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The Impact of Alternative Payment in Chronically Ill and Older Patients in the Patient-centered Medical Home

A. Salzberg, Claudia, PhD, MSE; Bitton, Asaf, MD, MPH; Lipsitz, Stuart R., ScD; Franz, Cal, PhD; Shaykevich, Shimon, MS; Newmark, Lisa P., BA; Kwatra, Japneet, BDS, MS; Bates, David W., MD, MSc

doi: 10.1097/MLR.0000000000000694
Original Articles
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Background: Patient-centered medical home (PCMH) has gained prominence as a promising model to encourage improved primary care delivery. There is a paucity of studies that evaluate the impact of payment models in the PCMH.

Objectives: We sought to examine whether coupling coordinated, team-based care transformation plan with a novel reimbursement model affects outcomes related to expenditures and utilization.

Research Design: Interrupted time-series model with a difference-in-differences approach to assess differences between intervention and control groups, across time periods attributable to PCMH transformation and/or payment change.

Results: Although results were modest and mixed overall, PCMH with payment reform is associated with a reduction of $1.04 (P=0.0347) per member per month (PMPM) in pharmacy expenditures. Patients with hypertension, hyperlipidemia, diabetes, and coronary atherosclerosis enrolled in PCMH without payment reform experienced reductions in emergency department visits of 2.16 (P<0.0001), 2.42 (P<0.0001), 3.98 (P<0.0001), and 3.61 (P<0.0001) per 1000 per month. Modest increases in inpatient admission were seen among these patients in PCMH either with or without payment reform. Patients 65 and older enrolled in PMCH without payment reform experienced reductions in pharmacy expenditures $2.35 (P=0.0077) PMPM with a parallel reduction in pharmacy standardized cost of $2.81 (P=0.0174) PMPM indicative of a reduction in the intensity of drug utilization.

Conclusions: We conclude that PCMH implementation coupled with an innovative payment arrangement generated mixed results with modest improvements with respect to pharmacy expenditures, but no overall financial improvement. However, we did see improvement within specific groups, especially older patients and those with chronic conditions.

*Division of General Medicine, Brigham and Women’s Hospital, Boston, MA

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health

Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD

§Harvard T.H. Chan School of Public Health

Harvard Medical School Center for Primary Care

Ariadne Labs, A Joint Center Between Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health

#Department of Health Care Policy, Harvard Medical School, Boston

**Eastern Research Group, Lexington

††Information Systems, Partners HealthCare System, Wellesley

‡‡Harvard School of Dental Medicine, Boston, MA

Supported by The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The views presented here are those of the author and not necessarily those of The Commonwealth Fund, its directors, officers, or staff.

D.W.B. is a coinventor on Patent No. 6029138 held by Brigham and Women’s Hospital on the use of decision support software for medical management, licensed to the Medicalis Corporation. He holds a minority equity position in the privately held company Medicalis which develops web-based decision support for radiology test ordering. He serves on the board for SEA Medical Systems, which makes intravenous pump technology. He is on the clinical advisory board for Zynx Inc., which develops evidence-based algorithms. He consults for EarlySense, which makes patient safety monitoring systems. He receives equity and cash compensation from QPID Inc., a company focused on intelligence systems for electronic health records. He receives cash compensation from CDI (Negev) Ltd, which is a not-for-profit incubator for health IT startups. He receives equity from Enelgy which makes software to support evidence-based clinical decisions. He receives equity from ValeraHealth which makes software to help patients with chronic diseases. He receives equity from Intensix which makes software to support clinical decision-making in intensive care. He receives equity from MDClone which takes clinical data and produces deidentified versions of it. D.W.B.’s financial interests have been reviewed by Brigham and Women’s Hospital and Partners HealthCare in accordance with their institutional policies. The remaining authors declare no conflict of interest.

Reprints: Claudia A. Salzberg, PhD, MSE, Department of General Internal Medicine, Johns Hopkins Medicine, 2024 E. Monument Street. Room 604-D, Baltimore, MD, 21287. E-mail: csalzbe2@jhu.edu.

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