÀÊ­f£]ÈxäÊÃ>ۈ˜}ÃÊ«iÀÊÞi>ÀÊ
among highest risk patients).
B. Private Payer Sponsored
PCMH Initiatives
BlueCross BlueShield of South Carolina-Palmetto
Primary Care Physicians
UÊ£ä°{¯ÊÀi`ÕV̈œ˜Êˆ˜Êˆ˜«>̈i˜ÌʅœÃ«ˆÌ>Ê`>ÞÃÊ«iÀÊ
£]äääÊi˜ÀœiiÃÊ«iÀÊÞi>ÀÊ>“œ˜}Ê*
Ê«>̈i˜ÌÃ]Ê
vÀœ“Êx{Ó°™Ê̜Ê{nÈ°x°Ê˜«>̈i˜ÌÊ`>ÞÃÊÎȰίÊ
œÜiÀÊ>“œ˜}Ê*
Ê«>̈i˜ÌÃÊ̅>˜Ê>“œ˜}ÊVœ˜ÌÀœÊ
«>̈i˜ÌðʣӰ{¯ÊÀi`ÕV̈œ˜Êˆ˜Êi“iÀ}i˜VÞÊ`i«>ÀÌment visits per 1,000 enrollees per month among
*
Ê«>̈i˜ÌÃ]ÊvÀœ“ÊÓ£°{Ê̜ʣn°n°Ê“iÀ}i˜VÞÊ
department visits per 1,000 enrollees were
ÎӰӯʏœÜiÀÊ>“œ˜}Ê*
Ê«>̈i˜ÌÃÊ̅>˜Ê>“œ˜}Ê
control patients.
UÊTotal medical and pharmacy costs PMPM were
È°x¯ÊœÜiÀʈ˜Ê̅iÊ*
Ê}ÀœÕ«Ê̅>˜Ê̅iÊVœ˜ÌÀœÊ
group.
BlueCross BlueShield of North Dakota-MeritCare
Health System
UÊHospital admissions decreased by 6% and
i“iÀ}i˜VÞÊ`i«>À̓i˜ÌÊۈÈÌÃÊ`iVÀi>Ãi`ÊLÞÊÓ{¯Ê
ˆ˜Ê̅iÊ*
Ê}ÀœÕ«ÊvÀœ“ÊÓääÎÊ̜ÊÓääx]Ê܅ˆiÊ
ˆ˜VÀi>Ș}ÊLÞÊ{x¯Ê>˜`Êί]ÊÀiëiV̈ÛiÞ]ʈ˜Ê̅iÊ
Vœ˜ÌÀœÊ}ÀœÕ«°Ê˜ÊÓääx]Ê*
Ê«>̈i˜ÌÃʅ>`Ê
£Î°äÓÊ>˜˜Õ>Êˆ˜«>̈i˜ÌÊ>`“ˆÃȜ˜ÃÊ«iÀÊ£ääÊ
«>̈i˜ÌÃ]ÊVœ“«>Ài`Ê܈̅ʣǰÈxÊ>`“ˆÃȜ˜ÃÊ«iÀÊ
£ääÊ«>̈i˜ÌÃʈ˜Ê̅iÊVœ˜ÌÀœÊ}ÀœÕ«°Ê*
Ê«>̈i˜ÌÃʅ>`ÊÓä°Î£Ê>˜˜Õ>Êi“iÀ}i˜VÞÊ`i«>À̓i˜ÌÊ
ۈÈÌÃÊ«iÀÊ£ääʓi“LiÀÃ]ÊVœ“«>Ài`Ê܈̅ÊÓx°ääÊ
among control patients.
UʘÊÓääx]Ê̜Ì>ÊVœÃÌÃÊ«iÀʓi“LiÀÊ«iÀÊÞi>ÀÊÜiÀiÊ
fxÎäʏœÜiÀÊ̅>˜ÊiÝ«iVÌi`ʈ˜Ê̅iʈ˜ÌiÀÛi˜Ìˆœ˜Ê
}ÀœÕ«ÊL>Ãi`ʜ˜Ê…ˆÃ̜ÀˆV>ÊÌÀi˜`ðÊiÌÜii˜ÊÓääÎÊ
>˜`ÊÓääx]Ê̜Ì>Ê>˜˜Õ>ÊiÝ«i˜`ˆÌÕÀiÃÊ«iÀÊ*
Ê
«>̈i˜Ìʈ˜VÀi>Ãi`ÊvÀœ“Êfx]xÈ£Ê̜ÊfÇ]{ÎÎ]Ê
compared with a much larger increase among
Vœ˜ÌÀœÊ«>̈i˜ÌÃÊvÀœ“Êfx]nÈnʈ˜ÊÓääÎÊ̜Ê
f£ä]£änʈ˜ÊÓääx°Ê
Metropolitan Health Networks-Humana (Florida)
UÊHospital days per 1,000 enrollees dropped
LÞÊ{°È¯Êˆ˜Ê̅iÊ*
Ê}ÀœÕ«ÊVœ“«>Ài`Ê̜Ê>˜Ê
ˆ˜VÀi>ÃiʜvÊÎȯʈ˜Ê̅iÊVœ˜ÌÀœÊ}ÀœÕ«°ÊœÃ«ˆÌ>Ê
admissions per 1,000 customers dropped by
ί]Ê܈̅ÊÀi>`“ˆÃȜ˜ÃÊȯÊLiœÜÊi`ˆV>ÀiÊ
benchmarks.
UʓiÀ}i˜VÞÊÀœœ“ÊiÝ«i˜ÃiÊÀœÃiÊLÞÊ{°x¯ÊvœÀÊ̅iÊ
*
Ê}ÀœÕ«ÊVœ“«>Ài`Ê̜Ê>˜Êˆ˜VÀi>Ãiʜvʣǰ{¯Ê
vœÀÊ̅iÊVœ˜ÌÀœÊ}ÀœÕ«°Êˆ>}˜œÃ̈Vʈ“>}ˆ˜}ÊiÝ«i˜ÃiÊvœÀÊ̅iÊ*
Ê}ÀœÕ«Ê`iVÀi>Ãi`ÊLÞʙ°n¯Ê
compared to an increase of 10.7% for the control group. Pharmacy expense increases were
È°x¯ÊvœÀÊ̅iÊ*
Ê}ÀœÕ«ÊÛiÀÃÕÃÊ£{°x¯ÊvœÀÊ
the control group.
UÊ"ÛiÀ>Ê“i`ˆV>ÊiÝ«i˜ÃiÊvœÀÊ̅iÊ*
Ê}ÀœÕ«Ê
ÀœÃiÊLÞÊx°Ó¯ÊVœ“«>Ài`Ê̜Ê>ÊÓȰίʈ˜VÀi>ÃiÊ
for the control group.
C. Medicaid Sponsored
PCMH Initiatives
Community Care of North Carolina
UÊ
ՓՏ>̈ÛiÊÃ>ۈ˜}ÃʜvÊf™Ç{°xʓˆˆœ˜ÊœÛiÀÊÈÊ
Þi>ÀÃÊ­Óää·Óään®°Ê{ä¯Ê`iVÀi>Ãiʈ˜Ê…œÃ«ˆÌ>izations for asthma and 16% lower emergency
department visit rate.
Colorado Medicaid and SCHIP
UÊi`ˆ>˜Ê>˜˜Õ>ÊVœÃÌÃÊfÇnxÊvœÀÊ*
ÊV…ˆ`Ài˜Ê
compared with $1,000 for controls. In an evalu䜘ÊëiVˆwV>ÞÊiÝ>“ˆ˜ˆ˜}ÊV…ˆ`Ài˜Êˆ˜Êi˜ÛiÀÊ
܈̅ÊV…Àœ˜ˆVÊVœ˜`ˆÌˆœ˜Ã]Ê*
ÊV…ˆ`Ài˜Ê…>`Ê
œÜiÀʓi`ˆ>˜Ê>˜˜Õ>ÊVœÃÌÃÊ­fÓ]ÓÇx®Ê̅>˜Ê̅œÃiÊ
˜œÌÊi˜Àœi`ʈ˜Ê>Ê*
Ê«À>V̈ViÊ­fÎ]{ä{®°
3
D. Other PCMH Programs
Johns Hopkins Guided Care PCMH Model
UÊÓ{¯ÊÀi`ÕV̈œ˜Êˆ˜Ê̜Ì>Ê…œÃ«ˆÌ>Êˆ˜«>̈i˜ÌÊ`>ÞÃ]Ê
£x¯ÊviÜiÀÊ,ÊۈÈÌÃ]ÊÎǯÊ`iVÀi>Ãiʈ˜ÊΈi`Ê
nursing facility days.
Uʘ˜Õ>Ê˜iÌÊi`ˆV>ÀiÊÃ>ۈ˜}ÃʜvÊfÇx]äääÊ«iÀÊ
*
ÊV>ÀiÊVœœÀ`ˆ˜>̜ÀʘÕÀÃiÊ`i«œÞi`ʈ˜Ê>Ê
practice.
Genesee Health Plan (Michigan)
UÊxä¯Ê`iVÀi>Ãiʈ˜Êi“iÀ}i˜VÞÊ`i«>À̓i˜ÌÊۈÈÌÃÊ
>˜`Ê£x¯ÊviÜiÀʈ˜«>̈i˜ÌʅœÃ«ˆÌ>ˆâ>̈œ˜Ã]Ê܈̅Ê
total hospital days per 1,000 enrollees 26.6%
lower than competitors.
4
Erie County PCMH Model
UÊiVÀi>Ãi`Ê`Õ«ˆV>̈œ˜ÊœvÊÃiÀۈViÃÊ>˜`ÊÌiÃÌÃ]Ê
lowered hospitalization rates, with an estimated
savings of $1 million for every 1,000 enrollees.
Geriatric Resources for Assessment and
Care of Elders
UÊUse of the emergency department significantly
lower. The subgroup defined at the start of the
study as having a high risk of hospitalization was
found to have significantly lower hospitalization
rates compared with high-risk usual care patients.
Section 2:
ՏÊ-Փ“>ÀˆiÃʜvÊ*>̈i˜ÌÊ
i˜ÌiÀi`Êi`ˆV>
Home Interventions and Outcomes
A. Integrated Delivery Systems
Group Health Cooperative of Puget Sound
ÀœÕ«Êi>Ì…Ê
œœ«iÀ>̈ÛiʜvÊ*Õ}iÌÊ-œÕ˜`]Ê>ʏ>À}i]Ê
consumer-owned integrated delivery system in the
Northwest, is rolling out a major transformation of its
primary care practices. In 2007, Group Health
œœ«iÀ>̈ÛiÊ«ˆœÌi`Ê>Ê«>̈i˜ÌÊVi˜ÌiÀi`ʓi`ˆV>Ê…œ“iÊ
redesign at one of its Seattle clinic sites. The redesign
included substantial workforce investments to reduce
primary care physician panels from an average of
Ó]ÎÓÇÊ«>̈i˜ÌÃÊ̜ʣ]nää]ÊiÝ«>˜`ʈ˜‡«iÀܘÊۈÈÌÃÊvÀœ“Ê
ÓäÊ̜ÊÎäʓˆ˜ÕÌiÃÊ>˜`ÊÕÃiʓœÀiÊ«>˜˜i`ÊÌii«…œ˜iÊ>˜`Ê
email virtual visits, and allocate daily “desktop medicine” time for staff to perform outreach, coordination,
and other activities. The redesign emphasized teamL>Ãi`ÊV…Àœ˜ˆVÊ>˜`Ê«ÀiÛi˜ÌˆÛiÊV>ÀiÊ>˜`ÊÓ{ÉÇÊ>VViÃÃÊ
using modalities including EHR patient portals.
