Assessing the Impact of the Patient-Centered Medical Home (PCMH) (Colorado)

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Summary:

For more than 20 years, the WellMed Medical Group, a 22-practice, 80-provider health system, has used a health care model that meets 97 of 100 points under the National Committee for Quality Assurance (NCQA) definition of a Patient Centered Medical Home (PCMH). The WellMed model meets the criteria for a level-3 PCMH, meaning that it utilizes a fully functional electronic health record in its provision of care. This project conducted an evaluation of the clinical outcomes, financial and economic impact, and patient and provider satisfaction of this medical group. A mixed-methods approach was used to look at the history of the group’s development and implementation, its impact on patient care and outcomes, and key cost allocation mechanisms used to finance it. In addition, the group looked at their model from the perspective of an Accountable Care Organization (ACO).

Specific features of the WellMed PCMH include increased primary care investments, reduced panel size, intensive population management, expanded outpatient teams, inpatient management and discharge transition processes, and strong provider incentives.

The main objectives of the project were to:

  • Determine how WellMed developed their level-3 PCMH model (facilitators, barriers, key components, history, and leadership) using a qualitative methods approach.
  • Determine if implementation of the WellMed model impacted patient and provider satisfaction.
  • Determine if implementation of the WellMed level-3 PCMH improved care and health outcomes for patients.
  • Determine the incremental in-practice expenses per patient per month required to operate the WellMed PCMH, and the key components of the program.

As compared to the Medicare Fee-For-Service (FFS) population, WellMed patients were found to do better on most measures of preventive and chronic care. In addition, there were dramatic reductions in average bed days (60 percent), admission rates (8 percent), and emergency department visits (10 percent) compared to the matched cohort of FFS Medicare patients.

Because the WellMed model was implemented more than 20 years ago with a plan-do-study-act approach, it was difficult to assess which specific process and structural adaptations led directly to the improvements. WellMed uses internal demonstration projects to implement PCMH elements, meaning that there is no system-wide implementation date for any given service, making it difficult to tie outcome improvements to specific elements. In addition, some improvements not seen may have been achieved prior to the study. For instance, outcomes and preventive service delivery were found to have had significant improvements in the prior 10 years. However, many important outcomes, such as reduced mortality compared to peer population did not show improvements, perhaps because the improvements occurred when the changes were made 10 years earlier.

WellMed’s experience suggests that there are options other than integrated or hospital-owned networks that can generate substantial savings as well as measurable quality improvement and patient-centered outcomes. When considered from an ACO perspective, WellMed offers a particularly efficient model because the savings from emergency and inpatient care do not have to be shared with hospitals or subspecialists, allowing more reinvestment in outpatient care. It was noted that transferring the model to other markets may be done faster than the time it took for WellMed to develop its model, but is likely to take much longer than the typical 2-3 years set aside for most PCMH demonstration projects. Purchasing practices usually take 4-5 years to achieve similar outcomes once full PCMH/ACO functions are implemented.

Assessing the Impact of the Patient-Centered Medical Home (PCMH) - 2011

Summary Highlights

Summary: A research team from the University of Colorado Health Sciences Center and the Robert Graham Center evaluated clinical outcomes, financial and economic impact, and patient and provider satisfaction for WellMed Medical Group. WellMed is a medium-sized primary care health system that, over the past 20 years, has implemented a patient-centered medical home (PCMH) as defined by the National Committee for Quality Assurance. The study examined outcomes and cost-effectiveness of the PCMH model implemented amongst WellMed's 22 practices and 80 providers. The evaluation focused on overall care; care for specific diseases such as coronary artery disease, diabetes mellitus, and chronic obstructive pulmonary disease; and preventive care, including adult immunizations.

The study team used a mixed-method qualitative and quantitative evaluation approach. Key informant interviews and participant observations helped the study team understand how WellMed developed its model of care over time, the critical organizational milestones on the road to becoming a PCMH, and what it means to WellMed to be a PCMH. These qualitative data provided a narrative foundation that complemented and informed the quantitative findings. Data collection focused on the strategic changes made to improve health outcomes for different conditions. Health outcome measures included clinical outcome test values, hospitalization rates, and mortality rates. Particular attention was given to the associated effects of specific elements of the medical home model, including care management, team-based care characteristics, and health information technology (IT) functions.

