Can Medical Homes Contain Health Care Costs?
A relatively small fraction of the US population consumes the vast majority of health care dollars (see our past blog). Often these patients present medically complex cases with multiple co-occurring physical and behavioral health conditions, exacerbated by social barriers that make accessing primary care difficult.
In addition to the burden from medically complex patients, another often cited reason for the high cost of health care is the overuse of expensive and unnecessary medical technologies. Unnecessary expenditures from overuse are estimated to account for 10-30% of total health care spending.
There is substantial evidence that ineffective medical procedures are still rife in a number of medical specialties. A Health Affairs blog argues that a great deal of “elective care is given to patients who would have chosen to avoid it, had they better understand their choices and the tradeoffs involved.” Often these procedures provide little to no medical benefit for the patient and produce unnecessary costs to the healthcare system.
Patients that over-utilize care and medical overuse are two main drivers of high health care costs. What can we do to redirect high utilizers to appropriate primary care and community services to prevent frequent and costly urgent care? And how do we encourage physicians and healthcare systems to refrain from prescribing unnecessary medical procedures?
The answer lies in care delivery models that provide personalized, coordinated primary care that places less emphasis on specialty care and volume of medical procedures. Personalized care is the one of the ideals of patient-centric medicine, which acknowledges that the best treatments and outcomes come from shared decision-making.
The Patient Centered Medical Home Model
The Patient Centered Medical Home is one such model that can address some of these drivers of high health care costs while also improving quality of care. According to the Agency for Healthcare Research and Quality, the PCMH model is built around 5 key components:
- Comprehensive care provided by a team of providers to meet the physical and behavioral health needs of the patient,
- Patient centered methods to help patients engage in their own health and well-being,
- Coordination of patient care across the health care system,
- Accessible services with convenient hours, short wait times, and the use of electronic medical records to improve responsiveness to patients’ acute needs, and
- Quality and safety assured through the collection of performance and patient satisfaction measures.
PCMH programs for diabetic patients
Although the PCMH model is increasingly used across the country, until recently, little evaluation data existed about its ability to contain costs. Results of a recent study of PCMH practices in Pennsylvania offer some insight into the effectiveness of the PCMH with respect to cost containment. Between 2008 and 2011, data were collected about diabetic patients in 26 PCMH practices and 97 non-PCMH primary care practices across Pennsylvania. Regression analyses found that the PCMH reduced costs for caring for diabetic patients by 21%. Most of these cost savings resulted from reductions in inpatient care, emergency department visits, and specialist visits. These positive results suggest that the PCMH model can be effective in containing the cost of care for patients with diabetes and other chronic conditions.
Peers for Progress is currently conducting a practical trial of a peer support program for diabetic patients in a PCMH clinic in Chicago. 400 diabetic patients are currently receiving intensive phone-based support and will be assessed on a number of outcomes including their engagement in diabetes self-management and improvement in clinical and self-management indicators. Because the PCMH model emphasizes comprehensive, patient centered care, peer supporters are a particularly promising addition to clinical care teams in PCMHs.
While the long-term impact of the PCMH and other care delivery systems on costs and quality remain to be seen, from early studies, it appears the PCMH model is a promising avenue for reducing the overuse of expensive health care services, including hospitalizations and specialist visits. This can lead to lower healthcare spending for the most medically complex patients and improve the overall patient experience by providing personalized care.
Brownlee, S., Saini, V., Cassel, C. (2014). When less is more: Issues of overuse in healthcare. Health Affairs Blog.
Berenson, R. A., Hammons, T., Gans, D. N., Zuckerman, S., Merrell, K., Underwood, W. S., & Williams, A. F. (2008). A house is not a home: keeping patients at the center of practice redesign. Health Affairs, 27(5), 1219-1230.