A controlled evaluation of the pilot clinic redesign, published in peer-reviewed journals,Î]{ found the following:
UÊTotal lives covered in PCMH model
ÊÇ]ä£nÊ>`ՏÌÃÊi˜Àœi`Ê>ÌÊ̅iÊÀœÕ«Êi>Ì…Ê
*
Ê«ˆœÌÊVˆ˜ˆVÆÊ«>̈i˜ÌÃʘœÌÊÃiiVÌi`ÊvœÀÊÀˆÃŽÊ
status or particular health conditions.
UÊComparison group
200,970 adults enrolled at the 19 other Group
Health clinic sites. Analyses adjusted for any
baseline differences between intervention and
control groups.
UÊData sources
>ˆ“ÃÊ`>Ì>Ê̜ʓi>ÃÕÀiÊṎˆâ>̈œ˜Ê>˜`ÊVœÃÌÃ
Surveys and quality indicator databases to measure patient experiences and processes of care.
UÊCost and utilization outcomes
$10 PMPM reduction in total costs; total PMPM
VœÃÌÊf{nnÊvœÀÊ*
Ê«>̈i˜ÌÃÊÛðÊf{™nÊvœÀÊ
control patients (p=.076).
16% reduction in hospital admissions (p<.001);
x°£Ê>`“ˆÃȜ˜ÃÊ«iÀÊ£]äääÊ«>̈i˜ÌÃÊ«iÀʓœ˜Ì…ʈ˜Ê
*
Ê«>̈i˜ÌÃÊÛðÊx°{ʈ˜ÊVœ˜ÌÀœÃ°Êf£{Ê**Ê
reduction in inpatient hospital costs relative to
controls.
29% reduction in emergency department use
(p<.001); 27 emergency department visits per
£]äääÊ«>̈i˜ÌÃÊ«iÀʓœ˜Ì…ʈ˜Ê*
Ê«>̈i˜ÌÃÊÛðÊ
Ιʈ˜ÊVœ˜ÌÀœÃ°Êf{Ê**ÊÀi`ÕV̈œ˜Êˆ˜Êi“iÀ}i˜VÞÊ
department costs relative to controls.
UÊTotal spending on PCMH enrollees
/œÌ>Ê**ÊVœÃÌÊf{nnÊvœÀÊ*
Ê«>̈i˜ÌÃÊÛðÊ
f{™nÊvœÀÊVœ˜ÌÀœÊ«>̈i˜ÌÃÊ­«r°äÇÈ®°
UÊReturn on investment
**Ê«Àˆ“>ÀÞÊV>ÀiÊṎˆâ>̈œ˜ÊVœÃÌÃÊf£°ÈnʓœÀiÊ
vœÀÊ*
Ê«>̈i˜ÌÃÊ̅>˜ÊvœÀÊVœ˜ÌÀœÊ«>̈i˜ÌÃÊ
(p=.001).
When fully accounting for all additional invest“i˜ÌÃʈ˜Ê̅iÊ*
ʓœ`i]ÊÀiÌÕÀ˜Êœ˜Ê*
ʈ˜ÛiÃ̓i˜ÌÊÜ>ÃÊ£°x\£°
UÊEvaluation design and time period
Pre-post controlled cohort study with 21 months
of follow-up cost and utilization data.
5
UÊQuality outcomes
/…iÊ«ˆœÌÊVˆ˜ˆVʅ>`Ê>˜Ê>L܏ÕÌiʈ˜VÀi>ÃiʜvÊ{¯Ê
more of its patients achieving target levels on
-ʵÕ>ˆÌÞʓi>ÃÕÀiÃÊ>ÌÊ£Óʓœ˜Ì…Ã]ÊÈ}˜ˆwcantly different from the control clinic trend; pilot
clinic patients also reported significantly greater
improvement on measures of patient experiences,
such as care coordination and patient activation,
relative to control patient trends.
Better work environment: Less staff burnout, with
only 10% of pilot clinic staff reporting high emöœ˜>Êi݅>ÕÃ̈œ˜Ê>ÌÊ£Óʓœ˜Ì…ÃÊVœ“«>Ài`Ê̜ÊÎä¯Ê
of staff at control clinics, despite being similar at
baseline; Group Health has seen a major improvement in recruitment and retention of primary
care physicians.
As a result of the success of the pilot clinic redesign,
ÀœÕ«Êi>Ì…ʈÃʈ“«i“i˜Ìˆ˜}Ê̅iÊ*
ʓœ`iÊ>ÌÊ>Ê
ÓÈʜvʈÌÃÊ«Àˆ“>ÀÞÊV>ÀiÊVˆ˜ˆVÃÊÃiÀۈ˜}ÊÎnä]äääÊ«>̈i˜ÌðÊ
Geisinger Health System ProvenHealth Navigator
PCMH Model
The Geisinger Health System, a large integrated
delivery system in Pennsylvania, implemented a patient
centered medical home redesign in 11 of its primary
care practices beginning in 2006, phased in over 17
months. Their ProvenHealth Navigator model focuses
on Medicare beneficiaries, emphasizing primary carebased care coordination with team models featuring
nurse care coordinators, EHR decision-support and
performance incentives.x
6
UÊEvaluation design and time period
*Ài‡«œÃÌÊVœ˜ÌÀœi`ÊVœ…œÀÌÊÃÌÕ`ÞÊ܈̅ÊÎÊÞi>ÀÃÊ
of follow-up data.
UÊData sources
>ˆ“ÃÊ`>Ì>Ê̜ʓi>ÃÕÀiÊṎˆâ>̈œ˜Ê>˜`ÊVœÃÌÃ]Ê
including patient out-of-pocket costs but excluding
pharmacy costs.6
UÊCost and utilization outcomes
£n¯ÊÀi`ÕV̈œ˜Êˆ˜Ê…œÃ«ˆÌ>Ê>`“ˆÃȜ˜ÃÊÀi>̈ÛiÊ̜Ê
Vœ˜ÌÀœÃ\ÊÓxÇÊ>`“ˆÃȜ˜ÃÊ«iÀÊ£]äääʓi“LiÀÃÊ
«iÀÊÞi>Àʈ˜Ê*
Ê«>̈i˜ÌÃÊÛðÊΣÎÊ>`“ˆÃȜ˜ÃÊ
per 1,000 members per year in controls (p<.01).
7ˆÌ…ˆ˜Ê*
ÊVœ…œÀÌ]Ê>`“ˆÃȜ˜ÊÀ>ÌiÃÊ`iVÀi>Ãi`Ê
vÀœ“ÊÓnnÊ«iÀÊ£]äääʓi“LiÀÃÊ«iÀÊÞi>ÀÊ>ÌÊL>Ãiˆ˜iÊ̜ÊÓxÇÊ`ÕÀˆ˜}Ê*
ʈ˜ÌiÀÛi˜Ìˆœ˜Ê«iÀˆœ`°
7% reduction in total PMPM costs relative to
controls (p=.21).
UÊTotal spending on PCMH enrollees
Published evaluation did not report actual spending amount PMPM “to protect the confidentiality
of GHP payment information.” National
Medicare spending per beneficiary, excluding
pharmacy benefits and patient cost-sharing, is
more than $7,000 per beneficiary per year. By
extrapolation, a 7% reduction in spending per
iˆÃi˜}iÀÊi`ˆV>ÀiÊ`Û>˜Ì>}iÊ*
Êi˜ÀœiiÊ
VœÕ`ÊVœ˜ÃiÀÛ>̈ÛiÞÊLiÊiÃ̈“>Ìi`Ê̜ÊÃ>ÛiÊfxääÊ
per enrollee per year.
UÊTotal lives covered in PCMH model
n]ÈÎ{Êi`ˆV>ÀiÊ`Û>˜Ì>}iÊi˜ÀœiiÃʈ˜Ê*
Ê
practices; included all Medicare Advantage
enrollees at these practices; not selected for risk
status or health conditions.
UÊReturn on investment
Geisinger has estimated in unpublished reports
an ROI of more than 2 to 1 for its investment
ˆ˜ÊˆÌÃÊ*
ʓœ`i]Ê>˜`ʈÃÊëÀi>`ˆ˜}Ê̅iÊ
*ÀœÛi˜i>Ì…Ê >ۈ}>̜ÀÊ*
ʓœ`iÊ
throughout the Geisenger Health System.
UÊComparison group
6,676 Medicare Advantage enrollees at non*
ÊiˆÃi˜}iÀʘiÌܜÀŽÊ«À>V̈ViÃ]ʓ>ÌV…i`Ê
using propensity scores to identify patients with
similar case mix profile.
