Vermont's Community-Oriented All-Payer Medical Home Model Reduces Expenditures and Utilization While Delivering High-Quality Care

Addressing social determinants of health in orthopaedics: A systematic review of strategies and solutions

BACKGROUND

Barriers stemming from Social Determinants of Health (SDOH) are known to contribute to higher rates of complications, poor patient adherence to treatment plans, and suboptimal outcomes following orthopaedic care. While SDOH's impact has been characterized, interventions to address SDOH-related inequities in orthopaedics have not yet been optimized.

PURPOSE

The objective of the present systematic review was to identify and synthesize current peer-reviewed literature focused interventions to address SDOH-related inequities to develop optimal mitigation strategies that improve outcomes for orthopaedic patients.

METHODS

A systematic search of PubMed, OVID, and CINAHL identified articles that referenced SDOH and an intervention to address inequities.

RESULTS

After screening 419 studies, 19 met inclusion criteria. Studies commonly looked at the impact of insurance policy change on the rate of the population with active insurance and associated use of elective surgery. Nine studies found that policy changes generally increased the rate of insured patients, though inequities remained for younger and racial minority patients. The relative paucity of literature in conjunction with methodological differences among studies highlights the need for further development and validation of effective interventions to address SDOH-related inequities in orthopaedics.

CONCLUSIONS

Insurance expansion was the focus of the majority of included articles, finding that expansion is associated with higher rates of insured patients undergoing elective and emergent procedures, however, gaps remain for young patients and racial minorities. Further research is needed to determine effective healthcare team, healthcare system, and policy-level interventions that overcome SDOH-related barriers to optimal care and outcomes for orthopaedic patients.

LEVEL OF EVIDENCE

Level-II.

Disentangling the impact of alternative payment models and associated service delivery models on quality of chronic care: A scoping review

Payment reforms are frequently implemented alongside service delivery reforms, thus rendering it difficult to disentangle their impact. This scoping review aims to link alternative payment arrangements within their context of service delivery, to assess their impact on quality of chronic care, and to disentangle, where possible, the impact of payment reforms from changes to service delivery. A search of literature published between 2013 and 2022 resulted in 34 relevant articles across five types of payment models: capitation/global budget (n = 13), pay-for-coordination (n = 10), shared savings/shared risk (n = 6), blended capitation (n = 3), and bundled payments (n = 1). The certainty of evidence was generally low due to biases associated with voluntary participation in reforms. This scoping review finds that population-based payment reforms are better suited for collaborative, person-centred approaches of service delivery spanning settings and providers, but also highlights the need for a wider evidence base of studies disentangling the impact of financing from service delivery reforms. Limited evidence disentangling the two suggests that transforming service delivery to a team-based model of care alongside a purchasing reform shifting to blended capitation was more impactful in improving quality of chronic care, than the individual components of payment and service delivery. Further comparative studies employing causal inference methods, accounting for biases and quantifying aspects of service delivery, are needed to better disentangle the mechanisms impacting quality of care.

Rethinking Health and Health Care: How Clinicians and Practice Groups Can Better Promote Whole Health and Well-Being for People and Communities

A new National Academies of Sciences, Engineering, and Medicine report, "Achieving Whole Health: A New Approach for Veterans and the Nation," redefines what it means to be healthy and creates a roadmap for health systems, including the Veterans Health Administration and the nation, to scale and spread a whole health approach to care. The report identifies 5 foundational elements for whole health care and sets 6 national, state, and local policy goals for change. This article summarizes the report, emphasizes the importance of preventive medicine, and identifies concrete actions clinicians and practices can take now to deliver whole health care.

Assessing the Relationship Between Well-Care Visit and Emergency Department Utilization Among Adolescents and Young Adults

PURPOSE

To investigate the association between adolescent and young adult (AYA) well-care visits and emergency department (ED) utilization.

METHODS

Vermont's all-payer claims data were used to evaluate visits for 49,089 AYAs (aged 12-21 years) with a health-care claim from January 1 through December 31, 2018. We performed multiple logistic regression analyses to determine the association between well-care visits and ED utilization, investigating potential moderating effects of age, insurance type, and medical complexity.

