- Larger primary care practices and patient-centered medical homes (PCMHs) are significantly more likely to have the resources and skills to offer population health management programs and employ dedicated care coordination staff, according to a new study in the Journal of the American Board of Family Medicine (ABFM).
Using data from family physicians in 2014 and 2015, researchers from Emory University, the Robert Graham Center, and the ABFM found that patient-centered medical homes are, in general, much more likely to boast at least one in-house care coordinator or population health manager.
Sixty percent of solo PCMH providers have population health management staff on hand, compared to just 27 percent of other solo family physicians.
The largest PCMHs, with 20 providers or more, are even more likely to engage in patient navigation and coordination services.
Ninety percent of large PCMHs have population health staff, while just over 60 percent of non-PCMHs can say the same.
Overall, approximately 53 percent of the 4649 participants in the study said they had a care coordinator on staff.
“Having a staff member function as a care coordinator has been associated with improved quality through increased medication adherence and enhanced chronic disease care and preventive care,” the researchers state.
“If effectively designed and implemented, care coordination and population health management each have the potential to improve patients' well-being and together are 1 of the 10 building blocks of high-performing primary care.”
According to Thomas Bodenheimer, MD, of the University of California San Francisco, the ten building blocks of quality care closely mirror the principles of the patient-centered medical home framework, which are designed to help providers enact meaningful quality improvements.
In a 2014 article in the Annals of Family Medicine, Bodenheimer and colleagues suggest that population health management skills are foundational to quality, combining with data-driven, team-based care, expanded access, patient-provider partnerships, and continuity of care to create a strong and comprehensive delivery strategy.
While many healthcare reform efforts, including value-based reimbursement arrangements and regulatory frameworks like the Quality Payment Program, are geared towards encouraging all primary care providers to embrace these principles, smaller organizations appear more likely than their larger counterparts to struggle with implementation.
“Some primary care practices may face challenges in providing personnel dedicated to coordinating care for their patients, particularly small practices and those that have not undergone patient-centered medical home transformation,” the ABFM authors explain.
“Having a dedicated staff member provide such services may be ideal to ensure these functions are conducted, but such personnel seem to be disproportionately prevalent in large practices and PCMHs.”
The financial strain of PCMH transformation and upkeep may be contributing to the divide between larger and smaller organizations. Previous studies have found that achieving the highest level of PCMH designation may take several years, cost an average of nearly $150,000 to implement, and that maintaining a high-level PCMH could require up to $8000 in investment per month.
Providers disillusioned with the PCMH environment have also voiced concerns that the initiative can actually prevent providers and patients from having a quality experience, since increasing reporting requirements, complicated certification processes, and diminished ability to focus on patient care are sometimes unwelcome byproducts of the process.
However, proponents of the strategy point to a strong body of research indicating that the PCMH can trim costs, improve outcomes, and foster efficient, effective care. Care coordination techniques rooted in the PCMH have been shown to reduce readmissions for high-risk patients, slash unnecessary use of high-cost services like the emergency department, and even cut overall spending for Medicare patients by nearly 5 percent.
A 2014 study also pointed out that care coordination staff are likely to pay for themselves in a mere two months by reducing hospital admissions, improving treatment adherence, and providing accountability for patients.
But despite the potential benefits, the initial outlay of money required to become a patient-centered medical home may simply be too much for many smaller organizations to handle.
Small providers that have not yet undertaken the health IT improvements required to become a PCMH may also struggle with dwindling opportunities for infrastructure development incentives, and may be shifting their focus instead to the challenges of the Quality Payment Program, which will demand a number of significant process and reporting changes.
The ABFM authors advise the healthcare industry to investigate ways to help smaller providers adopt the patient-centered medical home model without overwhelming them financially. Several federal programs, including the QPP and the Comprehensive Primary Care Plus initiative, depend on primary care providers’ ability to adopt and maintain patient-centered changes, including care coordination, they argue.
“For both of these efforts to succeed, primary care practices will need to coordinate care for their patients and provide population health management services,” the study says.
“Stakeholders should consider ways new programs such as the Merit-based Incentive Payment System and the Comprehensive Primary Care Initiative can be tailored to better meet the needs of small practices and those that have yet to transform to a PCMH to ensure they meet their intended goals of improving quality.”