These two articles from the September issue of Health Affairs highlight two experiences with patient centered medical homes: the Colorado Multipayer Patient-Centered Medical Home Pilot and Horizon Healthcare Services, Inc. The Colorado pilot was successful in reducing emergency department visits and hospital admissions, especially for patients with multiple chronic conditions. Early results from the Horizon program indicate patients are benefiting, but also that there are also issues that require non-monetary support, like an education program for population care coordinators or a specially developed guide to medical home transformation.

CMS has announced that 40+ payers--including Medicare--will soon begin supporting medical homes through multi-payer programs in seven regions across eight states. Medicaid and state employees are participating in several regions. Check out the announcement from CMS, as well as a recent blog post from Health Affairs on the announcement.

In case you haven't seen it, this recent article out of Geisinger:

http://www.ajmc.com/publications/issue/2012/2012-3-vol18-n3/Reducing-Lon...

discusses the long term ROI for PCMH. Outcomes are good, but the full ROI may take 4-5 years.

Bob

Medicaid expansion under the Affordable Care Act (ACA) will provide new insurance coverage to nearly all of the 1.2 million individuals who are homeless including an estimated 110,000 people who are chronically homeless and more likely to have chronic and complex health conditions. For these individuals, homelessness and housing instability can significantly impede health care access, often resulting in excessive use of expensive inpatient and emergency services. Stable affordable housing coupled with "high touch" supports that connect people with chronic health challenges to a network of comprehensive primary and behavioral health services can help improve health, increase survival rates, foster mental health recovery, and reduce alcohol and drug use among formerly homeless individuals.

This brief outlines the rationale for states to consider in designing Medicaid-financed, supportive housing-based care management services. To help states prepare for Medicaid expansion and anticipate the needs of this high-need population subset, the brief:

1. Outlines the potential benefits of care management linked to affordable housing;
2. Details the business case for using Medicaid to finance supportive housing-based services from the viewpoint of Medicaid as well as the supportive housing industry sector;
3. Highlights potential Medicaid authorities that states can use to fund supportive housing-based services; and
4. Raises considerations for policymakers to address in designing strategies that use Medicaid resources to provide supportive housing-based services.

One of my biggest concerns is that many PCMH pilots may either unintentionally or intentionally be set up to fail. A pilot that is too short in length or misdirected is unlikely to work. 2 examples:

Intentional example: A for-profit payer intentionally designs a PCMH pilot in 1 clinic with a 6 month set up and a 6 month evaluation phase using their own disease management nurse working only their plan's patients. The pilot would likely fail because it takes 1-2 years to set up a PCMH properly, the ROI is likely 2+ years, and a non-integrated care coordinator is less effective. The payer may then use these negative results as an excuse not to cooperate with other PCMH pilots in the state.

Unintentional example: A PCMH pilot focuses only on diabetes. Improvements in diabetes control results in most patients being started on 2nd line diabetes drugs (e.g., Byetta) increasing the patient care costs by $2,000/year on average. In addition, benefits of tighter A1c control take 4-5 years to materialize. The pilot lasts only 2-3 years and shows higher net costs because the huge up front increase in expense due to the diabetes meds is not made up in cost savings from complications unless the pilot continues for 5+ years.

Any meta-analysis will need to sift for these possible designed to fail interventions.

Bob Rauner, MD, MPH, FAAFP

Over the last 5 years an enormous amount of attention has been paid to the need to strengthen primary care as a precondition for broader delivery system reform. The concept of the patient-centered medical home (PCMH) has been an important focal point for this discussion. While there are many advocates for the PCMH and a great deal of face validity associated with the central elements of the model, the evidence for state policy makers and other key decision makers regarding the cost implications of broader dissemination of the PCMH is incomplete. The recent AHRQ-commissioned analyses by Mathematica of the literature and the evaluation challenges for medical home pilot studies document this landscape.

Many PCMH pilot evaluations underway now will begin to contribute greater clarity on these points over the next several years. But payers and policy makers need to make progress on delivery system reform now and want to know whether the PCMH is a worthwhile investment to that end. Based on my current evaluations in Rhode Island, Colorado, Greater Cincinnati, and Rochester NY as well as a careful reading of the literature the following impressions have emerged:

1. PCMH initiatives with at least moderate levels of financial support for transformation have been successful in terms of practice adoption of the key elements of patient-centered care (largely as measured by the NCQA PPC-PCMH scores).

2. PCMH initiatives (with financial support, again) have engaged the workforce in positive ways. Our surveys suggest that physicians and other clinicians perceive improvements in their ability to be effective for their patients and this has led to improved worklife.

3.Practice transformation is not instantaneous and there seems to be a pattern of building up from adoption of new structures and processes followed by infusion of quality improvement and team culture into the practice, followed by a focus on improving care management and care coordination beyond the four walls of the practice (into the so-called medical neighborhood.) This last component is likely at the heart of cost savings for PCMH if they are to materialize. Thus a reasonable expectation for savings from the PCMH in most cases should begin 2+ years from the launch of most pilots.

3. Savings are most likely for high-risk patients. We find, however, that practices tackle this area only after they have built a basic foundation of PCMH for all patients (e.g., team-based care, registries).

Finally, I would note that there is some information in the fact that numerous commercial payers have committed to new and expanded PCMH efforts based on their own data and observations. It may be that some have collected sufficient data on cost savings to satisfy the actuaries. I suspect also, however, these payers have begun looking to broader delivery system reforms and realized that a high-functioning primary care sector will be an important foundation for population-based risk sharing and some types of episode-based payment.

Having examined nearly 500 evaluations of medical home programs, the Agency for Healthcare Research and Quality (AHRQ) concluded that only 14 employed rigorous and reliable quantitative methods. Of these, just one evaluation reported conclusive evidence of savings. In addition to summarizing their understanding of the evidence base, AHRQ has released best practices for conducting trustworthy evaluations going forward.

What are your plans for medical home program evaluation?

Feel free to comment on the implications of the AHRQ study for program evaluation in your state. Is your state confident in moving forward to build medical homes given the state of the evidence?

The CMS guidance in their Dear State Medicaid Director Letters is always helpful, but particularly helpful in this release. Missouri's State Plan Amendment (SPA) was approved and provides additional helpful language that is very useful for other states to use as a checkpoint for some of their thinking. The link to Missouri's approved State Plan Amendment is http://dmh.mo.gov/docs/medicaldirector/MOSPA11-1110-21-11.pdf