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Cole ES, Campbell C, Diana ML, Webber L, Culbertson R. Patient-centered medical homes in Louisiana had minimal impact on Medicaid population's use of acute care and costs. Health Aff (Millwood) 2017; 34:87-94. [PMID: 25561648 DOI: 10.1377/hlthaff.2014.0582] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The patient-centered medical home model of primary care has received considerable attention for its potential to improve outcomes and reduce health care costs. Yet little information exists about the model's ability to achieve these goals for Medicaid patients. We sought to evaluate the effect of patient-centered medical home certification of Louisiana primary care clinics on the quality and cost of care over time for a Medicaid population. We used a quasi-experimental pre-post design with a matched control group to assess the effect of medical home certification on outcomes. We found no impact on acute care use and modest support for reduced costs and primary care use among medical homes serving higher proportions of chronically ill patients. These findings provide preliminary results related to the ability of the patient-centered medical home model to improve outcomes for Medicaid beneficiaries. The findings support a case-mix-adjusted payment policy for medical homes going forward.
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Affiliation(s)
- Evan S Cole
- Evan S. Cole is an associate project director at the Georgia Health Policy Center, Georgia State University, in Atlanta
| | - Claudia Campbell
- Claudia Campbell is a professor of health systems management at the School of Public Health and Tropical Medicine, Tulane University, in New Orleans, Louisiana
| | - Mark L Diana
- Mark L. Diana is an associate professor of health systems management at the School of Public Health and Tropical Medicine, Tulane University
| | - Larry Webber
- Larry Webber is a professor of biostatistics at the School of Public Health and Tropical Medicine, Tulane University
| | - Richard Culbertson
- Richard Culbertson is a professor and director of health policy and systems management in the School of Public Health, Louisiana State University, in New Orleans
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Shao H, Brown L, Diana ML, Schmidt LA, Mason K, Oronce CI, Shi L. Estimating the costs of supporting safety-net transformation into patient-centered medical homes in post-Katrina New Orleans. Medicine (Baltimore) 2016; 95:e4990. [PMID: 27684855 PMCID: PMC5265948 DOI: 10.1097/md.0000000000004990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
There is a need to understand the costs associated with supporting, implementing, and maintaining the system redesign of small and medium-sized safety-net clinics. The authors aimed to understand the characteristics of clinics that transformed into patient-centered medical homes and the incremental cost for transformation.The sample was 74 clinics in Greater New Orleans that received funds from the Primary Care Access and Stabilization Grant program between 2007 and 2010 to support their transformation. The study period was divided into baseline (September 21, 2007-March 21, 2008), transformation (March 22, 2008-March 21, 2009), and maintenance (March 22, 2009-September 20, 2010) periods, and data were collected at 6-month intervals. Baseline characteristics for the clinics that transformed were compared to those that did not. Fixed-effect models were conducted for cost estimation, controlling for baseline differences, using propensity score weights.Half of the 74 primary care clinics achieved transformation by the end of the study period. The clinics that transformed had higher total cost, more clinic visits, and a larger female patient proportion at baseline. The estimated incremental cost for clinics that underwent transformation was $37.61 per visit per 6 months, and overall it cost $24.86 per visit per 6 months in grant funds to support a clinic's transformation.Larger-sized clinics and those with a higher female proportion were more likely to transform. The Primary Care Access and Stabilization Grant program provided approximately $24.86 per visit over the 2 and 1/2 years. This estimated incremental cost could be used to guide policy recommendations to support primary care transformation in the United States.
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Affiliation(s)
- Hui Shao
- School of Public Health and Tropical Medicine, Tulane University
| | | | - Mark L. Diana
- School of Public Health and Tropical Medicine, Tulane University
| | | | - Karen Mason
- Louisiana Public Health Institute, New Orleans, LA
| | | | - Lizheng Shi
- School of Public Health and Tropical Medicine, Tulane University
- Correspondence: Professor Lizheng Shi, Department of Global Health Systems and Development, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA. E-mail:
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Van Cleave J, Okumura MJ, Swigonski N, O'Connor KG, Mann M, Lail JL. Medical Homes for Children With Special Health Care Needs: Primary Care or Subspecialty Service? Acad Pediatr 2016; 16:366-72. [PMID: 26523634 DOI: 10.1016/j.acap.2015.10.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/23/2015] [Accepted: 10/26/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine primary care pediatricians' (PCPs) beliefs about whether the family-centered medical home (FCMH) should be in primary or subspecialty care for children with different degrees of complexity; and to examine practice characteristics associated with these beliefs. METHODS Data from the American Academy of Pediatrics Periodic Survey (PS 79) conducted in 2012 were analyzed. Outcomes were agreement/strong agreement that 1) primary care should be the FCMH locus for most children with special health care needs (CSHCN) and 2) subspecialty care is the best FCMH locus for children with rare or complex conditions. In multivariate models, we tested associations between outcomes and practice barriers (eg, work culture, time, cost) and facilitators (eg, having a care coordinator) to FCMH implementation. RESULTS Among 572 PCPs, 65% agreed/strongly agreed primary care is the best FCMH setting for most CSHCN, and 43% agreed/strongly agreed subspecialty care is the best setting for children with complexity. Cost and time as barriers to FCMH implementation were oppositely associated with the belief that primary care was best for most CSHCN (cost: adjusted odds ratio [AOR] 2.31, 1.36-3.90; time: AOR 0.48, 0.29-0.81). Lack of skills to communicate and coordinate care was associated with the belief that specialty care was the best FCMH for children with complexity (AOR 1.99, 1.05-3.79). CONCLUSIONS A substantial minority endorsed specialty care as the best FCMH locus for children with medical complexity. Several barriers were associated with believing primary care to be the best FCMH for most CSHCN. Addressing medical complexity in FCMH implementation may enhance perceived value by pediatricians.
