Six ways PCPs can deliver efficient health care in a patient-centered medical home model
Researchers identified six activities tied to a patient-centered medical home model of care that were associated with lower health care spending and utilization among Medicare beneficiaries.
The patient-centered medical home model (PCMH) offers numerous activities, but there is “little evidence about which of these have the greatest positive effects on patient outcomes and health care service use,” Susan G. Haber, ScD, director of RTI International’s program on health coverage for low-income and uninsured populations, told Healio Primary Care.
“As more practices enter into alternative payment models like [accountable care organizations], identifying the activities that will help them achieve these goals is likely to become increasingly important to practices,” she said.
To fill the research gap, Haber and colleagues analyzed 302,719 Medicare claims from fee-for-service beneficiaries with mean Hierarchical Condition Category and Charlson Comorbidity Index scores of 1.02 and 0.76, respectfully. The mean age of the beneficiaries was 68.44 years, about 88% were white and 58% were female. The claims were linked to PCMH surveys completed by 19,456 primary care physicians from 394 practices in eight states.
The six activities that were associated with lower spending or utilization included:
Use of registries to identify and remind patients who are due for preventive services: Preventive services “are delivered at visits specifically scheduled for this purpose,” Haber said. “Practice staff also identify needed preventive services at other visits. In addition, registries or other clinical decision support tools are used to identify patients who have not received recommended preventive services, and reminders are given to patients to schedule these.” (Total spending per beneficiary per month [PBPM] = $69.77 less, P = .00; acute-care hospital spending PBPM = $36.62 less, P = .00; all-cause hospital admissions per 1,000 beneficiaries per quarter [P1KBPQ] = 6.78 fewer, P = .003; and ED visits P1KBPQ = 11.05 fewer, P = .05.).
Use of patient registries for pre-visit planning and clinician reminders: Haber said patient registries should be available to practice teams and “routinely used for pre-visit planning, reminders to providers, patient outreach and population health monitoring across a comprehensive set of diseases and high-risk patients.” (Total spending PBPM [only when used for pre-visit planning and clinician reminders] = $29.31 less, P = .05; acute-care hospital spending PBPM = $11.64 less, P = .13; all-cause hospital admissions rate P1KBPQ = 1.93 fewer, P = .21; and ED visits P1KBPQ = 5.49 fewer, P = .18.).
Engagement with patients with chronic conditions: This activity consists of “goal setting and action planning” with members of the practice who are well-versed in “patient education, empowerment and problem-solving methodologies,” Haber said. It also consists of “ongoing support” in either one-on-one visits or group interventions. (Total PBPM = $17.75 less, P = .34; acute-care hospital spending PBPM = $14.13 less, P = .09; all-cause hospital admissions rate P1KBPQ = 4.62 fewer, P = .01; and ED visits P1KBPQ = 11.53 fewer, P = .00.).
Monitoring patients during hospital stays: Patients undergoing ambulatory/outpatient care are “assigned a specific clinician and care team and are encouraged to seek care” from those health care professionals, Haber said. “The practice monitors patient’s care during hospital and post-acute facility stays and is involved as needed.” (Total health care expenditures [only when monitoring patients during hospital stays] PBPM = $22.56 less, P = .21; acute-care hospital spending PBPM = $22.06 less, P = .03; all-cause hospital admissions rate P1KBPQ = 2.05 fewer, P = .2; and ED visits P1KBPQ = 4.99 fewer, P = .22.).
Developing relationships with commonly referred-to practices: This consists of establishing and formalizing practice agreements and referral protocols with cardiologists, OB/GYNs and other specialists, according to Haber. (Total health care expenditures PBPM = $16.57 less, P = .28; acute-care hospital spending PBPM = $8.21 less, P = .25; all-cause hospital admissions rate P1KBPQ = 2.1 fewer, P = .25; and ED visits P1KBPQ = 11.62 fewer, P = .00.).
Use of quality improvement activities: These are systematic approaches, such as Plan-Do-Study-Act cycles and tracking performance on quality measures that are “used in meeting organizational goals,” Haber said. (Total health care expenditures PBPM = $7.83 less, P = .71; acute-care hospital spending PBPM = $4.17 less, P = .71; all-cause hospital admissions rate P1KBPQ = 0.2 fewer, P = .94; and ED visits P1KBPQ = 13.47 fewer, P = .00.).
Some of the activities that do not require patient contact would not need to be modified because of the pandemic — “for example, quality improvement activities, practice agreements and referral protocols,” Haber said. With the exception of preventive services, “the activities that involve patient contact do not require in-person visits and could be provided through telehealth.”
According to Haber, the activity with “the largest positive effect — keeping track of which patients have or have not received preventive services and reminding patients to schedule visits to receive these services — would be relatively easy to implement.”
“This activity could be fully automated yet could reap real rewards for practices — in the form of both revenue from these additional visits and healthier patients that get the medical care they need before chronic conditions develop,” she said.
Haber acknowledged that some physicians may be reluctant to change long-standing approaches to clinical and administrative tasks. However, “these six activities at least have some evidence behind them and could be worth considering. Other activities they may be contemplating may have no evidence behind them.”
Perspective
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In general, the ethos that Burton and colleagues discuss — proactively reaching out to patients and increasing patients’ touchpoints with the health care system — when they are done well, is a good strategy that primary care practices should be utilizing to decrease costs and improve patient outcomes overall.
However, it is important to note that 88% of the patients in their study were white and 59% lived in urban areas. It is hard to say the same activities that were particularly significant in this study will apply to other primary care practices, such as a federally qualified community health center that serves predominantly Black, Indigenous and people of color or that these activities will apply to patients in predominantly rural areas.
To ascertain which PCMH activities would be best for these types of practices, health care personnel can use the same methodology Burton and colleagues did. These personnel just need to pick geographical locations and or patient populations that were more reflective of their practice.
Director, Global Primary Care and Social Change
Harvard University Center for Primary Care
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