PCPCC PCMH Evidence Report Feb 2016
Transcript of PCPCC PCMH Evidence Report Feb 2016
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The Patient-Centered Medical Home’s Impact on Cost and Quality Annual Review of Evidence 2014-2015Published February 2016
Authors:
Marci Nielsen, PhD, MPH
Lisabeth Buelt, MPH
Kavita Patel, MD, MS
Len M. Nichols, PhD, MS, MA
Made possible with
support from the
Milbank Memorial Fund
601 13th Street NWSuite 430 N
Washington, DC 20005www.pcpcc.org
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transformation. For more information, or to become an executive member, visit www.pcpcc.org.
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AUTHORSMarci Nielsen, PhD, MPH
Chief ExecutLYH�2I÷�FHU��PCPCC
Lisabeth Buelt, MPH3ROLF\�DQG�5HVHDUFK�0DQDJHU��PCPCC
Kavita Patel, MD, MSNonresident Senior Fellow, Economic Studies, The Brookings Institution
Len M. Nichols, PhD, MS, MA 'LUHFWRU��&HQWHU�IRU�+HDOWK�3ROLF\�5HVHDUFK�DQG�(WKLFV��George Mason University
The Patient-Centered Medical Home’s Impact on Cost and QualityAnnual Review of Evidence 2014-20153DWLHQW�&HQWHUHG�3ULPDU\�&DUH�&ROODERUDWLYH
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ACKNOWLEDGMENTS7KH�3&3&&�DQG�WKH�0LOEDQN�0HPRULDO�)XQG�JUDWHIXOO\�DFNQRZOHGJH�WKH�IROORZLQJ�LQGLYLGXDOV�IRU�WKHLU�
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REVIEWERS Christine Bechtel, MA
President and CEO, Bechtel Health;
Advisor, National Partnership for Women & Families
Asaf Bitton, MD, MPH
Director, Primary Health Care Performance Initiative at Ariadne Labs;
$VVLVWDQW�3URIHVVRU�RI�0HGLFLQH�DQG�+HDOWK�&DUH�3ROLF\��Brigham and Women’s Hospital &
Harvard Medical School
Jean Malouin, MD, MPH
Medical Director, Value Partnerships, Blue Cross Blue Shield of Michigan�
Assistant Professor, Associate Medical Director, University of Michigan Medical Group
Mary Minniti, BS, CPHQ
6HQLRU�3ROLF\�DQG�3URJUDP�6SHFLDOLVW��Institute for Patient- and Family-Centered Care
Bob Phillips, MD, MPH
9LFH�3UHVLGHQW�RI�5HVHDUFK�DQG�3ROLF\� American Board of Family Medicine
Sarah Hudson Scholle, DrPH, MPH
9LFH�3UHVLGHQW�RI�5HVHDUFK�DQG�$QDO\VLV��National Committee for Quality Assurance
Lisa Dulsky Watkins, MD
Director, Milbank Memorial Fund Multi-State Collaborative
Reviewer Disclaimer: $OWKRXJK�WKH�UHYLHZHUV�OLVWHG�DERYH�SURYLGHG�PDQ\�FRQVWUXFWLYH�FRPPHQWV�DQG�
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would like to thank Christopher Koller, President of the Milbank Memorial Fund, and his staff for their
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PCPCC STAFF
Marci Nielsen, PhD, MPH
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Lisabeth Buelt, MPH
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Amy Gibson, RN, MS
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Tara Hacker, MSPH
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Katy Hill, MS
Administrative Coordinator
Amanda Holt, MPH
Director of Communications &
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Fatema Salam, MPH
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PCPCC BOARD OF DIRECTORS
Douglas Henley, MD, FAAFP, Chair
([HFXWLYH�9LFH�3UHVLGHQW��&KLHI�([HFXWLYH�2I÷�FHU��
American Academy of Family Physicians
Jill Rubin Hummel, JD, Chair-Elect
3UHVLGHQW��*HQHUDO�0DQDJHU��Anthem Blue Cross and Blue Shield of Connecicut
Andrew Webber, Treasurer
&KLHI�([HFXWLYH�2I÷�FHU��Maine Health Management Coalition
Susan Edgman-Levitan, PA-C
Executive Director, John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital
Elizabeth J. Fowler, PhD, JD
9LFH�3UHVLGHQW��*OREDO�+HDOWK�3ROLF\��Johnson & Johnson
Paul Grundy, MD, MPH, FACOEM
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David Hebert, JD
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Beverley H. Johnson
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Institute for Patient- and Family-Centered Care
Hal C. Lawrence III, MD
([HFXWLYH�9LFH�3UHVLGHQW��&KLHI�([HFXWLYH�2I÷�FHU��
The American College of Obstetricians and Gynecologists
David K. Nace, MD
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Marci Nielsen, PhD, MPH
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Karen Remley, MD, MBA, MPH, FAAP
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American Academy of Pediatrics
Steven E. Weinberger, MD, FACP
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American College of Physicians
Adrienne White-Faines, MPA
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American Osteopathic Association
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TABLE OF CONTENTS
EXECUTIVE SUMMARY .........................................................................................................4
SECTION ONE:A CHANGING POLICY LANDSCAPE ............................................................................. ...6
Why PCMH? The Case for Increased Investment in Primary Care ............................................... 6
'H÷�QLWLRQ�RI�0HGLFDO�+RPH��,Q�1HHG�RI�D�8QL÷�HG�9LHZ ................................................................... 7
PCMH and Primary Care Innovations: Growing in Size and Scope .............................................. 8
New Era: Delivery Reform Meets Payment Reform .......................................................................... 8
Payment Reform & PCMH: Value-based Purchasing in the Public and Private Sector ......... 9
Multi-payer Collaboratives: Opportunities for Alignment & Health System Redesign ......10
Payment Reform & Medicare .................................................................................................................11
SECTION TWO:NEW EVIDENCE FOR PCMH AND INNOVATIONS IN PRIMARY CARE ...........12
Methods ..........................................................................................................................................................12
Table 1. Peer-Reviewed Studies ..............................................................................................................14
Table 2. State Government Evaluations ...............................................................................................21
Table 3. Industry Reports ..........................................................................................................................23
Table 4. Independent Evaluations of Federal Initiatives .................................................................26
SECTION THREE: DISCUSSION OF FINDINGS AND IMPLICATIONS ................................................28
Peer-Reviewed Studies (Table 1) ............................................................................................................28
State Government Evaluations (Table 2)..............................................................................................30
Industry Reports (Non Peer-Reviewed) (Table 3) .............................................................................31
Independent Evaluations of Federal Initiatives (Table 4) ...............................................................31
Payment Model Insights and the Importance of Multi-Payer Initiatives ..................................32
Challenges in Evaluating Primary Care PCMH Interventions ......................................................33
CONCLUSION ........................................................................................................................ 33
APPENDIX 1: EDUCATIONAL INFOGRAPHIC FOR PATIENTS AND FAMILIES ........................ 35
REFERENCES .......................................................................................................................... 36
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Key points from this year’s evidence review include:
Controlling Costs by Right Sizing Care: Advanced primary care is foundational to delivery system transformation — medical home initiatives continue to reduce health care costs and unnecessary utilization of services
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Aligning Payment and Performance: Payment reform is necessary to sustain delivery system changes, but alignment across payers is critical for health care provider buy-in
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Assessing and Promoting Value: Measurement for PCMHs must be aligned and focused on value for patients, providers, and payers
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Why PCMH? The Case for Increased Investment in Primary Care
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health care spend can be attributed to overuse, underuse, and misuse of health care resources.9 The spread
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economic welfare.10
For most Americans, primary care serves as the entry point and touchstone of the health care system,
delivering and coordinating care for patients and families, with an emphasis on promoting population
health and managing chronic illness. As such, primary care is well positioned to help repair and
optimize our broken care delivery system. :LWK�JUHDWHU�LQYHVWPHQW�LQ�DQG�VXSSRUW�IRU�FRPSUHKHQVLYH�
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WKH�$JHQF\�IRU�+HDOWKFDUH�5HVHDUFK�DQG�4XDOLW\12 are:
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• Comprehensive: The PCMH offers whole-person care from a team of providers that is accountable
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and chronic care.
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care supports.
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all.” PCMH practices differ in terms of their implementation, measurement, and performance,�� and the
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PCMH and Primary Care Innovations: Growing in Size and Scope
As this report and our PCMH innovations map16�GHPRQVWUDWH��WKH�QXPEHU�RI�SUDFWLFHV�WUDQVIRUPLQJ�
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Map is a comprehensive up-to-date resource.
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State View
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Primary Care Innovations and PCMH Map
New Era: Delivery Reform Meets Payment Reform
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broader commercial marketplace.
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Medicare Access and CHIP Reauthorization Act (MACRA)
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as a failure to achieve improvement for that outcome but rather an indication that no information on that
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Location/Initiative
Multi-State
CHIPRA Quality Demonstration Grant Program42
Published: Academic Pediatrics, May 2015
Data Review: 2010-2012 claims data
Study evaluated utilization and access measures
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Published: Annals of Emergency Medicine, March 2015
Data Review: July 2007-June 2008 (baseline group); July 2008- June 2010 (comparison groups)
Study evaluated cost and utilization measures
Compared with non-PCMH practices, PCMHs had lower rate of growth for:• ('�SD\PHQWV�SHU�EHQH÷�FLDU\�������OHVV�IRU�����������OHVV�for 2010)
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Veterans Health Administration Patient Aligned Care Teams (PACTs)44
Published: American Journal of Managed Care, March 2015
Data Review: FY 2009 (baseline); FY 2011 (comparison group)
Study evaluated cost, utilization and access measures
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Payment Model
Description Additional OutcomesCost & Utilization
���� &KULVWHQVHQ��$�/���=LFNDIRRVH��-�6���1DW]NH��%���0F0RUURZ��6����,UH\V��+�7����������$VVRFLDWLRQV�EHWZHHQ�SUDFWLFH�UHSRUWHG�PHGLFDO�KRPHQHVV�DQG�KHDOWK�FDUH�XWLOL]DWLRQ�DPRQJ�SXEOLFO\�LQVXUHG�FKLOGUHQ��Academic Pediatrics, 15�������������GRL����������M�DFDS��������������6WXG\�DXWKRUV�FRQGXFWHG�D�ÜFURVV�VHFWLRQDO�DQDO\VLV�DVVHVVLQJ�WKH�UHODWLRQVKLS�EHWZHHQ�SUDFWLFH�UHSRUWHG�PHGLFDO�ÙKRPHQHVVÚ�DQG�KHDOWK�VHUYLFH�XVH�E\�FKLOGUHQ�HQUROOHG�LQ�0HGLFDLG�LQ����SUDFWLFHV�LQ���VWDWHV�SDUWLFLSDWLQJ�LQ�WKH�&+,35$�4XDOLW\�'HPRQVWUDWLRQ�*UDQW�3URJUDP��,OOLQRLV��,/���1RUWK�&DUROLQD��1&���DQG�6RXWK�&DUROLQD��6&��Ý�:KLOH�UHGXFWLRQV�LQ�XWLOL]DWLRQ�ZHUH�UHDOL]HG�LQ�,OOLQRLV�SUDFWLFHV��QR�DVVRFLDWLRQ�ZDV�IRXQG�LQ�1RUWK�&DUROLQD�RU�6RXWK�&DUROLQD�SUDFWLFHV��
���� 3LQHV��-�0���.H\HV��9���9DQ�+DVVHOW��0����0F&DOO��1����������(PHUJHQF\�GHSDUWPHQW�DQG�LQSDWLHQW�KRVSLWDO�XVH�E\�0HGLFDUH�EHQH÷�FLDULHV�in patient-centered medical homes. Annals of Emergency Medicine, �������������GRL����������M�DQQHPHUJPHG��������������7KH�VWXG\�DXWKRUV�XVHG�D�UHWURVSHFWLYH��ORQJLWXGLQDO��SUDFWLFH�OHYHO�DQDO\VLV�WR�HYDOXDWH�RXWFRPHV�GDWD�IURP�1&4$�UHFRJQL]HG�3&0+�SUDFWLFHV�XVLQJ�0HGLFDUH�FODLPV�GDWD�IURP�)<����������FRPSDUHG�WR�EDVHOLQH�FODLPV�GDWD�IURP�-XO\������-XQH�������
���� <RRQ��-���/LX��&�)���/R��-���6FKHFWPDQ��*���6WDUN��5���5XEHQVWHLQ��/�9����<DQR��(�0����������(DUO\�FKDQJHV�LQ�9$�PHGLFDO�KRPH�FRPSRQHQWV�DQG�XWLOL]DWLRQ��American Journal of Managed Care, 21��������������6WXG\�DXWKRUV�FRQGXFWHG�D�ORQJLWXGLQDO�VWXG\��ZKLFK�HYDOXDWHG�SDWLHQWV�WKDW�KDG�DW�OHDVW�WZR�SULPDU\�FDUH�YLVLWV�LQ�)<������DQG�XVHG�DQ\�RXWSDWLHQW�FDUH�LQ�������7KH�VWXG\�VDPSOH�LQFOXGHG�����������SDWLHQWV�IURP�����FOLQLFV��7R�VXSSRUW�3$&7�LPSOHPHQWDWLRQ��WKH�9$�KLUHG�51�FDUH�PDQDJHUV�IRU�HDFK�3$&7�FDUH�WHDP��DV�ZHOO�DV�D�IXOO�WLPH�KHDOWK�SURPRWLRQ�VSHFLDOLVW�DQG�D�KHDOWK�EHKDYLRU�FRRUGLQDWRU�DW�HYHU\�9+$�IDFLOLW\�
TABLE 1: PEER-REVIEWED STUDIES: Primary Care/PCMH Interventions That Assessed Cost or Utilization, Selected Outcomes by Location, 2014-2015
PAGE 15
National (continued)
Veterans Health Administration Patient Aligned Care Teams (PACTs)45
Published: Journal of Health Care Quality, November 2014
Data Review: April 2009 – March 2010 (Pre-PACT baseline); June 2011 – May 2012 (Post-PACT comparison group)
Study evaluated utilization and access measures
For all veterans:• 8.61% reduction in
hospitalizations (p<.05)• 7.54% reduction in specialty
visits (p<.05)
Veterans under age 65:• 9.41% reduction in
hospitalizations (p<.05)• 2.56% reduction in specialty
visits(p<.05)
Veterans over age 65:• 3.49% reduction in specialty
visits (p<.05)• 18.47% reduction in urgent
care visits (p<.05)
• 10.79% increase in primary care visits for all veterans (p<.05)
• 11.23% increase in primary care visits for those under age 65 (p<.05)
• 11.86% increase in primary care visits over age 65 (p<.05)
Single payer
Location/InitiativePayment Model
Description Additional OutcomesCost & Utilization
Table 1 continued
45 Randall, I., Mohr, D.C., & Maynard, C. (2014). VHA Patient-Centered Medical Home associated with lower rate of hospitalizations and specialty care among veterans with Posttraumatic Stress Disorder. Journal of Health Care Quality. doi: 10.1111/jhq.12092 Researchers conducted a “pre–post implementation study to explore the associations between PACT implementation and utilization outcomes using clinical and administrative data from the VHA’s Corporate Data Warehouse.” This study only evaluated PACT participants with Post-Traumatic Stress Disorder.
