Tuesday, June 8, 2010

Two Reports on the Patient Centered Medical Home (PCMH): One Not So Good, One Hopeful

Once primary care sites commit to starting up Patient Centered Medical Homes, how much support do they need, and long does it take before patients discern a difference, before clinical outcomes improve and before costs go down?

For an answer to three of those questions, check out this report on the 26 month outcomes from the American Academy of Family Physicians’ National Demonstration Project (NDP). This is a multi-year nationwide program designed to assist selected non-academic independent primary care practices adopt “a defined set of PMCH components.” The authors were particularly interested in knowing if different types of implementations correlated with varying levels of effectiveness.

NDP was a clinical trial that randomized 36 clinical practices into either a “self-directed” or “facilitated" group. The latter got help from a "change facilitator," learning sessions, additional expert assistance, discounted software and ongoing phone support. All the "self-directed" practices got was access to web-based tools.

At the 26 month mark, 31 practices remained in the study: 16 in the "facilitated group" and 15 in the "self-directed group." 1067 patients (29% response rate) completed a baseline survey and 760 (21%) completed one at 26 months. 1964 and 1861 patient charts were reviewed at baseline and at 26 months respectively (interestly, one practice had an electronic record that “lost” data)

At 26 months, the facilitated practices added approximately 11 “components” to their baseline 17, while the self directed practices added approximately 8 to their baseline of 20. If that doesn't sound like much, there was even less movement in terms of patient-survey reported outcomes. Measures in access to care, care coordination, physician relationship, global practice experience, service relationship satisfaction, patient empowerment and self-rated health status 1) didn't change over time and in some instances seemed to slip, and 2) didn't really favor the facilitated over the self directed clinics. In contrast, there were minor incremental improvements in the chart reviews in some of the measures of ambulatory care, prevention and chronic care management. Finally, there was only weak correlation at best between the number of components adopted and the patient survey data.

To say this study was a disappointment would be an understatment. According to the authors:

"Practices in both the facilitated and self-directed groups were able to adopt multiple components of the NDP model of the PCMH over 26 months. Practices that received intensive coaching from a facilitator adopted more model components. Adopting these predominantly technological elements of the PCMH appeared to have a price, however, as average patient ratings of the practices’ core primary care attributes slipped slightly, regardless of group assignment."

But the Disease Management Care Blog says be of good cheer. There are many pilots out there and while the Academy of Family Physicians may not have found the secret sauce, others are working on this.

For example, Blue Cross Blue Shield of Michigan. And how costs can go down. Really.

There may, repeat may, be the possibility that a credible positive report will emerge out there on the cost savings associated with the PCMH. By fully credible, the DMCB means it has to be prospective with a reasonable comparator, transparent and peer reviewed and has to achieve significant results. Unfortunately, this is just a press release from Blue Cross Blue Shield of Michigan about their PCMH Pilot that is one of the PCPCC programs. The description of the Michigan BCBS PCMH program seems pretty standard/generic to the DMCB but nonetheless, compared to "non-PCMH practices" and apparently based on less than a full year of data......

• PCMH practices have a 2 percent lower rate of adult radiology usage than non-PCMH practices, and a per member per month cost that is 1.2 percent lower.

• PCMH practices have a 1.4 percent lower rate of adult ER visits than non-PCMH practices, and a per member per month cost that is 0.6 percent lower.

• PCMH practices have a 2.6 percent lower rate of adult inpatient admissions than non-PCMH practices, and a per member per month cost that is 2.6 percent lower.

• PCMH practices have a 2.2 percent lower rate of pediatric ER visits than non-PCMH practices, and a per member per month cost that is 4.2 percent lower.

The DMCB has in inquiry into Michigan BCBS asking if the results will be eventually submitted for peer review publication. If the data withstand statistically controlling for baseline differences and if the savings exceed the cost of the program/physician fees, then the this could turn out to be the first time that PCMH has achieved real savings in the commercial setting.

Take note, David Cutler. In your Health Affairs article, you note the long term prospects for cost savings in health reform will largely depend on the private sector's efforts in uncovering what really works in care coordination. The DMCB agrees and hopes, assuming the findings hold, that Michigan BCBS may be a timely example.


Phil 314 said...

Correct me if I'm reading these wrong. I note the AAFP study report was looking at practice characteristics and patient outcomes but not costs. Furthermore they were looking at statistical significance.

The North Carolina project looked at percentage changes and dollars saved.

So different analysis (rigor notwithstanding)

As much as I like the principles and goals of the PCMH I still feel its a concept in search of reimbursement

I would say that some of the items in the AAFP study that changed (i.e. appointment availability) are valuable to patients Is it reasonable to assume that patients would be willing to pay extra for a PCMH practice. And having said that I wonder how much imput from "the patients" has been solicited and/or considered in putting together these pilots.

Jaan Sidorov said...

c3 is correct. Different analysis that demonstrate how important peer review is.

Good point on the pilots and patient input. Maybe it's better thought of as POLICY in search of reimbursement.