Monday, April 2, 2012

The Patient Centered Medical Home's Return On Investment (not?)

Read this lead American Journal of Managed Care article on Geisinger's approach to the patient centered medical home (PCMH), and you may agree that the major findings are:

1) the longer patients with chronic conditions are exposed to care coordination, the greater the impact on claims expense, and

2) while insurance claims went down, the savings weren't enough to generate a return on investment, i.e., the program itself cost too much.

The DMCB also agreed but mined the article to find out more.

Geisinger has a ""Proven Health Navigator" system of primary care sites with "embedded" nurse case managers who serve medically complex patients. As more primary care sites were recruited into the system and as more Medicare Advantage patients were enrolled by the nurses, it became possible to contrast the duration of exposure to Navigator with the amount of savings. Based on over one million member-months in 43 primary care sites over four years, the authors found that from one to twelve months of exposure, patients' claims expenses were not statistically significantly less than expected. However, once more than twelve months elapsed, the percent savings ranged from 4.3% to 6.7%. Yet, while the savings per member per month ranged from approximately $70 to $120, that was still not enough to exceed "the actual dollar amount invested in implementing" Navigator.

What else can the DMCB conclude?

1) When it comes to reducing claims expense, it'll take more than 12 months to see a reduction in claims expense, i.e., "to bend the curve."  According to these data, it'll take 2 years or more.  That means starting a care coordination program is a two to three year commitment.

2) The authors point out that with more time or more patients, they may have been able to achieve enough observations to achieve a statistically significant return on investment. Unfortunately, close reading shows there is little information in the manuscript on the program costs which led to the authors' conclusions.

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