46 Pourat, N., Davis, A., Chen, X., Vrungos, S., & Kominski, G. (2015). In California, primary care continuity was associated with reduced emergency department use and fewer hospitalizations. Health Affairs, (34)7. doi: 10.1377/hlthaff.2014.1165 The Health Care Coverage Initiative required counties to assign patients to a “medical home”. At a minimum, a medical home had to consist of a provider who was an enrollee’s usual source of primary care, maintained the enrollee’s medical records, and coordinated his or her care. This study evaluated the intervention using pre and post-intervention claims data. In the 3rd year of the intervention, the program declined to pay providers for the non-urgent claims submitted for non-assigned patients.
California
Health Care Coverage Initiative46
Published: Health Affairs, July 2015
Data Review: September 2008–August 2009 (pre period); September 2009-August 2010 (post period)
Study evaluated utilization and access to care measures
Enrollees who saw their assigned primary care providers had:• Higher probability of no
ED visits (2.1%) and no hospitalizations (1.7%)
Among this population, the percent of patients with:• 2 or more annual ED visits
decreased from 4.11% to 3.13%
• 2 or more hospitalizations decreased from 1.37% to 1.17%
After the intervention, enrollees had:• Improved continuity with one
primary care provider (69.6% vs. 31.4%)
• 41.8% higher probability of seeing the same provider
Fee-for-service withpotential provider “penalties”
PAGE 16
Table 1 continued
California (continued)
UCLA Health System47
Published: American Journal of Managed Care, September 2015
Data Review: May 2012-July 2013
Study evaluated utilization measures, but reported on estimated cost and provider satisfaction
Compared with control practices, patients served by practices with coordinated care had:• ����JUHDWHU�UHGXFWLRQ�LQ�
pre-post ED visits (p<.0001)• 12% reduction in ED XWLOL]DWLRQ��p<.001)
• This led to estimated UHGXFWLRQ�RI������PLOOLRQ�LQ�total cost of care over one \HDU��FRVW�RI�VWDII�EHQH÷�WV�ZDV����������RYHU�WKH�VDPH�WLPH
An internal survey of 52 physicians at the time of the intervention found: • ����VDLG�WKH�SURJUDP�ZDV�
effective• ����VDLG�WKHLU�SDWLHQWV�ZHUH�HQWKXVLDVWLF�DERXW�DXJPHQWHG�services
Mixed payment model“Although UCLA Health has population-based capitation and risk-sharing contracts, many patients are in traditional fee-for-service plans. The CCCs evaluated in this study support patients irrespective of insurance type”
Colorado
Colorado Multi-payer PCMH pilot48
Published: Journal of General Internal Medicine, October 2015
Data Review: April 2007-March 2009 (pre-intervention baseline); April 2009-March 2012 (post-intervention)
Study evaluated cost, utilization and quality measures
• 1R�QHW�RYHUDOO�FRVW�VDYLQJV�LQ�VWXG\�SHULRG��SRVVLEO\�GXH�WR�RIIVHWWLQJ�LQFUHDVHV�LQ�RWKHU�VSHQGLQJ�FDWHJRULHV
Two years after initiation of pilot, PCMH practices (vs. baseline) had:• 5HGXFWLRQ�LQ�('�FRVWV�RI�������3030���������p< 0.001) and �������3030�IRU�SDWLHQWV�with 2 or more comorbidities ��������p<.0001)
• ~7.9 % reduction in ED use (p=0.02)
• �����UHGXFWLRQ�LQ�SULPDU\�care visits (p=.006) for patients with 2 or more comorbidities
Three years after initiation, PCMH practices showed sustained improvements with:• 5HGXFWLRQ�LQ�('�FRVWVRI�������3030���������p ��������DQG�������3030�for patients with 2 or more FRPRUELGLWLHV���������p� �����
• �����UHGXFWLRQ�LQ�('�YLVLWV�(p=0.01)
• �����UHGXFWLRQ�LQ�SULPDU\�care visits (p=.06) for patients with 2 or more comorbidities
• ������UHGXFWLRQ�LQ�$&6&�inpatient admissions (p=0.05)
PCMH pilot practices were associated with:• ,QFUHDVHG�FHUYLFDO�FDQFHU�VFUHHQLQJ�UDWHV�DIWHU���\HDUV�(12.5% increase, p<.001) DQG���\HDUV�������LQFUHDVH��p<.001)
• /RZHU�UDWHV�RI�+E$�F�WHVWLQJ�in patients with diabetes (.7% UHGXFWLRQ�DW���\HDUV��p ����
• Lower rates of colon cancer VFUHHQLQJ��������DQG�������DW���DQG���\HDUV�UHVSHFWLYHO\�p<.001)
• 'HFUHDVHG�SULPDU\�FDUH�YLVLWV�������DW���\HDUV��p=.02)
PMPM fees based on the level of NCQA accreditation that each practice attained
Pay-for-performance�SURJUDP��which awarded bonuses to SUDFWLFHV�EDVHG�RQ�PHHWLQJ�ERWK�TXDOLW\�DQG�XWLOL]DWLRQ�benchmarks
This is a multi-payer initiative
Location/InitiativePayment Model
Description Additional OutcomesCost & Utilization
���� &ODUNH��5���%KDUPDO��1���'L�&DSXD��3���7VHQJ��&���0DQJORQH��&�0���0LWWPDQ��%����6NRRWVN\��6�$����������,QQRYDWLYH�DSSURDFK�WR�SDWLHQW�FHQWHUHG�FDUH�FRRUGLQDWLRQ�LQ�SULPDU\�FDUH�SUDFWLFHV��American Journal of Managed Care, 21��������������5HWULHYHG�IURP�KWWS���ZZZ�DMPF�FRP�MRXUQDOV�LVVXH�����������YRO���Q��LQQRYDWLYH�DSSURDFK�WR�SDWLHQW�FHQWHUHG�FDUH�FRRUGLQDWLRQ�LQ�SULPDU\�FDUH�SUDFWLFHV�7KH�VWXG\�DXWKRUV�XVHG�D�PXOWLYDULDWH�UHJUHVVLRQ�PRGHO�FRQWUROOLQJ�IRU�DJH��JHQGHU��DQG�PHGLFDO�FRPSOH[LW\�WR�HYDOXDWH��������XQLTXH�SDWLHQWV�LQ����RI�WKH����HYDOXDWHG�SUDFWLFHV�RYHU�D�RQH�\HDU�SHULRG��7KH�VWXG\�DXWKRUV�QRWH�WKDW�WKH�Ü8&/$�+HDOWK�6\VWHP�GHYHORSHG�D�WUDQVIRUPDWLRQ�PRGHO�WKDW�LQFOXGHV�DVSHFWV�IURP�PDQ\�3&0+�GRPDLQV�Ý�7KLV�PRGHO�LQFOXGHV�&RPSUHKHQVLYH�&DUH�&RRUGLQDWRUV��&&&V��LQ�WKH�FDUH�WHDP��&&&V�DUH�HPEHGGHG�LQ�HDFK�SUDFWLFH�WR�VXSSRUW�SDWLHQWV�DQG�KHOS�WKHP�QDYLJDWH�WKH�KHDOWK�FDUH�V\VWHP��
���� 5RVHQWKDO��0�%���$OLGLQD��6���)ULHGEHUJ��0�:���6LQJHU��6�-���(DVWPDQ��'���/L��=����6FKQHLGHU��(�&����������$�GLIIHUHQFH�LQ�GLIIHUHQFH�DQDO\VLV�RI�FKDQJHV�LQ�TXDOLW\��XWLOL]DWLRQ�DQG�FRVW�IROORZLQJ�WKH�&RORUDGR�0XOWL�3D\HU�3DWLHQW�&HQWHUHG�0HGLFDO�+RPH�3LORW��Journal of General Internal Medicine.�GRL����������V�����������������$XWKRUV�FRQGXFWHG�GLIIHUHQFH�LQ�GLIIHUHQFH�DQDO\VHV�HYDOXDWLQJ����VPDOO�DQG�PHGLXP�VL]HG�SUDFWLFHV�SDUWLFLSDWLQJ�LQ�D�PXOWL�SD\HU�3&0+�SLORW��7KH�DXWKRUV�H[DPLQHG�WKH�SRVW�LQWHUYHQWLRQ�SHULRG�WZR�\HDUV�DQG�WKUHH�\HDUV�DIWHU�WKH�LQLWLDWLRQ�RI�WKH�SLORW��
PAGE 17
Table 1 continued
Location/Initiative
Michigan
Blue Cross Blue Shield of Michigan Physician Group Incentive Program49
Published: Health Affairs, April 2015
Data Review: 2008 claims data (pre-intervention period); 2009-2011 claims data for cost analyses and 2009–2010 claims data for quality analyses (post-intervention period)
Study evaluated cost and quality measures
• PCMH practices decreased WRWDO�3030�VSHQGLQJ�E\�������PRUH�WKDQ�FRQWURO�practices (a 1.1% difference)
• However practice PMPM VSHQGLQJ�LQFUHDVHG�E\�������LQ�\HDU����3UDFWLFHV�GLG�QRW�VHH�QHW�VDYLQJV�XQWLO�VHFRQG�\HDU�
• 3&0+�SURYLGHUV�VSHQW�������PMPM less for pediatric SDWLHQWV��D�VDYLQJV�RI�����
3URJUDP�SUDFWLFHV�DFKLHYHG�same or better performance RYHU�VWXG\�SHULRG�RQ����RI����TXDOLW\�PHDVXUHV
Pay-for-Performance“Participating PCPs: • were eligible for up to 20%
increased reimbursement for RI÷�FH�YLVLW�IHHV�
• could bill for care coordination and care management services provided by ancillary providers
• had opportunity to earn an additional 5% in EM* fees for achieving high performance on quality measures”
0LFKLJDQ�%&%6�SDUWLFLSDWHV�LQ�a multi-payer demonstration (MAPCP)
Blue Cross Blue Shield of Michigan Physician Group Incentive Program49
Published: Medical Care Research and Review, August 2015
