A Difference-in-Difference Analysis of Changes in Quality, Utilization and Cost Following the Colorado Multi-Payer Patient-Centered Medical Home Pilot A multipayer medical home program piloted in Colorado led to a Synopsis sustained reduction in emergency department use and costs over three years, although there were no overall cost savings for practices October 23, 2015 or patients. Primary care visits also decreased. The impact on quality Authors Meredith B. Rosenthal, was mixed: cervical cancer screening rates improved, yet colon cancer Shehnaz Alidina, Mark W. Friedberg, Sara J. Singer, Diana Eastman, screenings and hemoglobin testing for diabetes patients decreased. Zhonghe Li, and Eric C. Schneider Journal Journal of General Internal Medicine, published online Oct. 8, 2015 By delivering primary care services in a proactive, coordinated manner, The Issue Contact Meredith B. Rosenthal, the patient-centered medical home (PCMH) aims to improve health Department of Health Policy and outcomes for patients, particularly those with multiple or complex care Management, Harvard School of needs. The PCMH also aims to lower costs, largely by diminishing the Public Health, meredith_rosenthal@harvard.edu need for expensive hospital stays and emergency department visits. To Access to full article. date, research on the effects of the care model has yielded mixed results. Few studies, however, have evaluated outcomes beyond two years, even though evidence suggests that transforming practices into fully functioning PCMHs can take years. Researchers supported by The Commonwealth Fund evaluated a pilot program involving 15 PCMH practices in Colorado serving approximately 98,000 patients both prior to the program’s launch and then again at two and three years. Key Findings We found a reduction in After two years, the participating PCMH practices reduced their patients’ ambulatory care– use of the emergency department (ED) by 1.4 visits per thousand • sensitive inpatient member-months, or by approximately 7.9 percent. At the end of three hospital admissions years, they had sustained this improvement—with 1.6 fewer ED visits per for patients with two thousand member-months, or a 9.3 percent drop from baseline. or more comorbidities, Among patients with two or more illnesses, there was a 10.3 percent drop suggesting that some from baseline in the rate of hospital admissions for conditions that could • PCMH interventions may be have been avoided had timely treatment been provided in an be able to deliver on ambulatory care setting. the promise to reduce hospital use by patients with chronic illness. After three years, the program reduced emergency department costs by $3.50 per member per month, a drop of 11.8 percent. For patients with two or more conditions, the reduction was $6.61 per member per • month, or 14.5 percent. The PCMH pilot practices saw a decline in primary care visits. At three years, there was a reduction of 4.2 primary care visits per thousand member-months. • Cervical cancer screenings improved by 4.7 percent after two years and 3.3 percent after three years. However, the pilot also was associated with lower rates of hemoglobin A1c testing in diabetes patients and • lower rates of colon cancer screening. The reduction in emergency department costs produced nearly $5 million per year in savings, the authors say. The Big Picture But because of spending increases for other services, this did not translate into overall cost savings. Speculating on the reduced number of primary care visits, the authors posit that phone or email consultations and group visits—all components of the PCMH model—might have substituted for additional office visits. Alternatively, improvement in the effectiveness of office visits might have reduced the need for return visits. This decline in visits may have resulted in fewer opportunities to counsel patients and order preventive health screenings. If the PCMH model persists in reducing visits, practices may need to develop other methods for prompting such screenings. The research team examined changes in patient care following the launch, with support from five commercial About the Study insurers, of a PCMH pilot in Colorado in April 2009. The pilot included 15 medium-sized practices with 51 physicians, 35 nurse practitioners and physician assistants, and 205 staff serving approximately 98,000 patients. The team looked at Healthcare Effectiveness Data and Information Set (HEDIS) measures before the start of the intervention and then again two and three years after the pilot launch. Comparison practices in the same area served as a control group. A patient-centered medical home initiative helped to reduce hospital admissions and the use of emergency The Bottom Line departments—even over a sustained time period—but produced mixed results on quality measures. M. B. Rosenthal, S. Alidina, M. W. Friedberg et al., “A Difference-in-Difference Analysis of Changes in Quality, Utilization and Cost Following the Colorado Multi-Payer Patient-Centered Medical Home Pilot,” Journal of General Internal Medicine, published online Oct. 8, 2015. This summary was prepared by Deborah Lorber.