I read with great interest an analysis of the patient-centered medical home (PCMH) phenomenon, as developed within the context of care management in federally qualified health centers (FQHCs). The article, entitled “Implementation of Medical Homes in Federally Qualified Health Centers,” appeared in the June 21, 2017 issue of The New England Journal of Medicine, and was authored by a team of 17 health care policy researchers, led by Justin W. Timbie, Ph.D. The analysis was an extremely complex and nuanced one, and difficult to summarize, but it showed that, when it comes to analyzing the extent to which the implementation of the patient-centered medical home model will work in a clinic setting depends on a host of factors; and the devil is absolutely in the details in terms of understanding the myriad elements that can positively or negatively impact patient outcomes and utilization rates for various services. In other words, it’s all very complicated.
As Dr. Timbie and his 16 fellow researchers noted at the outset of their article, “A strong primary care delivery system is critical to improving population health and controlling health care spending. The use of the patient-centered medical home—a care-delivery model that emphasizes enhanced access along with comprehensive and coordinated primary care—has spread widely during the past decade. Despite early positive evidence from high-performing health systems, recent regional and multi-payer initiatives have shown a lower-than-expected benefit from medical homes, although several initiatives are still in progress.”
Meanwhile, the researchers report, “Federally qualified health centers, a critical source of primary care for vulnerable populations, are increasingly adopting medical-home models. Medical-home recognition is associated with improved prevention and chronic disease management in such health centers,” they note, “but the effects on patients’ outcomes are not yet known. Although many federally qualified health centers have historically provided patient-centered, team-based care, the implementation of other medical-home components, such as expanding access to care after hours and developing data-analytic capabilities, may present substantial challenges in health centers that have limited financial resources or high staff turnover. Moreover, nearly half of Medicare beneficiaries who receive care at such health centers are dually eligible for Medicaid, have substantial social service needs, or have limited English proficiency or health literacy.”
In this case, the researchers focused on the Federally Qualified Health Center Advanced Primary Care Practice Demonstration, a three-year demonstration project executed between November 2011 and November 2014, and one whose goal was to “strengthen the delivery of primary care in federally qualified health centers conducted by the Centers for Medicare and Medicaid Services (CMS) in partnership with the Health Resources and Services Administration,” through the testing of support for the implementation of a medical-home model in a nationwide sample of 503 sites. “The purpose of the demonstration,” the authors noted, “was to provide technical and financial assistance to help sites achieve the highest level of Patient-Centered Medical Home recognition (level 3) by the National Committee for Quality Assurance and, through such recognition, to improve the quality of care and health care experiences for Medicare beneficiaries while reducing expenditures.”
Well, of course, determining just how valuable it was for the demonstration project’s leaders to accelerate the PCMH model inside FQHCs, was and is a tricky proposition. Would adoption of the PCMH model alone dramatically improve outcomes and utilization? That’s where this narrative gets exceedingly complicated. To begin with, let’s look at which types of FQHCs were compared. The researchers compared FQHCs that had been approved to participate in the demonstration project, with some that had not been approved. Approval was based on volume of Medicare beneficiaries (at least 200 per site), with the demonstration project’s leaders eliminating those FQHCs that served only special populations, such as homeless individuals, and not Medicare-Medicaid dual-eligibles (the types of Medicare patients seen in FQHCs).
Meanwhile, what types of outcomes were analyzed? The authors write that “We used five process-quality measures that are part of the Healthcare Effectiveness Data and Information Set [HEDIS measures], including a four-measure composite for patients with diabetes (annual testing of glycated hemoglobin and low-density lipoprotein cholesterol levels, eye examinations, and nephropathy testing) and an annual lipid test for patients with ischemic vascular disease. Measures of Medicare expenditures included costs associated with inpatient services, with Medicare Part B (including physician and supplier claims), and with all Medicare services (including inpatient, Part B, outpatient, skilled nursing, home health, durable medical equipment, and hospice).” And the researchers compared all those outcomes and measures across a span of 19 months, based on both beneficiary surveys (16,000 were completed) and interviews with leaders at 20 demonstration-site FQHCs and 10 non-demonstration-participant comparison sites.