Data Review: July 2009- June 2012
Study evaluated cost and quality measures
3UDFWLFHV�EHJLQQLQJ�WKH�VWXG\�ZLWK�KLJK�LPSOHPHQWDWLRQ�VFRUHV�(“full implementation”) versus those with low implementation scores (“no implementation”) KDG��������3030�ORZHU�FRVWV�IRU�DGXOW�SDWLHQWV�DIWHU���\HDUV��������p = .02)
• 3UDFWLFHV�EHJLQQLQJ�WKH�VWXG\�ZLWK�KLJK�LPSOHPHQWDWLRQ�scores “full PCMH implementation” vs. those with low scores “no PCMH LPSOHPHQWDWLRQÝ�KDG�KLJKHU�DGXOW�TXDOLW\�FRPSRVLWH�VFRUHV��������p�������DQG�KLJKHU�adult preventive composite VFRUH��������p<.001) after ��\HDUV
• 3UDFWLFHV�WKDW�FKDQJHG�WKHLU�PCMH implementation score KDG�KLJKHU�DGXOW�TXDOLW\�FRPSRVLWH�VFRUHV��������S�������DQG�KLJKHU�DGXOW�preventive composite score �������p�������DIWHU���\HDUV
Pay-for-PerformanceÜ7KH�SURJUDP�SURYLGHV�÷�QDQFLDO�incentives to physician organiza-tions when their member practices implement PCMH capabilities” 0LFKLJDQ�%&%6�SDUWLFLSDWHV�LQ�a multi-payer demonstration (MAPCP)
New York
Hudson Valley Initiative51
Published: American Journal of Managed Care, May 2015
Data Review: 2008-2010 claims data
Study evaluated utilization measures
• Patients in a PCMH had 6% reduction in specialist visits YV��QRQ�3&0+V�DIWHU�RQH�\HDU�of implementation, without LQFUHDVLQJ�('�YLVLWV�RU�KRVSLWDO�admissions
“This study evaluates part of the Hudson Valley Initiative,a multi-payer program in which six health plans agreed to provide ÷�QDQFLDO�LQFHQWLYHV�UDQJLQJ�IURP�$2 to $10 PMPM, to practices that implemented Level III PCMHs based on 2008 NCQA standards”This is a multi-payer initiative
Payment Model
Description Additional OutcomesCost & Utilization
���� /HPDN��&+���1DKUD��7$���&RKHQ��*5���(UE��1'���3DXVWLDQ��0/���6KDUH��'����+LUWK��5$����������0LFKLJDQÚV�IHH�IRU�YDOXH�SK\VLFLDQ�LQFHQWLYH�SURJUDP�UHGXFHV�VSHQGLQJ�DQG�LPSURYHV�TXDOLW\�LQ�SULPDU\�FDUH��Health Affairs, (34)���GRL����������KOWKDII�����������6WXG\�DXWKRUV�XVHG�D�GLIIHUHQFH�LQ�GLIIHUHQFHV�GHVLJQ�WR�HYDOXDWH�PRUH�WKDQ�����PLOOLRQ�SDWLHQWV�XQGHU�DJH����VHUYHG�E\�%OXH�&URVV�%OXH�6KLHOG�RI�0LFKLJDQ�
50 $OH[DQGHU��-�$���0DUNRYLW]��$�5���3DXVWLDQ��0�/���:LVH��&�*���(O�5HGD��'�.���*UHHQ��/�$����)HWWHUV��0�'����������,PSOHPHQWDWLRQ�RI�3DWLHQW�&HQWHUHG�0HGLFDO�+RPHV�LQ�$GXOW�3ULPDU\�&DUH�3UDFWLFHV��Medical Care Research and Review, 72�������������GRL���������������������������7KLV�VWXG\�XVHV�D�ORQJLWXGLQDO�GHVLJQ�DQG�D�YDOLGDWHG�3&0+�LPSOHPHQWDWLRQ�LQVWUXPHQW�WR�DVVHVV�WKH�LPSDFW�RI�3&0+�LPSOHPHQWDWLRQ�RQ�WKUHH�SDWLHQW�UHODWHG�RXWFRPHV��XVH�RI�SUHYHQWLYH�VHUYLFHV��TXDOLW\�RI�FDUH��DQG�FRVW�RI�FDUH�
51�� .DXVKDO��5���(GZDUGV��$����.HUQ��/�0����������$VVRFLDWLRQ�EHWZHHQ�WKH�SDWLHQW�FHQWHUHG�PHGLFDO�KRPH�DQG�KHDOWKFDUH�XWLOL]DWLRQ��American Journal of Managed Care, 21�������������7KLV�VWXG\�XVHG�D�ORQJLWXGLQDO��SURVSHFWLYH�FRKRUW�VWXG\�GHVLJQ�WR�HYDOXDWH�SULPDU\�FDUH�SK\VLFLDQV�LQ�WKH�+XGVRQ�9DOOH\�UHJLRQ�RI�1HZ�<RUN�RYHU���\HDUV��������������7KH�DXWKRUV�QRWH��ÜWKLV�VWXG\�HYDOXDWHV�SDUW�RI�WKH�+XGVRQ�9DOOH\�,QLWLDWLYH��ZKLFK�VHHNV�WR�WUDQVIRUP�KHDOWKFDUH�GHOLYHU\�WKURXJK�KHDOWK�LQIRUPDWLRQ�WHFKQRORJ\��SUDFWLFH�WUDQVIRUPDWLRQ��DQG�YDOXH�EDVHG�SXUFKDVLQJ�Ý�7KLV�VWXG\�HYDOXDWHG���PHDVXUHV�RI�XWLOL]DWLRQ��EXW�RQO\�RQH�\LHOGHG�VWDWLVWLFDOO\�VLJQL÷�FDQW�UHVXOWV��DV�GHSLFWHG�LQ�WKH�table above).
PAGE 18
Table 1 continued
Location/Initiative
New York (continued)
Rochester Medical Home Initiative (RMHI)52
Published: Medical Care, November 2015
Data Review: August 2007-July 2009 (comparison group); August 2009-July 2012 (intervention group)
Study evaluated cost, utilization and quality measures
• 'UXJ�VSHQGLQJ�GHFUHDVHG�E\��������3030��GHVSLWH�LQFUHDVLQJ�XWLOL]DWLRQ�RI�SUHVFULSWLRQ�GUXJV�RYHU�VWXG\�period (p=.015)
• 3LORW�SUDFWLFHV�KDG�KLJKHU�VSHQGLQJ�RQ�LQSDWLHQW�VHUYLFHV��������3030��p=0.015)
RMHI pilot associated with reductions vs. baseline in: • $&6& �('�YLVLWV��p �����• 2YHUDOO�FRXQW�RI�LPDJLQJ�WHVWV������IHZHU�SHU������PHPEHU�months p<.001)
• 50+,�SLORW�LQFUHDVHG�SULPDU\�care visits (p<.001) and ODERUDWRU\�WHVWV��p �����
• Decrease in preventable KRVSLWDOL]DWLRQV��DV�PHDVXUHG�E\�3UHYHQWLRQ�4XDOLW\�,QGLFDWRU��34,���p=.027)
• 2.6% increase in breast cancer VFUHHQLQJ��p=.005)
• �����LQFUHDVH�LQ�/'/�GLDEHWHV�tests (p �����
Blended payment model: • Model includes fee-for-
service and a pay-for-performance SURJUDP�IRFXVHG�RQ�TXDOLW\�DQG�FRVW�
• 3D\PHQW�OHYHOV�ZHUH�VHW�VR�as to support practice costs related to the intervention, LQFOXGLQJ�VXSSRUW�RI�D�1XUVH�&DUH�0DQDJHU
Pennsylvania
Geisinger Health System patient-centered medical home (ProvenHealth Navigator)53
Published: Health Affairs, April 2015
Data Review: January 2006-June 2013
Study evaluated cost measures
• $YJ��RI������WRWDO�FRVW�VDYLQJV�DFURVV����PRQWK�VWXG\�SHULRG��DQ�DYJ��RI�����VDYLQJV�LQ�PMPM total cost of care per site)
• ����3030�VDYLQJV�IRU�DFXWH�LQSDWLHQW�FDUH������VDYLQJV�PMPM)
• $FXWH�LQSDWLHQW�FRVW�VDYLQJV�DFFRXQW�IRU�a����RI�WKH�WRWDO�HVWLPDWHG�VDYLQJV�
• /RQJHU�LPSOHPHQWDWLRQ�WLPH�DVVRFLDWHG�ZLWK�JUHDWHU�FRVW�VDYLQJV
Fee-for-servicePay-for-performance based on TXDOLW\�RXWFRPHV�
Shared savings model based on performance
Pennsylvania Chronic Care Initiative54
Published: JAMA Internal Medicine, June 2015
Data Review: October 2007–September 2012 (2 years prior to and 3 years after the pilot inception date)
Study evaluated utilization, access and quality measures
By year 3, pilot participation was associated with lower rates (per 1000 patients per month) for:• $OO�FDXVH�KRVSLWDOL]DWLRQ�������• $OO�FDXVH�('�YLVLWV�������• $PEXODWRU\�FDUH�VHQVLWLYH�('�YLVLWV�������
• $PEXODWRU\�YLVLWV�IRU�VSHFLDOLVWV��������
• +LJKHU�SHUIRUPDQFH�LQ�DOO���H[DPLQHG�PHDVXUHV�RI�GLDEHWHV�FDUH�TXDOLW\��+E$�F�WHVWLQJ��/'/�&�WHVWLQJ��QHSKURSDWK\�PRQLWRULQJ��H\H�examinations) and breast FDQFHU�VFUHHQLQJ�
• %\�\HDU����SLORW�ZDV�DVVRFLDWHG�ZLWK�KLJKHU�UDWHV�RI�DPEXODWRU\�SULPDU\�FDUH�YLVLWV�(+77.5) per 1000 patients per month
Participating practices received:• $1.50 PMPM in care PDQDJHPHQW�SD\PHQWV
• $1.50 PPPM in “practice VXSSRUW�SD\PHQWVÝ
• Shared savings bonuses FRQWLQJHQW�RQ�PHHWLQJ�TXDOLW\�EHQFKPDUNV��ERQXV�SD\PHQWV�FRXOG�UDQJH�IURP�����WR�����RI�FDOFXODWHG�VDYLQJV�LQ�HDFK�\HDU
This is a multi-payer initiative
Payment Model
Description Additional OutcomesCost & Utilization
52 5RVHQWKDO��0�%���6LQDLNR��$�'���(DVWPDQ��'���&KDSPDQ��%����3DUWULGJH��*����������,PSDFW�RI�WKH�5RFKHVWHU�0HGLFDO�+RPH�,QLWLDWLYH�RQ�SULPDU\�FDUH�SUDFWLFHV��TXDOLW\��XWLOL]DWLRQ��DQG�FRVWV��Medical Care, 53��������������GRL����������0/5������������������6WXG\�DXWKRUV�FRQGXFWHG�D�GLIIHUHQFH�LQ�GLIIHUHQFH�DQDO\VLV�ZLWK�D�PDWFKHG�FRPSDULVRQ�JURXS�XVLQJ�FODLPV�GDWD�IURP�([FHOOXV�%OXH�&URVV�%OXH�6KLHOG�DQG�093�+HDOWK�&DUH��,Q�DGGLWLRQ�WR�WKH�UHVXOWV�LQFOXGHG�DERYH��WKH�DXWKRUV�QRWH�ÜHVWLPDWHV�RQ�RWKHU�XWLOL]DWLRQ�DQG�VSHQGLQJ�PHDVXUHV��LQFOXGLQJ�WRWDO�VSHQGLQJ�SHU�SDWLHQW�SHU�PRQWK�ZHUH�QRW�VWDWLVWLFDOO\�VLJQL÷�FDQW��ZKLFK�PHDQV�ZH�FDQQRW�GHWHUPLQH�ZKHWKHU�WKH�HIIHFW�RI�WUDQVIRUPLQJ�LQWR�D�3&0+�KDV�D�SRVLWLYH�RU�QHJDWLYH�HIIHFW�RQ�WKHVH�RXWFRPHV�Ý
