Effect of a multipayer patient-centered medical home on health care utilization and quality: The rhode island chronic care sustainability initiative pilot program

摘要

IMPORTANCE: The patient-centered medical home is advocated to reduce health care costs and improve the quality of care. OBJECTIVE: To evaluate the effects of the pilot program of a multipayer patient-centered medical home on health care utilization and quality. DESIGN: An interrupted time series design with propensity score-matched comparison practices, including multipayer claims data from 2 years before (October 1, 2006-September 30, 2008) and 2 years after (October 1, 2008-September 30, 2010) the launch of the pilot program. Uptake of the intervention was measured with audit data from the National Committee for Quality Assurance patient-centered medical home recognition process. SETTING: Five independent primary care practices and 3 private insurers in the Rhode Island Chronic Care Sustainability Initiative. PARTICIPANTS: Patients in 5 pilot and 34 comparison practices. INTERVENTIONS: Financial support, care managers, and technical assistance for quality improvement and practice transformation. MAIN OUTCOMES AND MEASURES: Hospital admissions, emergency department visits, and 6 process measures of quality of care (3 for diabetes mellitus and 3 for colon, breast, and cervical cancer screening). RESULTS: The mean National Committee for Quality Assurance recognition scores of the pilot practices increased from 42 to 90 points of a possible 100 points. The pilot and comparison practices had statistically indistinguishable baseline patient characteristics and practice patterns, except for higher numbers of attributed member months per year in the pilot practices (31 130 per practice vs 14 779, P = .01) and lower rates of cervical cancer screening in the comparison practices. Although estimates of the emergency department visits and inpatient admissions of patients in the pilot practices trended toward lower utilization, the only significant difference was a lower rate of ambulatory care sensitive emergency department visits in the pilot practices. The Chronic Care Sustainability Initiative pilot program was associated with a reduction in ambulatory care-sensitive emergency department visits of approximately 0.8 per 1000 member months or approximately 11.6% compared with the baseline rate of 6.9 for emergency department visits per 1000 member months (P = .002). No significant improvements were found in any of the quality measures. CONCLUSION AND RELEVANCE: After 2 years, a pilot program of a patient-centered medical home was associated with substantial improvements in medical home recognition scores and a significant reduction in ambulatory care sensitive emergency department visits. Although not achieving significance, there were downward trends in emergency department visits and inpatient admissions.