Skip to main content

Advertisement

SpringerLink
Log in

Quality and Efficiency in Small Practices Transitioning to Patient Centered Medical Homes: A Randomized Trial

  • Original Research
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

ABSTRACT

BACKGROUND

There is growing evidence that even small and solo primary care practices can successfully transition to full Patient Centered Medical Home (PCMH) status when provided with support, including practice redesign, care managers, and a revised payment plan. Less is known about the quality and efficiency outcomes associated with this transition.

OBJECTIVE

Test quality and efficiency outcomes associated with 2-year transition to PCMH status among physicians in intervention versus control practices.

DESIGN

Randomized Controlled Trial.

PARTICIPANTS

Eighteen intervention practices with 43 physicians and 14 control practices with 24 physicians; all from adult primary care practices.

INTERVENTIONS

Modeled on 2008 NCQA PPC®-PCMH™, intervention practices received 18 months of tailored practice redesign support; 2 years of revised payment, including up to $2.50 per member per month (PMPM) for achieving quality targets and up to $2.50 PMPM for PPC-PCMH recognition; and 18 months of embedded care management support. Controls received yearly participation payments.

MAIN MEASURES

Eleven clinical quality indicators from the 2009 HEDIS process and health outcomes measures derived from patient claims data; Ten efficiency indicators based on Thomson Reuter efficiency indexes and Emergency Department (ED) Visit Ratios; and a panel of costs of care measures.

KEY RESULTS

Compared to control physicians, intervention physicians significantly improved TWO of 11 quality indicators: hypertensive blood pressure control over 2 years (intervention +23 percentage points, control –2 percentage points, p = 0.02) and breast cancer screening over 3 years (intervention +3.5 percentage points, control −0.4 percentage points, p = 0.03). Compared to control physicians, intervention physicians significantly improved ONE of ten efficiency indicators: number of care episodes resulting in ED visits was reduced (intervention −0.7 percentage points, control + 0.5 percentage points, p = 0.002), with 3.8 fewer ED visits per year, saving approximately $1,900 in ED costs per physician, per year. There were no significant cost-savings on any of the pre-specified costs of care measures.

CONCLUSIONS

In a randomized trial, we observed that some indicators of quality and efficiency of care in general adult primary care practices transitioning to PCMH status can be significantly, but modestly, improved over 2 years, although most indicators did not improve and there were no cost-savings compared with control practices. For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1.
Figure 2.

Similar content being viewed by others

REFERENCES

  1. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Affair. 2008;27(3):759–69.

    Article  Google Scholar 

  2. Barr MS. The need to test the patient-centered medical home. JAMA. 2008;300(7):834–5.

    Article  PubMed  CAS  Google Scholar 

  3. Peikes D, Zutshi A, Genevro J, Smith K, Parchman M, Meyers D. Early Evidence on the Patient-Centered Medical Home. Final Report. Rockville (MD): Agency for Healthcare Research and Quality; 2012 Feb. Contract No.: HHSA290200900019I/HHSA29032002T and HHSA290200900019I/HHSA29032005T. Sponsored by: Agency for Healthcare Research and Quality.

  4. Counsell SR, Callahan CM, Tu W, Stump TW, Arling GW. Cost analysis of the geriatric resources for assessment and care of elders management intervention. J Am Geriatr Soc. 2009;57(8):1420–6.

    Article  PubMed  Google Scholar 

  5. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care. JAMA. 2000;284(22):2877–85.

    Article  PubMed  CAS  Google Scholar 

  6. Boult C, Reider L, Leff B, et al. The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med. 2011;171(5):460–6.

    Article  PubMed  Google Scholar 

  7. Unützer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14(2):95–100.

    PubMed  Google Scholar 

  8. Steele GD, Haynes JA, Davis DE, et al. How Geisinger’s advanced medical home model argues the case for rapid-cycle innovation. Health Affair. 2010;29(11):2047–53.

    Article  Google Scholar 

  9. Bielaszka-DuVernay C. The ‘GRACE’ model: in-home assessments lead to better care for dual eligibles. Health Affair. 2011;30(3):431–4.