���� 0DHQJ��'�'���.KDQ��1���7RPFDYDJH��-���*UDI��7�5���'DYLV��'�(����6WHHOH��*�'����������5HGXFHG�DFXWH�LQSDWLHQW�FDUH�ZDV�ODUJHVW�VDYLQJV�FRPSRQHQW�RI�*HLVLQJHU�KHDOWK�V\VWHPÚV�SDWLHQW�FHQWHUHG�PHGLFDO�KRPH� Health Affairs, (34)������������GRL����������KOWKDII�����������7KLV�VWXG\�IRFXVHG�RQ�WKH�LPSDFW�RI�WKH�3URYHQ+HDOWK�1DYLJDWRU�RQ�WKH�HOGHUO\�0HGLFDUH�$GYDQWDJH�SDWLHQW�SRSXODWLRQ��5HVHDUFKHUV�XVHG�D�VHW�RI�PXOWLYDULDWH�UHJUHVVLRQ�PRGHOV�WR�H[DPLQH�WKH�SURJUDP�DQG�EUHDN�GRZQ�WKH�WRWDO�FRVW�VDYLQJV�DVVRFLDWHG�LQWR�LWV�PDMRU�FRPSRQHQWV��RXWSDWLHQW��LQSDWLHQW��SURIHVVLRQDO��DQG�SUHVFULSWLRQ�GUXJV��DQG�HVWDEOLVK�WKH�DVVRFLDWLRQV�VHSDUDWHO\�EHWZHHQ�D�FOLQLFÚV�H[SRVXUH�WR�WKH�1DYLJDWRU�DQG�HDFK�RI�WKH�FRVW�FRPSRQHQWV��
��� �)ULHGEHUJ��0�:���5RVHQWKDO��0�%���:HUQHU��5�0���9ROSS��.�*����6FKQHLGHU��(�&����������(IIHFWV�RI�D�PHGLFDO�KRPH�DQG�VKDUHG�VDYLQJV�LQWHUYHQWLRQ�RQ�TXDOLW\�DQG�XWLOL]DWLRQ�RI�FDUH��JAMA Internal Medicine, 175����������������GRL���������MDPDLQWHUQPHG������������7KH�DXWKRUV�XVHG�D�ÜGLIIHUHQFH�LQ�GLIIHUHQFHV�GHVLJQ�WR�FRPSDUH�FKDQJHV�GXULQJ�D���\HDU�SHULRG�LQ�WKH�TXDOLW\�DQG�XWLOL]DWLRQ�RI�FDUH�IRU�SDWLHQWV�DWWULEXWHG�WR�SUDFWLFHV�WKDW�SDUWLFLSDWHG�LQ�WKH�QRUWKHDVW�3$&&,�DQG�FRPSDULVRQ�SUDFWLFHV�WKDW�GLG�QRW�SDUWLFLSDWH�LQ�WKLV�PHGLFDO�KRPH�LQWHUYHQWLRQ�Ý�,Q�WKH�1RUWKHDVW�5HJLRQ��SDUWLFLSDWLQJ�SUDFWLFHV�ZHUH�UHTXLUHG�WR�DFKLHYH�1&4$�UHFRJQLWLRQ�ZLWKLQ����PRQWKV�RI�LPSOHPHQWDWLRQ�
PAGE 19
Table 1 continued
Location/Initiative
Pennsylvania
Pennsylvania Chronic Care Initiative55
Published: American Journal of Managed Care, January 2015
Data Review: 2008 (baseline); 2009-2011 (comparison group)
Study evaluated cost and utilization measures
• Lower total costs in PCMH SUDFWLFHV�LQ�DOO���IROORZ�XS�\HDUV��p������GULYHQ�E\�VLJQL÷�FDQWO\�ORZHU�LQSDWLHQW�(p<.01) and specialist (p<.0001) costs
• 5HODWLYH�WR�EDVHOLQH��RYHUDOO�PMPM costs were:
• �������ORZHU�LQ�����• �������ORZHU�LQ�����• �������ORZHU�LQ������• ,Q�������DGMXVWHG�FRVWV�IRU�
PCMH were 17.5% lower than those in non-PCMH practices.
• PCMH practices maintained ORZHU�XWLOL]DWLRQ�IRU�KRVSLWDO�admissions (p<.0001) and specialist visits (p<.01) each IROORZ�XS�\HDU
“To facilitate transition to the PCMH model, practices received VXSSOHPHQWDO�÷�QDQFLDO�LQFHQWLYHVÝ� This is a multi-payer initiative
Texas
Texas Children’s Health Plan56
Published: Journal of Health Care for the Poor and Underserved, May 2015
Data Review: August 2011–August 2012
Study evaluated utilization measures
• +DYLQJ�D�XVXDO�VRXUFH�RI�care per parent-report was associated with lower rate of documented ED visits and KRVSLWDOL]DWLRQV
• +LJKHU�PHDQ�VFRUH�IRU�RUJDQL]DWLRQDO�FDSDFLW\�ZDV�VLJQL÷�FDQWO\�DVVRFLDWHG�ZLWK�both lower rates of ED visits DQG�KRVSLWDOL]DWLRQV
• +LJKHU�GDWD�PDQDJHPHQW�PHDQ�VFRUH�ZDV�VLJQL÷�FDQWO\�associated with lower rates of ED visits
1RQH�VSHFL÷�HG�ZLWKLQ�WKLV�publication
Payment Model
Description Additional OutcomesCost & Utilization
55 1HDO��-���&KDZOD��5���&RORPER��&���6Q\GHU��5����1LJDP��6����������0HGLFDO�KRPHV��FRVW�HIIHFWV�RI�XWLOL]DWLRQ�E\�FKURQLFDOO\�LOO�SDWLHQWV��American Journal of Managed Care, 21(1), e51-61. 6WXG\�DXWKRUV�XVHG�D�ORQJLWXGLQDO�REVHUYDWLRQDO�GHVLJQ�DQG�DQDO\]HG�WKH�LPSDFW�RI�WKH�3&0+�PRGHO�RQ�3030�FRVWV�XVLQJ�D�JHQHUDOL]HG�OLQHDU�UHJUHVVLRQ�PRGHO��7KLV�VWXG\�HYDOXDWHG�D�ÜFRKRUW�RI�FKURQLFDOO\�LOO�PHPEHUVØGH÷�QHG�DV�SDWLHQWV�KDYLQJ�DVWKPD��FRURQDU\�DUWHU\�GLVHDVH��FRQJHVWLYH�KHDUW�IDLOXUH��FKURQLF�REVWUXFWLYH�SXOPRQDU\�GLVHDVH��GLDEHWHV��DQG�RU�K\SHUWHQVLRQØZKLFK�ZDV�FUHDWHG�IURP�DGPLQLVWUDWLYH�PHGLFDO�FODLPV�LQ�WKH�EDVHOLQH�\HDU�������Ý�
56 5DSKDHO��-�/���&RROH\��:�&���9HJD��$���.RZDONRZVNL��0�$���7UDQ��;���7UHDGZHOO��-���*LDUGLQR��$�3����*LRUGDQR��7�3����������2XWFRPHV�IRU�children with chronic conditions associated with parent-and provider-reported measures of the medical home. Journal of Health Care for the Poor and Underserved, 26�������������GRL����������KSX�����������6WXG\�DXWKRUV�FRQGXFWHG�D�FURVV�VHFWLRQDO��UHWURVSHFWLYH�DQDO\VLV�RI�DGPLQLVWUDWLYH�FODLPV�GDWD�IURP�7H[DV�&KLOGUHQÚV�+HDOWK�3ODQ��D�PDQDJHG�FDUH�RUJDQL]DWLRQ��7KH�VWXG\�HYDOXDWHG�����FKLOGUHQ�ZLWK�FKURQLF�GLVHDVHV�IURP�����SUDFWLFHV��7KH�DXWKRUV�GH÷�QH�RUJDQL]DWLRQDO�FDSDFLW\�DV�ÜWKH�SUDFWLFHÚV�FRPPLWPHQW�WR�SDWLHQW�FHQWHUHG�FDUH�DV�GHPRQVWUDWHG�E\�VROLFLWDWLRQ�RI�SDWLHQW�IHHGEDFN��PXOWLSOH�PHFKDQLVPV�IRU�FRPPXQLFDWLRQ�ZLWK�IDPLOLHV��SDWLHQW�DFFHVV�WR�PHGLFDO�UHFRUGV��DQG�FRQWLQXDO�VWDII�HGXFDWLRQ�DQG�WUDLQLQJ�Ý
(continued)
PAGE 20
Table 1 continued
Location/Initiative
Utah
University of Utah Care By Design57
Published: Journal for Healthcare Quality, January 2015
Data Review: June 2010- May 2011 (baseline); June 2011 – September 2013 (intervention period)
Study evaluated utilization measures
• $OO�FDXVH����GD\�KRVSLWDO�readmission rate decreased IURP�������WR�������p<.05)
• Mean time to hospital UHDGPLVVLRQ�ZLWKLQ�����GD\V�ZDV�GHOD\HG�IURP����WR�����GD\V��p<.05)
1RQH�VSHFL÷�HG�ZLWKLQ�WKLV�publication
Vermont
Vermont Blueprint for Health58
Published: Population Health Management, September 2015
Data Review: Review of annual outcomes from 2008-2013
Study evaluated cost, utilization, access and quality of care measures
• Participant expenditures were UHGXFHG�E\�î�����303< �(p<.001)
• 5HGXFWLRQ�LQ�LQSDWLHQW��î�����303< ��p<.001) and outpatient hospital H[SHQGLWXUHV��î�����303< ��p<.001)
• ,QFUHDVH�LQ�H[SHQGLWXUHV�IRU�GHQWDO��VRFLDO��DQG�FRPPXQLW\�EDVHG�VXSSRUW�VHUYLFHV������303< ��p<.001)
• Total annual reduction in H[SHQGLWXUHV�ZDV��������million
• Medical expenditures GHFUHDVHG�E\�DSSUR[LPDWHO\������PLOOLRQ�IRU�HYHU\����million spent on the Blueprint initiative
• 5HGXFWLRQ�LQ�LQSDWLHQW�GLVFKDUJHV�UHGXFHG�E\�����SHU�1000 members (p<.001)
• 5HGXFWLRQ�LQ�LQSDWLHQW�GD\V�UHGXFHG�E\������SHU������members (p<.001)
• 6LJQL÷�FDQW�UHGXFWLRQ�LQ�VWDQGDUG�LPDJLQJ��DGYDQFHG�LPDJLQJ��HFKRJUDSK\
• +LJKHU�UDWHV�RQ���RI����effective and preventive care measures
• +LJKHU�VFUHHQLQJ�UDWHV�for breast cancer and cervical cancer (p<.001) DQG�DSSURSULDWH�WHVWLQJ�IRU�SKDU\QJLWLV��p<.001)
• Participants with diabetes had KLJKHU�UDWHV�RI�H\H�WHVWLQJ�DQG�/'/�&�WHVWLQJ��p<.001)
• 3DUWLFLSDQWV�KDG�VLJQL÷�FDQWO\�KLJKHU�UDWHV�RI�DGROHVFHQW�well-care visits (p<.001)
Fee-for-service + capitated payments“Two payment reforms were implemented to support PCMH and CHT* operations: • a capitated payment that went
directly to the practice based on its NCQA PCMH score
• a capitated payment that went to the administrative entity in each service area to operate the CHT*”
Vermont Blueprint for Health is a multi-payer initiative that participates in the MAPCP demonstration
Payment Model
Description Additional OutcomesCost & Utilization
57 )DUUHOO��7�:���7RPRDLD�&RWLVHO��$���6FDPPRQ��'�/���%UXQLVKRO]��.���.LP��-���'D\��-���â�0DJLOO��0�.����������,PSDFW�RI�DQ�LQWHJUDWHG�WUDQVLWLRQ�PDQDJHPHQW�SURJUDP�LQ�SULPDU\�FDUH�RQ�KRVSLWDO�UHDGPLVVLRQV��Journal for Healthcare Quality, 37������������GRL�������������-+4����������������������6WXG\�DXWKRUV�QRWH�WKDW�WKH�Ü8QLYHUVLW\�RI�8WDK�&RPPXQLW\�&OLQLFV��88&&V��GHYHORSHG�DQG�LPSOHPHQWHG�WKH�Ü&DUH�%\�'HVLJQÝ��&%'��PRGHO��ZKLFK�LV�Ù88&&VÚ�YHUVLRQ�RI�WKH�3&0+Úâ�WKH�WKUHH�RUJDQL]LQJ�SULQFLSOHV�RI�&%'�Ø�$SSURSULDWH�Access (AA), Care Teams (CTs), and Planned Care (PC) — correspond to core PCMH principles.”