RESULTS

Nearly half (49%) of AYAs who engaged with the health-care system did not attend a well-care visit in 2018. AYAs who did not attend a well-care visit had 24% greater odds (95% confidence interval [CI]: 1.19-1.30) of going to the ED at least once in 2018, controlling for age, sex, insurance type, and medical complexity. Older age, female sex, Medicaid insurance, and greater medical complexity independently predicted greater ED utilization in the adjusted model. In stratified analyses, late adolescents and young adults (aged 18-21 years) who did not attend a well-care visit had 47% greater odds (95% CI: 1.37 - 1.58) of ED visits, middle adolescents (aged 15-17 years) had 9% greater odds (95% CI: 1.01-1.18), and early adolescents (aged 12-14 years) had 16% greater odds (95% CI: 1.06 - 1.26).

CONCLUSIONS

Not attending well-care visits is associated with greater ED utilization among AYAs engaged in health care. Focus on key quality performance metrics such as well-care visit attendance, especially for 18- to 21-year-olds during their transition to adult health care, may help reduce ED utilization.

Family Experience of Caregiver Burden and Health Care Usage in a Statewide Medical Home Program

OBJECTIVE

To evaluate family-reported caregiver experiences and health care utilization of patients enrolled in the Pennsylvania Medical Home Program (PA-MHP) statewide practice network and compare results to PA-MHP practices' Medical Home Index (MHI) scores. We hypothesized families enrolled in higher-scoring patient-and-family-centered medical homes (PCMH) on completed MHIs would report decreased caregiver burden and improved health care utilization.

METHODS

We analyzed surveys completed by families receiving care coordination services in PA-MHP's network and each practice's mean MHI score. A total of 3221 caregivers completed surveys evaluating hours spent coordinating care/week, missed school/workdays, sick visits, and emergency department (ED) visits. A total of 222 providers from 54 participating PA-MHP practices completed the nationally recognized MHI. Family/practice demographics were collected. We developed multivariate logistic regression models assessing independent associations among family survey outcomes and corresponding practices' MHI scores.

RESULTS

Families enrolled in high-scoring PCMHs had decreased odds of spending >1 h/wk coordinating care (odds ratio [OR] 0.82, adjusted OR [aOR]: 0.70, 95% confidence interval [CI] 0.55-0.90), missing workdays in the past 6 months (OR 0.82, aOR: 0.72, 95% CI 0.69-0.97), and ED visits in the past 12 months (OR 0.83, aOR: 0.81, 95% CI 0.65-0.99) in comparison to families enrolled in lower-scoring PCMHs. Families enrolled in higher-scoring PCMHs did not report fewer sick visits despite fewer ED visits, indicating more appropriate health care utilization. High-scoring PCMHs had lower percentages of publicly insured and low-income children.

CONCLUSIONS

Higher-scoring PCMHs are associated with decreased caregiver burden and improved health care utilization across diverse PA practices. Future studies should evaluate interventions uniformly improving PCMH quality and equity.

Patient-Centered Medical Homes and Pediatric Preventive Counseling

OBJECTIVE

To measure pediatric preventive counseling at patient-centered medical homes (PCMHs) compared with practices that reported undertaking some or no quality-related activities.

METHODS

We analyzed 4814 children and adolescents ages 0 to 17 who visited their usual sources of care in the nationally representative Medical Expenditure Panel Survey Medical Organizations Survey (MEPS-MOS), a household survey combined with a survey of household members' usual sources of care. We identified PCMHs using lists from certifying or accrediting organizations. For other practices in the MEPS-MOS, 2 quality-related activities were 1) reports to physicians about their clinical quality of care, and 2) electronic health record system reminders to physicians. Regressions controlled for practice, child, and family characteristics.

RESULTS

Compared with other practices, PCMHs were generally associated with greater likelihood of receiving preventive counseling. Estimates varied with the quality-related activities of the comparison practices. Counseling against smoking in the home was 10.4 to 18.7 percentage points (both P < .01) more likely for PCMHs. More associations were statistically significant for PCMHs compared with practices that undertook 1 of 2 quality-related activities examined. Among children ages 2 to 5, compared with practices undertaking both quality-related activities, those with PCMHs were more likely to receive counseling on 3 of 5 topics. Among adolescents, compared with practices undertaking both quality-related activities, those with PCMHs were more likely to receive counseling on smoking, exercise, and eating healthy.

CONCLUSIONS

PCMHs were associated with substantially greater receipt of pediatric preventive counseling. Evaluations of PCMHs need to account for the quality-related activities of comparison practices.