    Article  Google Scholar 

  10. Counsell SR, Callahan CM, Clark DO, et al. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007;298(22):2623–33.

    Article  PubMed  CAS  Google Scholar 

  11. Hunkeler EM, Katon W, Tang L, et al. Long term outcomes from the IMPACT randomized trial for depressed elderly patients in primary care. BMJ. 2006;332(7536):259–62.

    Article  PubMed  Google Scholar 

  12. Dorr DA, Wilcox AB, Brunker CP, Burdon RE, Donnelly SM. The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors. J Am Geriatr Soc. 2008;56(12):2195–202.

    Article  PubMed  Google Scholar 

  13. National Committee for Quality Assurance. Standards and Guidelines for Physician Practice Connections—Patient-Centered Medical Home Version. 2008 [cited 2013 February 4]. Available from: URL: http://www.usafp.org/PCMH-Files/NCQA-Files/PCMH_Overview_Apr01.pdf.

  14. Fifield J, Dauser Forrest D, Martin-Peele M, Burleson JA, Goyzueta J, Fujimoto M, Gillespie W. A Randomized, Controlled Trial of Implementing the Patient-Centered Medical Home Model in Solo and Small Practices. JGIM 2012; Online First 07 September 2012, doi: 10.1007/s11606-012-2197-z.

  15. Bitton A, Martin C, Landon BE. A nationwide survey of patient centered medical home demonstration projects. JGIM. 2010;25(6):584–92.

    Article  PubMed  Google Scholar 

  16. Stout RL, Wirtz PW, Carbonari JP, Del Boca FK. Ensuring balanced distribution of prognostic factors in treatment outcome research. J Stud Alcohol 1994; Suppl 12:70–5.

    Google Scholar 

  17. Gawande A. Medical Report: the Hot Spotters. The New Yorker 2011 January 24 [cited 2013 February 4]. Available from: URL: http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande.

  18. Robert Wood Johnson Foundation. Expanding “Hot spotting” to New Communities. Princeton (NJ): Robert Wood Johnson Foundation; 1 January 2012 [cited 2013 February 4]. Available from: URL: http://www.rwjf.org/content/dam/farm/meetings_and_conferences/speeches_and_presentations/2012/rwjf72538.

  19. National Committee for Quality Assurance (US). HEDIS 2009. Washington: Technical Specifications. 2008;2.

  20. National Committee for Quality Assurance. Quality Compass 2012. Available at: URL: http://www.ncqa.org/tabid/177/Default.aspx. Accessed February 4, 2013.

  21. Rosenthal MB, Abrams MK, Bitton A, Patient-Centered Medical Home Evaluators’ Collaborative. Recommended Core Measures for Evaluating the Patient-Centered Medical Home: Cost, Utilization, and Clinical Quality [data brief]. New York: Commonwealth Fund; 2012 May. Publication No. 1601,12.

  22. Meyers D, Peikes D, Dale S, Lundquist E, Genevro J. Improving Evaluations of the Medical Home. Rockville (MD): Agency for Healthcare Research and Quality; 2011 Sept. AHRQ Publication No. 11-0091.

  23. Thomson Healthcare. MEG—Medical Episode Grouper™ [manual]. New York (NY): Thomson Healthcare; 2007.

    Google Scholar 

  24. Lyons K, Sayer A. Longitudinal dyad models in family research. J Marriage Fam. 2005;67(4):1048–60.

    Article  Google Scholar 

  25. Preacher KJ, Curran PJ, Bauer DJ. Computational tools for probing interactions in multiple linear regression, multilevel modeling, and latent curve analysis. J Educ Behav Stat. 2006;31(3):437–48.

    Article  Google Scholar 

  26. Barnett R, Marshall N, Raudenbush S, Brennan R. Gender and the relationship between job experiences and psychological distress: a study of dual-earner couples. J Pers Soc Psychol. 1993;64(5):794–806.

    Article  PubMed  CAS  Google Scholar 

  27. Raudenbush S, Brennan R, Barnett R. A multivariate hierarchical model for studying psychological change within married couples. J Fam Psychol. 1995;9(2):161–74.

    Article  Google Scholar 

  28. Sheskin DJ. Handbook of Parametric and Nonparametric Statistical Procedures. 3rd ed. Boca Raton (FL): Chapman & Hall; 2004.