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Affiliation(s)
- Jeanne Van Cleave
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Megumi J Okumura
- Department of Pediatrics and Internal Medicine, University of California San Francisco School of Medicine, San Francisco, Calif
| | - Nancy Swigonski
- Children's Health Services Research, University of Indiana, Indianapolis, Ind
| | - Karen G O'Connor
- Department of Research, American Academy of Pediatrics, Elk Grove Village, Ill
| | - Marie Mann
- HRSA/Maternal and Child Health Bureau, US Department of Health and Human Services, Rockville, Md
| | - Jennifer L Lail
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Abstract
BACKGROUND Recent efforts to revitalize primary care have centered on the patient-centered medical home (PCMH). Although enhanced access is an integral component of the PCMH model, the effect of PCMHs on access to primary care services is understudied. OBJECTIVE To determine whether PCMH practices are associated with better access to new appointments for nonelderly adults by direct measurement. RESEARCH DESIGN We estimated the relationship between practice PCMH status and access to care in multivariate regression models, adjusting for a robust set of patient, practice, and geographic characteristics; using data on 11,347 simulated patient calls to 7266 primary care practices across 10 US states merged with data on PCMH practices. PARTICIPANTS Trained field staff posing as patients (age younger than 65 y) seeking a new primary care appointment with varying insurance status (private, Medicaid, or self-pay). MEASURES Our primary predictor was practice PCMH status and our primary outcome was the ability of simulated patients to schedule a new appointment. Secondary outcomes included the number of days to that appointment; availability of after-hour appointments; and an appointment with an ongoing primary care provider. RESULTS Of the 7266 practices contacted for an appointment, 397 (5.5%) were National Committee for Quality Assurance-recognized PCMHs. In adjusted analyses, callers to PCMH practices compared with non-PCMH practices were more likely to schedule a new appointment (adjusted odds ratio=1.26 (95% CI, 1.01-1.58); P=0.04] and be offered after-hour appointments [adjusted odds ratio=1.36 (95% CI, 1.04-1.75); P=0.02]. DISCUSSION PCMH practices maybe associated with better access to new primary care appointments for nonelderly adults, those most likely to gain insurance under the Affordable Care Act.
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Martsolf GR, Kandrack R, Schneider EC, Friedberg MW. Categories of Practice Transformation in a Statewide Medical Home Pilot and their Association with Medical Home Recognition. J Gen Intern Med 2015; 30:817-23. [PMID: 25670396 PMCID: PMC4441668 DOI: 10.1007/s11606-014-3176-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 12/01/2014] [Accepted: 12/17/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Healthcare purchasers have created financial incentives for primary care practices to achieve medical home recognition. Little is known about how changes in practice structure vary across practices or relate to medical home recognition. OBJECTIVE We aimed to characterize patterns of structural change among primary care practices participating in a statewide medical home pilot. DESIGN We surveyed practices at baseline and year 3 of the pilot, measured associations between changes in structural capabilities and National Committee for Quality Assurance (NCQA) medical home recognition levels, and used latent class analysis to identify distinct classes of structural transformation. PARTICIPANTS Eighty-one practices that completed surveys at baseline and year 3 participated in the study. MAIN MEASURES Study measures included overall structural capability score (mean of 69 capabilities); eight structural subscale scores; and NCQA recognition levels. RESULTS Practices achieving higher year-3 NCQA recognition levels had higher overall structural capability scores at baseline (Level 1: 28.4 % of surveyed capabilities, Level 2: 40.9 %, Level 3: 48.7 %; p value = 0.001). We found no association between NCQA recognition level and change in structural capability scores (Level 1: 33.2 % increase, Level 2: 30.8 %, Level 3: 33.7 %; p value = 0.88). There were four classes of practice transformation: 27 % of practices underwent "minimal" transformation (changing little on any scale); 20 % underwent "provider-facing" transformation (adopting electronic health records, patient registries, and care reminders); 26 % underwent "patient-facing" transformation (adopting shared systems for communicating with patients, care managers, referral to community resources, and after-hours care); and 26 % underwent "broad" transformation (highest or second-highest levels of transformation on each subscale). CONCLUSIONS AND RELEVANCE In a large, state-based medical home pilot, multiple types of practice transformation could be distinguished, and higher levels of medical home recognition were associated with practices' capabilities at baseline, rather than transformation over time. By identifying and explicitly incentivizing the most effective types of transformation, program designers may improve the effectiveness of medical home interventions.