UÊQuality outcomes
Statistically significant improvements in quality of
«ÀiÛi˜ÌˆÛiÊ­Ç{°ä¯Êˆ“«ÀœÛi“i˜Ì®]ÊVœÀœ˜>ÀÞÊ>ÀÌiÀÞÊ
`ˆÃi>ÃiÊ­ÓӰ䯮Ê>˜`Ê`ˆ>LiÌiÃÊV>ÀiÊ­Î{°x¯®ÊvœÀÊ
*
Ê«ˆœÌÊ«À>V̈ViÊÈÌið
Veterans Health Administration and VA Midwest
Healthcare Network, Veterans Integrated Service
Network 23 (VISN 23)
Veterans Health Administration is the largest integrated
health care delivery system in the country, providing
…i>Ì…ÊV>ÀiÊÃiÀۈViÃÊ̜ÊÇ]n£Ç]ș{Êi˜ÀœiiÃÊ>˜`Ê
x]{{Ç]nn™Ê՘ˆµÕiÊÛiÌiÀ>˜Ãʈ˜ÊÓä䙰Ê6ʈ`ÜiÃÌÊ
i>Ì…V>ÀiÊ-ÞÃÌi“Ê­6- ÊÓήÊi˜Vœ“«>ÃÃiÃʈ˜˜iÜÌ>]Ê
œÀ̅Ê>˜`Ê-œÕ̅Ê>ŽœÌ>]ʜÜ>Ê>˜`Ê iLÀ>Î>Ê>˜`Ê«ÀœÛˆ`iÃʅi>Ì…ÊV>ÀiÊ̜ÊΙÓ]™™ÎÊi˜ÀœiiÃÊ>˜`Êәn]£ä™Ê
՘ˆµÕiÊÛiÌiÀ>˜Ã°Ê6- ÊÓÎʈ˜ÛiÃÌi`ÊÃÕLÃÌ>˜Ìˆ>ÊܜÀŽforce and telehealth resources in 2006 to establish
6- ‡Üˆ`iÊV…Àœ˜ˆVÊ`ˆÃi>Ãiʓ>˜>}i“i˜ÌÊ­
®ÊL>Ãi`Ê
œ˜Ê̅iÊ7>}˜iÀÊ
…Àœ˜ˆVʈÃi>Ãiʜ`i°Ê6iÌiÀ>˜ÃÊ>ÌÊ
highest risk for acute hospitalization related to chronic
disease were targeted for intervention including
>ÃÈ}˜i`Ê
…Àœ˜ˆVʈÃi>ÃiÊ, ÊV>ÀiÉV>Ãiʓ>˜>}iÀÃÊ
>˜`ÊÌii…i>Ì…Ê…œ“iʓœ˜ˆÌœÀˆ˜}Ê­
/®°ÊՈ`ˆ˜}Ê
Õ«œ˜Ê
ÊivvœÀÌÃ]ʈ˜ÊÓäänÊ6- ÊÓÎÊ«ˆœÌi`Ê>Ê«>̈i˜ÌÊ
centered medical home (subsequently branded Patient
ˆ}˜i`Ê
>ÀiÊ/i>“p*
/pˆ˜Ê̅iÊ6iÌiÀ>˜ÃÊi>Ì…Ê
Administration) in a rural-based primary care outpatient
clinic. This pilot project redesigned clinical delivery to
be team-based, continuously improving, and performance oriented. The pilot project leveraged the electronic medical record and existing chronic disease care
capabilities to enhance population-based care as well
as improve community partnerships for co-managed
care with the private sector.
UÊTotal lives covered in PCMH model
>˜>}i`ʈ˜Ê
\Ê£ä]n{ÇÊ"V̜LiÀÊ
ÓääÇqÕ}ÕÃÌÊÓä䙰Ê>˜>}i`ʈ˜Ê*
/Ê
­*
®Ê*ˆœÌ\ÊÓ]{äÇÊՏÞÊÓäänqÕ}ÕÃÌÊÓä䙰Ê
UÊComparison group
œÀÊ
]ÊÀ>˜`œ“ˆâi`Ê}ÀœÕ«ÃÊ܈̅ʈ˜ÌiÀÛi˜Ìˆœ˜Ê
>˜`ÊVœ˜ÌÀœÊ>À“ðʜÀÊ*
/]ÊVœ˜ÌÀœÃÊÜiÀiÊ
˜œ˜‡*
/Ê«>̈i˜ÌÃÊ>ÌÊÃ>“iÊv>VˆˆÌÞÊ>˜`Ê>ÃœÊ
VHA statewide comparison group.
UÊEvaluation design and time period
ÊÊÓääȇÓä£äÆÊ*
/ÊÓäänqœ˜}œˆ˜}°ÊœÀÊ
]Ê`iÈ}˜ÊÜ>ÃÊ>ÊÀ>˜`œ“ˆâi`ÊVˆ˜ˆV>ÊÌÀˆ>°Ê
œÀÊ*
/]Ê`iÈ}˜ÊÜ>ÃÊ>Ê«ÀœÃ«iV̈ÛiÊVœ…œÀÌÊ
ÃÌÕ`Þ°Ê
ÊiÛ>Õ>̈œ˜Ãʅ>ÛiÊLii˜Ê«ÕLˆÃ…i` 7
and submitted for publicationn]™ in peerreviewed journals.
UÊData sources
Multiple sources including randomized control
trials, primary data collection, VHA Support
-iÀۈViÊ
i˜ÌiÀÊ>˜`ÊiVˆÃˆœ˜Ê-Õ««œÀÌÊ-ÞÃÌi“Ê
œÃÌÊ>˜`Ê
ˆ˜ˆV>Êi>ÃÕÀiÃ]Ê6- ÊÓÎÊ
ˆ˜ˆV>Ê
"ÕÌVœ“iÃÊ­-‡ˆŽi®Ê“i>ÃÕÀiÃ]Ê6- ÊÓÎÊ
Patient Satisfaction Survey, and VA Nebraska7iÃÌiÀ˜ÊœÜ>Ê
ˆ˜ˆV>Ê"ÕÌVœ“iÃÊ­-‡ˆŽi®Ê
measures.
UÊCost and utilization outcomes
…Àœ˜ˆVʈÃi>ÃiÊ>˜>}i“i˜Ìp
"*\Ê6- ÊÓÎÊ
ˆ‡œ`ÊÀˆÃŽÊ
"*Ê«>̈i˜ÌÃÊ>ÃÈ}˜i`Ê>ÊV…Àœ˜ˆVÊ
disease case manager and provided a home
>V̈œ˜Ê«>˜Ê­˜rÎÇήÊŜÜi`Ê>Êx£¯ÊÀi>̈ÛiÊÀˆÃŽÊ
Ài`ÕV̈œ˜ÊVœ“«>Ài`Ê̜ÊVœ˜ÌÀœÃÊ­˜rÎÇä®Êˆ˜ÊÊ
ۈÈÌÃÊ>˜`ÊΣ¯ÊÀi>̈ÛiÊÀˆÃŽÊÀi`ÕV̈œ˜ÊvœÀÊ
acute hospitalization.
…Àœ˜ˆVʈÃi>ÃiÊ>˜>}i“i˜Ìp
"*\Ê
ˆ}…‡ÀˆÃŽÊ
Ê­˜rÎÇÓ®Ê>˜`ʅˆ}…‡ÀˆÃŽÊ1ÃÕ>Ê
>ÀiÊ­˜rÎÇ£®ÊVœ“«œÃˆÌiʜÕÌVœ“iÊvœÀÊ>Ê…œÃ«ˆÌ>ˆâ>̈œ˜ÃʜÀÊÊۈÈÌÃÊÜiÀiÊÓǯʏœÜiÀʈ˜Ê̅iÊ
Ê}ÀœÕ«Ê­£Óΰnʓi>˜ÊiÛi˜ÌÃÊ«iÀÊ£ääÊ«>̈i˜Ì‡Þi>ÀîÊVœ“«>Ài`Ê̜Ê̅iÊ1
Ê}ÀœÕ«Ê­£Çä°xÊ
mean events per 100 patient-years) (rate ratio
ä°ÇÎÆÊä°xȇ䰙äÆʫʐÊä°ääή°Ê/…iÊVœÃÌʜvÊ̅iÊ
ʈ˜ÌiÀÛi˜Ìˆœ˜ÊÜ>ÃÊfÓ{£]ÈÓäʜÀÊfÈxäÊ«iÀÊ
«>̈i˜Ì°ÊÊ/…iÊ̜Ì>Ê“i>˜Ê´Ê-Ê«iÀÊ«>̈i˜ÌÊVœÃÌÊ
̅>Ìʈ˜VÕ`i`Ê̅iÊVœÃÌʜvÊ
ʈ˜Ê̅iÊ
Ê}ÀœÕ«Ê
Ü>ÃÊf{{™£Ê´Ê{ÈÇnÊVœ“«>Ài`Ê̜Êfxän{Ê´Ê
xäÈäÊÀi«ÀiÃi˜Ìˆ˜}Ê>Êfx™ÎÊ«iÀÊ«>̈i˜ÌÊVœÃÌÊ
Ã>ۈ˜}ÃÊvœÀÊ̅iÊ
Ê«Àœ}À>“°9
…Àœ˜ˆVʈÃi>ÃiÊ>˜>}i“i˜Ìp
\Ê6- ÊÓÎÊ
ˆ‡œ`ÊÀˆÃŽÊ
Ê«>̈i˜ÌÃÊ̅>ÌÊÜiÀiÊV>Ãiʓ>˜>}i`Ê>˜`ɜÀʜ˜Ê
/ÊvœÀÊ>Ìʏi>ÃÌÊ£ÓÊVœ˜ÃiVṎÛiÊÜiiŽÃÊ`ÕÀˆ˜}Ê̅iÊ«>ÃÌÊÈʓœ˜Ì…Ãʈ˜Ê9ÊÓä£äÊ
Ài`ÕVi`ÊÉ1
ÊۈÈÌÃÊLÞÊÎx¯ÊVœ“«>Ài`Ê̜ÊL>Ãiˆ˜i°ÊÌÊL>Ãiˆ˜iÊ­9ä™+ή]Ê{{xÊÉ1
ÊۈÈÌÃÊLÞÊ
Ó{™Ê
‡
/Ê
Ê«>̈i˜ÌÃÊ­£°Ç™ÊۈÈÌÃÉ«ÌÆÊ
7
£Çn°Ç£Ê6ÊʜÀÊ1
ÊۈÈÌÃÉ£ääÊ
‡
/Ê
Ê«>̈i˜Ìîʈ˜Ê̅iÊ«ÀiVi`ˆ˜}ÊÈʓœ˜Ì…ÃÆÊ>ÌÊi˜`Ê
­9£ä+ή]ÊÎx£ÊÉ1
ÊۈÈÌÃÊLÞÊÎäÎÊ
É
/Ê
Ê«>̈i˜ÌÃÊ­£°£ÈÊۈÈÌÃÉ«ÌÆÊ££x°n{Ê6Ê
ʜÀÊ1
ÊۈÈÌÃÉ£ääÊ
‡
/Ê
Ê«>̈i˜ÌîÊ
in the preceding 6 months.
…Àœ˜ˆVʈÃi>ÃiÊ>˜>}i“i˜ÌÊp
\Ê
œ˜}‡ÌiÀ“ʈ“«>VÌʜvÊ
ʜ˜Ê
Ê>`“ˆÃȜ˜Ê
>˜`ÊÊۈÈÌÊÀ>ÌiÃÊvœÀÊ£{{Ê
ÊV>ÃiÉV>Àiʓ>˜aged patients, paired sample, retrospective design with patients serving as their own control.
­ œ˜‡«ÕLˆÃ…i`®°Ê"˜Ê>ÛiÀ>}i]Ê̅iÀiÊÜiÀiÊä°£xÊ
viÜiÀÊ>`“ˆÃȜ˜ÃÉ«>̈i˜ÌÊvœÀʅi>ÀÌÊv>ˆÕÀiÊ£xÊ
months after initial date of case management
Vœ“«>Ài`Ê̜ʣxʓœ˜Ì…ÃÊLivœÀiʈ˜ˆÌˆ>Ê`>ÌiʜvÊ
case management. On average, there were
£°äÓÊviÜiÀÊÊۈÈÌÃÉ«>̈i˜ÌÊvœÀʅi>ÀÌÊv>ˆÕÀiÊ
£xʓœ˜Ì…ÃÊ>vÌiÀʈ˜ˆÌˆ>Ê`>ÌiʜvÊV>Ãiʓ>˜>}i“i˜ÌÊ
Vœ“«>Ài`Ê̜ʣxʓœ˜Ì…ÃÊLivœÀiʈ˜ˆÌˆ>Ê`>ÌiʜvÊ
case management.