���� -RQHV��&���)LQLVRQ��.���0F*UDYHV�/OR\G��.���7UHPEOD\��7���0RKOPDQ��0�.���7DQ]PDQ��%���â�6DPXHOVRQ��-����������9HUPRQWÚV�FRPPXQLW\�RULHQWHG�DOO�SD\HU�PHGLFDO�KRPH�PRGHO�UHGXFHV�H[SHQGLWXUHV�DQG�XWLOL]DWLRQ�ZKLOH�GHOLYHULQJ�KLJK�TXDOLW\�FDUH��Population Health Management. GRL���������SRS�����������7KLV�VWXG\�XVHG�D�VHTXHQWLDO�FURVV�VHFWLRQDO�GHVLJQ�WR�UHYLHZ�DQQXDO�RXWFRPHV�IURP������WKURXJK������IRU�SDUWLFLSDQWV�YHUVXV�D�FRPSDULVRQ�SRSXODWLRQ�DW�HDFK�VWDJH�RI�SURJUDP�LPSOHPHQWDWLRQ�DQG�PDWXUDWLRQ��
PAGE 21
TABLE 2: STATE GOVERNMENT EVALUATIONS: Primary Care/PCMH Interventions That Assessed Cost or Utilization, Selected Outcomes by Location, 2014-2015
Location/Initiative
Arkansas
Arkansas PCMH program59
Published: Arkansas Department of Human Services, October 2015
Data Review: 2014 claims data
• ,Q�������WKH�VWDWH�DYRLGHG�����PLOOLRQ�LQ�0HGLFDLG�FRVWV�LQ������
• 19 providers received shared VDYLQJV�SD\PHQWV�IRU�D�WRWDO�RI�RYHU����PLOOLRQ
Fee-for-service + PMPM SD\PHQWV�IRU�FDUH�FRRUGLQDWLRQ�and enhanced access
2SSRUWXQLW\�WR�TXDOLI\�IRU�shared savings7KH�$UNDQVDV�3&0+�SURJUDP�is a multi-payer SURJUDP�WKDW�participates in the CPC initiative
Payment Model
Description Additional OutcomesCost & Utilization
59 Arkansas Department of Human Services. (2015). Arkansas Medicaid Rewarding Primary Care Providers for Prevention, Disease Management. 5HWULHYHG�IURP�KWWS���KXPDQVHUYLFHV�DUNDQVDV�JRY�SUHVVURRP�3UHVV5RRP'RFV�'06SDWLHQWFHQWHUPKDZDUGV15RFW���SGI�To determine FRVW�DYRLGDQFH��WKH�VWDWH�÷�UVW�HYDOXDWHG�EDVHOLQH�FRVWV�IRU�������������DQG�������,W�JDYH�HDFK�\HDU�D�ZHLJKW������IRU�����������IRU������DQG�����IRU������DQG�XVHG�WKLV�IRUPXOD�WR�GHWHUPLQH�����ÚV�SURMHFWHG�FRVW��
60 &RORUDGR�'HSDUWPHQW�RI�+HDOWK�&DUH�3ROLF\�DQG�)LQDQFLQJ����������Creating a Culture of Change: Accountable Care Collaborative 2014 Annual Report. 5HWULHYHG�IURP��KWWSV���ZZZ�FRORUDGR�JRY�SDFL÷�F�VLWHV�GHIDXOW�÷�OHV�$FFRXQWDEOH���&DUH���&ROODERUDWLYH����������$QQXDO���5HSRUW�SGI�3ULPDU\�FDUH�SURYLGHUV�FRQWUDFWHG�ZLWK�D�5&&2�WR�VHUYH�DV�PHGLFDO�KRPHV�IRU�$&&�PHPEHUV�
Colorado
Colorado Accountable Care Collaborative (ACC)60
Published: Colorado Department of Health Care Policy and Financing, November 2014
Data Review: FY 2013-2014
• ���������PLOOLRQ�LQ�JURVV�SURJUDP�VDYLQJV����������PLOOLRQ�LQ�QHW�VDYLQJV��
• a����PLOOLRQ�UHLQYHVWHG�LQWR�SURYLGHUV�E\�SURJUDP��LQFOXGLQJ�LQFHQWLYH�SD\PHQWV�
• ���IHZHU�(5�VHUYLFHV�IRU�DGXOW�$&&�HQUROOHHV�LQ�SURJUDP�more than 6 months vs. non-enrolled
• 6OLJKWO\�KLJKHU�XVH�RI�(5�services for ACC enrollees with disabilities vs. non-enrolled
• Fewer readmissions for children and adult ACC members without disabilities vs. non-enrolled
Fewer high cost imaging services for ACC enrollees vs. non-enrolled: • ���IHZHU�IRU�$&&�PHPEHUV�
with disabilities • 16% fewer for adult ACC
members• 12% fewer for children ACC
members
Fee-for-service base + additional incentives$&&�XVHV�K\EULG�RI�VHYHUDO�SD\PHQW�VWUDWHJLHV�ZLWK�D�EDVH�of fee-for-service:
• 5&&2V �DQG�3&03V �UHFHLYH�LQFHQWLYH�SD\PHQWV�IRU�UHDFKLQJ�NH\�SHUIRUPDQFH�LQGLFDWRU��.3,��WDUJHWV�(pay for performance)
• 3&03V�JHW�3030�SD\PHQWV�IRU�DFKLHYLQJ���RI���VWDQGDUGV�of enhanced PCMH
In FY 2014-2015:• 5&&2V�DQG�3&03V�ZLOO�UHFHLYH�D�VKDUH�RI�WKH�VDYLQJV�when the ACC saves on medical expenditures
• $&&�LV�WHVWLQJ�IXOO�ULVN�capitation�LQ�RQH�UHJLRQ�DQG�LQFUHDVLQJ�3&03 �3030�SD\PHQWV
PAGE 22
Table 2 continued
Location/Initiative
Oregon
Oregon Coordinated Care Organizations61
Published: Oregon Health Authority, June 2015
Data Review: 2011 (comparison group); 2014 (PCMH group)
• 2UHJRQ�LV�PHHWLQJ�LWV�&06�FRPPLWPHQW�WR�UHGXFH�JURZWK�LQ�VSHQGLQJ�E\���SHUFHQWDJH�SRLQWV��303<�
• PMPM costs for inpatient hospital services have GHFUHDVHG�E\�������VLQFH�2011
• ���RXW�RI����&&2V�HDUQHG������RI�WKHLU�TXDOLW\�SRRO�SD\PHQWV
• 5HGXFWLRQ�LQ�DOO�FDXVH����GD\�UHDGPLVVLRQV��IURP�������LQ������WR�������LQ������
• 5HGXFWLRQ�LQ�('�YLVLWV�������per 1000 member months in �����YV�������LQ����������LQ�2011)
• 5HGXFWLRQ�LQ�DYRLGDEOH�('�visits
Since 2011 baseline:• 22% reduction in ED visits • 26.9% reduction in admissions
for patients with diabetes and short-term complications
• 60% reduction in admissions for patients with COPD or asthma
• Almost 50% reduction in avoidable ED visits
• ,QFUHDVHG�6%,57 �LQWHUYHQWLRQ�������WR������
• 3HUFHQWDJH�RI�LQGLYLGXDOV�DEOH�WR�DFFHVV�FDUH�TXLFNO\�ZKHQ�QHHGHG�UHPDLQHG�VWHDG\
• Childhood and adolescent DFFHVV�WR�SULPDU\�FDUH�providers declined
Since 2011 baseline:• ,QFUHDVHG�DSSURSULDWH�WHVWLQJ�IRU�FKLOGUHQ�ZLWK�SKDU\QJLWLV
• ,QFUHDVHG�ZHOO�FDUH�YLVLWV• PCPCH enrollment increased
56%• ,QFUHDVHG�VDWLVIDFWLRQ�ZLWK�
care
Fee-for-service + Pay-for-performance To earn full incentive payment, CCOs must:• Meet benchmarks or LPSURYHPHQW�WDUJHWV�RQ�at least 12 of 17 incentive PHDVXUHV�
• Meet benchmark or LPSURYHPHQW�WDUJHW�IRU�(+5�DGRSWLRQ��$1'
• Have at least 60% of members enrolled in a PCPCH
CCOs earn “challenge pool funds” for meeting benchmark of improvement target on:• $OFRKRO�DQG�GUXJ�PLVXVH��6%,57���
• 'LDEHWHV�+E$�F�SRRU�FRQWURO��• 'HSUHVVLRQ�VFUHHQLQJ�DQG�IROORZ�XS�SODQ��
• PCPCH enrollment
North Carolina
Community Care of North Carolina (CCNC)62
Published: State Auditor Report, August 2015
Data Review: July 2003-December 2012
• 6DYLQJV�RI�a����SHU�TXDUWHU�SHU�EHQH÷�FLDU\��a�����D�\HDU��a���VDYLQJV�
• 'HFUHDVHG�VSHQGLQJ�LQ�DOPRVW�DOO�FDWHJRULHV��ZLWK�ODUJHVW�reduction in inpatient services
• CCNC saved the state 0HGLFDLG�SURJUDP�DERXW������million
• 5HGXFWLRQ�LQ�UHDGPLVVLRQV��inpatient admissions for GLDEHWHV��DOWKRXJK�QRW�VWDWLVWLFDOO\�VLJQL÷�FDQW���DQG�ED visits for asthma
• ~25% reduction in inpatient admissions
• $SSUR[LPDWHO\�D�����LQFUHDVH�LQ�SK\VLFLDQ�VHUYLFHV
• $SSUR[LPDWHO\�D�������GHFOLQH�LQ�SUHVFULSWLRQ�GUXJ�XVH
Fee-for-service + Care coordination fee0HGLFDLG�SDLG�DQ�DGMXVWHG�DGPLQLVWUDWLYH�IHH�UDQJLQJ�IURP�������WR��������IURP������WKURXJK�����
&&1&�IRUPHUO\�SDUWLFLSDWHG�in the multi-payer MAPCP demonstration
Payment Model
Description Additional OutcomesCost & Utilization
61 2UHJRQ�+HDOWK�$XWKRULW\����������Oregon’s Health System Transformation: 2014 Final Report.�5HWULHYHG�IURP��KWWS���ZZZ�RUHJRQ�JRY�RKD�0HWULFV�'RFXPHQWV��������)LQDO���5HSRUW�������-XQH��������SGI�7KLV�÷�QDO�UHSRUW�RXWOLQHV�WKH�SURJUHVV�RI�2UHJRQ�&&2V�LQ����������SHUFHQW�RI�&&2�PHPEHUV�DUH�HQUROOHG�LQ�D�UHFRJQL]HG�SDWLHQW�FHQWHUHG�SULPDU\�FDUH�KRPH��3&3&&�GLG�QRW�LQFOXGH�DOO�HYDOXDWHG�PHDVXUHV�LQ�WKH�WDEOH�DERYH��)ROORZ�WKH�OLQN�IRU�FRPSUHKHQVLYH�SURJUDP�UHVXOWV�
62 �2I÷�FH�RI�WKH�6WDWH�$XGLWRU����������Community Care of North Carolina.�5HWULHYHG�IURP��KWWS���ZZZ�QFDXGLWRU�QHW�(36:HE�5HSRUWV�)LVFDO&RQWURO�)&$�����������SGI�7KH�VWXG\�SRSXODWLRQ�LV�OLPLWHG�WR�QRQ�HOGHUO\��QRQ�GXDO�0HGLFDLG�EHQH÷�FLDULHV��$OO�FRVW�÷�QGLQJV�DUH�HVWLPDWHG�LQ������LQø�DWLRQ�DGMXVWHG�GROODUV�
PAGE 23
