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

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.