Quality and Efficiency in Small Practices Transitioning to Patient Centered Medical Homes: A Randomized Trial
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There is growing evidence that even small and solo primary care practices can successfully transition to full Patient Centered Medical Home (PCMH) status when provided with support, including practice redesign, care managers, and a revised payment plan. Less is known about the quality and efficiency outcomes associated with this transition.
Test quality and efficiency outcomes associated with 2-year transition to PCMH status among physicians in intervention versus control practices.
Randomized Controlled Trial.
Eighteen intervention practices with 43 physicians and 14 control practices with 24 physicians; all from adult primary care practices.
Modeled on 2008 NCQA PPC®-PCMH™, intervention practices received 18 months of tailored practice redesign support; 2 years of revised payment, including up to $2.50 per member per month (PMPM) for achieving quality targets and up to $2.50 PMPM for PPC-PCMH recognition; and 18 months of embedded care management support. Controls received yearly participation payments.
Eleven clinical quality indicators from the 2009 HEDIS process and health outcomes measures derived from patient claims data; Ten efficiency indicators based on Thomson Reuter efficiency indexes and Emergency Department (ED) Visit Ratios; and a panel of costs of care measures.
Compared to control physicians, intervention physicians significantly improved TWO of 11 quality indicators: hypertensive blood pressure control over 2 years (intervention +23 percentage points, control –2 percentage points, p = 0.02) and breast cancer screening over 3 years (intervention +3.5 percentage points, control −0.4 percentage points, p = 0.03). Compared to control physicians, intervention physicians significantly improved ONE of ten efficiency indicators: number of care episodes resulting in ED visits was reduced (intervention −0.7 percentage points, control + 0.5 percentage points, p = 0.002), with 3.8 fewer ED visits per year, saving approximately $1,900 in ED costs per physician, per year. There were no significant cost-savings on any of the pre-specified costs of care measures.
In a randomized trial, we observed that some indicators of quality and efficiency of care in general adult primary care practices transitioning to PCMH status can be significantly, but modestly, improved over 2 years, although most indicators did not improve and there were no cost-savings compared with control practices. For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial.
KEY WORDSpatient centered care outcomes randomized trials primary care
- 3.Peikes D, Zutshi A, Genevro J, Smith K, Parchman M, Meyers D. Early Evidence on the Patient-Centered Medical Home. Final Report. Rockville (MD): Agency for Healthcare Research and Quality; 2012 Feb. Contract No.: HHSA290200900019I/HHSA29032002T and HHSA290200900019I/HHSA29032005T. Sponsored by: Agency for Healthcare Research and Quality.Google Scholar
- 13.National Committee for Quality Assurance. Standards and Guidelines for Physician Practice Connections—Patient-Centered Medical Home Version. 2008 [cited 2013 February 4]. Available from: URL: http://www.usafp.org/PCMH-Files/NCQA-Files/PCMH_Overview_Apr01.pdf.
- 14.Fifield J, Dauser Forrest D, Martin-Peele M, Burleson JA, Goyzueta J, Fujimoto M, Gillespie W. A Randomized, Controlled Trial of Implementing the Patient-Centered Medical Home Model in Solo and Small Practices. JGIM 2012; Online First 07 September 2012, doi: 10.1007/s11606-012-2197-z.
- 16.Stout RL, Wirtz PW, Carbonari JP, Del Boca FK. Ensuring balanced distribution of prognostic factors in treatment outcome research. J Stud Alcohol 1994; Suppl 12:70–5.Google Scholar
- 17.Gawande A. Medical Report: the Hot Spotters. The New Yorker 2011 January 24 [cited 2013 February 4]. Available from: URL: http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande.
- 18.Robert Wood Johnson Foundation. Expanding “Hot spotting” to New Communities. Princeton (NJ): Robert Wood Johnson Foundation; 1 January 2012 [cited 2013 February 4]. Available from: URL: http://www.rwjf.org/content/dam/farm/meetings_and_conferences/speeches_and_presentations/2012/rwjf72538.
- 19.National Committee for Quality Assurance (US). HEDIS 2009. Washington: Technical Specifications. 2008;2.Google Scholar
- 20.National Committee for Quality Assurance. Quality Compass 2012. Available at: URL: http://www.ncqa.org/tabid/177/Default.aspx. Accessed February 4, 2013.
- 21.Rosenthal MB, Abrams MK, Bitton A, Patient-Centered Medical Home Evaluators’ Collaborative. Recommended Core Measures for Evaluating the Patient-Centered Medical Home: Cost, Utilization, and Clinical Quality [data brief]. New York: Commonwealth Fund; 2012 May. Publication No. 1601,12.Google Scholar
- 22.Meyers D, Peikes D, Dale S, Lundquist E, Genevro J. Improving Evaluations of the Medical Home. Rockville (MD): Agency for Healthcare Research and Quality; 2011 Sept. AHRQ Publication No. 11-0091.Google Scholar
- 23.Thomson Healthcare. MEG—Medical Episode Grouper™ [manual]. New York (NY): Thomson Healthcare; 2007.Google Scholar
- 28.Sheskin DJ. Handbook of Parametric and Nonparametric Statistical Procedures. 3rd ed. Boca Raton (FL): Chapman & Hall; 2004.Google Scholar
- 29.Tabachnick BG, Fidell LS. Using Multivariate Statistics. 5th ed. Boston (MA): Pearson; 2007.Google Scholar
- 30.Raudenbush S, Bryk A, Congdon R. HLM 6 for Windows [computer program]. Skokie (IL): Scientific Software International, Inc; 2004.Google Scholar
- 31.Raudenbush SW, Bryk AS. Hierarchical Linear Models. Thousand Oaks (CA): Sage Publications, Inc; 2002.Google Scholar
- 32.Hox J. Multilevel Analysis: Techniques and Applications. 2nd ed. New York (NY): Routledge; 2010:233–56.Google Scholar
- 38.Nelson EC, Batalden PB, Godfrey MM, eds. Quality by Design: A Clinical Microsystems Approach. San Francisco (CA): Jossey-Bass; 2007.Google Scholar