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CareFirst medical home model did not improve quality-of-care

Extension of CareFirst’s medical home program did not significantly enhance quality-of-care processes or reduce service use or spending and thus needs adaptations and more testing before being broadly scaled to Medicare patients, according to findings published in JAMA Internal Medicine.

“CareFirst, the largest commercial insurer in the mid-Atlantic Region of the United States, runs a medical home program focusing on financial incentives for primary care practices and care coordination for high-risk patients,” G. Greg Peterson, PhD, MPA, from Mathematica Policy Research, and colleagues wrote. “From 2013 to 2015, CareFirst extended the program to Medicare fee-for-service beneficiaries in participating practices. If the model extension improved quality while reducing spending, the [CMS] could expand the program to Medicare beneficiaries broadly.”

Peterson and colleagues analyzed whether the CareFirst’s medical home program improves care processes and reduces hospitalizations (all-cause and ambulatory-care sensitive), ED visits and Medicare Part A and B spending. They performed a difference-in-differences analysis to compare the outcomes of approximately 35,000 Medicare fee-for-service patients attributed to 52 intervention practices in Maryland, which were grouped into 14 “medical panels,” with the outcomes of approximately 69,000 Medicare patients attributed to 42 matched comparison panels. The analysis consisted of a 1-year baseline period and 2.5-year intervention period. Nurses who worked with patients’ usual PCPs coordinated care for 3,656 high-risk Medicare patients. Panels were advised by CareFirst on how to meet cost and quality targets and received financial incentives for meeting such targets.

In the baseline period, there was an average of 9.3 PCPs and 2,202 Medicare fee-for-service patients (average age, 73.8 years; 59.2% female; 85.1% white) in each of the 14 intervention panels. Data indicated that no statistically significant improvements in any outcomes for either the full Medicare population to the high-risk subgroup resulted from extending the CareFirst’s program to Medicare patients. In the full population, there were 1.4 hospitalizations per 1,000 patients per quarter (90% CI, –2.1 to 5), –2.5 outpatient ED visits per 1,000 patients per quarter (90% CI, –6.2 to 1.1) and –$1 per patient per month in Medicare Part A and B spending (90% CI, –40 to 39). The 90% CIs for hospitalizations and Medicare spending did not reach the expected impacts. For the intervention group, there was a 10% decline in hospitalizations from baseline to the final 18 months of the intervention; however, the comparison group showed similar declines.

“This study’s null findings do not support scaling the current version of CareFirst’s program to Medicare patients broadly,” Peterson and colleagues concluded. “The contrast with more favorable results for commercial patients suggests several ways the program could be further adapted to the Medicare population. These include refining the targeting algorithm to better identify those who could benefit from care coordination, adopting care coordination strategies (like in-person contacts) shown to be effective for Medicare patients, and tiering specialists on episode costs for Medicare, rather than commercial, patients. Furthermore, using local benchmarks of actual spending growth to calculate panel performance would improve signals to panels about when they need to refine their approaches. Additional testing would be needed to determine whether these or other changes would lead to a more successful medical home program for Medicare patients.” – by Alaina Tedesco

Disclosure: The researchers report no relevant financial disclosures.