Community social determinants and health outcomes drive availability of patient-centered medical homes

The collaborative design of America's patient-centered medical homes places these practices at the forefront of emerging efforts to address longstanding inequities in the quality of primary care experienced among socially and economically marginalized populations. We assessed the geographic distribution of the country's medical homes and assessed whether they are appearing within communities that face greater burdens of disease and social vulnerability. We assessed overlapping spatial clusters of mental and physical health surveys; health behaviors, including alcohol-impaired driving deaths and drug overdose deaths; as well as premature mortality with clusters of medical home saturation and community socioeconomic characteristics. Overlapping spatial clusters were assessed using odds ratios and marginal effects models, producing four different scenarios of resource need and resource availability. All analyses were conducted using county-level data for the contiguous US states. Counties having lower uninsured rates and lower poverty rates were the most consistent indicators of medical home availability. Overall, the analyses indicated that medical homes are more likely to emerge within communities that have more favorable health and socioeconomic conditions to begin with. These findings suggest that intersecting the spatial footprints of medical homes in relation to health and socioeconomic data can provide crucial information for policy makers and payers invested in narrowing the gaps between clinic availability and the communities that experience the brunt of health and social inequalities.

The impact of patient-centered medical home certification on quality of care for patients with diabetes

OBJECTIVE

To identify the impact of changes surrounding certification as a patient-centered medical home (PCMH) on outcomes for patients with diabetes.

STUDY SETTING

Minnesota legislation established mandatory quality reporting for patients with diabetes and statewide standards for certification as a PCMH. Patient-level quality reporting data (2008-2018) were used to study the impact of transition to a PCMH.

STUDY DESIGN

Achievement of Minnesota's optimal diabetes care standard-in aggregate and by component-was modeled for adult patients with Type 1 or Type 2 diabetes as a function of time relative to the year the patient's primary care practice achieved PCMH certification. Patients from uncertified practices were used to control for general trend. Practice-level random effects captured time-invariant characteristics of practices and the practices' average patient.

DATA COLLECTION

Electronic health record data were submitted by 695 Minnesota practices capturing components of the quality standard: blood sugar control, cholesterol control, blood pressure control, nonsmoking status, and use of aspirin.

PRINCIPAL FINDINGS

The first cohort of practices achieving PCMH certification (July 2010-June 2014) showed statistically insignificant changes in optimal care. The next cohort of practices (July 2014-June 2018) achieved larger, clinically meaningful increases in quality of care during the time prior to and following certification. Specifically, this second cohort of practices was estimated to achieve a 12.8 percentage-point improvement (P < .001) in the predicted probability of providing optimal diabetes care over the period spanning 3 years before to 3 years after certification.

CONCLUSIONS

Our results suggest that the initial cohort of certified practices was already performing at a high level before certification, perhaps requiring little change in their operations to achieve PCMH certification. The second cohort, on the other hand, made meaningful, quality-improving changes in the years surrounding certification. Differences by cohort may partially explain the inconsistent PCMH impacts found in the literature.

Impact of Healthcare Delivery System Type on Clinical, Utilization, and Cost Outcomes of Patient-Centered Medical Homes: a Systematic Review

BACKGROUND

As healthcare reimbursement shifts from being volume to value-focused, new delivery models aim to coordinate care and improve quality. The patient-centered medical home (PCMH) model is one such model that aims to deliver coordinated, accessible healthcare to improve outcomes and decrease costs. It is unclear how the types of delivery systems in which PCMHs operate differentially impact outcomes. We aim to describe economic, utilization, quality, clinical, and patient satisfaction outcomes resulting from PCMH interventions operating within integrated delivery and finance systems (IDFS), government systems including Veterans Administration, and non-integrated delivery systems.

METHODS

We searched PubMed, the Cochrane Library, and Embase from 2004 to 2017. Observational studies and clinical trials occurring within the USA that met PCMH criteria (as defined by the Agency for Healthcare Research and Quality), addressed ambulatory adults, and reported utilization, economic, clinical, processes and quality of care, or patient satisfaction outcomes.

RESULTS

Sixty-four studies were included. Twenty-four percent were within IDFS, 29% were within government systems, and 47% were within non-IDFS. IDFS studies reported decreased emergency department use, primary care use, and cost relative to other systems after PCMH implementation. Government systems reported increased primary care use relative to other systems after PCMH implementation. Clinical outcomes, processes and quality of care, and patient satisfaction were assessed heterogeneously or infrequently.

