Today’s Managing Health Care Costs Number is $9 pmpm
Most of the academic literature on patient centered medical homes has shown that these can improve quality, patient satisfaction, and physician satisfaction. However, cost savings are by no means a guarantee. PCMH studies self-published by health plans and provider organizations have shown cost savings, but generally been small or have used weak methods or inappropriate comparison groups.
I’ve been skeptical about claims from CareFirst BCBS of Maryland over its claims of cost savings from its PCMH program – especially with its very large increases in exchange premiums for 2016.
CareFirst gave its data to academic researchers, and they published an evaluation of the third year of this program, and concluded (in the Journal of General Internal Medicine):
By the third intervention year, annual adjusted total claims payments were $109 per participating member (95 % CI: −$192, −$27), or 2.8 % lower than before the program and compared to those who did not participate. Forty-two percent of the overall decline in spending was explained by lower inpatient care, emergency care, and prescription drug spending. Much of the reduction in inpatient and emergency spending was explained by lower utilization of services.
Further, the difference in cost of care within PCMH panels was higher for those with diagnosed chronic disease, where the PCMH intervention is likely to have the most impact.
This is a better study than many – although the researchers decided to use the panels of physicians who did not join the PCMH program as a “control” group. The paper consistently talks of “reductions” in cost – while the data is actually not really reductions but rather difference in cost between the PCMH and the non-PCMH patients.
There are systemic differences between primary care physicians who joined the CareFirst PCMH program.
1) Physicians who joined had to agree to be part of virtual groups and cooperate with and participate in CareFirst programs
2) Specialists who function as PCPs tend to have sicker panels – they were excluded from the PCMH program
3) It’s possible that older physicians are overrepresented among the control group – as they are more likely to be in totally independent practices. Older physicians tend to have older (sicker) panels. Risk adjustment helps – but systemically underadjusts for the sickest.
Over time, the number of physicians who joined the program increased from about half to about 85%. Researchers evaluating the BCBSMA Alternative Quality Contract chose to have a control group in another state to avoid the problem of a dwindling and systematically different control group.
I don’t know how big the systematic bias is in the control group – and the researchers did regression analysis to try to remove some of this bias.
Here’s the final paragraph of the conclusions:
Total spending declined more than the sum of reductions in inpatient care, emergency room care, and prescription drugs. It is possible that these extra reductions could be explained by other covered services, including outpatient specialty care, laboratory tests, imaging, and home care, or by lower prices. Lower spending on outpatient specialty care would point to the possibility that referral management was an important contributor to the results reported here. The physician portal offered by this program allowed primary care physicians to identify less expensive specialists more easily. Future work should address specialty care referral outcomes and quality outcomes
The conclusion is not supported. The researchers did not include any evidence that the participating providers used the CareFirst tools, did not include program costs, and appear not to have considered that the control group of patients was systematically less healthy than those of the PCMH panels.
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