A trend analysis assessed the impact of PCMH-related interventions on patient and provider satisfaction. In addition, a detailed analysis of the data assessed the impact of the WellMed PCMH on patient care and health outcomes over a period of 10 years (1997-2006), comparing the full claims data available during various blocks of time with similar patient panels. Purposeful implementation of a comprehensive patient data management system allowed for internal and external cohort analyses.

Specific Aims:

  • Determine how WellMed developed their level-3 PCMH model (facilitators, barriers, key components, history, and leadership) using a qualitative methods approach. (Achieved)
  • Determine if implementation of the WellMed model impacted patient and provider satisfaction. (Achieved)
  • Determine if implementation of the WellMed level-3 PCMH improved care and health outcomes for patients. (Achieved)
  • Determine the incremental in-practice expenses per patient per month required to operate the WellMed PCMH, and key components of the program. (Achieved)

2011 Activities: The quantitative comparison analysis was completed in 2010 and the first of four studies, Case Study of a Primary-Care Based Accountable Care System Approach to Medical Home Transformation, was published in the January 2011 Journal of Ambulatory Care Management. This manuscript reported that WellMed patients older than 65 had an adjusted mortality rate that was half of the statewide average. Hospitalization and readmission rates and emergency department visits had not changed over time, but preventive services improved. The authors concluded that phased implementation across the network made it difficult to link improvements to specific processes, but they seem to improve outcomes collectively.

Three additional papers were finalized in 2011, including: 1) A Cohort Analysis of Medicare Beneficiaries in a Primary Care-based Accountable Care Organization vs. Medicare Fee-for-service; 2) A 20-year Evolving Patient-Centered Medical Home-Based Accountable Care Organization that Works for Older Americans; and 3) The Economics of a Primary Care-based Accountable Care Organization. Publication of these papers is pending. The final analyses were also presented as part of an invited panel at Academy Health in June 2011.

The contract was extended for 6 months, during which a significant portion of the manuscript development occurred. The project was completed in February 2011.

Impact and Findings: This study found that WellMed, Inc., a primary-care based accountable care organization (ACO), produced clinical, financial, and utilization outcomes that are demonstrably better than matched cohorts of fee-for-service Medicare patients. This evaluation demonstrated that a 40-50 percent increase in investment in primary care over typical Medicare payments-up to 10 percent of total health care spending and investment in a sophisticated array of support services-can produce impressive savings, largely by reducing inpatient admissions and bed days. The specific reductions in emergency and inpatient services, particularly of bed-days, produce considerable return on investments in outpatient care, disease, and complex-care management; intensive clinical data monitoring and related quality feedback loops; and unusual services designed to solve costly patterns of care. WellMed also pays primary care providers more than twice as much as the national average, much of it through incentives that are large enough to shape behavior. The hospital used by WellMed generally reported larger margins than are typical of Medicare, but does not share in the broader savings, allowing more to be reinvested in outpatient services or shared as profit to outpatient team members.

This study supports findings from other ACO experiments and offers another model for reaping the fuller fruits of primary care. It also suggests a need to better understand the IT needs associated with population health management. WellMed demonstrated the need to have broader data-capture than clinical electronic health record systems; sophisticated analytic and feedback capacity (for quality improvement and intervention evaluation); and capacity for sharing data securely in a variety of ways, perhaps most importantly for patients to carry their key information electronically.  

Target Population: Chronic Care*, Chronic Obstructive Pulmonary Disease, Diabetes, Heart Disease

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions, and the electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.

Assessing the Impact of the Patient-Centered Medical Home (PCMH) - 2010

Summary Highlights



Target Population: Chronic Care*, Chronic Obstructive Pulmonary Disease, Diabetes, Heart Disease

Summary: The University of Colorado Health Sciences Center and the Robert Graham Center are conducting an evaluation of clinical outcomes, financial and economic impact, and patient and provider satisfaction for a medium-sized primary care health system that has implemented a long-established patient-centered medical home (PCMH) model. For 20 years, the WellMed Medical Group has provided care that matches the National Committee for Quality Assurance definition of a PCMH. The study examines outcomes and cost-effectiveness of the PCMH model implemented in WellMed’s 22-practice, 80-provider health system. The evaluation is on overall care; care for specific diseases such as coronary artery disease, diabetes mellitus, and chronic obstructive pulmonary disease; and preventive care, including adult immunizations.