DISCUSSION

Published articles assessing PCMH interventions generally report improved outcomes related to utilization and cost. IDFS and government systems exhibit different outcomes relative to non-integrated systems, demonstrating that different health systems and populations may be particularly sensitive to PCMH interventions. Both the definition of PCMH interventions and outcomes measured are heterogeneous, limiting the ability to perform direct comparisons or meta-analysis.

Health Care Spending Slowed After Rhode Island Applied Affordability Standards To Commercial Insurers

States are introducing regulations to slow health care spending growth, but which of these successfully reduce spending growth remains unclear. We studied Rhode Island's 2010 affordability standards, which imposed price controls-particularly inflation caps and diagnosis-based payments-on contracts between commercial insurers and hospitals and clinics and required commercial insurers to increase their spending on primary care and care coordination services. Using a difference-in-differences design, we compared spending among 38,001 commercially insured adults in Rhode Island to that among 38,001 matched adults in other states in the period 2007-16. Relative to quarterly fee-for-service (FFS) spending among the control group, quarterly FFS spending among the Rhode Island group decreased by $76 per enrollee after implementation of the policy, or a decline of 8.1 percent from 2009 spending. Quarterly non-FFS primary care coordination spending increased by $21 per enrollee. Total spending growth decreased, driven by lower prices concordant with the adoption of price controls. Quality measures were unaffected or improved. The Rhode Island experience indicates that states may be able to slow total commercial health care spending growth through price controls while maintaining quality.

Patient-Centered Medical Home Implementation and Improved Chronic Disease Quality: A Longitudinal Observational Study

OBJECTIVE

To examine associations between clinics' extent of patient-centered medical home (PCMH) implementation and improvements in chronic illness care quality.

DATA SOURCE

Data from 808 Veterans Health Administration (VHA) primary care clinics nationwide implementing the Patient Aligned Care Teams (PACT) PCMH initiative, begun in 2010.

DESIGN

Clinic-level longitudinal observational study of clinics that received training and resources to implement PACT. Clinics varied in the extent they had PACT components in place by 2012.

DATA COLLECTION

Clinical care quality measures reflecting intermediate outcomes and care processes related to coronary artery disease (CAD), diabetes, and hypertension care were collected by manual chart review at each VHA facility from 2009 to 2013.

FINDINGS

In adjusted models containing 808 clinics, the 77 clinics with the most PACT components in place had significantly larger improvements in five of seven chronic disease intermediate outcome measures (e.g., BP < 160/100 in diabetes), ranging from 1.3 percent to 5.2 percent of the patient population meeting measures, and two of eight process measures (HbA1c measurement, LDL measurement in CAD) than the 69 clinics with the least PACT components. Clinics with moderate levels of PACT components showed few significantly larger improvements than the lowest PACT clinics.

CONCLUSIONS

Veterans Health Administration primary care clinics with the most PCMH components in place in 2012 had greater improvements in several chronic disease quality measures in 2009-2013 than the lowest PCMH clinics.

Synthesis Of Research On Patient-Centered Medical Homes Brings Systematic Differences Into Relief

The patient-centered medical home (PCMH) model emphasizes comprehensive, coordinated, patient-centered care, with the goals of reducing spending and improving quality. To evaluate the impact of PCMH initiatives on utilization, cost, and quality, we conducted a meta-analysis of methodologically standardized findings from evaluations of eleven major PCMH initiatives. There was significant heterogeneity across individual evaluations in many outcomes. Across evaluations, PCMH initiatives were not associated with changes in the majority of outcomes studied, including primary care, emergency department, and inpatient visits and four quality measures. The initiatives were associated with a 1.5 percent reduction in the use of specialty visits and a 1.2 percent increase in cervical cancer screening among all patients, and a 4.2 percent reduction in total spending (excluding pharmacy spending) and a 1.4 percent increase in breast cancer screening among higher-morbidity patients. These associations were significant. Identification of the components of PCMHs likely to improve outcomes is critical to decisions about investing resources in primary care.

A Balanced Portfolio Model For Improving Health: Concept And Vermont's Experience

A successful strategy for improving population health requires acting in several sectors by implementing a portfolio of interventions. The mix of interventions should be both tailored to meet the community's needs and balanced in several dimensions-for example, time frame, level of risk, and target population. One obstacle is finding sustainable financing for both the interventions and the community infrastructure needed. This article first summarizes Vermont's experience as a laboratory for health reform. It then presents a conceptual model for a community-based population health strategy, using a balanced portfolio and diversified funding approaches. The article then reviews Vermont's population health initiative, including an example of a balanced portfolio and lessons learned from the state's experience.

