PCMH Project Evaluations Report Positive Results for Metrics Related to 'Triple Aim'

January 31, 2014 03:13 pm Paula Haas

A review of 20 recent patient-centered medical home (PCMH) project evaluations found that a majority of them (60 percent) reported cost reductions or reduced emergency department (ED) visits. Forty percent of the evaluations reported fewer hospital admissions, and 30 percent reported improved population health or increased provision of preventive services. Smaller percentages reported improvements in access to care (25 percent), patient satisfaction (20 percent) and hospital readmissions (15 percent).

Family physician J. Nwando Olayiwola, M.D., M.P.H., discusses the need for more studies that look at physician satisfaction with the patient-centered medical home model during a Patient-Centered Primary Care Collaborative panel discussion in Washington.

The review, The Patient-Centered Medical Home's Impact on Cost and Quality: An Annual Update of the Evidence, 2012-2013,(www.pcpcc.org) was released Jan. 13 by the Patient-Centered Primary Care Collaborative (PCPCC). The PCPCC's mission is to advance a health system built on a strong foundation of primary care and the PCMH.

The PCPCC report focused primarily on improvements in a range of metrics related to the "Triple Aim" -- improving population health, enhancing the patient experience of care, and reducing or controlling the cost of care -- for improving the U.S. health care system.

Sponsored by the Milbank Memorial Fund, the report looked at quantitative outcomes reported in 13 peer-reviewed and seven industry-generated evaluations released between August 2012 and December 2013. Tables in the PCPCC report show findings from each of the 20 PCMH evaluations.

"We didn't 'cherry-pick' and report on only the positive findings," said PCPCC CEO Marci Nielsen, M.P.H., Ph.D. "For example, regarding the 15 percent of studies that looked at readmissions, those weren't just the studies that found a reduction in readmissions -- those were the studies that measured readmissions at all. Those studies all reported that readmissions were reduced."

Story highlights
  • A review of 20 recent patient-centered medical home (PCMH) project evaluations found improvements reported in key areas, including reduced costs, reduced emergency department visits and hospital admissions, improved population health, and increased provision of preventive services.
  • The review, conducted by the Patient-Centered Primary Care Collaborative, focused primarily on improvements in a range of metrics related to the "Triple Aim" -- improving population health, enhancing the patient experience, and reducing or controlling the cost of care -- for improving the U.S. health care system.
  • The report also addresses the importance of payment reform, because without it, delivery system reform using the PCMH falls short of achieving the end goal of system-wide improvement.

None of the 20 evaluations reported on all of the Triple Aim metrics within the same study, according to the PCPCC report. However, when a metric was reported on, the result almost always was positive.

"This report shows that the delivery of primary care through a PCMH continues to hold significant promise for addressing the Triple Aim," said AAFP EVP Douglas Henley, M.D., who is vice chair of the PCPCC Board of Directors. "I personally believe that we are well beyond the tipping point -- well into PCMH implementation in many areas of the country -- and that it is paying dividends most importantly for patients, but also for physicians and payers.

"The greatest challenge in health care in the next five years will be the focus on controlling the total cost of care. That focus and that necessity will create a lot of change and chaos in the lives of our members. To me, transforming the practice into a PCMH is the family physician's best bet for the future, in terms of being well positioned to improve quality of care and to embrace new payment models."

Nielsen said she was very encouraged by the PCPCC report's findings. "There are cost savings associated with the PCMH model, as found consistently in the studies that measured cost," she said. "The same was found in regard to reducing utilization of health care services, especially ED use and hospital admissions."

Not Just About Money

But the PCMH isn't just about saving money, Nielsen said.

"We know that many payers and policymakers are first and foremost interested in containing costs, but it's also important to know whether the model improves health outcomes," she said. "We are encouraged that the news was good from the studies that chose to measure outcomes for population health, preventive services or patient satisfaction."

It's also important to measure clinician satisfaction, Nielsen said; however, only one of the 20 evaluations reported on satisfaction, although it found clinician satisfaction had improved.

"This country faces a primary care workforce shortage, so it's imperative to talk about this model not just as a means to save money and improve population outcomes, but also as a way to improve clinician satisfaction and attract more physicians to primary care," Nielsen said. "Otherwise, it will be difficult to convince primary care clinicians to change the way they practice. They need to see that after they've done all the hard transformation work to make the PCMH model operational, they will feel less burnout, have more engaged patients, and experience improved doctor-patient communication."

"There is a gap in the assessment of physicians and their satisfaction," acknowledged J. Nwando Olayiwola, M.D., M.P.H., assistant professor in the Department of Family and Community Medicine at the University of California, San Francisco, and associate director of the Center for Excellence in Primary Care, at a PCPCC panel discussion in Washington. She and the other panelists noted that any research on the PCMH needs to better engage clinicians in the process.

There often is a disconnect between what is said about the PCMH and what clinicians hear, said Olayiwola, so it is critical that more research be done to evaluate the reactions of those clinicians to the PCMH.

Both Nielsen and Henley pointed out that studies that have been done seem to show that clinicians like the PCMH model after they've implemented it(www.annfammed.org).

Right Measures, Right Methods

According to the PCPCC report, the differences in the 20 evaluations included in the analysis illustrate the need for a broad and inclusive common set of measures for evaluating PCMH initiatives.

"For the study of a care delivery model that includes 'patient-centered' in its title, are the PCMH metrics being used sufficiently 'patient-centered'?" the report asked. "Or are the metrics too 'medical'?"

For example, having blood pressure within a target range is not the same as being functionally in good health or feeling a subjective state of well-being. "Additional core measures of self-reported health status and well-being could enhance our understanding of patient-centeredness," said the report.

PCMH evaluation metrics also need to be more rigorous about taking into account the socioeconomic diversity and health disparities of patient populations. Moreover, in addition to selecting the right metrics, researchers must choose study designs appropriate for investigating the complexity of health system reform, the report said.

Payment Reform Critical

In its final section, the PCPCC report looks to the future, discussing the PCMH's role in achieving delivery system reform, including its foundational role in accountable care organizations and the "medical neighborhood" concept. The section also advocates payment reform.

"We addressed payment reform in this report because we didn't want physicians to glance at the report and say, 'They don't get the real challenge -- it's the economics, stupid,'" Nielsen said. "We do get it. We support investing in primary care, fixing the Medicare sustainable growth rate formula, moving away from fee-for-service payments, and getting the private sector engaged in paying for this model of care.

"If we do delivery reform but don't pay adequately for primary care, the PCMH model will only go so far."