High-Cost Utilization Persists Despite PCMH Implementation

A study of the Veterans Health Administration’s patient-centered medical home (PCMH) implementation found no association between progress with the alternative care delivery model and high-cost utilization.

In a cohort study involving over 1.6 million veterans, researchers from the VA Puget Sound Health Care System and the University of Washington found no consistent change in the number of emergency department (ED) visits, ambulatory care-sensitive condition (ACSC) hospitalizations, and all-cause hospitalizations even if a clinic made progress with PCMH implementation.

In fact, researchers found that ED visits among veterans younger than 65 years fell at clinics that made improvements through PCMH implementation as well as clinics that experienced somewhat negative consequences following PCMH implementation. There was no association with PCMH implementation progress and total hospitalizations.

Among veterans 65 years and older, worse and somewhat worse performance following PCHM implementation were also associated with fewer ED visits. Veterans in this age bracket who were seen at clinics with somewhat worse performance also had 12.4 fewer all-cause hospitalizations per 1,000 patients during the period.

Overall, the findings, which were recently published in JAMA Network Open, are raising questions about the PCMH business case.

“These results were surprising, given that our previous research found that better PCMH implementation in care delivery elements, such as team-based care and care continuity, was significantly associated with lower rates of high-cost acute health care utilization,” authors of the study stated.

The patient-centered medical home is a set of guidelines and best practices intended to bolster comprehensive, accessible, coordinated preventative care and patient management.

It is through this patient-centered approach to patient management that clinics aim to improve quality of care and reduce costs for items like high-cost healthcare utilization. But there has been a mixed bag on whether the investment price tag is worth it.

PCMH implementation can cost a clinic anywhere between $83,829 and $346,603 per annum during the process, which could take several years, research from the RAND Corporation found. And those costs tend to run on the larger side for smaller providers, a similar report from 2015 found.

Initial evaluations have shown PCMH implementation to have positive effects on care delivery and patient outcomes, with one such analysis from 2016 finding that a majority of programs can reduce spending in one or more categories and decrease inappropriate utilization of services.

However, these case studies may only be measuring achievements of PCMH implementation at a point in time, not over time, researchers wrote in JAMA Network Open.

“This ability of clinics to transform, including experiencing improvement in PCMH capabilities over time, represents a fundamentally different construct than what has been captured in prior cross-sectional studies, to our knowledge,” they explained. “Our study is consistent with findings by Martsolf et al that suggested that longitudinal analyses could attenuate the estimated associations seen in cross-sectional designs.”

Their findings are raising questions that “are critical for PCMH evaluations in and outside of the VHA,” they added. One of those questions is: Do certain functions or domains of the PCMH have a threshold effect?

If so, improvement in certain PCMH capabilities like team-based care and care coordination may not result in additional improvements in outcomes. Furthermore, specific domains of PCMH may be more important for optimizing care for certain groups of patients, researchers stated.

“This information is vital as health care organizations invest and expand primary care delivery based on the principles of the PCMH,” they wrote.