TABLE 3: INDUSTRY REPORTS: Primary care/PCMH interventions that assessed cost or utilization, selected outcomes by location, 2014-2015
Location/Initiative
Multi-state
Anthem Enhanced Personal Health Care (EPHC)63
Published: Anthem industry report, 2015
Data Review: Results from program year 1 (vs. matched control group)
• �����PLOOLRQ�LQ�VDYLQJV�RYHU�12 month period
• *URVV�PHGLFDO�VDYLQJV�RI�������3HU�$WWULEXWHG�0HPEHU�3HU�0RQWK��3D030� ��QHW�VDYLQJV�RI�������3D030
• 2YHUDOO�SKDUPDF\�VDYLQJV�RI������3D030
• �����ORZHU�(5�FRVWV• �����UHGXFWLRQ�LQ�LQSDWLHQW�FRVWV��GULYHQ�E\�D������reduction in acute inpatient admissions
• �����GHFUHDVH�LQ�DOORZHG�(5�FRVWV��GULYHQ�E\������UHGXFWLRQ�LQ�(5�XWLOL]DWLRQ
• �����UHGXFWLRQ�LQ�RI÷�FH�YLVLW�costs
• �����LQFUHDVH�LQ�SULPDU\�FDUH�YLVLW�FRVWV�IRU�KLJK�ULVN�population
• �����UHGXFWLRQ�LQ�UHIHUUDOV�WR�HOHFWLYH�SURFHGXUHV�DQG�KLJK�FRVW�UDGLRORJ\
Compared with non-EPHC peers, EPHC providers performed:• 9.6% better in pediatric
prevention • �����EHWWHU�LQ�DQQXDO�PRQLWRULQJ�RI�SHUVLVWHQW�medications
• �����EHWWHU�LQ�GLDEHWHV�FDUH�• �����EHWWHU�LQ�FHUYLFDO�DQG�EUHDVW�FDQFHU�VFUHHQLQJ�
• �����EHWWHU�LQ�RWKHU�DFXWH�DQG�chronic care measures
Fee-for-service + PMPM Clinical Coordination 5HLPEXUVHPHQW (care coordination payment)$GGLWLRQDO�RSSRUWXQLW\�IRU�shared savings�WKURXJK�LWV�LQFHQWLYH�SURJUDP
Anthem participates in multi-payer efforts (CPC and MAPCP)
Louisiana
Blue Cross Blue Shield of Louisiana Quality Blue Primary Care (QBPC) Program64, 65
Published: Blue Cross Blue Shield of Louisiana Press Release, “Quality Blue Primary Care Collaborative” presentation slide deck, October 2015
Data Review: 2013- 2014 claims data
QBPC program vs. comparison practices: • 5HGXFHG�WRWDO�FRVWV�E\�a����
PMPM• 5HGXFHG�RYHUDOO�FRVW�RI�RI÷�FH�EDVHG�YLVLWV��ODUJHO\�GXH�WR�UHGXFWLRQ�LQ�VSHFLDOW\�YLVLWV
• 5HGXFHG�LQSDWLHQW�DGPLVVLRQV�RYHUDOO�DQG�DPRQJ�SDWLHQWV�with heart disease, K\SHUWHQVLRQ��GLDEHWHV��DQG�FKURQLF�NLGQH\�GLVHDVH
• ,QFUHDVHG�RYHUDOO�DQG�$&6&�ED visits
• ,QFUHDVHG�RI÷�FH�EDVHG�SULPDU\�FDUH�YLVLWV
From January 2015 to September 2015, the program showed:• 25% improvement in diabetes TXDOLW\�PHDVXUHV
• ����LPSURYHPHQW�LQ�K\SHUWHQVLRQ�TXDOLW\�PHDVXUHV
• ����LPSURYHPHQW�LQ�YDVFXODU�GLVHDVH�TXDOLW\�PHDVXUHV
• 69% improvement on chronic NLGQH\�GLVHDVH�PHDVXUHV
Fee-for-service + Care Management Fee (CMF) “Twice a year, Blue Cross evaluates CMFs for adjustment, based on how each QBPC-enrolled practice performed on the program’s core measures”
Payment Model
Description Additional OutcomesCost & Utilization
���� $QWKHP��,QF����������Innovation with proven results: Enhanced Personal Health Care. 5HWULHYHG�IURP�KWWSV���ZZZ�SFSFF�RUJ�VLWHV�GHIDXOW�÷�OHV�(3+&B:KLWH3DSHUB$QWKHP�SGI�$FFRUGLQJ�WR�WKH�SURJUDP�GHVFULSWLRQ�PRGL÷�HG�����������WKH�$QWKHP�(3+&�3URJUDP�EXLOGV�XSRQ�WKH�VXFFHVV�RI�3&0+�SURJUDPV�DQG�IRVWHUV�D�FROODERUDWLYH�UHODWLRQVKLS�EHWZHHQ�$QWKHP�DQG�LWV�FRQWUDFWHG�SURYLGHUV��7KH�UHVXOWV�LQ�WKLV�VWXG\�UHø�HFW�FDUH�IRU�$QWKHP�PHPEHUV�LQ�LWV�DI÷�OLDWHG�SODQV�LQ�&DOLIRUQLD��&RORUDGR��2KLR��1HZ�<RUN��DQG�9LUJLQLD�
��� Blue Cross Blue Shield of Louisiana. (2015). Blue Cross getting better results for customers.�5HWULHYHG�IURP��KWWS���ZZZ�EFEVOD�FRP�$ERXW%OXH�PHGLDFHQWHU�QHZV�3DJHV�%OXH&URVV*HWWLQJ%HWWHU+HDOWK5HVXOWVIRU&XVWRPHUV�DVS[�5HVXOWV�SXEOLVKHG�LQ�WKLV�SUHVV�UHOHDVH�ZHUH�YDOLGDWHG�E\�7XODQH�8QLYHUVLW\ÚV�6FKRRO�RI�3XEOLF�+HDOWK��
65�� 6KL��/����������4%3&�3URJUDP�(YDOXDWLRQ��3UHVHQWDWLRQ�DW�WKH�4XDOLW\�%OXH�3ULPDU\�&DUH�&ROODERUDWLYH��7KH�VWXG\�XVHG�D�GLIIHUHQFH�LQ�GLIIHUHQFH�DSSURDFK�WR�HYDOXDWH�RXWFRPHV�DVVRFLDWHG�ZLWK�WKH�4%3&�SURJUDP�
PAGE 24
66 CareFirst BlueCross BlueShield. (2015). Quality Remains Strong as Cost Increases Slow Dramatically for Members in Patient-Centered Medical Home Program. 5HWULHYHG�IURP��KWWSV���PHPEHU�FDUH÷�UVW�FRP�LQGLYLGXDOV�QHZV�PHGLD�QHZV������TXDOLW\�UHPDLQV�VWURQJ�DV�FRVW�LQFUHDVHV�IRU�PHPEHUV�LQ�SDWLHQW�FHQWHUHG�PHGLFDO�KRPH�SURJUDP�VORZ�GUDPDWLFDOO\�SDJH
67�� %OXH�&URVV�%OXH�6KLHOG�RI�0LFKLJDQ����������Michigan continues to lead nation in patient-centered health care, thanks to Blue Cross Blue Shield of Michigan Patient-Centered Medical Home program. 5HWULHYHG�IURP��KWWS���ZZZ�EFEVP�FRP�EOXH�FURVV�EOXH�VKLHOG�RI�PLFKLJDQ�QHZV�QHZV�UHOHDVHV������MXO\������EOXH�FURVV�SDWLHQW�FHQWHUHG�PHGLFDO�KRPH�SURJUDP�KWPO
Maryland
CareFirst Blue Cross Blue Shield PCMH Program66
Published: CareFirst Blue Cross Blue Shield Press Release, July 2015
Data Review: 2014 claims data
• Costs for members in a PCMH ZHUH������PLOOLRQ�OHVV�WKDQ�SURMHFWHG�LQ������DQG������million less than expected since 2011
• a����RI�SURYLGHU�SDQHOV�HDUQHG�2XWFRPH�,QFHQWLYH�$ZDUGV��2,$��DYHUDJLQJ�����������������
Since 2011, PCMH members have had*:• 19% fewer hospital admissions ������IHZHU�LQ������
• ����IHZHU�GD\V�LQ�WKH�KRVSLWDO��������IHZHU�LQ������
• 20% fewer hospital readmissions for all causes ������IHZHU�LQ������
• 5% fewer outpatient health IDFLOLW\�YLVLWV��������IHZHU�LQ�������
Fee-for-service +
All PCMH providers earned a 12 SHUFHQWDJH�SRLQW�SDUWLFLSDWLRQ�fee (risk-adjusted PMPM)
3ULPDU\�FDUH�SDQHOV�FDQ�HDUQ�2XWFRPH�,QFHQWLYH�$ZDUGV��2,$V��EDVHG�RQ�ERWK�WKH�OHYHO�RI�TXDOLW\�DQG�GHJUHH�RI�VDYLQJV�WKH\�DFWXDOO\�DFKLHYHG�DJDLQVW�SURMHFWLRQV��SDLG�SURVSHFWLYHO\
Michigan
Blue Cross Blue Shield of Michigan Physician Incentive Program67
Published: Blue Cross Blue Shield of Michigan Press Release, July 2015
Data Review: 2015 claims data
• (VWLPDWHG������PLOOLRQ�LQ�VDYLQJV�RYHU���\HDUV
• 3&0+�SUDFWLFHV�KDG�DQ������ORZHU�UDWH�RI�DGXOW�KLJK�WHFK�UDGLRORJ\�XVH
Patients that visited PCMH practices:• 26% lower rate of hospital
admissions for common conditions
• ������ORZHU�UDWH�RI�DGXOW�(5�visits
• ������ORZHU�UDWH�RI�SHGLDWULF�(5�YLVLWV
• ������ORZHU�UDWH�RI�SHGLDWULF�(5�YLVLWV�IRU�FRPPRQ�FKURQLF�and acute conditions (i.e. asthma)
1RQH�VSHFL÷�HG�ZLWKLQ�WKLV�publication
%&%6�0LFKLJDQ�SDUWLFLSDWHV�LQ�multi-payer efforts (MAPCP)
Location/InitiativePayment Model
Description Additional OutcomesCost & Utilization
Table 3 continued
PAGE 25
Table 3 continued
New Jersey
Horizon Blue Cross Blue Shield New Jersey Patient-Centered Programs68
Published: Horizon Blue Cross Blue Shield Press Release, August 2015
Data Review: 2014 claims data
Compared with members served by traditional primary care practices: • 9% lower total cost of care• ���ORZHU�UDWH�RI�KRVSLWDO�
admission • 5% lower rate of ED visits
Compared with members served by traditional primary care practices:• ���KLJKHU�UDWH�LQ�LPSURYHG�
diabetes control• ����KLJKHU�UDWH�LQ�FKROHVWHURO�PDQDJHPHQW�IRU�GLDEHWLF�patients
• ���KLJKHU�UDWH�LQ�FRORUHFWDO�FDQFHU�VFUHHQLQJV
• ���KLJKHU�UDWH�LQ�EUHDVW�FDQFHU�VFUHHQLQJ
Fee-for-service +PCMH practices have an RSSRUWXQLW\�WR�UHFHLYH�outcome-based or shared-savings payments, provided WKH\�PHHW�VSHFL÷�HG�JRDOV�IRU�DFKLHYLQJ�EHWWHU�KHDOWK�RXWFRPHV��LPSURYLQJ�WKH�SDWLHQW�H[SHULHQFH�DQG�ORZHULQJ�WKH�cost of care.
