Impact of Medical Home Implementation Through Evidence-Based Quality Improvement on Utilization and Costs

Published in: Medical Care, v. 54, no. 2, Feb. 2016, p. 118-125

Posted on RAND.org on June 27, 2016

by Jean Yoon, Adam Chow, Lisa V. Rubenstein

Read More

Access further information on this document at Medical Care

This article was published outside of RAND. The full text of the article can be found at the link above.

Research Question

  1. How does the use of evidence-based quality improvement (EBQI) methods affect health care utilization and costs among Veterans Administration (VA) patients during early implementation of patient-centered medical homes?

BACKGROUND: Evidence-based quality improvement (EBQI) methods may facilitate practice redesign for more effective implementation of the patient-centered medical home (PCMH). OBJECTIVE: We assessed changes in health care utilization and costs for patients receiving care from practices using an EBQI approach to implement PCMH and comparison practices over a 5-year period. RESEARCH DESIGN: We used longitudinal, electronic data from patients in 6 practices using EBQI and 28 comparison practices implementing standard PCMH for 1 year before and 4 years after PCMH implementation. We analyzed trends in utilization and costs using bivariate analyses and independent effects of EBQI status on outcomes using multivariate regressions adjusting for year, patient and clinic factors, and patient random effects for repeated measures. SUBJECTS: A total of 136,856 patients using Veterans Affairs primary care. MEASURES: Veterans Affairs ambulatory care encounters, emergency department visits, admissions, and total health care costs per patient. RESULTS: After PCMH implementation, overall utilization for primary care, specialty care, and mental health/substance abuse care decreased, whereas utilization for telephone care increased among all practices. Patients also had fewer hospitalizations and lower costs per patient. In adjusted analyses, EBQI practice was independently associated with fewer primary care (IRR=0.85), specialty care (IRR=0.83), and mental health care encounters (IRR=0.69); these effects attenuated over time (all P<0.01). There was no independent effect of EBQI on prescription drug use, acute care, health care costs, or mortality rate relative to comparison practices. CONCLUSION: EBQI methods enhanced the effects of PCMH implementation by reducing ambulatory care while increasing non-face-to-face care.

Key Findings

  • Utilization of primary care, specialty care, and mental health and substance use was reduced with use of evidence-based quality improvement (EBQI) methods; use of telephone-based care increased.
  • The utilization reductions happened more quickly in practices that adopted EBQI methods than those that did not.
  • EBQI use did not reduce costs, nor did it change utilization patterns of prescription drugs, emergency department (ED), hospitalizations, or total costs.
  • EBQI did not significantly affect mortality rates.
  • The observed changes in utilization suggest that the reduction of in-person visits did not adversely affect patients' health.

Recommendation

Future studies should further examine impacts of EBQI methods on the primary care triple aims of improved health, care, and costs.

This report is part of the RAND Corporation external publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.