PCMH Finds Success Within Narrow Limits

A patient-centered medical home (PCMH) geared toward children with chronic conditions won health care’s triple crown of improving care and outcomes while lowering costs.

The question: Can this success be broadly replicated? Researchers conceded that better outcomes and savings “seem likely to be achievable only in high-risk populations treated in major academic centers with the subspecialists, resources, and clinician commitment to provide such care.”

Michael Millenson, a quality improvement consultant and a member of Managed Care’s Editorial Advisory Board, points to the red flags about the widespread applicability of PCMHs.

He notes that while the concept has been promoted as an improvement in primary care, the researchers specifically acknowledge that the study’s findings may support the viewpoint of those who “reject the [PCMH] as a generic approach to health care delivery.”

Yet will better care coordination be better for patients than the alternative? Of course, says Millenson.

In the study, the PCMH reduced the number of youngsters with serious illness by 55%. It also reduced total hospital and clinic costs compared with children who received usual care (about $16,500 vs. $27,000 per child-year respectively).

Millenson notes that coordination comes with costs, and this study is an indication that the big-dollar savings from PCMHs may come from better care for the very sick, while most PCMH patients have run-of-the-mill maladies.

The study looked at 201 high-risk children treated at the University of Texas Medical School; 105 were enrolled in a PCMH, and 96 were given usual care. The study ran from March 2011 to February 2013.

Patients were included if, in the previous year, they’d gone to the emergency department three or more times, had two or more hospitalizations, or had one or more admissions into a pediatric intensive care unit.

The PCMH included services from primary care clinicians and specialists with multiple features to promote effective care, according to the study, which was published in the December 24/30 issue of JAMA. Usual care was provided in private offices or faculty-supervised clinics.

PCMHs have been overshadowed recently by ACOs, and there has been some question whether they can deliver on the dollar aspects of the triple aim.

The authors of the JAMA study mentioned that prior studies have found that PCMHs do not save money and that the payments needed to develop and sustain PCMHs may not be forthcoming unless they are shown to improve outcomes with minimal or no increase in costs. That kind of home improvement won’t be easy.