UÊTotal spending on PCMH enrollees
/œÌ>ÊVœÃÌÃÊV>VՏ>Ìi`ÊvœÀÊiÛ>Õ>̈œ˜ÊœvÊ
…Àœ˜ˆVÊ
ˆÃi>ÃiÊ>˜>}i“i˜Ìp
"*Ê«Àœ}À>“ÊvœVÕÃi`Ê
œ˜Ê…ˆ}…‡ÀˆÃŽÊ«>̈i˜ÌðÊ/…iÊ̜Ì>Ê“i>˜Ê´Ê-Ê«iÀÊ
«>̈i˜ÌÊVœÃÌÊ̅>Ìʈ˜VÕ`i`Ê̅iÊVœÃÌʜvÊ
ʈ˜Ê̅iÊ
Ê}ÀœÕ«ÊÜ>ÃÊf{{™£Ê´Ê{ÈÇnÊVœ“«>Ài`Ê̜Ê
fxän{Ê´ÊxäÈäÊÀi«ÀiÃi˜Ìˆ˜}Ê>Êfx™ÎÊ«iÀÊ«>̈i˜ÌÊ
VœÃÌÊÃ>ۈ˜}ÃÊvœÀÊ̅iÊ
Ê«Àœ}À>“°9
UÊReturn on investment
˜ÛiÃ̓i˜ÌÊVœÃÌÊvœÀÊi˜…>˜Vi`Ê*
ÊV>ÀiÊÜ>ÃÊ>ÃÃiÃÃi`ÊvœÀÊ̅iÊ*
/Ê«Àœ}À>“°ÊœÀÊ>Ê«Àˆ“>ÀÞÊV>ÀiÊ
face-to-face patient visit per individual primary
V>ÀiÊ«ÀœÛˆ`iÀ]Ê̅iʓi>˜ÊˆÀiVÌÊ
œÃÌÉ6ˆÃˆÌÊÜ>ÃÊ
…ˆ}…iÀÊvœÀÊ̅iÊ*
/ÊÌi>“Ê«ÀœÛˆ`iÀÃÊ­f£Çx®ÊVœ“«>Ài`Ê̜Ê̅iÊÃ>“iÊv>VˆˆÌÞʘœ˜‡*
/ÊÌi>“Ê«ÀœÛˆ`iÀÃÊ­f£ÈήÊvœÀÊՏÞÊÓäänqÊ>˜°ÊÓä䙰Ê/…iʜÛiÀ>Ê
change in total costs of care for patients in the
*
/ʓœ`iÊ…>ÃʘœÌÊÞiÌÊLii˜ÊVœ“«ÕÌi`]ÊLÕÌÊ
based on the overall cost savings of the VHA
ʓœ`iÊˆÌʈÃÊÀi>ܘ>LiÊ̜ÊiÝ«iVÌÊ̅>ÌÊ̅iÊ
“>À}ˆ˜>Ê>``i`ÊVœÃÌʜvÊ*
/Ê«Àˆ“>ÀÞÊV>ÀiÊۈÈÌÃÊ
would be more than offset by the savings from
8
reductions in emergency department and acute
hospital services.
UÊQuality outcomes
‡
"*\ʏÊV>ÕÃiʓœÀÌ>ˆÌÞÊÜ>Ãʣ䰣ɣääÊ
«>̈i˜ÌÊÞÀʈ˜Ê̅iʈ˜ÌiÀÛi˜Ìˆœ˜Ê}ÀœÕ«Ê>˜`ʣΰnÊ
É£ääÊ«>̈i˜ÌÊÞÀʈ˜Ê̅iÊÕÃÕ>ÊV>ÀiÊ}ÀœÕ«Ê­«ÊrÊ
0.09).7Ê
qˆ>LiÌiÃ\ʯʜvÊ«>̈i˜ÌÃÊ܈̅ʣÊÞi>ÀÊ
œvÊ
ÊÛðÊ1ÃÕ>Ê
>ÀiÊ>V…ˆiۈ˜}Ê̅iÀ>«iṎVÊ
}œ>ÃʜvÊ}L£
ʐÊn°ä¯Ê>˜`ÊʐʣääÊ>˜`Ê*Ê
Ê£ÎäÉnäÊÜ>ÃÊÓӰίÊ܈̅Ê
Ê>˜`Ê£ä°{¯Ê
܈̅ÊÕÃÕ>ÊV>ÀiÊ­˜rxxÈ®°n
*
/pˆ>LiÌiÃ\ʈ>LïVÊ«>̈i˜ÌÃʈ˜Ê*
/ʈ“«ÀœÛi`Ê}L£
ʐʙ°ä¯ÊvÀœ“Ê™£¯ÊœvÊ`ˆ>LïVÊ
patients to 96%, compared to same facility
˜œ˜‡*
/Ê­™ä¯Ê̜ʙӯ®Ê>˜`Ê6ÊÃÌ>Ìi܈`iÊ­n™¯Ê
to 90%) in 12 months. HTN control in diabetic
«>̈i˜ÌÃ\Ê*
/ʈ“«ÀœÛi`ÊLœœ`Ê«ÀiÃÃÕÀiÊVœ˜ÌÀœÊ
­£ÎäÉnä®ÊvÀœ“Ê{ǯÊ̜ÊÈӯʜvÊ`ˆ>LïVÊ«>tients with hypertension, compared to same faVˆˆÌÞʘœ˜‡*
/Ê­{ä¯Ê̜Ê{™¯®Ê>˜`Ê6ÊÃÌ>Ìi܈`iÊ
­{Ó¯Ê̜Ê{x¯®Êˆ˜Ê£Óʓœ˜Ì…ðʈ«ˆ`ÊVœ˜ÌÀœÊˆ˜Ê`ˆ>LïVÊ«>̈i˜ÌÃ\Ê*
/ʈ“«ÀœÛi`ʏˆ«ˆ`ÊVœ˜ÌÀœÊ­Ê
Ê£ää®ÊvÀœ“ÊÇn¯ÊœvÊ`ˆ>LïVʅޫiÀˆ«ˆ`i“ˆVÊ
«>̈i˜ÌÃÊ̜Ênȯ]ÊVœ“«>Ài`Ê̜ÊÃ>“iÊv>VˆˆÌÞÊ
˜œ˜‡*
/Ê­ÇǯÊ̜Ên䯮Ê>˜`Ê6ÊÃÌ>Ìi܈`iÊ
­ÇÓ¯Ê̜Ên䯮ʈ˜Ê£Óʓœ˜Ì…ð
*
/p/ \Ê*
/ʈ“«ÀœÛi`ÊLœœ`Ê«ÀiÃÃÕÀiÊ
Vœ˜ÌÀœÊ­£{äəäʓ“}®ÊvÀœ“ÊnӯʜvÊ«>̈i˜ÌÃÊ
܈̅ʅޫiÀÌi˜Ãˆœ˜Ê̜Ênȯ]ÊVœ“«>Ài`Ê̜ÊÃ>“iÊ
v>VˆˆÌÞʘœ˜‡*
/Ê­nä¯Ê̜Ên䯮Ê>˜`Ê6Ê
ÃÌ>Ìi܈`iÊ­Ç{¯Ê̜ÊÇȯ®Êˆ˜Ê£Óʓœ˜Ì…ð
*
/pVViÃÃ\Ê*
/ÊÌi>“ʈ“«ÀœÛi`Êv>Vi‡Ìœ‡
v>ViÊVˆ˜ˆVÊۈÈÌÊ>VViÃÃÊvÀœ“Ê“i>˜ÊÓÈ°xÊ`>ÞÃÊ
­/…ˆÀ`Ê iÝÌÊÛ>ˆ>LiÊ««œˆ˜Ì“i˜Ì®Ê̜ʣ{Ê`>ÞÃÊ
­…ˆ}…ÊÓÈ°xÊ`>ÞÃ]ʏœÜÊÈ°nÊ`>Þîʈ˜Ê£xʓœ˜Ì…Ã]Ê
Vœ“«>Ài`Ê̜ÊÃ>“iÊv>VˆˆÌÞʘœ˜‡*
/ʓi>˜ÊœvÊ
Σ°xÊ`>ÞÃÊ̜ʣǰnÊ`>ÞÃÊ­…ˆ}…ÊΣ°ÈÊ`>ÞÃ]ʏœÜÊ
x°{Ê`>Þî°
*
/p*>̈i˜ÌÊ->̈Ãv>V̈œ˜\ÊÀœ“ÊՏÞÊÓäänÊ̜Ê
April of 2009, overall patient satisfaction (Good
TRIPLE AIM: Health-Experience-Affordability HealthPartners Clinics
100%
42.5%
45%
1.000
97.1%
0.980
0.940
Total Cost Index
0.960
97.6% 35%
95%
25%
0.920
15%
0.900
9.0%
0.880
90%
5%
4Q
04
1Q
05
2Q
05
3Q
05
4Q
05
1Q
06
2Q
06
3Q
06
4Q
06
1Q
07
2Q
07
3Q
07
4Q
07
1Q
08
2Q
08
3Q
08
4Q
08
1Q
09
2Q
09
3Q
09
4Q
09
1Q
10
2Q
10
3Q
10
Source: HealthPartners
0.8952
Total Cost Index
(compared to statewide average)
< 1 is better than network average
% patients with Optimal Diabetes
Control*
* controlled blood sugar, BP and cholesterol (per
ICSI guideline A1c changed from < 7 to < 8 in
1Q09 and BP control changed from <130/80 to
<140/90 in 3Q10), AND daily aspirin use, AND
non-tobacco user
œÀÊÝVii˜Ì]ÊxÊ«œˆ˜ÌʈŽiÀÌÊÃV>i®Êˆ˜Ê*
/ÊÌi>“Ê
Üi˜ÌÊvÀœ“Ên™¯ÊœvÊÀi뜘`i˜ÌÃÊ̜Ên{¯]ÊVœ“«>Ài`Ê̜ÊÃ>“iÊv>VˆˆÌÞʘœ˜‡*
/ÊÌi>“Ê܈̅ʜÛiÀ>Ê«>̈i˜ÌÊÃ>̈Ãv>V̈œ˜ÊÃVœÀiÃʜvÊÇȯÊ̜Ên䯰
6ʈÃÊVÕÀÀi˜ÌÞʈ“«i“i˜Ìˆ˜}Ê̅iÊ*
/ʓœ`iÊ*
Ê
“œ`iÊ>VÀœÃÃÊ̅iÊi˜ÌˆÀiÊ6ÊÃÞÃÌi“°Ê
…Àœ˜ˆVÊ`ˆÃi>ÃiÊ
“>˜>}i“i˜ÌʈÃÊi“Li``i`ʈ˜Ê̅iÊ*
/ʓœ`iÊ>ÃÊ«>ÀÌÊ
œvÊ̅iÊÀi뜘ÈLˆˆÌˆiÃʜvÊ̅iÊ*
/ÊÌi>“iÌðÊ
HealthPartners Medical Group
HealthPartners Medical Group, a 700-physician group
that is part of a consumer-governed health organization
in Minnesota, implemented a patient centered medical
…œ“iʓœ`iÊˆ˜ÊÓää{Ê>ÃÊ«>ÀÌʜvʈÌÃʺiÃÌ
>Ài»Ê“œ`iÊœvÊ
`iˆÛiÀÞÊÃÞÃÌi“ÊÀi`iÈ}˜°Ê/…iÊiÃÌ
>Àiʓœ`iÊˆ˜ÛiÃÌi`Ê
in better care coordination centered in the primary care
medical home, including proactive chronic disease
management through phone, computer and face-to-face
coaching. The program also emphasized more convenient access to primary care through online scheduling,
test results, email consults and post-visit coaching, and
has become the standard model in HealthPartners
Medical Group primary care sites. 10,11
% patients “Would
Recommend” HealthPartners
Clinics
UÊTotal lives covered in PCMH model
œÀiÊ̅>˜ÊÎxä]äääÊi>Ì…*>À̘iÀÃÊ«>˜Êi˜Àœees cared for by HealthPartners Medical Group.