    Google Scholar 

  29. Tabachnick BG, Fidell LS. Using Multivariate Statistics. 5th ed. Boston (MA): Pearson; 2007.

    Google Scholar 

  30. Raudenbush S, Bryk A, Congdon R. HLM 6 for Windows [computer program]. Skokie (IL): Scientific Software International, Inc; 2004.

    Google Scholar 

  31. Raudenbush SW, Bryk AS. Hierarchical Linear Models. Thousand Oaks (CA): Sage Publications, Inc; 2002.

    Google Scholar 

  32. Hox J. Multilevel Analysis: Techniques and Applications. 2nd ed. New York (NY): Routledge; 2010:233–56.

    Google Scholar 

  33. Steiner BD, Denham AC, Ashkin E, Newton WP, Wroth T, Dobson LA. Community care of North Carolina: improving care through community health networks. Ann Fam Med. 2008;6(4):361–7.

    Article  PubMed  Google Scholar 

  34. Reid RJ, Coleman K, Johnson EA, et al. The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for physicians. Health Affair. 2010;29(5):835–43.

    Article  Google Scholar 

  35. Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;7(3):254–60.

    Article  PubMed  Google Scholar 

  36. Solberg LI, Asche SE, Fontaine P, Flottemesch TJ, Anderson LH. Trends in quality during medical home transformation. Ann Fam Med. 2011;9(6):515–21.

    Article  PubMed  Google Scholar 

  37. Milstein A, Gilbertson E. American medical home runs: four real-life examples of primary care practices that show a better way to substantial savings. Health Affair. 2009;28(5):1317–26.

    Article  Google Scholar 

  38. Nelson EC, Batalden PB, Godfrey MM, eds. Quality by Design: A Clinical Microsystems Approach. San Francisco (CA): Jossey-Bass; 2007.

    Google Scholar 

  39. Villagra VG. Accelerating the adoption of medical homes in connecticut: a chronic-care support system modeled after public utilities. Conn Med. 2012;76(3):173–8.

    PubMed  Google Scholar 

  40. Asch DA, Muller RW, Volpp KG. Automated hovering in health care—watching the 5,000 hours. N Engl J Med. 2012;367(1):1–3.

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgements

The Commonwealth Fund supported the independent evaluation of this demonstration by the Ethel Donaghue Center for Translating Research into Practice and Policy (TRIPP Center) at the University of Connecticut Health Center from 1 December 2007 through 31 March 2010. EmblemHealth has provided continued evaluation support for the purposes of data analysis, 1 March 2011 through 31 May 2011 and 1 September 2011 to 31 December 2013. The full trial protocol can be accessed by contacting EmblemHealth.

Conflict of Interest

Judith Fifield, PhD, reports having received two honoraria from Zimmer in the last 3 years. All other authors declare no conflict of interest.

Author information

Authors and Affiliations

  1. University of Connecticut Health Center, Farmington, CT, USA

    Judith Fifield PhD, Deborah Dauser Forrest PhD, Joseph A. Burleson PhD & Melanie Martin-Peele MA

  2. EmblemHealth, New York, NY, USA

    William Gillespie MD

  3. Ethel Donaghue TRIPP Center, 263 Farmington Ave. MC6229, Farmington, CT, 06030, USA

    Judith Fifield PhD, Deborah Dauser Forrest PhD & Melanie Martin-Peele MA

  4. Community Medicine and Health Care, Famington, CT, USA

    Joseph A. Burleson PhD

Authors
  1. Judith Fifield PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Deborah Dauser Forrest PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Joseph A. Burleson PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Melanie Martin-Peele MA
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. William Gillespie MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Judith Fifield PhD.

Electronic supplementary material

Below are the links to the electronic supplementary material.

ESM 1

(DOCX 24.2 kb)

ESM 2

(DOCX 60.5 kb)

ESM 1

(DOCX 20 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Fifield, J., Forrest, D.D., Burleson, J.A. et al. Quality and Efficiency in Small Practices Transitioning to Patient Centered Medical Homes: A Randomized Trial. J GEN INTERN MED 28, 778–786 (2013). https://doi.org/10.1007/s11606-013-2386-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-013-2386-4

KEY WORDS

Search

Navigation