Maryland Multipayor Patient-centered Medical Home Program: A 4-Year Quasiexperimental Evaluation of Quality, Utilization, Patient Satisfaction, and Provider Perceptions

OBJECTIVE

To evaluate impact of the Maryland Multipayor Patient-centered Medical Home Program (MMPP) on: (1) quality, utilization, and costs of care; (2) beneficiaries' experiences and satisfaction with care; and (3) perceptions of providers.

DESIGN

4-year quasiexperimental design with a difference-in-differences analytic approach to compare changes in outcomes between MMPP practices and propensity score-matched comparisons; pre-post design for patient-reported outcomes among MMPP beneficiaries.

SUBJECTS

Beneficiaries (Medicaid-insured and privately insured) and providers in 52 MMPP practices and 104 matched comparisons in Maryland.

INTERVENTION

Participating practices received unconditional financial support and coaching to facilitate functioning as medical homes, membership in a learning collaborative to promote education and dissemination of best practices, and performance-based payments.

MEASURES

Sixteen quality, 20 utilization, and 13 cost measures from administrative data; patient-reported outcomes on care delivery, trust in provider, access to care, and chronic illness management; and provider perceptions of team operation, team culture, satisfaction with care provided, and patient-centered medical home transformation.

RESULTS

The MMPP had mixed impact on site-level quality and utilization measures. Participation was significantly associated with lower inpatient and outpatient payments in the first year among privately insured beneficiaries, and for the entire duration among Medicaid beneficiaries. There was indication that MMPP practices shifted responsibility for certain administrative tasks from clinicians to medical assistants or care managers. The program had limited effect on measures of patient satisfaction (although response rates were low) and on provider perceptions.

CONCLUSIONS

The MMPP demonstrated mixed results of its impact and indicated differential program effects for privately insured and Medicaid beneficiaries.

Reducing Emergency Room Visits and In-Hospitalizations by Implementing Best Practice for Transitional Care Using Innovative Technology and Big Data

BACKGROUND

Efforts to improve care transitions require coordination across the healthcare continuum and interventions that enhance communication between acute and community settings.

AIMS

To improve post-discharge utilization value using technology to identify high-risk individuals who might benefit from rapid nurse outreach to assess social and behavioral determinants of health with the goal of reducing inpatient and emergency department visits.

METHODS

The project employed a before and after comparison of the intervention site with similar primary care practice sites using population-level Medicaid claims data. The intervention targeted discharged persons with preexisting chronic disease and delivered a care transition alert to a nurse care coordinator for immediate telephonic outreach. The nurse assessed social determinants of health and incorporated problems into the EHR to share across settings. The project evaluated health outcomes and the value of nursing care on existing electronic claims data to compare utilization in the years before and during the intervention using negative binomial regression to account for rare events such as inpatient visits.

RESULTS

Avoiding readmissions and emergency visits, and increasing timely outpatient visits improved the individual's experience of care and the work life of healthcare providers, while reducing per capita costs (Quadruple Aim). In the intervention practice, the nurse care coordinator demonstrated the value of nursing care by reducing inpatient (25%) and emergency (35%) visits, and increasing outpatient visits (27%). The estimated value of avoided encounters over the secular Medicaid trend was $664 per adult with chronic disease, generating $71,289 in revenue from additional outpatient visits.

LINKING EVIDENCE TO ACTION

Using health information exchange to deliver appropriate and timely evidence-based clinical decision support in the form of care transition alerts and assessment of social determinants of health, in conjunction with data science methods, demonstrates the value of nursing care and resulted in achieving the Quadruple Aim.

Successful Integration of Pediatrics Into State Health Care Reform Efforts

Health care reform in Vermont promotes patient-centered medical homes (PCMH) and multi-disciplinary community health teams to support population health. This qualitative study describes the expansion of Vermont's health care reform efforts, initially focused on adult primary care, to pediatrics through interviews with project managers and facilitators, CHT members, pediatric practitioners and care coordinators, and community-based providers. Analyses used grounded theory, identifying themes confirmed by repeat occurrence across respondents. Respondents believed that PCMH recognition and financial and community supports would improve care for pediatric patients and families. Respondents shared three main challenges with health care reform efforts: achieving PCMH recognition, adapting community health teams for pediatric patients and families, and defining roles for care coordinators. For health care reform efforts to support pediatric patients and be family-centered, states may need additional resources to understand how pediatric and adult primary care differ and how best to support pediatrics during health care reform efforts.