UÊComparison group
œÀÊVœÃÌÃ]ÊiÝ«i˜`ˆÌÕÀiÃÊvœÀÊi>Ì…*>À̘iÀÃÊ
members compared with average Minnesota
per person health expenditures. No control
group for quality evaluation.
UÊEvaluation design and time period
x‡Þi>Àʏœ˜}ˆÌÕ`ˆ˜>ÊÌÀ>VŽˆ˜}ʜvÊVœÃÌÊ>˜`ʵÕ>ˆÌÞÊ
`>Ì>ÊvœÀÊi˜ÀœiiÃÊLiÌÜii˜ÊÓää{Ê>˜`ÊÓä䙰
UÊData sources
>ˆ“ÃÊ`>Ì>Ê>˜`ʵÕ>ˆÌÞÊ`>Ì>L>Ãið
UÊCost and utilization outcomes
Ι¯Ê`iVÀi>Ãiʈ˜Êi“iÀ}i˜VÞÊ`i«>À̓i˜ÌÊۈÈÌÃÊ
>˜`ÊÓ{¯Ê`iVÀi>Ãiʈ˜Ê…œÃ«ˆÌ>Ê>`“ˆÃȜ˜ÃÊ«iÀÊ
i˜ÀœiiÊLiÌÜii˜ÊÓää{Ê>˜`ÊÓä䙰
UÊTotal spending on PCMH enrollees
Overall costs for enrollees in HealthPartners
9
Medical Group decreased from being equal to
̅iÊÃÌ>ÌiÊ>ÛiÀ>}iʈ˜ÊÓää{Ê̜ʙӯʜvÊ̅iÊÃÌ>ÌiÊ
>ÛiÀ>}iʈ˜ÊÓään]ʈ˜Ê>ÊÃÌ>ÌiÊ܈̅ÊVœÃÌÃÊ>Ài>`ÞÊ
well below the national average.
UÊReturn on investment
Not reported.
UÊQuality outcomes
£Ó™¯Êˆ˜VÀi>Ãiʈ˜Ê*
Ê«>̈i˜ÌÃÊÀiViˆÛˆ˜}Ê
œ«Ìˆ“>Ê`ˆ>LiÌiÃÊV>Ài]Ê{n¯Êˆ˜VÀi>Ãiʈ˜Ê*
Ê
patients receiving optimal heart disease care.
Îxä¯ÊÀi`ÕV̈œ˜Êˆ˜Ê>««œˆ˜Ì“i˜ÌÊÜ>ˆÌˆ˜}Ê̈“iÊ
>ÌÊ*
ÊVˆ˜ˆVð
Intermountain Healthcare Medical Group Care
Management Plus PCMH Model
Intermountain Healthcare Medical Group, part of an
integrated delivery system in Utah, began implementˆ˜}Ê>Ê*
ÊÀi`iÈ}˜Ê“œ`iÊˆ˜ÊÓä䣰Ê/…iÊ
>ÀiÊ
>˜>}i“i˜ÌÊ*ÕÃÊ*
ʓœ`iÊvœVÕÃiÃʜ˜Ê«Àˆ“>ÀÞÊ
care-based care coordination of high-risk elders, embedding RN care managers in primary care practices
and enhancing EHR functionality in support of chronic
care and care coordination.12
UÊTotal lives covered in PCMH model
£]£{{Ê«>̈i˜ÌÃÊ>}i`ÊÈxʜÀʜÛiÀÊ܈̅Ê>Ìʏi>ÃÌʜ˜iÊ
chronic condition and a need for targeted care
management, at 7 primary care practices.
UÊComparison group
Ó]ÓnnÊ«>̈i˜ÌÃÊ>ÌÊÈÊVœ˜ÌÀœÊ«Àˆ“>ÀÞÊV>ÀiÊVˆ˜ˆVÃ]Ê
matched to intervention patients by age, gender
and clinical risk profile.
UÊEvaluation design and time period
Prospective, controlled matched trial,
Vœ˜`ÕVÌi`ÊLiÌÜii˜ÊÓääÓÊ>˜`ÊÓääx°
UÊData sources
Intermountain Healthcare utilization and
clinical databases.
10
UÊCost and utilization outcomes
,i`ÕVi`ʅœÃ«ˆÌ>ˆâ>̈œ˜Ãʈ˜Ê*
Ê}ÀœÕ«ÆÊLÞÊ
Þi>ÀÊÓʜvÊvœœÜ‡Õ«]ÊΣ°n¯ÊœvÊ*
Ê«>̈i˜ÌÃÊ
…>`ÊLii˜Ê…œÃ«ˆÌ>ˆâi`Ê>Ìʏi>ÃÌʜ˜ViÊÛðÊÎ{°Ç¯Ê
œvÊVœ˜ÌÀœÊ«>̈i˜ÌÃÊ­«r°Óή°Ê“œ˜}Ê«>̈i˜ÌÃÊ܈̅Ê
`ˆ>LiÌiÃ]ÊÎä°x¯ÊœvÊ̅iÊ*
Ê}ÀœÕ«ÊÜiÀiÊ
…œÃ«ˆÌ>ˆâi`ÊÛÃÊΙ°Ó¯ÊœvÊVœ˜ÌÀœÃÊ­«r°ä£®°Ê
UÊTotal spending on PCMH enrollees
iÌÊÀi`ÕV̈œ˜Êˆ˜Ê̜Ì>ÊVœÃÌÃÊÜ>ÃÊfÈ{äÊ«iÀÊ«>̈i˜ÌÊ
«iÀÊÞi>ÀÊ­f£]ÈxäÊÃ>ۈ˜}ÃÊ«iÀÊÞi>ÀÊ>“œ˜}Ê
highest risk patients).
UÊQuality outcomes
L܏ÕÌiÊÀi`ÕV̈œ˜ÊœvÊΰ{¯Êˆ˜ÊӇÞi>ÀʓœÀÌ>ˆÌÞÊ
­£Î°£¯Ê`ˆi`ʈ˜Ê*
Ê}ÀœÕ«]ʣȰȯʈ˜Ê
controls, p=.07).
>Ãi`ʜ˜Ê̅iÃiÊiÛ>Õ>̈œ˜ÊÀiÃՏÌÃ]Ê̅iÊ
>ÀiÊ>˜>}i“i˜ÌÊ
*ÕÃÊ*
ʓœ`iÊˆÃʘœÜÊLiˆ˜}ʈ“«i“i˜Ìi`Ê>ÌʓœÀiÊ
̅>˜ÊÇxÊ«À>V̈ViÃʈ˜Ê“œÀiÊ̅>˜ÊÈÊÃÌ>ÌiðÊ
B. Private Payer Sponsored
PCMH Initiatives
BlueCross BlueShield of North Carolina-Palmetto
Primary Care Physicians
˜ÊÓää™]ʏÕi
ÀœÃÃʏÕi-…ˆi`ʜvÊ-œÕ̅Ê
>Àœˆ˜>Ê
>˜`ʏÕi
…œˆViÊi>Ì…Ê*>˜Ê«>À̘iÀi`Ê܈̅Ê>ʓi`ˆV>Ê
}ÀœÕ«]Ê*>“iÌ̜Ê*Àˆ“>ÀÞÊ
>ÀiÊ*…ÞÈVˆ>˜Ã]ʈ˜Ê>Ê*
Ê
«Àœ}À>“ÊÌ>À}ï˜}Ê`ˆ>LïVðÊ/…iÊ*
ʓœ`iÊˆ˜cludes care teams to coordinate patient outreach and
support activities, and a blended payment model to
primary care physicians consisting of fee-for-service
payments, monthly care coordination payments and
performance-based incentive payments. Palmetto
*Àˆ“>ÀÞÊ
>ÀiÊ*…ÞÈVˆ>˜Ãʅ>ÃÊ>««ÀœÝˆ“>ÌiÞÊxxÊ«Àˆ“>ÀÞÊ
care providers at 22 sites. Participating sites were
+‡ÀiVœ}˜ˆâi`ʏiÛiÊÎʓi`ˆV>Ê…œ“ið£Î
UÊTotal lives covered in PCMH model
nä™Ê
-Êi˜ÀœiiÃÊ܈̅Ê`ˆ>LiÌiÃÊ܅œÊÜiÀiÊ
Vœ˜Ìˆ˜ÕœÕÏÞÊi˜Àœi`ʈ˜Ê̅iÊ*
ʓœ`iÊvœÀÊ
1 year.
UÊComparison group
È]xxnÊVœ˜Ìˆ˜ÕœÕÏÞÊi˜Àœi`Ê
-Ê`ˆ>LïVÊ
patients treated by all other primary care providiÀÃʈ˜Ê̅iÊ
…>ÀiÃ̜˜Ê>Ài>°Ê}iÊ>˜`Ê}i˜`iÀÊ
«ÀœwiÊÜ>ÃÊȓˆ>ÀÊvœÀÊ*
Ê>˜`ÊVœ˜ÌÀœÊ}ÀœÕ«Ã°
UÊEvaluation design and time period
Pre-post controlled cohort study with 1 year of
follow-up data.
UÊData sources
>ˆ“ÃÊ`>Ì>Ê̜ʓi>ÃÕÀiÊṎˆâ>̈œ˜Ê>˜`ÊVœÃÌð
UÊCost and utilization outcomes
£ä°{¯ÊÀi`ÕV̈œ˜ÊvÀœ“ÊL>Ãiˆ˜iÊ̜ʣ‡Þi>ÀÊvœœÜÊ
up in inpatient hospital days per 1,000 enrolliiÃÊ«iÀÊÞi>ÀÊ>“œ˜}Ê*
Ê«>̈i˜ÌÃ]ÊvÀœ“Ê
x{Ó°™Ê̜Ê{nÈ°x°Ê˜«>̈i˜ÌÊ`>ÞÃÊÜiÀiÊÎȰίÊ
œÜiÀÊ>“œ˜}Ê*
Ê«>̈i˜ÌÃÊ̅>˜Ê>“œ˜}Ê
control patients at 1 year; at baseline, the
*
Ê}ÀœÕ«Ê…>`Ê£ä°Î¯Ê“œÀiʈ˜«>̈i˜ÌÊ
days per year than the control group.