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Affiliation(s)
- Grant R Martsolf
- RAND Corporation, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA, 15213, USA,
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Van Cleave J, Le TT, Perrin JM. Point-of-Care Child Psychiatry Expertise: The Massachusetts Child Psychiatry Access Project. Pediatrics 2015; 135:834-41. [PMID: 25896844 PMCID: PMC4411776 DOI: 10.1542/peds.2014-0720] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Since 2005, after a pilot program, the Massachusetts Child Psychiatry Access Project (MCPAP) has provided point-of-care psychiatry expertise and referral assistance by telephone to primary care providers. We examined its adoption and use and the practice characteristics associated with different adoption timelines and use patterns. METHODS We merged data on calls to MCPAP in 2005 to 2011 with practice data (enrollment year, panel size, regional team assignment). We categorized practices' days from enrollment to first call (adoption) (0-100, 101-365, > 365 days) and quartile of call frequency (use) (annual highest, middle, and lowest quartiles of number of calls per 1000 empanelled patients). We determined associations between adoption and use and practice characteristics using multivariate models. RESULTS Among 285 practices, adoption and use varied: 55% called 0 to 100 days from enrollment and 16% called >365 days from enrollment. Practices in the highest quartile of use made a mean 15.5 calls/year per 1000 patients, whereas the lowest quartile made 0.4 calls/year per 1000 patients. Adoption within 100 days was associated with enrollment during or after 2007 (odds ratio [OR] 4.09, 95% confidence interval [CI] 2.23-7.49) and assignment to the team at the pilot site (OR 4.42, 95% CI 2.16-9.04 for central Massachusetts). Highest-quartile use was associated with team assignment (OR 3.58, 95% CI 1.86-6.87 for central Massachusetts) and panel size (OR 0.10, 95% CI 0.03-0.31 for ≥ 10,000 vs < 2000 patients). CONCLUSIONS Adoption and use of MCPAP varied widely. Timing of enrollment, assignment to the team from the program's pilot site, and panel size were associated with patterns of adoption and use. Findings may help other programs design effective implementation strategies.
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Affiliation(s)
- Jeanne Van Cleave
- Division of General Academic Pediatrics/Center for Child and Adolescent Health Research & Policy, Massachusetts General Hospital for Children, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
| | - Thuy-Tien Le
- Department of Internal Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - James M. Perrin
- Division of General Academic Pediatrics/Center for Child and Adolescent Health Research & Policy, Massachusetts General Hospital for Children, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
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Goldman RE, Parker DR, Brown J, Walker J, Eaton CB, Borkan JM. Recommendations for a mixed methods approach to evaluating the patient-centered medical home. Ann Fam Med 2015; 13:168-75. [PMID: 25755039 PMCID: PMC4369592 DOI: 10.1370/afm.1765] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 12/16/2014] [Accepted: 01/05/2015] [Indexed: 12/14/2022] Open
Abstract
PURPOSE There is a strong push in the United States to evaluate whether the patient-centered medical home (PCMH) model produces desired results. The explanatory and contextually based questions of how and why PCMH succeeds in different practice settings are often neglected. We report the development of a comprehensive, mixed qualitative-quantitative evaluation set for researchers, policy makers, and clinician groups. METHODS To develop an evaluation set, the Brown Primary Care Transformation Initiative convened a multidisciplinary group of PCMH experts, reviewed the PCMH literature and evaluation strategies, developed key domains for evaluation, and selected or created methods and measures for inclusion. RESULTS The measures and methods in the evaluation set (survey instruments, PCMH meta-measures, patient outcomes, quality measures, qualitative interviews, participant observation, and process evaluation) are meant to be used together. PCMH evaluation must be sufficiently comprehensive to assess and explain both the context of transformation in different primary care practices and the experiences of diverse stakeholders. In addition to commonly assessed patient outcomes, quality, and cost, it is critical to include PCMH components integral to practice culture transformation: patient and family centeredness, authentic patient activation, mutual trust among practice employees and patients, and transparency, joy, and collaboration in delivering and receiving care in a changing environment. CONCLUSIONS This evaluation set offers a comprehensive methodology to enable understanding of how PCMH transformation occurs in different practice settings. This approach can foster insights about how transformation affects critical outcomes to achieve meaningful, patient-centered, high-quality, and cost-effective sustainable change among diverse primary care practices.
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Affiliation(s)
- Roberta E Goldman
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Donna R Parker
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Joanna Brown
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Judith Walker
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Charles B Eaton
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jeffrey M Borkan
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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