Model Homes: Comparing Approaches to PCMH Implementation

The Patient Centered Medical Home (PCMH) has been widely adopted, with over 13,000 practices having achieved recognition by the National Committee for Quality Assurance (NCQA) as of 2018. NCQA grants practices PCMH recognition based on the implementation of 127 capabilities (factors) nested within 6 categories. The PCMH provides guidelines for primary care practices, encouraging expanded electronic and in-person access to providers, improved coordination, and use of information technology for guiding and tracking the care delivered. Practices receive a score on all factors that leads to a PCMH recognition level between 1 and 3, with 3 being the highest category. A wave of early evaluations of the medical home showed mixed evidence as to whether PMCH adoption had any impact on health care utilization and expenditure outcomes. However, practices can achieve recognition by self-selecting a subset of improvements to implement, leading to substantial heterogeneity even among practices with the same level of recognition. Recent work has found that different approaches to achieving PCMH recognition yielded varying impacts on patient outcomes.

A previous cluster analysis work using a small, more geographically limited sample of medical home practices pointed to three distinct practice capability clusters. Among them were two high performing practice clusters that each utilized a different approach to reach recognition, and a third practice cluster only satisfying minimum requirements. One high performing cluster received recognition based on “patient-facing” (emphasizing population health management) capabilities and another cluster primarily focused on “physician-facing” (greater access, decision support and data reporting) capabilities.

In this study we utilize the same clustering methodology, analyzing proprietary data from an insurer spanning the period of 2006 to 2016 that includes information on over 4,000 practices who were granted recognition based on the 2011 NCQA recognition guidelines. The cluster methodology points to more commonalities between the high performers than was found in the previous analysis, with an emphasis on electronic communications within the practice differentiating the two high performance clusters.

We assess the PCMH impact on healthcare utilization and expenditures using a generalized difference-in-differences approach based on the staggered timing of PCMH adoption by practices in our sample. With respect to the general PCMH level recognition level effect, we find significant reductions in emergency department (ED) utilization as well as in outpatient care generally, with specific reductions in both generalist and specialist physician visits, and both lab and imaging services. In our practice cluster results we find that while the reduction in outpatient care is significant across all three clusters, we find a reduction in ED utilization is driven entirely by the high performance (electronic communication) cluster, suggesting a possible substitution between ED visits and use of expanded contact options with primary care practices. These reductions in utilization are accompanied by significant reductions in overall expenditures.