£Ó°{¯ÊÀi`ÕV̈œ˜ÊvÀœ“ÊL>Ãiˆ˜iÊ̜ʣ‡Þi>ÀÊvœœÜÊ
up in emergency department visits per 1,000
i˜ÀœiiÃÊ«iÀʓœ˜Ì…Ê>“œ˜}Ê*
Ê«>̈i˜ÌÃ]Ê
vÀœ“ÊÓ£°{Ê̜ʣn°n°Ê“iÀ}i˜VÞÊ`i«>À̓i˜ÌÊۈÈÌÃÊ
«iÀÊ£]äääÊi˜ÀœiiÃÊÜiÀiÊÎӰӯʏœÜiÀÊ>“œ˜}Ê
*
Ê̅>˜Ê>“œ˜}ÊVœ˜ÌÀœÊ«>̈i˜ÌÃÊ>ÌÊ£ÊÞi>ÀÆÊ
>ÌÊL>Ãiˆ˜i]Ê̅iÊ*
Ê}ÀœÕ«Ê…>`ʣΰǯÊviÜiÀÊ
emergency department visits per 1,000 enrollees than the control group.
UÊTotal spending on PCMH enrollees
At 1 year, total medical and pharmacy costs
**ÊÜiÀiÊÈ°x¯ÊœÜiÀʈ˜Ê̅iÊ*
Ê}ÀœÕ«Ê
than the control group. At baseline, total
costs per enrollee were almost identical
in the 2 groups.
UÊReturn on investment
Not reported.
UÊQuality outcomes
*
Ê«>̈i˜ÌÃÊ`i“œ˜ÃÌÀ>Ìi`ʈ“«ÀœÛi“i˜ÌÃʜ˜Ê
ÈʜvÊ̅iÊ£äʵÕ>ˆÌÞʓiÌÀˆVÃÊ>ÃÃiÃÃi`\ÊʏiÛiÃÊ
less than 100, mAB testing, annual eye exam,
Ài`ÕVi`Ê]ÊÀi}Տ>ÀÊL£
ÊÌiÃ̈˜}Ê>˜`ÊL£VÊ
iÃÃÊ̅>˜Ên°
ÃÊ>ÊÀiÃՏÌʜvÊ̅iÊÃÕVViÃÃʜvÊ̅iʈ˜ˆÌˆ>Ê*
ʈ˜ˆÌˆ>̈Ûi]Ê
-œÕ̅Ê
>Àœˆ˜>Ê
-ʏ>՘V…i`Ê>ÊÃiVœ˜`Ê*
ʈ˜ˆÌˆ>̈Ûiʈ˜Ê"V̜LiÀÊÓää™ÊvœÀʘi>ÀÞÊÎääÊi`iÀ>Ê“«œÞiiÊ
*Àœ}À>“Ê“i“LiÀÃp̅iÊÃiVœ˜`ʓi`ˆV>Ê…œ“iÊ«ˆœÌÊ
>««ÀœÛi`ÊLÞÊ*ʈ˜Ê̅iʘ>̈œ˜p>˜`ʅ>ÃÊ>ÃœÊÃÌ>ÀÌi`Ê
*
ʈ˜ˆÌˆ>̈ÛiÃÊ܈̅ÊÓʜ̅iÀʓi`ˆV>Ê}ÀœÕ«ÃÊ܈̅Ê
+‡ÀiVœ}˜ˆâi`ʏiÛiÊÎʓi`ˆV>Ê…œ“iðÊ
BlueCross BlueShield of North DakotaMeritCare Health System
œÌ‡vœÀ‡«ÀœwÌÊiÀˆÌ
>ÀiÊi>Ì…Ê-ÞÃÌi“ʈÃÊ>˜Êˆ˜Ìi}À>Ìi`Ê
`iˆÛiÀÞÊÃÞÃÌi“ʈ˜Ê œÀ̅Ê>ŽœÌ>Ê܈̅Ê{ÎäÊi“«œÞi`Ê
«…ÞÈVˆ>˜ÃÊ>˜`Ê£näʘœ˜‡«…ÞÈVˆ>˜ÊVˆ˜ˆVˆ>˜ÃÊ>ÌÊ{ÈÊ
Vˆ˜ˆVÊÈÌiÃʈ˜Ê œÀ̅Ê>ŽœÌ>Ê>˜`ʈ˜˜iÜÌ>°ÊÕiÊ
ÀœÃÃÊ
ÕiÊ-…ˆi`ʈ˜ˆÌˆ>Ìi`Ê>Ê*
ʓœ`iÊvœÀÊ`ˆ>LïVÊ«>̈i˜ÌÃʈ˜ÊÓääxÊ>Ìʜ˜iʜvÊ̅iÊiÀˆÌ
>ÀiÊ«Àˆ“>ÀÞÊV>ÀiÊ
clinics, replacing an external disease management
program with a primary care-oriented care
management program that embedded a nurse at the
primary care medical home and included tracking of
clinical indicators and shared-savings for reduced
costs for the patients in the model.£{
UÊTotal lives covered in PCMH model
£™ÓÊ
-Êi˜ÀœiiÃÊ܈̅Ê`ˆ>LiÌiÃÊ«>À̈Vˆ«>̈˜}Ê
ˆ˜Ê̅iÊ*
ʓœ`i°Ê
UÊComparison group
1˜Ã«iVˆwi`ʘՓLiÀʜvÊ
-Ê«>̈i˜ÌÃÊ܈̅Ê
`ˆ>LiÌiÃÊV>Ài`ÊvœÀÊ>ÌÊ>ÊVœ˜ÌÀœÊiÀˆÌ
>ÀiÊVˆ˜ˆV°Ê
UÊEvaluation design and time period
Pre-post controlled cohort study comparing
ÓääÎÊ>˜`ÊÓääxÊ`>Ì>°
11
UÊData sources
>ˆ“ÃÊ`>Ì>Ê̜ʓi>ÃÕÀiÊṎˆâ>̈œ˜Ê>˜`ÊVœÃÌÃ]Ê
adjusted for case mix.
UÊCost and utilization outcomes
Hospital admissions decreased by 6% and
i“iÀ}i˜VÞÊ`i«>À̓i˜ÌÊۈÈÌÃÊ`iVÀi>Ãi`ÊLÞÊÓ{¯Ê
ˆ˜Ê̅iÊ*
Ê}ÀœÕ«ÊvÀœ“ÊÓääÎÊ̜ÊÓääx]Ê܅ˆiÊ
ˆ˜VÀi>Ș}ÊLÞÊ{x¯Ê>˜`Êί]ÊÀiëiV̈ÛiÞ]ʈ˜Ê̅iÊ
Vœ˜ÌÀœÊ}ÀœÕ«°Ê˜ÊÓääx]Ê*
Ê«>̈i˜ÌÃʅ>`Ê
£Î°äÓÊ>˜˜Õ>Êˆ˜«>̈i˜ÌÊ>`“ˆÃȜ˜ÃÊ«iÀÊ£ääÊ
«>̈i˜ÌÃ]ÊVœ“«>Ài`Ê܈̅ʣǰÈxÊ>`“ˆÃȜ˜ÃÊ«iÀÊ
£ääÊ«>̈i˜ÌÃʈ˜Ê̅iÊVœ˜ÌÀœÊ}ÀœÕ«°Ê*
Ê«>̈i˜ÌÃʅ>`ÊÓä°Î£Ê>˜˜Õ>Êi“iÀ}i˜VÞÊ`i«>À̓i˜ÌÊ
ۈÈÌÃÊ«iÀÊ£ääʓi“LiÀÃ]ÊVœ“«>Ài`Ê܈̅ÊÓx°ääÊ
among control patients.
UÊTotal spending on PCMH enrollees
˜ÊÓääx]Ê̜Ì>ÊVœÃÌÃÊ«iÀʓi“LiÀÊ«iÀÊÞi>ÀÊÜiÀiÊ
fxÎäʏœÜiÀÊ̅>˜ÊiÝ«iVÌi`ʈ˜Ê̅iʈ˜ÌiÀÛi˜Ìˆœ˜Ê
group based on historical trends, saving an
estimated $102,000 for the 192 patients in the
*
ʓœ`i°ÊiÌÜii˜ÊÓääÎÊ>˜`ÊÓääx]Ê̜Ì>Ê
>˜˜Õ>ÊiÝ«i˜`ˆÌÕÀiÃÊ«iÀÊ*
Ê«>̈i˜Ìʈ˜VÀi>Ãi`Ê
vÀœ“Êfx]xÈ£Ê̜ÊfÇ]{ÎÎ]ÊVœ“«>Ài`Ê܈̅Ê>ʓÕV…Ê
larger increase among control patients from
fx]nÈnʈ˜ÊÓääÎÊ̜Êf£ä]£änʈ˜ÊÓääx°Ê
UÊReturn on investment
Not reported.
UÊQuality outcomes
£n¯Êˆ˜VÀi>Ãiʈ˜Ê̅iÊ«Àœ«œÀ̈œ˜ÊœvÊ«>̈i˜ÌÃÊ>ÌÊ̅iÊ
*
ÊÈÌiÊ܅œÊÀiViˆÛi`Ê>ʺVœ“«iÌiÊV>Ài»ÊL՘`iʜvÊwÛiÊÀiVœ““i˜`i`ÊÃiÀۈViÃp>Ê«…ÞÈVˆ>˜Ê
office visit, hemoglobin A1c test, eye exam, lipid
ÌiÃÌÊ>˜`ʓˆVÀœ>LՓˆ˜ÊÌiÃÌpvÀœ“Ê{n°x¯Êˆ˜ÊÓääÎÊ
̜ÊxÇ°{¯Êˆ˜ÊÓääx]ÊVœ“«>Ài`Ê̜Ê>ʘœ˜Ãˆ}˜ˆwV>˜ÌÊ
decline in this bundle of measures at the control
ÈÌi]ÊvÀœ“Êxǰίʈ˜ÊÓääÎÊ̜Êxΰǯʈ˜ÊÓääx°
iV>ÕÃiʜvÊ̅iÃiÊÃÕVViÃÃvՏʜÕÌVœ“iÃ]Ê̅iÊiÀˆÌ
>ÀiÊ
Vœ˜ÌÀœÊVˆ˜ˆVÊ>`œ«Ìi`Ê̅iÊÃ>“iÊ*
ʓœ`iÊˆ˜ÊÓääÈ]Ê
and total costs among patients at that clinic fell to
“>ÌV…Ê̅œÃiʜvÊ̅iʈ˜ˆÌˆ>Ê*
ÊÈÌiÊLÞÊÓääÇ°Ê
-Ê
12
œvÊ œÀ̅Ê>ŽœÌ>ʈÃʘœÜÊëÀi>`ˆ˜}Ê̅iÊ*
ʓœ`iÊ
statewide.
