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Health Plan Data Help Drive Medical Home Success Story


Health insurance data helped power a patient-centered medical home (PCMH) initiative in Pennsylvania that significantly improved care while cutting costs.

A study in JAMA Internal Medicine by Rand researchers states that the “timely availability of data on emergency department visits and hospitalizations may encourage and enable primary care practices to contain unnecessary or avoidable utilization… ”

That’s what happened in this case, says Michael Bailit, president of Bailit Health Purchasing, who provided the researchers with data on pilot intervention design and National Committee for Quality Assurance regulations. The two insurers—Geisinger Health Plan and Blue Cross of Northeastern Pennsylvania—provided regular utilization reports on the practices’ panels and sat with the practices to review them. They also provided the practices with information about when their patients were admitted.

The study looked at data from more than 17,000 patients in the Pennsylvania Chronic Care Initiative (PCCI), one of the nation’s largest regional PCMH pilots. Researchers compared data from 27 participating physician practices with 29 practices that did not participate in the program from 2009 to 2012.

Practices participating as PCMHs saw 1.7 fewer hospitalizations per 1,000 patients and 17.3 fewer specialty care visits per month than their non-PCMH counterparts. People in the PCMHs also went to the emergency department less often for problems that could be dealt with in an ambulatory setting.

This is quite a turnaround for PCMHs. The same researchers published a study last year that showed that another PCMH intervention made no difference in care or savings.

There was some overlap, lead author Mark Friedberg, MD, tells Managed Care. The intervention in the 2014 paper ran from June 1, 2008, to May 31, 2011.

The intervention in the new study began on Oct. 1, 2009, and researchers evaluated the first three years. In addition, the earlier study was of a PCMH program in a different part of the state.

“The patient populations weren’t all that different, but it is always possible that having different patient populations could have contributed to the different results,” says Friedberg.

Why the improvement? The new study wasn’t designed to parse the specific mechanisms, but the Rand researchers offered some possible explanations.

One candidate is that regular feedback from participating health plans on utilization of hospitals, emergency departments, and other medical services by patients had an effect on physician practices.

Of course, giving providers the opportunity to earn more for providing quality care never hurts. The shared savings incentive that included bonuses for meeting quality benchmarks “may have been a particularly strong motivator for practices to invest and engage more effectively in care management efforts,” say Friedberg and his coauthors.

A third possibility is the progress that physician practices have made in installing EHRs. All of the chronic care initiative had EHRs at baseline.

Researchers note that there are more than 100 medical home interventions in the United States, and that their study could offer guidance to program designers and policymakers.

Among the limitations of the study were that researchers did not have access to important financial considerations, such as how much it cost to coach providers and how much insurers paid out in bonuses.