+RUL]RQ�%&%6�SDUWLFLSDWHV�LQ�multi-payer efforts (CPC)
Rhode Island
Blue Cross Blue Shield of Rhode Island PCMH program69
Published: Blue Cross Blue Shield of Rhode Island Press Release, November 2015
Data Review: 2009-2014 claims data
• PCMH practices were 5% OHVV�FRVWO\�DQG�VDYHG����0�YV��VWDQGDUG�SULPDU\�FDUH�providers
• 250% return on investment
Patients with complex medical conditions were:• ����OHVV�OLNHO\�WR�EH�KRVSLWDOL]HG�RU�QHHG�DQ�('�visit
• ����ORZHU�UHDGPLVVLRQV�WR�hospitals
“BCBSRI and partners have shared ÷�QDQFLDO�LQFHQWLYHV�WR�LPSURYH�access to care, coordination among clinicians”
%&%6�5KRGH�,VODQG�SDUWLFLSDWHV�in multi-payer efforts (MAPCP)
Location/InitiativePayment Model
Description Additional OutcomesCost & Utilization
���� +RUL]RQ�%OXH�&URVV�%OXH�6KLHOG�RI�1HZ�-HUVH\����������Patient-centered care continues to deliver on promise of better quality care at a lower cost. 5HWULHYHG�IURP��KWWS���ZZZ�KRUL]RQEOXH�FRP�DERXW�XV�QHZV�RYHUYLHZ�FRPSDQ\�QHZV�KRUL]RQ�EFEVQM�SDWLHQW�FHQWHUHG�FDUH�RQ�SURPLVH�RI�EHWWHU�TXDOLW\
69 %OXH�&URVV�%OXH�6KLHOG�RI�5KRGH�,VODQG����������New Study Shows Patient Centered Medical Homes Improve Health, Lower Costs. 5HWULHYHG�IURP��KWWSV���ZZZ�EFEVUL�FRP�DERXW�XV�QHZV�HYHQWV�QHZV�QHZ�VWXG\�VKRZV�SDWLHQW�FHQWHUHG�PHGLFDO�KRPHV�LPSURYH�KHDOWK�ORZHU�costs 7KH�UHSRUW�WUDFNHG�PRUH�WKDQ��������FRPPHUFLDO�DQG��������0HGLFDUH�$GYDQWDJH�PHPEHUV�ZLWKLQ�%&%65,ÚV�3&0+�RYHU�WKH������×������WLPH�SHULRG�
PAGE 26
TABLE 4: INDEPENDENT EVALUATIONS OF FEDERAL INITIATIVES: Primary care/PCMH interventions that assessed cost or utilization, selected outcomes by location, 2014-2015
Location/Initiative
Multi-state (7 regions)
Comprehensive Primary Care (CPC) Initiative37
Published: Mathematica Independent Evaluation, January 2015
Data Review: Performance Year 2013
Participating practices located in Arkansas, Oklahoma (Greater Tulsa region), Oregon, Colorado, Ohio (Cincinnati-Dayton region and Northern Kentucky region), New Jersey, and New York (Capitol District-Hudson Valley region)
Report evaluated cost, utilization, quality, access, and patient satisfaction measures
Cost and utilization outcomes for the CPC program varied across regions; overall program results include: • $FURVV�WKH���UHJLRQV��&3&�
reduced Medicare Part A and Part B expenditures E\�����3%30 ��ZLWK�FDUH�PDQDJHPHQW�IHHV�H[FOXGHG��PHGLDQ�RI���������SHU�clinician)
• 2% reduction in hospital DGPLVVLRQV�DQG����UHGXFWLRQ�in ED visits
• ���&3&�ZLGH�GHFOLQH�LQ�XQSODQQHG����GD\�UHDGPLVVLRQV��QRW�VWDWLVWLFDOO\�VLJQL÷�FDQW�
• 0DMRULW\�RI�VDYLQJV�JHQHUDWHG�E\�SDWLHQWV�LQ�WKH�KLJKHVW�ULVN�TXDUWLOH��EXW�IDYRUDEOH�results were also seen in other patients
Quality outcomes for the CPC program varied across regions
Medicare payments:• Fee-for-service + care
management fee. ,Q�WKH�÷�UVW�WZR�\HDUV�RI�&3&��WKH�0HGLFDUH�ULVN�DGMXVWHG�3030�SD\PHQW�UDWHV�DUH���������������DQG������GHSHQGLQJ�RQ�D�SDWLHQWÚV�+&& �VFRUH��DYHUDJH�UDWH�LV�����3%30 �
• 2SSRUWXQLW\�IRU�shared savings LQ��QG���UG��DQG��WK�\HDU�LI�QHW�VDYLQJV�LQ�0HGLFDUH�Part A and B health care FRVWV�LV�DFKLHYHG���TXDOLW\�performance
Other participating payers:• 3URYLGH�HQKDQFHG�SD\PHQWV�
for each of their members attributed to a practice �DOPRVW�DOZD\V�D�3030�FDUH�PDQDJHPHQW�SD\PHQW��
This is a multi-payer initiative
Multi-state (8 regions)
Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration70
Published: RTI International Independent Evaluation, January 2015
Data Review: Performance Year 2013
8 states began MAPCP in 2011: Maine, Michigan, Minnesota, New York, North Carolina, Pennsylvania, Rhode Island and Vermont (5 continuing to participate through 2016: ME, MI, NY, RI, VT)
Cost and utilization outcomes for the MAPCP program varied by state, overall the program:• *HQHUDWHG�DQ�HVWLPDWHG������PLOOLRQ�LQ�VDYLQJV�LQ�LWV�÷�UVW�\HDU�WKURXJK�WKH�XVH�RI�DGYDQFHG�SULPDU\�FDUH�initiatives
Fee-for-service +• Each state has its own SD\PHQW�OHYHOV�DQG�established its own PHWKRGRORJLHV
• &06�PDNHV�PRQWKO\�0$3&3�SD\PHQWV�WR�3&0+V�IRU�DVVLJQHG�GHPRQVWUDWLRQ�EHQH÷�FLDULHV
• 6WDWHV�LQVWUXFWHG�WKDW�WKH�DYJ��0HGLFDUH�3030�SD\PHQW�VKRXOG�QRW�H[FHHG�����DQG�WKDW�SD\PHQW�PHWKRGV�VKRXOG�EH�DSSOLHG�FRQVLVWHQWO\�E\�DOO�SDUWLFLSDWLQJ�SD\HUVØEXW�QRW�QHFHVVDULO\�DW�WKH�VDPH�GROODU�level
This is a multi-payer demonstration
Payment Model
Description Additional OutcomesCost & Utilization
���� 7D\ORU��(�)���'DOH��6���3HLNHV��'���%URZQ��5���*KRVK��$���&URVVRQ��-��â6KDSLUR��5����������(YDOXDWLRQ�RI�WKH�&RPSUHKHQVLYH�3ULPDU\�&DUH�,QLWLDWLYH��)LUVW�$QQXDO�5HSRUW��Mathematica Policy Research. 5HWULHYHG�IURP��KWWS���LQQRYDWLRQ�FPV�JRY�)LOHV�UHSRUWV�&3&,�(YDO5SW��pdf 0DWKHPDWLFD�3ROLF\�5HVHDUFK�FRQGXFWHG�DQ�LQGHSHQGHQW�HYDOXDWLRQ�RI�WKH�÷�UVW�SHUIRUPDQFH�\HDU�RI�WKH�&3&�LQLWLDWLYH��WKURXJK�6HSWHPEHU��������7KH�&3&�LQLWLDWLYH�LV�D�PXOWL�SD\HU�SDUWQHUVKLS�EHWZHHQ�0HGLFDUH��0HGLFDLG�SULYDWH�KHDOWK�FDUH�SD\HUV��DQG�SULPDU\�FDUH�SUDFWLFHV�LQ�IRXU�VWDWHV��$UNDQVDV��&RORUDGR��1HZ�-HUVH\�DQG�2UHJRQ��DQG�WKUHH�UHJLRQV��1HZ�<RUNÚV�&DSLWDO�'LVWULFW�DQG�+XGVRQ�9DOOH\��2KLR�DQG�.HQWXFN\ÚV�&LQFLQQDWL�'D\WRQ�UHJLRQ��DQG�2NODKRPDÚV�*UHDWHU�7XOVD�UHJLRQ��
70�� 57,�,QWHUQDWLRQDO����������Evaluation of the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration: First Annual Report. 5HWULHYHG�IURP��KWWSV���GRZQORDGV�FPV�JRY�÷�OHV�FPPL�0$3&3�)LUVW(YDOXDWLRQ5HSRUWB�B��B���SGI�57,�,QWHUQDWLRQDO�FRQGXFWHG�DQ�LQGHSHQGHQW�HYDOXDWLRQ�RI�WKH�HLJKW�SDUWLFLSDWLQJ�0$3&3�VWDWHV�LQ�WKH�÷�UVW�SHUIRUPDQFH�\HDU��7KH�HYDOXDWLRQ�XVHV�D�PL[�RI�TXDOLWDWLYH�DQG�TXDQWLWDWLYH�PHWKRGV�WR�FDSWXUH�HDFK�RI�WKH�VWDWHVÚ�XQLTXH�IHDWXUHV�DQG�WR�GHYHORS�DQ�LQ�GHSWK�XQGHUVWDQGLQJ�RI�WKH�WUDQVIRUPDWLYH�SURFHVVHV�WKDW�RFFXU�ZLWKLQ�DQG�DFURVV�WKH�VWDWHVÚ�KHDOWK�FDUH�V\VWHPV�DQG�SDUWLFLSDWLQJ�3&0+�SUDFWLFHV��7KH�HYDOXDWLRQ�XVHG�D�PL[HG�PHWKRG�GHVLJQ��ZLWK�ERWK�TXDQWLWDWLYH�DQG�TXDOLWDWLYH�PHWKRGV�DQG�GDWD��&KDSWHU���LQFOXGHV�D�VXPPDU\�RI�FURVV�VWDWH�÷�QGLQJV��SDJH�����
PAGE 27
Table 4 continued
48 States
)HGHUDOO\�4XDOL÷�HG�Health Center Advanced Primary Care Practice Demonstration FQHC 71
Published: Rand Corporation, July 2015
Data Review: November 2011- October 2014
Report evaluated cost, utilization, access and quality measures
Relative to 4 baseline quarters, claims-based analyses across ��TXDUWHUV�VKRZ�VLJQL÷�FDQWO\�more utilization and costs for demonstration FQHCs vs. comparison FQHCs.Demonstration FQHC users KDG�VLJQL÷�FDQWO\�PRUH��• 7RWDO�0HGLFDUH�SD\PHQWV����TXDUWHUV��
• Hospital admissions (2 TXDUWHUV���
• 5HDGPLVVLRQV����TXDUWHU��• ('�YLVLWV����TXDUWHUV�
• The demonstration )4+&�JURXS�VLJQL÷�FDQWO\�outperformed comparison JURXS�IRU�DW�OHDVW���TXDUWHUV�IRU�+E$�&�WHVWV��UHWLQDO�H\H�H[DPV��DQG�QHSKURSDWK\�WHVWLQJ
• ,Q�\HDU����GHPRQVWUDWLRQ�FQHCs associated with a ~1% GHFUHDVH�LQ�FRQWLQXLW\�ZKHQ�ORRNLQJ�DFURVV�DOO�SULPDU\�care provider visits and when ORRNLQJ�DW�SULPDU\�FDUH�DQG�VSHFLDOLVW�FDUH�WRJHWKHU
Fee-for-service +&06�SURYLGHV�SDUWLFLSDWLQJ�)4+&V�ZLWK�D�TXDUWHUO\�care management payment of ����IRU�HDFK�HOLJLEOH�0HGLFDUH�EHQH÷�FLDU\
Location/InitiativePayment Model
Description Additional OutcomesCost & Utilization
71 .DKQ��.�/���7LPELH��-�:���)ULHGEHUJ��0�:���/DYHOOH��7�$���0HQGHO��3���$VKZRRG��-�6������6HWRGML��&�0����������Evaluation of CMS FQHC APCP Demonstration: Second Annual Report. 5DQG�&RUSRUDWLRQ��5HWULHYHG�IURP��KWWSV���LQQRYDWLRQ�FPV�JRY�)LOHV�UHSRUWV�ITKF�VFQGHYDOUSW�SGI�5$1'�&RUSRUDWLRQ�FRQGXFWHG�DQ�LQGHSHQGHQW�HYDOXDWLRQ�RI�WKH�)4+&�$GYDQFHG�3ULPDU\�&DUH�3UDFWLFH��$3&3��GHPRQVWUDWLRQ�DQG�DVVHVVHG�WKH�HIIHFWV�RI�WKH�$3&3�PRGHO�RQ�DFFHVV��TXDOLW\��DQG�FRVW�RI�FDUH�SURYLGHG�WR�0HGLFDUH�DQG�0HGLFDLG�EHQH÷�FLDULHV�FXUUHQWO\�VHUYHG�E\�)4+&V��)RU�WKLV�GHPRQVWUDWLRQ��&06�UHFRJQL]HV�DGYDQFHG�SULPDU\�FDUH�DV�WKH�W\SH�RI�FDUH�WKDW�LV�RIIHUHG�E\�)4+&V�WKDW�KDYH�DFKLHYHG�/HYHO���1&4$�UHFRJQLWLRQ�DV�D�3&0+�
SNAPSHOT OF THE EVIDENCE
21 of 23 studies that reported on cost measures found reductions in one or more measures
studies that reported on XWLOL]DWLRQ�PHDVXUHV
found reductions in one or more measures
23 of 25
Aggregated Outcomes from the 30 Studies
PAGE 28
SECTION THREE: DISCUSSION OF FINDINGS AND IMPLICATIONS7KH�UHSRUW�FRQFOXGHV�ZLWK�DQ�DQDO\VLV�DQG�GLVFXVVLRQ�RI�WKH�HYLGHQFH�DQG�LWV�LPSOLFDWLRQV�LQ�OLJKW�RI�SD\PHQW�
UHIRUP��$OWKRXJK�WKH�SULPDU\�FDUH�3&0+�LQWHUYHQWLRQV�LQFOXGHG�LQ�WKLV�UHSRUW�YDULHG�VXEVWDQWLDOO\�LQ�VL]H��
VFRSH��JHRJUDSKLF�ORFDWLRQ��3&0+�LPSOHPHQWDWLRQ�VWUDWHJ\��DQG�SD\PHQW�PRGHO��WUHQGV�LQ�WKH�UHSRUWHG�
UHVXOWV�DUH�FOHDU�DQG�HQFRXUDJLQJ��$FURVV�WKH�YDULRXV�VWXGLHV��WKH�3&0+�PRGHO�ZDV�DVVRFLDWHG�ZLWK�ODUJHO\�
SRVLWLYH�DQG�FRQVLVWHQW�WUHQGV�RQ�FRVW�DQG�XWLOL]DWLRQ�PHDVXUHV��WKH�PDMRU�IRFXV�RI�WKLV�DQQXDO�HYLGHQFH�
report.