Among the FQHCs participating in both the demonstration project and this study, no sites had achieved level-3 PCMH recognition (which recently was eliminated; going forward, there will be only one level of PCMH recognition now) in November 2011, before the demonstration began, whereas 70 percent had achieved level-3 recognition by 2014. Meanwhile, 11 percent of the comparison sites had achieved level-3 recognition by November 2014.
Now, here’s the really interesting stuff: while the demonstration sites outperformed the comparison sites on several process measures, at the same time, beneficiaries at demonstration sites had increased emergency department (ED) visits over time, whereas ED visits among beneficiaries at comparison sites remained flat during that same time period. The researchers drilled down into the data and came up with some conclusions about that counter-intuitive research result. First, they noted that, “Despite a relative increase in the number of primary care visits, beneficiaries at demonstration sites had increased rates of visits to emergency departments over time, whereas the rates in comparison sites remained unchanged, which resulted in a net increase of 30.3 visits per 1000 beneficiaries per year at demonstration sites. The utilization of inpatient services by beneficiaries increased in the two groups, but the increase was larger in demonstration sites (5.7 additional admissions per 1000 beneficiaries per year),” they discovered. “Several factors may explain the lack of improvements at demonstration sites across a wide array of quality measures and reductions in utilization and expenditures,” they stated.
First, the amount of PCMH-related funding and technical assistance unrelated to the demonstration project was essentially similar between the demonstration and comparison sites. Second, the supplementary care management payments provided to the FQHC demonstration sites was quite small--$6 per patient per month—not enough to lead to wholesale operational or care management changes. “Third,” as they pointed out, “most demonstration sites required the entire 3-year period to achieve level 3 medical-home recognition, with a majority doing so in the final quarter of the demonstration. The full effect of medical-home–related changes on utilization, expenditures, and beneficiary experiences might be observed only with the use of an extended measurement period.”
Meanwhile, they wrote that, “Although the reasons for increased rates of emergency department visits in demonstration sites remain unclear, several site leaders mentioned guiding their patients to seek care at emergency departments when their clinics were unable to provide timely technical or specialty services.37 Thus, these increases may reflect the increased commitment of staff members at demonstration sites to encourage care-seeking behavior while leveraging their improved care-coordination systems with emergency departments. These same factors could also account for higher rates of inpatient admissions and the lack of a reduction in Medicare expenditures, especially for patients at federally qualified health centers, who often report an inconsistent history of access to medical care and a pattern of presenting late in the course of an illness.”
In other words, there are good explanations for these ostensibly counter-intuitive findings.
And what do all these detailed findings say about where this is all headed? They say a lot. To begin with, as care management and population health management become more broadly and deeply embedded in the core operations of all types of health clinics, and particularly as more funding goes to creating the kinds of patient-clinic staff interactions needed in order to get patients fully on board as members of their own care management teams, some of these kinds of statistics are bound to shift. Of course, that shift will only take place as funds are made available to be channeled into such processes, on patients’ behalf. Federal healthcare officials’ simply pushing more FQHCs in particular, to adopt the PCMH model, will not do the job.
Or, as the authors put it, “The fact that patients in demonstration sites had better access to and utilization of primary care services than did those in comparison sites provides some empirical evidence to support the role of medical-home transformation among federally qualified health centers. Despite these findings, demonstration sites did not achieve significant relative reductions in key utilization and expenditure measures during a 3-year period, and the demonstration was not expanded. Any future tests of medical-home interventions in federally qualified health centers should build on these results by considering alternative designs, with attention to the magnitude of financial assistance and the duration of the evaluation, to better understand how to facilitate practice transformation and ensure that these changes translate into improved outcomes for vulnerable Medicare beneficiaries.”
In other words, parallel gains in both patient outcomes improvement and patient utilization reduction are quite possible, but it will take adequate funding from the federal government (and where appropriate, state governments) to universalize the patient-centered medical home model across all, or nearly all, FQHCs; and it will also take operational change and organizational cultural change, for those gains to move forward in parallel.
In the meantime, I salute Dr. Timbie and his 16 fellow researchers for doing such an intensive and extensive study as this one, and for bringing forward some very complex, nuanced conclusions, based on very intelligent analysis of data that can be inherently challenging to analyze and understand. Moving forward, studies like these will continue to enlighten the industry and show the way, as we inch forward towards a stronger and more innovative healthcare delivery system.