DOES THE PATIENT CENTERED MEDICAL HOME IMPROVE THE CARE FOR THE HIGH NEED, HIGH COST POPULATION?
Salzberg, Claudia A
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Background: The patient-centered medical home (PCMH) has been proposed as a transformative model of delivery of health care that aims to improve health outcomes and lower health spending by providing care that is patient centered, comprehensive, coordinated, accessible and focused on quality and safety. Although PCMH is rapidly becoming widespread, there is mixed evidence on the effectiveness of current medical homes in delivering any or all of these objectives. There is disagreement as to whether this model is intended to improve care for all or should be targeted only at patients with high medical needs. However, recent findings are identifying benefits among subgroups with chronic conditions. Studies are also finding that care for mental health conditions is not commensurate with care for physical conditions in the PCMH. Individuals with multiple chronic conditions and those with comorbid depression are among the most medically needy and costliest patients. In addition, the role of payment reform in PCMH is understudied. This dissertation evaluates how adults with multiple chronic conditions and co-morbid depression respond to a specific PCMH intervention with two methods of reimbursement; fee-for-service and partial capitation. Methods: Administrative medical and pharmacy claims from a single commercial payer in the Albany and upstate New York areas for the years 2008 – 2013 are used. A segmented, interrupted time series design with individual level data clustered at the PCP level, with matched practice-level controls, was used to assess the effect of the transformation to PCMH of 22 practices recognized as NCQA Level 3, and the subsequent adoption of partial capitation of 13 of those practices. Outcomes include total medical, inpatient, ambulatory and drug expenditures as well as inpatient, emergency department, and office visit utilization. Results: PCMH affects subgroups with multiple chronic conditions. Payment through partial capitation increased access to ambulatory services and drugs while reducing the expenditures among those who used these services. PCMH continuing to remain on FFS had no effect among patients with co-morbid depression whereas PCMH with partial capitation has significant effects on ambulatory and drug expenditures. Conclusions: This study finds that PCMH affects outcomes for those with multiple chronic conditions. Further innovations in care need to be implemented in the PCMH to address the subgroup of patients with multiple chronic conditions with co-morbid depression. Payment reform is critical for the success of PCMH.