The study team is using a mixed-method qualitative and quantitative evaluation approach. Key informant interviews and participant observations are helping the study team understand how WellMed developed its model of care over time, the critical organizational milestones on the road to becoming a PCMH, and what it means to be a PCMH for WellMed. These qualitative data will provide a narrative foundation that complements and informs the quantitative findings. Data collection is focusing on the strategic changes made to improve health outcomes for different conditions. Health outcome measures will include clinical outcome test values, hospitalization, and mortality. Particular attention will be given to the associated effects of specific elements of the medical home model, including care management, team-based care characteristics, and health information technology (IT) functions.

A trend analysis to assess the impact of the WellMed model on patient and provider satisfaction will examine PCMH-related interventions associated with changes in satisfaction. In addition, a detailed analysis of data will assess the impact of the WellMed PCMH on patient care and health outcomes over a period of 10 years (1997-2006), comparing the full claims data available during various blocks of time with similar patient panels. Purposeful implementation of a comprehensive patient data management system allows internal and external cohort analyses. This study will provide ample opportunity for a well-functioning PCMH to demonstrate any improved outcomes.

Project Objectives:
  • Determine how WellMed developed their level-3 PCMH model (facilitators, barriers, key components, history, and leadership) using a qualitative methods approach. (Ongoing)
  • Determine if implementation of the WellMed model impacted patient and provider satisfaction. (Ongoing)
  • Determine if implementation of the WellMed level-3 PCMH improved care and health outcomes for patients. (Ongoing)
  • Determine the incremental in-practice expenses per patient per month required to operate the WellMed PCMH, and the key components of the program. (Ongoing)

2010 Activities: The quantitative comparison analysis is complete and the first of four studies was published in the January 2011 volume of the Journal of Ambulatory Care Management, Case Study of a Primary Care–Based Accountable Care System Approach to Medical Home Transformation. During a qualitative analysis meeting in July, a set of nine questions were identified where supplemental information was necessary from WellMed. The questions were submitted to WellMed, and were incorporated in the overall qualitative analysis and resulting paper. The project team developed a revised timeline describing WellMed’s 20-year evolution based on the qualitative analysis and a table that summarized the important qualitative themes identified to date and how they connect to PCMH, the accountable care organization, and community elements of the WellMed model. The three remaining papers are currently being finalized.

The analyses from the first paper were presented at AcademyHealth Research Meeting in June, at the Agency for Healthcare Research and Quality (AHRQ) Annual Conference in September, at the Patient Centered-Collaborative Care Conference in October, and to the North American Primary Care Research Group in November. The final analyses will be part of an invited panel at AcademyHealth in June 2011.

The final report is under review by AHRQ staff.

Preliminary Impact and Findings: Preliminary results from the satisfaction survey analyses show high overall satisfaction with WellMed: 95.9 percent of patients responded they were “very satisfied or satisfied” with the WellMed staff in 2006, and 96.0 percent of patients responded they were “very satisfied or satisfied” in 2009. WellMed Medicare bed days are 60 percent lower than in the fee-for-service population; hospital admission rates, readmission rates, and emergency department visits are all significantly lower as well. WellMed invests 40 to 50 percent more in the primary care setting than is typical of Medicare (approximately 10 percent of total spending). WellMed beneficiaries appear to enjoy mortality reduction of nearly 50 percent compared to an age and sex adjusted peer cohort in Texas.

The qualitative analysis showed 13 emergent themes which will be elaborated on in the final report. Some of the themes include:

  • Patients generally report feeling like “one of them”, like they are part of a family, and feel “at home” when visiting their WellMed clinic.
  • The guiding principles from which the WellMed model was constructed and the way in which the model has evolved stem from and promote the four pillars of primary care.
  • Areas of further work for WellMed include greater focus on: 1) the patient’s experience; 2) definition, clarification, and optimization of roles; 3) bolstering capacity for fast continuous change; 4) patient activation, engagement, and self-management; 5) going from a physician-centric to a more patient-focused team-based model; 6) integrated mental health care; 7) formal linkages and processes to tap into community resources; 8) formal behavior change strategies; and 9) a common IT platform.
  • Commonly used mechanisms to promote buy-in and facilitate change include formal and informal trainings and learning opportunities, regular clinic meetings, rewards and incentives, open-door policy for suggestions and ideas, facilitative leadership, and tapping into WellMed resources such as services, tools, and other departments.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions, and the electronic exchange of health information to improve quality of care

Business Goal: Knowledge Creation

*AHRQ Priority Population.

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