Today's Managing Health Care Costs Number is less than one percent
CareFirst BCBS of Maryland has vigorously promoted its patient centered medical home plan -and has taken the important step to publish some data on its efficacy. I faulted earlier reports, but the current research is substantially more complete.
Researchers in the Journal of General Internal Medicine last fall concluded that the program was associated with $109 per member per year decrease in costs, although only 42% of that difference was due to changes in inpatient, emergency room, and prescription drug spending. The comparison was between physicians who participated in the program and those who refused, and the participating physicians had lower claims costs in the pre-intervention period.
The annual savings of $109 is small - less than 1% of total medical spending. Specialists who served as primary care physicians were always in the comparison group, and PCMH practices could have encouraged their sickest patients to seek care elsewhere. Nonetheless, a “difference in difference” analytic approach is good- and better than most evaluations of medical management programs.
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A contrasting report in JAMA Internal Medicine this summer showed that the CareFirst PCMH program, extended to the Medicare population, had no appreciable impact on quality or cost. Both the intervention and the control group had about a 10% decline in hospitalization, and 13 of the 14 participating groups earned bonuses by the third year of the program. These incentive payments weren't trivial - averaging over $18,000 per primary care physician.
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That's a surprise - in general, medical management interventions like patient centered medical home should have the most impact on those with the highest amount of illness -and Medicare beneficiaries are much more likely to have high costs that are amenable to intensive management . So I'd expect to see much more apparent efficacy in the Medicare population than in the general population.
My conclusions:
- The impact of PCMHs is likely not enormous.
- It's hard to scale these programs - even those which are designed and implemented by health plans as opposed to at the practice level
- We need to encourage health plans to share their data with independent academics, as CareFirst has done, so that we can learn of program efficacy
- We need to continue to experiment with interventions such as patient centered medical home - to ascertain what interventions are likely to have the most impact.
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