Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care

Published in: JAMA, The Journal of the American Medical Association, v. 311, no. 8, Feb. 2014, p. 815-825

Posted on RAND.org on February 01, 2014

by Mark W. Friedberg, Eric C. Schneider, Meredith B. Rosenthal, Kevin G. Volpp, Rachel M. Werner

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Research Question

  1. Was participation in a relatively large, multipayer medical home pilot associated with changes in the quality, utilization, or cost of care?

IMPORTANCE: Interventions to transform primary care practices into medical homes are increasingly common, but their effectiveness in improving quality and containing costs is unclear. OBJECTIVE: To measure associations between participation in the Southeastern Pennsylvania Chronic Care Initiative, one of the earliest and largest multipayer medical home pilots conducted in the United States, and changes in the quality, utilization, and costs of care. DESIGN, SETTING, AND PARTICIPANTS: Thirty-two volunteering primary care practices participated in the pilot (conducted from June 1, 2008, to May 31, 2011). We surveyed pilot practices to compare their structural capabilities at the pilot's beginning and end. Using claims data from 4 participating health plans, we compared changes (in each year, relative to before the intervention) in the quality, utilization, and costs of care delivered to 64 243 patients who were attributed to pilot practices and 55 959 patients attributed to 29 comparison practices (selected for size, specialty, and location similar to pilot practices) using a difference-in-differences design. EXPOSURES: Pilot practices received disease registries and technical assistance and could earn bonus payments for achieving patient-centered medical home recognition by the National Committee for Quality Assurance (NCQA). MAIN OUTCOMES AND MEASURES: Practice structural capabilities; performance on 11 quality measures for diabetes, asthma, and preventive care; utilization of hospital, emergency department, and ambulatory care; standardized costs of care. RESULTS Pilot practices successfully achieved NCQA recognition and adopted new structural capabilities such as registries to identify patients overdue for chronic disease services. Pilot participation was associated with statistically significantly greater performance improvement, relative to comparison practices, on 1 of 11 investigated quality measures: nephropathy screening in diabetes (adjusted performance of 82.7% vs 71.7% by year 3, P < .001). Pilot participation was not associated with statistically significant changes in utilization or costs of care. Pilot practices accumulated average bonuses of $92 000 per primary care physician during the 3-year intervention. CONCLUSIONS AND RELEVANCE: A multipayer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement.

Key Findings

  • Participation in the medical home pilot was associated with greater performance in one of 11 quality measures: screening for kidney functioning in patients with diabetes.
  • Participation was not associated with improvements in other measures of quality (e.g., asthma care, preventive screenings).
  • Participation was not associated with decreases in emergency department use, hospitalizations, or total cost of care.

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