Study Results Confirm PCMH Success in Improving Quality, Reducing Costs

The patient-centered medical home, or PCMH, continues to demonstrate its value to the health care system in terms of improving quality, enhancing access and reducing costs, according to a new study (92-page PDF; About PDFs) published by the Patient-Centered Primary Care Collaborative, or PCPCC.

The study looked at a cross section of 10 PCMH projects in nearly every part of the country. Although the projects cover different population groups and vary in size, scope and age, they all achieved similar results. In every instance, the PCMH projects created better coordination and more effective upstream care, which led to fewer hospitalizations and emergency room visits and a corresponding reduction in costs.

"The numbers change a little bit from practice to practice, but we are consistently seeing positive outcomes," said Paul Grundy, M.D., president of the PCPCC and one of the authors of the study.

Although the projects differ, they all share some common elements -- components that are essential building blocks of the patient-centered medical home. For example, most of the programs employ care teams to coordinate and manage care. They also use health information technology to standardize workflows and to enhance the patient/physician relationship. And all of the programs in the study have made substantial investments in primary care.

HealthPartners Medical Group, a Minneapolis-based, not-for-profit integrated health care system with a health plan, a hospital and a medical group composed of 700 physicians, implemented a PCMH model in 2004 as part of an overall system redesign. During the past five years, the group has experienced a 39 percent decrease in emergency room visits and a 24 percent reduction in hospital admissions, according to the PCPCC study. The medical group also documented a 129 percent increase in patients receiving optimal diabetes care and a 48 percent increase in patients receiving optimal heart disease care.

Robert VanWhy, M.D., senior vice president for primary care at HealthPartners Medical Group, attributes the success of the system to a combination of factors, including standardized workflows, the integration of health IT and a culture that emphasizes continuous quality improvement.

"A lot of this guided by the Triple A notion of improving health, experience and affordability simultaneously -- that is the framework that we use," said VanWhy.

One of the first steps taken by the medical group was to put a uniform information system in place across the entire delivery system, making it possible to standardize care processes.

"That allows us to go back and intentionally design work flows to improve different parts of the system," said VanWhy. "We do quite well in optimal diabetes care, and we think we will achieve our goal this year of having 40 percent of our patients receiving optimal diabetes care. We do that by sharing information down to the individual physician level on how the (physicians) are doing across all of the dimensions, which includes optimal diabetic care."

The medical group also created care teams at each of its 23 clinic locations in the Minneapolis area. It relies on these teams to work with patients and to augment the care delivered by the physicians.

"The care teams take the clinical information we develop and make it available to everyone in the system," said VanWhy. "They work with their panel of patients on a monthly basis, calling people to bring people back in and to make necessary modifications in their regimens, if necessary."

Group Health Cooperative of Puget Sound, a consumer-owned, integrated delivery system headquartered in Seattle, took similar steps when launching its own PCMH demonstration project at one of its Seattle clinics in 2007. Group Health created health care teams to manage and coordinate the care of patients at the clinic, thus applying a team-based approach to care.

Under this approach, the primary care physicians head the team, but they work in tandem with other members of the unit, such as pharmacists and nurses, to ensure that care is anticipatory instead of reactive, said Robert Reid, M.D., Ph.D., associate investigator for Group Health Research Institute, a nonproprietary, public-interest research center within Group Health Cooperative.

According to Reid, Group Health made a substantial investment in the workforce at the PCMH clinic, hiring more nurses, medical assistants, clinical pharmacists and primary care physicians. As a result, the clinic was able to reduce panel sizes for each physician from an average of 2,400 patients to 1,800 patients. This gave each physician ample time to redesign his or her workload and to spend more time with patients.

"The objectives were to improve the experience of patients, but also to make sure that patient care needs were being met in primary care and not in other places of the health care system, such as emergency rooms, urgent care centers and patient hospitalizations, because primary care was not available," said Reid.

Group Health also uses electronic information systems to identify patient needs and problems on a continual basis. When a patient comes in for an appointment, the electronic system delivers a reminder to the patient's health care team. For example, the system would alert the caregiver that the patient might need a screening for breast cancer or diabetes. Patients also have access to a health care records Web portal, which allows them to view most of their medical records and to refill prescriptions online. In addition, the Web portal allows patients to interact with their care teams online.

"Physicians and patients e-mail each other, so we do e-mail visits, all of which is recorded in the e-mail record," said Reid. "Many patients would prefer not to be seen in the clinics and wait in waiting rooms. They would much rather get their questions answered by e-mail."

According to Reid, the pilot project was successful. During a one-year period, from 2007 to 2008, the PCMH clinic registered a 29 percent reduction in emergency room visits and an 11 percent reduction in ambulatory care sensitive care admissions compared to a non-PCMH control clinic. In addition, there was a greater improvement on measures gauging patient experiences, such as care coordination and patient involvement in their own health care.

The study also noted that the Group Health clinic undergoing the PCMH trial experienced less staff burnout. Only 10 percent of staff members at the PCMH clinic reported high emotional exhaustion at 12 months compared to 30 percent of staff at the control clinic. The lower staff burnout level has led to a major improvement in recruitment and retention of primary care physicians at the clinic, according to the study.

"That is an important statistic in health care," said Reid. "We previously saw substantial burnout at base line and that dropped by two-thirds at one year."

The staff members at the PCMH clinic are more satisfied with their work, believing it is much more meaningful, said Reid. "They are getting patient care needs met," he noted, and "In the words of the physicians, they feel like they are practicing in the way they always wanted to practice."

Group Health now is planning to transform all of its 26 clinics in Washington and Idaho into PCMH clinics because of the early findings from its trial PCMH clinic, according to Reid, who added that he was surprised by the rapid turnaround at the test clinic.

Sandeep Wadhwa, M.D., M.B.A., Colorado's Medicaid director, also was surprised by the relatively quick results produced by a PCMH project for low-income children enrolled in the state's Medicaid and State Children's Health Insurance Program. The state began the medical home project in 2008, and by March of 2009, 150,000 children were enrolled with a primary care practice.

Within one year, the median annual costs for children in the PCMH practices was $785 compared to $1,000 for children in non-PCMH practices, a result of reductions in emergency room visits and hospitalizations, according to the study. In an evaluation specifically examining children with chronic conditions, children enrolled in the PCMH clinics had lower median costs at $2,275 compared to $3,404 for children in non-PCMH clinics.

"This is what we were hoping to see," said Wadhwa. "It met expectations, but we were surprised at how quickly some of these results were materializing. Though it is a preliminary study, we thought it might have taken two years, not one year, to show the differences."