READ CASE 6.1 AND ANSWER ALL THE QUESTIONS

1. Why is the evidence about effects on cost so varied?

2. Why is the evidence about effects on quality so varied?

3. Why is the evidence about effects on the patient experience so varied?

4. How would a successful PCMH program affect patients? Hospitals? Participating practices?

mics for He althcare Managers Can Patient-Centered Medical Homes Help Realize the Triple Aim? CASE 6.1 CAS (co A PCMH emphasizes a team approach to care, typically including physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coor- dinators. This team cooperates to improve access (e.g., after-hours care and same-day visits), patient engagement (e.g., teaching patients how to manage their care and contribute to decision making), care coordination (e.g., tracking care plans among providers and improving transitions from hospitals to home), quality (e.g., improving patient satisfaction and tracking compliance with practice protocols), and safety (e.g., decision support for prescribing and tracking abnormal test results). Despite broad similarities, PCMHS vary in their emphases and implementation strategies. Not surprisingly, reviews find weak variable evidence that PCMHS save money, although the evidence is stronger and less variable for high-risk patients (Sinaiko et al. 2017) Similarly, some studies find improvements in patients' experiences in PCMH practices, whereas others do not (Sarinopoulos et al. 2017). How much PCMHS improve quality and safety also remains unclear (Green et al. 2018) An analysis of Geisinger Health System's implementation of PCMHS offers some strong evidence that they can reduce costs (Maeng et al. 2015). An integrated health system that offers PPOS and HMOS for Medicare, Medicaid, and the ACA marketplace, Geisinger's PCMH approach differs from most others in a number of ways: grate Greer it see Blue comp done and for impl year impl Cost ate fou tice Dis Geisinger used a standardized model. Geisinger had clear incentives to reduce cost and improve quality because it offered an HMO. Geisinger had a long history of experimenting with PCMH models. Geisinger focused on high-risk patients. Geisinger used a mix of volume-based and quality-based payments 6.1. The Geisinger study found that implementation of a PCMH significantly reduced costs (primarily by reducing hospitalization), and the size of the reduction grew with experience as a PCMH practice. An earlier Geisinger study found that patients perceived that some aspects of In iden imp incr Un ser (continued Chapter 6: Realizing the Triple Aim care had improved and some had not (Maeng et al. 2013). Only modest evidence about quality and safety has been analyzed. For this highly inte- CASE 6.1 (continued) grated system, PCMHS appear to contribute to realizing the Triple Aim. Can becoming a PCMH help other practices realize the Triple Aim? Green and colleagues (2018) suggest that the evidence is clearer than it seems. Their analysis focused on conditions that were targeted by Blue Cross Blue Shield of Michigan and measured how many PCMH components each practice had implemented (which had seldom been done before). Their analysis found that emergency department costs and hospitalization costs fell for all conditions but fell by much more for targeted conditions and for practices with more complete PCMH implementation. An earlier study that analyzed data for only two years of PCMH implementation (Paustian et al. 2014) found that full implementation was associated with higher quality and significant eoct reductions for adults. Partial PCMH implementation was associ- ated with higher quality but not with cost reductions. A separate study found that the patient experience was rated more highly in PCMH prac- tices (Sarinopoulos et al. 2017). Discussion Questions Why does offering HMO plans affect incentives? How could improving access reduce costs? How could improving care coordination reduce costs? Why is the evidence about effects on cost so varied? Why is the evidence about effects on quality so varied? Why is the evidence about effects on the patient experience so varied? How would a successful PCMH program affect patients? Hospitals? Participating practices? 6.1.4 Value-Based Insurance Designs In response to rising spending, employers and insurers have sought identify benefit designs that would simultaneously reduce spending and improve the health of beneficiaries. These goals can conflict. For example, increasing deductibles appears to reduce Unfortunately, patients appear to reduce use of effective and ineffective to use of services and therefore costs. ervices, often including preventive care that is covered in full (Agarwal, mics for He althcare Managers Can Patient-Centered Medical Homes Help Realize the Triple Aim? CASE 6.1 CAS (co A PCMH emphasizes a team approach to care, typically including physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coor- dinators. This team cooperates to improve access (e.g., after-hours care and same-day visits), patient engagement (e.g., teaching patients how to manage their care and contribute to decision making), care coordination (e.g., tracking care plans among providers and improving transitions from hospitals to home), quality (e.g., improving patient satisfaction and tracking compliance with practice protocols), and safety (e.g., decision support for prescribing and tracking abnormal test results). Despite broad similarities, PCMHS vary in their emphases and implementation strategies. Not surprisingly, reviews find weak variable evidence that PCMHS save money, although the evidence is stronger and less variable for high-risk patients (Sinaiko et al. 2017) Similarly, some studies find improvements in patients' experiences in PCMH practices, whereas others do not (Sarinopoulos et al. 2017). How much PCMHS improve quality and safety also remains unclear (Green et al. 2018) An analysis of Geisinger Health System's implementation of PCMHS offers some strong evidence that they can reduce costs (Maeng et al. 2015). An integrated health system that offers PPOS and HMOS for Medicare, Medicaid, and the ACA marketplace, Geisinger's PCMH approach differs from most others in a number of ways: grate Greer it see Blue comp done and for impl year impl Cost ate fou tice Dis Geisinger used a standardized model. Geisinger had clear incentives to reduce cost and improve quality because it offered an HMO. Geisinger had a long history of experimenting with PCMH models. Geisinger focused on high-risk patients. Geisinger used a mix of volume-based and quality-based payments 6.1. The Geisinger study found that implementation of a PCMH significantly reduced costs (primarily by reducing hospitalization), and the size of the reduction grew with experience as a PCMH practice. An earlier Geisinger study found that patients perceived that some aspects of In iden imp incr Un ser (continued Chapter 6: Realizing the Triple Aim care had improved and some had not (Maeng et al. 2013). Only modest evidence about quality and safety has been analyzed. For this highly inte- CASE 6.1 (continued) grated system, PCMHS appear to contribute to realizing the Triple Aim. Can becoming a PCMH help other practices realize the Triple Aim? Green and colleagues (2018) suggest that the evidence is clearer than it seems. Their analysis focused on conditions that were targeted by Blue Cross Blue Shield of Michigan and measured how many PCMH components each practice had implemented (which had seldom been done before). Their analysis found that emergency department costs and hospitalization costs fell for all conditions but fell by much more for targeted conditions and for practices with more complete PCMH implementation. An earlier study that analyzed data for only two years of PCMH implementation (Paustian et al. 2014) found that full implementation was associated with higher quality and significant eoct reductions for adults. Partial PCMH implementation was associ- ated with higher quality but not with cost reductions. A separate study found that the patient experience was rated more highly in PCMH prac- tices (Sarinopoulos et al. 2017). Discussion Questions Why does offering HMO plans affect incentives? How could improving access reduce costs? How could improving care coordination reduce costs? Why is the evidence about effects on cost so varied? Why is the evidence about effects on quality so varied? Why is the evidence about effects on the patient experience so varied? How would a successful PCMH program affect patients? Hospitals? Participating practices? 6.1.4 Value-Based Insurance Designs In response to rising spending, employers and insurers have sought identify benefit designs that would simultaneously reduce spending and improve the health of beneficiaries. These goals can conflict. For example, increasing deductibles appears to reduce Unfortunately, patients appear to reduce use of effective and ineffective to use of services and therefore costs. ervices, often including preventive care that is covered in full (Agarwal