Metropolitan Health Networks-Humana
Metropolitan Health Networks, Inc., operates several
«Àˆ“>ÀÞÊV>ÀiÊ«À>V̈ViÃʈ˜ÊœÀˆ`>]Ê>˜`Ê«>À̘iÀi`Ê
܈̅ÊՓ>˜>ʜ˜Ê>Ê*
ʈ˜ˆÌˆ>̈ÛiÊvœÀÊ«>̈i˜ÌÃʈ˜Ê
>ÊՓ>˜>Êi`ˆV>ÀiÊ`Û>˜Ì>}iÊ«>˜°Ê/…iÊ*
Ê
model was piloted at several practices between
œÛi“LiÀÊÓäänÊ>˜`Ê"V̜LiÀÊÓä䙰Ê/…iÊ«À>V̈ViÃÊ
were paid under a capitated contract and participated in a comprehensive practice evaluation, focusing on process, workflow, forms and policies and
procedures and implementation of team-care models,
HIT innovations and other approaches to achieve a
more patient-centered model of care.£x
UÊTotal lives covered in PCMH model
Not specified.
UÊComparison group
œ˜ÌÀœÊ}ÀœÕ«ÊœvÊi`ˆV>ÀiÊ`Û>˜Ì>}iÊ«>̈i˜ÌÃÊ
V>Ài`ÊvœÀÊ>Ìʘœ˜‡*
ÊÈÌiÃÊ՘`iÀÊV>«ˆÌ>Ìi`Ê
contracts.
UÊEvaluation design and time period
Pre-post cohort study comparing baseline data
vÀœ“Ê œÛ°ÊÓääÇq"VÌ°ÊÓäänÊ܈̅ʈ˜ÌiÀÛi˜Ìˆœ˜Ê
«iÀˆœ`Ê`>Ì>ÊvÀœ“Ê œÛ°ÊÓäänq"VÌ°ÊÓä䙰
UÊData sources
>ˆ“ÃÊ`>Ì>°
UÊCost and utilization outcomes
Hospital days per 1,000 enrollees dropped
LÞÊ{°È¯Êˆ˜Ê̅iÊ*
Ê}ÀœÕ«ÊVœ“«>Ài`Ê̜Ê>˜Ê
ˆ˜VÀi>ÃiʜvÊÎȯʈ˜Ê̅iÊVœ˜ÌÀœÊ}ÀœÕ«°ÊœÃ«ˆÌ>Ê
admissions per 1,000 customers dropped by
ί]Ê܈̅ÊÀi>`“ˆÃȜ˜ÃÊȯÊLiœÜÊi`ˆV>ÀiÊ
benchmarks.
“iÀ}i˜VÞÊÀœœ“ÊiÝ«i˜ÃiÊÀœÃiÊLÞÊ{°x¯ÊvœÀÊ̅iÊ
*
Ê}ÀœÕ«ÊVœ“«>Ài`Ê̜Ê>˜Êˆ˜VÀi>Ãiʜvʣǰ{¯Ê
vœÀÊ̅iÊVœ˜ÌÀœÊ}ÀœÕ«°Êˆ>}˜œÃ̈Vʈ“>}ˆ˜}ÊiÝ«i˜ÃiÊvœÀÊ̅iÊ*
Ê}ÀœÕ«Ê`iVÀi>Ãi`ÊLÞʙ°n¯Ê
compared to an increase of 10.7% for the
control group. Pharmacy expense increases
ÜiÀiÊÈ°x¯ÊvœÀÊ̅iÊ*
Ê}ÀœÕ«ÊÛiÀÃÕÃÊ£{°x¯Ê
for the control group.
UÊTotal spending on PCMH enrollees
"ÛiÀ>Ê“i`ˆV>ÊiÝ«i˜ÃiÊvœÀÊ̅iÊ*
Ê}ÀœÕ«Ê
ÀœÃiÊLÞÊx°Ó¯ÊVœ“«>Ài`Ê̜Ê>ÊÓȰίʈ˜VÀi>ÃiÊ
for the control group.
UÊReturn on investment
Not stated.
UÊQuality outcomes
Breast and colorectal cancer screening rates
ÜiÀiʣΰίÊ>˜`ÊȰίʅˆ}…iÀÊÀiëiV̈ÛiÞ]ÊVœ“pared to the control group. Seasonal influenza
Û>VVˆ˜>̈œ˜ÊÀ>ÌiÃʈ˜VÀi>Ãi`Ê̜ÊÈ{¯]ÊVœ“«>Ài`Ê
̜Ê̅iʘ>̈œ˜>Ê>ÛiÀ>}iʜvÊ{ί°Ê™{¯ÊœvÊ`ˆ>LïVÊ
«>̈i˜ÌÃʈ˜Ê*
Ê}ÀœÕ«Ê…>`Ê>˜Ê£
ʏiÛiÊœvʏiÃÃÊ
̅>˜Ê™¯°Ê
ÕÃ̜“iÀÊÃ>̈Ãv>V̈œ˜ÊÀiÃՏÌÃʈ“«ÀœÛi`Ê
œÀÊÃÌ>Þi`Ê̅iÊÃ>“iʈ˜Ê{xʜvÊÈ£ÊV>Ìi}œÀˆið
>Ãi`ʜ˜Ê̅iÊÃÕVViÃÃʜvÊ̅ˆÃÊ*
Ê«ˆœÌ]ÊiÌÀœ«œˆÌ>˜Ê
i>Ì…Ê iÌܜÀŽÃʈÃÊëÀi>`ˆ˜}Ê̅iÊ*
ʓœ`iÊ
throughout its network of primary care practices in
œÀˆ`>Ê>˜`Ê>««Þˆ˜}ÊvœÀÊ +ʓi`ˆV>Ê…œ“iÊ
recognition.
C. Medicaid Sponsored
PCMH Initiatives
Community Care of North Carolina
œ““Õ˜ˆÌÞÊ
>ÀiʜvÊ œÀ̅Ê
>Àœˆ˜>ʅ>ÃʓœÀiÊ̅>˜Ê>Ê
decade of experience with innovations in the delivery
œvÊ«Àˆ“>ÀÞÊV>ÀiÊ̜Êi`ˆV>ˆ`Ê>˜`Ê-
*ÊLi˜iwVˆ>ÀˆiðÊ
œ““Õ˜ˆÌÞÊ
>Àiʏˆ˜Ži`Ê̅iÃiÊLi˜iwVˆ>ÀˆiÃÊ̜Ê>Ê«Àˆmary care medical home, provided technical assistance to practices to improve chronic care services, directly hired a cadre of nurses to collaborate with practices in case management of high-risk patients, and
>``i`Ê>ÊfÓ°xäÊ­˜œÜÊfΰää®Ê«iÀʓi“LiÀÊ«iÀʓœ˜Ì…Ê
care coordination fee for each patient registered with
the practice, contingent on practices reporting clinical
ÌÀ>VŽˆ˜}Ê`>Ì>°Ê/…iÊ
œ““Õ˜ˆÌÞÊ
>ÀiÊ*
Ê«Àœ}À>“Ê
˜œÜʈ˜ÛœÛiÃʓœÀiÊ̅>˜Ê£]ÎääÊVœ““Õ˜ˆÌއL>Ãi`Ê
«À>V̈ViÊÈÌiÃÊ܈̅Ê>««ÀœÝˆ“>ÌiÞÊ{]xääÊ«Àˆ“>ÀÞÊ
V>ÀiÊVˆ˜ˆVˆ>˜ÃÊ̅ÀœÕ}…œÕÌÊ œÀ̅Ê
>Àœˆ˜>°£È]Ê£Ç]Ê£n
UÊTotal lives covered in PCMH model
™Çä]äääÊi`ˆV>ˆ`Ê>˜`Ê-
*Êi˜ÀœiiÃÊ
>˜˜Õ>Þʈ˜Ê œÀ̅Ê
>Àœˆ˜>°
UÊComparison group
i`ˆV>ˆ`Ê>˜`Ê-
*Êi˜ÀœiiÃʈ˜Ê œÀ̅Ê
>Àœˆ˜>Ê
ˆ˜Êvii‡vœÀ‡ÃiÀۈVi]ʘœ˜‡*
ʓœ`iÊV>Ài°
UÊEvaluation design and time period
External evaluation conducted by Mercer com«>Àˆ˜}ÊVœÃÌÃʈ˜ÊÓää·ÓääÇÊvœÀÊi`ˆV>ˆ`Ê>˜`Ê
-
*Êi˜ÀœiiÃʈ˜Ê
œ““Õ˜ˆÌÞÊ
>ÀiʜvÊ œÀ̅Ê
>Àœˆ˜>Ê܈̅Ê̅œÃiÊvœÀʘœ˜‡*
Êi`ˆV>ˆ`Ê>˜`Ê
-
*Êi˜ÀœiiÃʈ˜Ê̅iÊÃÌ>Ìi]Ê>`ÕÃÌi`ÊvœÀÊV>ÃiÊ
“ˆÝÊÕȘ}Ê̅iʜ…˜Ãʜ«Žˆ˜ÃÊ`ÕÃÌi`Ê
ˆ˜ˆV>Ê
Groups method.
UÊData sources
i`ˆV>ˆ`Ê>˜`Ê-
*ÊV>ˆ“ÃÊ`>Ì>°
UÊCost and utilization outcomes
ՓՏ>̈ÛiÊÃ>ۈ˜}ÃʜvÊf™Ç{°xʓˆˆœ˜ÊœÛiÀÊÈÊ
Þi>ÀÃÊ­Óää·Óään®°Ê{ä¯Ê`iVÀi>Ãiʈ˜Ê…œÃ«ˆÌ>izations for asthma and 16% lower emergency
department visit rate.
UÊReturn on investment
Not reported.
UÊQuality outcomes
™Î¯ÊœvÊ>Ã̅“>̈VÃÊÀiViˆÛi`Ê>««Àœ«Àˆ>ÌiÊ
maintenance medications; diabetes quality
“i>ÃÕÀiÃʈ“«ÀœÛi`ÊLÞÊ£x¯°
Colorado Medicaid and SCHIP
/…iÊ
œœÀ>`œÊi«>À̓i˜ÌʜvÊi>Ì…Ê
>ÀiÊ*œˆVÞÊ>˜`Ê
ˆ˜>˜Vˆ˜}ʅ>Ãʈ“«i“i˜Ìi`Ê>Ê«>̈i˜ÌÊVi˜ÌiÀi`ʓi`ˆV>Ê
home program for low-income children enrolled in the
13
ÃÌ>Ìi½ÃÊi`ˆV>ˆ`Ê>˜`Ê-
*Ê«Àœ}À>“ðÊ/œÊµÕ>ˆvÞÊ>ÃÊ
medical homes, primary care practices must have
Ó{ÉÇÊ>VViÃÃ]ʜ«i˜Ê>VViÃÃÊÃÞÃÌi“ÃʜÀÊȓˆ>ÀÊVœ˜Ûinient scheduling of appointments, and provide care
coordination; these make practices eligible for extra
«>އvœÀ‡«iÀvœÀ“>˜ViÊ«>ޓi˜ÌÃʈ˜`iÝi`Ê̜Ê*-/ʓiÌrics. As of March 2009, when the evaluation was
«iÀvœÀ“i`]Ê̅iÊ*
ʈ˜ˆÌˆ>̈Ûiʈ˜ÛœÛi`ÊΣäÊ
physicians working at 97 different practices.