Pediatric-Informed Facilitation of Patient-Centered Medical Home Transformation

Patient-centered medical home (PCMH) transformation has been challenging for pediatric practices, in part because of the National Committee for Quality Assurance (NCQA) PCMH focus on conditions and processes specific to adult patients. Realizing the potential challenges faced by pediatric practices, Vermont supported pediatric-informed facilitators to help practices during PCMH transformation. This study characterizes the impact of pediatric-informed facilitators; provides benchmark data on NCQA scores, number of facilitation meetings, and the time between facilitation start and end; and compares pediatric- and adult-serving practices. We found no difference between pediatric and matched adult-serving practices in NCQA score, number of facilitation meetings, or weeks to NCQA scoring. These results suggest that pediatric-informed facilitators can help pediatric practices achieve NCQA PCMH recognition on par with practices serving adult patients. Supporting primary care practices with specialty-informed facilitators can assist integration into health care reform efforts.

Patient-Centered Medical Home Recognition and Diabetes Control Among Health Centers: Exploring the Role of Enabling Services

The patient-centered medical home (PCMH) model has been considered a promising approach to improve chronic care delivery, particularly among patients with diabetes. There is theoretical support to suggest that certain nonmedical services, such as enabling services (eg, case management, social work, transportation), embedded within PCMH could be contributing to successful model implementation. It remains unclear whether PCMH recognition or enabling services are related to diabetes control. Federally Qualified Health Centers (FQHCs) are an important setting in which to study this relationship given the considerable effort required to implement the PCMH model and the ubiquity of enabling services in these safety net settings. This cross-sectional, population-based study used 2012 data from the Health Resources and Services Administration's Uniform Data System and PCMH Recognition Initiative Dataset to determine whether PCMH recognition status was associated with diabetes control rates among FQHCs, while controlling for covariates including enabling services. The study linear regression model estimated that PCMH recognition was associated with a 1.5% increase in the proportion of patients with controlled diabetes (B = 0.015; 95% CI 0.002, 0.027). Clinic region, patient age, and race/ethnicity groups also were related to diabetes control; however, enabling services were not. These findings suggest there is a positive association between PCMH recognition and diabetes control rates among FQHCs. Future research, using data that accurately reflect the provision and utilization of PCMH primary care functions and related enabling services, is needed to fully understand the relationship between the PCMH model and population health measures such as diabetes control.

The CareFirst Patient-Centered Medical Home Program: Cost and Utilization Effects in Its First Three Years

BACKGROUND

Enhanced primary care models have diffused slowly and shown uneven results. Because their structural features are costly and challenging for small practices to implement, they offer modest rewards for improved performance, and improvement takes time.

OBJECTIVE

To test whether a patient-centered medical home (PCMH) model that significantly rewarded cost savings and accommodated small primary care practices was associated with lower spending, fewer hospital admissions, and fewer emergency room visits.

DESIGN

We compared medical care expenditures and utilization among adults who participated in the PCMH program to adults who did not participate. We computed difference-in-difference estimates using two-part multivariate generalized linear models for expenditures and negative binomial models for utilization. Control variables included patient demographics, county, chronic condition indicators, and illness severity.

PARTICIPANTS

A total of 1,433,297 adults aged 18-64 years, residing in Maryland, Virginia, and the District of Columbia, and insured by CareFirst for at least 3 consecutive months between 2010 and 2013.

INTERVENTION

CareFirst implemented enhanced fee-for-service payments to the practices, offered a large retrospective bonus if annual cost and quality targets were exceeded, and provided information and care coordination support.

MEASURES

Outcomes were quarterly claims expenditures per member for all covered services, inpatient care, emergency care, and prescription drugs, and quarterly inpatient admissions and emergency room visits.

RESULTS

By the third intervention year, annual adjusted total claims payments were $109 per participating member (95 % CI: -$192, -$27), or 2.8 % lower than before the program and compared to those who did not participate. Forty-two percent of the overall decline in spending was explained by lower inpatient care, emergency care, and prescription drug spending. Much of the reduction in inpatient and emergency spending was explained by lower utilization of services.

CONCLUSIONS

A PCMH model that does not require practices to make infrastructure investments and that rewards cost savings can reduce spending and utilization.