Tuesday, February 25, 2014

A Huge Medical Home Pilot Fails: the Pennsylvania Chronic Care Initiative

Back in 2007, Pennsylvania Governor Ed Rendell created the "Chronic Care Management Reimbursement and Cost Reduction Commission."  Months later, the Commission presented its strategic plan to the Governor, which then led to the Pennsylvania Chronic Care Initiative (PACCI). The "Rx for PA" was launched, promoting the medical home as a means of increasing quality and lowering costs for Pennsylvanians with diabetes and pediatric asthma.

The Commission recognized that one of the problems with the medical home was that not all health insurers covered its services the same way.  That left the primary care practices with the dilemma of having to offer different services to different patients depending on insurance status.  As only big Ed Rendell could do in his "discussions" with the Commonwealth's health insurers, the PACCI "leveled" the playing field by getting Medicaid and the dominant Pennsylvania health insurers to similarly "cover" the medical home. This minimized - outside of Medicare - the impact of multiple insurers with different benefit and coverage standards.

The PACCI was a statewide, multipayer medical home pilot that was started in southeast portion of the state.  It started in June of 2008 involved six health plans (3 commercial and 3 Medicaid) that agreed to give NCQA-recognized clinics additional yearly practice support payments and other bonuses.

Three years later, 32 out of 34 of the originally selected southeast Pennsylvania practices completed the pilot, of which 6 were independently managed by nurse practitioners; at the end, about half had achieved high "Level 3: NCQA status. 

The PACCI clinics and their approximately 64,000 patients were compared to a parallel group of 29 comparison practices that were similar in size, specialty and patient mix; they had approximately 56,000 patients.  Of the six health plans, only four could supply claims data that went back to 2007.

Results?  The article is here, but the short version is as follows:

Using 2007 as the baseline, there was no difference in any change in hospitalization rates, ED visit rates, primary care visits, visits to specialists or overall costs of care. In fact, the medical home clinics had MORE "ambulatory sensitive" hospitalizations. 


Of 11 HEDIS® quality measures (blood sugar testing and control, cholesterol testing and control, monitoring for kidney or eye disease in diabetes, childhood asthma treatment, plus the health maintenance chlamydia screening and breast, cervical and colon cancer testing) only the kidney monitoring was statistically significantly improved compared to the non-pilot clinic populations.

Double ouch.

The DMCB's take:

This is bad news for the medical home community. While the methodology is not pristine (the clinics were not randomly assigned, opening the possibility of bias and some of the data were not available), this is a real world study that should have detected some cost savings or quality improvement. Instead, none were found. 

The DMCB and AHRQ have worried about this before, but the DMCB remains open minded:

Medical home is necessary but not sufficient? The authors points out that there were no other economic incentives to reduce costs and that there was no feedback on performance.  The DMCB agrees that had the practices known which patients were at greatest risk, they might have been able to better target their services.  In other words, medical homes may be more likely to succeed if they are paired with predictive modeling to proactively identify and intervene on their patients who were most likely to have ambulatory-sensitive hospitalizations

Not really "all payer." As the DMCB understands it, Medicare was not a participant in PACCI, and its failure to cover medical home services could have repressed its complete adoption throughout the practice.  Small wonder, since Medicare can account for half of a doctor's income.

Generalizability to small physician-owned practices? Medical homes arguably work in "closed" integrated or Medicaid care systems.  It may be that the sum of smaller independent practices is equal to all its uncoordinated parts.

Nurse practitioners? It sure would be nice to know how the nurse practitioner-led PACCI practices fared vs. physicians.

Image from Wikipedia

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