/…iÊ
œœÀ>`œÊi«>À̓i˜ÌʜvÊi>Ì…Ê
>ÀiÊ*œˆVÞÊ>˜`Ê
ˆ˜>˜Vˆ˜}ʅ>ÃÊ«iÀvœÀ“i`Ê>˜Êˆ˜ÌiÀ˜>ÊiÛ>Õ>̈œ˜ÊœvʈÌÃÊ
*
Ê«Àœ}À>“°19
UÊTotal lives covered in PCMH model
ÃʜvÊ>ÀV…ÊÓää™]Ê£xä]äääÊV…ˆ`Ài˜Êˆ˜Ê
œœÀ‡
>`œÊi`ˆV>ˆ`Ê>˜`Ê-Ì>ÌiÊ
…ˆ`Ài˜½ÃÊi>Ì…ʘÃÕÀq
>˜ViÊ*Àœ}À>“ÃÊÜiÀiÊi˜Àœi`ʈ˜Ê*
Ê«À>V̈Við
UÊComparison group
œœÀ>`œÊi`ˆV>ˆ`Ê>˜`Ê-
*ÊV…ˆ`Ài˜Ê˜œÌÊ
i˜Àœi`ʈ˜Ê*
Ê`iÈ}˜>Ìi`Ê«À>V̈ViðÊ
UÊEvaluation design and time period
ÀœÃÇÃiV̈œ˜>ÊVœ“«>ÀˆÃœ˜ÊœvÊV…ˆ`Ài˜Êˆ˜Ê
i`ˆV>ˆ`Ê>˜`Ê-
*ÊÀiViˆÛˆ˜}ÊV>Àiʈ˜Ê̅iÊ
*
ʓœ`iÊÛðÊÕÃÕ>ÊV>Ài°
UÊData sources
-Ì>ÌiÊi`ˆV>ˆ`Ê>˜`Ê-
*Ê`>Ì>°
UÊReturn on investment
Not specified
UÊQuality outcomes
ÇӯʜvÊV…ˆ`Ài˜Êˆ˜Ê̅iÊ*
Ê«À>V̈ViÃʅ>Ûiʅ>`Ê
well-child visits, compared with 27% of controls.
D. Other PCMH Programs
Johns Hopkins Guided Care PCMH Model
/…iÊՈ`i`Ê
>ÀiÊ*
ʓœ`i]ʜÀ}>˜ˆâi`ÊLÞÊ>Ê}ÀœÕ«Ê
>Ìʜ…˜Ãʜ«Žˆ˜ÃÊ-V…œœÊœvÊi`ˆVˆ˜iÊvi>ÌÕÀiÃÊV>ÀiÊ
coordination by teams of RNs and primary care physicians working in community-based practices. Guided
>Àiʓœ`iÊ, ÃÊ>ÀiÊÌÀ>ˆ˜i`Ê̜ÊÌi>V…Ê«>̈i˜ÌÃÊ>˜`Êv>“ˆlies self-management skills, including early identification
of worsening symptoms that can be addressed before
an emergency department or hospital admission
becomes necessary. The RNs focus on Medicare
beneficiaries in the top quartile of health risk.
Ê«Àiˆ“ˆ˜>ÀÞÊiÛ>Õ>̈œ˜Ê>vÌiÀÊnʓœ˜Ì…ÃʜvÊ>ÊVÕÃÌiÀÊ
À>˜`œ“ˆâi`ÊÌÀˆ>ÊœvÊ̅ˆÃʓœ`iÊˆ˜ÛœÛˆ˜}ʙä{Ê«>̈i˜ÌÃÊ
has been published in a peer-reviewed journal.20
The trends indicate:
UÊÓ{¯ÊÀi`ÕV̈œ˜Êˆ˜Ê̜Ì>Ê…œÃ«ˆÌ>Êˆ˜«>̈i˜ÌÊ`>ÞÃ
UÊCost and utilization outcomes
i`ˆ>˜Ê>˜˜Õ>ÊVœÃÌÃÊÜiÀiÊfÇnxÊvœÀÊ*
Ê
children compared with $1,000 for controls, due
to reductions in ER visits and hospitalizations.
UÊTotal spending on PCMH enrollees
i`ˆ>˜Ê>˜˜Õ>ÊVœÃÌÃÊfÇnxÊvœÀÊ*
ÊV…ˆ`Ài˜Ê
compared with $1,000 for controls. In an evalu䜘ÊëiVˆwV>ÞÊiÝ>“ˆ˜ˆ˜}ÊV…ˆ`Ài˜Êˆ˜Êi˜ÛiÀÊ
܈̅ÊV…Àœ˜ˆVÊVœ˜`ˆÌˆœ˜Ã]Ê*
ÊV…ˆ`Ài˜Ê…>`Ê
œÜiÀʓi`ˆ>˜Ê>˜˜Õ>ÊVœÃÌÃÊ­fÓ]ÓÇx®Ê̅>˜Ê̅œÃiÊ
˜œÌÊi˜Àœi`ʈ˜Ê>Ê*
Ê«À>V̈ViÊ­fÎ]{ä{®°
14
UÊ£x¯ÊviÜiÀÊ,ÊۈÈÌÃ
UÊÎǯÊ`iVÀi>Ãiʈ˜ÊΈi`ʘÕÀȘ}Êv>VˆˆÌÞÊ`>ÞÃ
Uʘ˜Õ>Ê˜iÌÊi`ˆV>ÀiÊÃ>ۈ˜}ÃʜvÊfÇx]äääÊ«iÀÊ
Ո`i`Ê
>ÀiʘÕÀÃiÊ`i«œÞi`ʈ˜Ê>Ê«À>V̈Vi
Genesee Health Plan
/…iÊi˜iÃiiÊi>Ì…Ê*>˜]ÊL>Ãi`ʈ˜Êˆ˜Ì]ʈV…ˆ}>˜]Ê
developed a patient centered medical home model
vœÀʈÌÃʅi>Ì…Ê«>˜ÊÃiÀۈ˜}ÊÓx]äääÊ՘ˆ˜ÃÕÀi`Ê>`ՏÌðÊ/…iÊ
i˜iÃiiÊ*
ʓœ`i]ÊV>i`Êi˜iÃÞÃÊi>Ì…7œÀŽÃ]Ê
invested in a team approach to improve health and
reduce costs, including a Health Navigator to work
with primary care clinicians to support patients to
adopt healthy behaviors, improve chronic and preventive care and provide links to community resources.
Ê{‡Þi>Àʏœ˜}ˆÌÕ`ˆ˜>ÊiÛ>Õ>̈œ˜ÊœvÊ̅iÊ«>̈i˜ÌÊ
centered medical home approach used in the Genesys
HealthWorks model, as reported by the Institute for
Healthcare Improvement,21 found the following results:
UÊImproved access: 72% of the uninsured adults
ˆ˜Êi˜iÃiiÊ
œÕ˜ÌÞʘœÜʈ`i˜ÌˆvÞÊ>Ê«Àˆ“>ÀÞÊV>ÀiÊ
practice as their medical home.
UÊiÌÌiÀʵÕ>ˆÌÞ\Ê£Îǯʈ˜VÀi>Ãiʈ˜Ê“>““œ}À>«…ÞÊ
ÃVÀii˜ˆ˜}ÊÀ>ÌiÃÆÊÎȯÊÀi`ÕV̈œ˜Êˆ˜ÊӜŽˆ˜}Ê>˜`Ê
improvements in other healthy behaviors.
UÊ,i`ÕV̈œ˜Êˆ˜Ê,Ê>˜`ʈ˜«>̈i˜ÌÊVœÃÌÃ\Êxä¯Ê
`iVÀi>Ãiʈ˜Ê,ÊۈÈÌÃÊ>˜`Ê£x¯ÊviÜiÀʈ˜«>̈i˜ÌÊ
hospitalizations, with total hospital days per
1,000 enrollees now cited as 26.6% lower
than competitors.
Erie County PCMH Model
˜Ê̅iÊ£™™äÃ]ÊÀˆiÊ
œÕ˜ÌÞ]Ê iÜÊ9œÀŽÊˆ“«i“i˜Ìi`Ê>Ê
primary care medical home program for dual eligible
Medicaid-Medicare patients with chronic disabilities,
including substance abuse. A key part of the interven̈œ˜ÊÜ>ÃÊ>Ê«iÀ‡“i“LiÀÉ«iÀ‡“œ˜Ì…ÊV>ÀiÊVœœÀ`ˆ˜>̈œ˜Ê
fee to primary care practices to support enhanced
team-based chronic care management. An evaluation
published in a peer-reviewed journal found that the
intervention improved quality of care, decreased duplication of services and tests, lowered hospitalization
rates and improved patient satisfaction while saving
$1 million for every 1,000 enrollees.22
ÜiÀiÊ>Ìʅˆ}…‡ÀˆÃŽÊvœÀʅœÃ«ˆÌ>ˆâ>̈œ˜°Ê/…iÊ,
Ê
*
ʓœ`iÊˆ˜VÕ`i`Ê>ʘÕÀÃiÊ«À>V̈̈œ˜iÀÉÜVˆ>Ê
worker care coordination team, working closely with
primary care physicians and a geriatrician. At 2 years,
the use of the emergency department was significantly
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ʈ˜ÌiÀÛi˜Ìˆœ˜Ê
compared with controls. The subgroup defined at the
start of the study as having a high risk of hospitalization was found to have a significantly lower hospitalization rate compared with high-risk usual care patients.ÓÎ
Appendix: Review Methods
We reviewed peer-reviewed and non-peer-reviewed
literature to identify evaluations of patient centered
medical home interventions. To be eligible for inclusion
in the review, evaluations needed to assess an intervention in the United States that consisted of a change in a
primary care delivery model that involved at least some
of the key redesign principles of the patient centered
medical home. The evaluations also needed to report
outcome data on service utilization and costs, and not
only quality of care or patient experiences, and to include some type of control group to allow comparisons
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Ê
model. When evaluations reported formal tests of
significance, we cite the p values in our review.
Geriatric Resources for Assessment
and Care of Elders
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system of community clinics affiliated with the Indiana
University School of Medicine, enrolled low-income
seniors with multiple diagnoses, one-fourth of whom
15
Endnotes
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workforce, and beneficiaries’ quality of care. Health
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care and outcomes, reduce costs. Institute for Healthcare
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