Peer-Reviewed Studies (Table 1)
2YHUDOO��WKH�UHVXOWV�IURP����SHHU�UHYLHZHG�VWXGLHV�DVVRFLDWH�3&0+�LPSOHPHQWDWLRQ�ZLWK�JHQHUDO�
LPSURYHPHQWV�LQ�FRVW�DQG�XWLOL]DWLRQ�PHDVXUHV��2I�WKH����VWXGLHV�WKDW�GHVLJQDWHG�FRVW�DV�DQ�RXWFRPH�
YDULDEOH��QLQH�VKRZHG�DQ�LPSURYHPHQW�LQ�RQH�RU�PRUH�FRVW�PHDVXUHV��VXFK�DV�HPHUJHQF\�GHSDUWPHQW��('��
FRVWV�RU�LQSDWLHQW�VSHQGLQJ��7KH�9HUPRQW�%OXHSULQW�IRU�+HDOWK�IRXQG�LPSUHVVLYH�UHGXFWLRQV�LQ�LQSDWLHQW�
������p�������DQG�RXWSDWLHQW�KRVSLWDO�H[SHQGLWXUHV�������p�������ZKLOH�VLPXOWDQHRXVO\�LQFUHDVLQJ�
VSHQGLQJ�IRU�GHQWDO��VRFLDO��DQG�FRPPXQLW\�EDVHG�VXSSRUW�VHUYLFHV�������p<.001), which resulted in total
FRVW�VDYLQJV�IRU�WKH�VWDWH�DQG�D�UHWXUQ�RQ�LQYHVWPHQW�RI�QHDUO\���WR����DQQXDOL]HG�FRVW�JDLQ�UDWLR���� Both
SHHU�UHYLHZHG�VWXGLHV�IURP�%OXH�&URVV�%OXH�6KLHOG�0LFKLJDQ�LGHQWL÷�HG�WRWDO�FRVW�RI�FDUH�VDYLQJV��ZLWK�RQH�
VWXG\�UHSRUWLQJ�D�����SHUFHQW�ORZHU�FRVW�DPRQJ�DGXOWV�50�ZKLOH�WKH�*HLVLQJHU�VWXG\�LGHQWL÷�HG�DQ�LPSUHVVLYH�
����SHUFHQW�WRWDO�FRVW�VDYLQJV�DFURVV�D����PRQWK�VWXG\�SHULRG��� One of the two peer-reviewed studies
GHVFULELQJ�WKH�3HQQV\OYDQLD�&KURQLF�&DUH�LQLWLDWLYH�IRXQG�VWDWLVWLFDOO\�VLJQL÷�FDQW�FRVW�VDYLQJV�DVVRFLDWHG�
ZLWK�3&0+�SUDFWLFHV�VHUYLQJ�WKRVH�ZLWK�FKURQLF�LOOQHVV�LQ�DOO�WKUHH�IROORZ�XS�\HDUV��p������GULYHQ�E\�
VLJQL÷�FDQWO\�ORZHU�LQSDWLHQW��p<.01) and specialist (p<.0001) costs.55
1RW�DOO�QLQH�VWXGLHV��KRZHYHU��UHSRUWHG�RQ�WRWDO�FRVW�RI�FDUH��7KH�&RORUDGR�0XOWL�SD\HU�3&0+�SLORW�VWXG\��
ZKLFK�UHSRUWHG�ORZHU�('�FRVWV�HVSHFLDOO\�IRU�WKRVH�ZLWK�FKURQLF�LOOQHVV��PHDVXUHG�EXW�GLG�QRW�÷�QG�QHW�
RYHUDOO�FRVW�VDYLQJV��� Most studies did not assess the total cost of care, but the trend across these 17 peer-
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were demonstrated.”
PAGE 29
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FRQWLQXLW\�RI�FDUH��ZDV�GHPRQVWUDWHG�LQ�WKH�&DOLIRUQLD�+HDOWK�&DUH�&RYHUDJH�,QLWLDWLYH��� which evaluated
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'HVSLWH�DSSURSULDWH�FDXWLRQ�DERXW�WKH�XQLQWHQGHG�FRQVHTXHQFHV�RI�SROLFLHV�RU�SURJUDPV�WKDW�OLPLW�DFFHVV�
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incentives, etc.).”$QRWKHU�H[DPSOH�RI�D�PXOWL�SD\HU�FROODERUDWLYH�WKDW�UHVXOWHG�LQ�ERWK�VLJQL÷�FDQW�FRVW�VDYLQJV�DQG�XWLOL]DWLRQ�
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SRVLWLYH�UHVXOWV��FRQWUDVWLQJ�ZLWK�ODVW�\HDUÚV�ZLGHO\�FLWHG�-$0$�VWXG\72 that reported no association
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PAGE 30
State Government Evaluations (Table 2)
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initiatives, and each reported improvement in one or more cost metric. The Colorado Accountable Care
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Southeast Region Northeast Region
Nature Practices • 0RVWO\�VPDOO��LQGHSHQGHQW�SUDFWLFHV�• $�IHZ�YHU\�ODUJH�DFDGHPLF�PHGLFDO�
centers and FQHCs
• 6HYHUDO�ÜULJKW�VL]HÝ��PHGLXP�VL]HG��practices
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Patient population
• 0DQ\�KDG�VLJQL÷�FDQW�HFRQRPLF�hardship
• Less diverse, fewer with economic FKDOOHQJHV
Nurture Quality improvement focus
• 4,�IRFXVHG�DOPRVW�H[FOXVLYHO\�RQ�diabetes care
• Focused on multiple chronic conditions
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• 2QO\�����RI�SUDFWLFHV�KDG�(+5V�DW�WKH�EHJLQQLQJ�RI�LPSOHPHQWDWLRQ
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• $OO�SUDFWLFHV�KDG�(+5V�DW�EHJLQQLQJ�RI�implementation
Payment model • Practices received PMPM after HDUQLQJ�1&4$�UHFRJQLWLRQ
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2 streams of payment: • ��IRU�FDUH�PDQDJHPHQW�DQG• 1 for practice transformation
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Payer support ,Q�PDQ\�SUDFWLFHV��QR�GDWD�DQG�QR�technical support provided
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Results • Limited improvement on diabetes care
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• 5HGXFWLRQV�LQ�XQQHFHVVDU\�LQDSSURSULDWH�XWLOL]DWLRQ
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NATURE VS. NURTURE: Factors Driving PCMH Outcomes in Two Regions of Pennsylvania73
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PAGE 31
Industry Reports (Non Peer-Reviewed) (Table 3)
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Independent Evaluations of Federal Initiatives (Table 4)
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PAGE 35
To learn more about the PCMH, visit www.pcpcc.org
Creates stronger relationships with your providers
Saves you time
Provides better support and communication
A Patient-Centered Medical Home is the right care at the right time. It offers:
Medication review to help you understand and monitor the prescriptions you’re taking.
Connection to support and encouragement from peers in your community who share similar health issues and experiences.
Coaching and advice to help you follow your care plan and meet your goals.
Personalized care plans you help design that address your health concerns.
As you pursue your health care journey, you may make stops at different places:
Studies show that PCMH:
Wherever your journey takes you, your primary care team will help guide the way and coordinate your care.
Primary Care
Patient and Family
Specialists Community Supports
Pharmacy
Behavioral & Mental Health
Hospital
What Is a Patient-Centered Medical Home (PCMH)?
Technology makes it easy to get health care when and how you need it. You can reach your doctor through email, video chat, or after-hour phone calls. Mobile apps and electronic resources help you stay on top of your health and medical history.
It’s not a place… It’s a partnership with your primary care provider.
PCMH puts you at the center of your care, working with your health care team to create a personalized plan for reaching your goals.
Your primary care team is focused on getting to know you and earning your trust. They care about you while caring for you.
APPENDIX 1: EDUCATIONAL INFOGRAPHIC FOR PATIENTS AND FAMILIES
PAGE 36
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51 .DXVKDO��5���(GZDUGV��$����.HUQ��/�0����������$VVRFLDWLRQ�EHWZHHQ�WKH�SDWLHQW�FHQWHUHG�PHGLFDO�KRPH�DQG�KHDOWKFDUH�XWLOL]DWLRQ��American Journal of Managed Care, 21������������
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55 1HDO��-���&KDZOD��5���&RORPER��&���6Q\GHU��5����1LJDP��6����������0HGLFDO�KRPHV��FRVW�HIIHFWV�RI�XWLOL]DWLRQ�E\�FKURQLFDOO\�ill patients. American Journal of Managed Care, 21(1), e51-61.
56 5DSKDHO��-�/���&RROH\��:�&���9HJD��$���.RZDONRZVNL��0�$���7UDQ��;���7UHDGZHOO��-��â*LRUGDQR��7�3����������2XWFRPHV�IRU�children with chronic conditions associated with parent- and provider-reported measures of the medical home. Journal of Health Care for the Poor and Underserved, 26�������������GRL����������KSX����������
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