Impact of Case Mix Severity on Quality Improvement in a Patient-centered Medical Home (PCMH) in the Maryland Multi-Payor Program

Abstract

Background: We present data on quality of care (QC) improvement in 35 of 45 National Quality Forum metrics reported annually by 52 primary care practices recognized as patient-centered medical homes (PCMHs) that participated in the Maryland Multi-Payor Program from 2011 to 2013.Methods: We assigned QC metrics to (1) chronic, (2) preventive, and (3) mental health care domains. The study used a panel data design with no control group. Using longitudinal fixed-effects regressions, we modeled QC and case mix severity in a PCMH.Results: Overall, 35 of 45 quality metrics reported by 52 PCMHs demonstrated improvement over 3 years, and case mix severity did not affect the achievement of quality improvement. From 2011 to 2012, QC increased by 0.14 (P < .01) for chronic, 0.15 (P < .01) for preventive, and 0.34 (P < .01) for mental health care domains; from 2012 to 2013 these domains increased by 0.03 (P ‫؍‬ .06), 0.04 (P ‫؍‬ .05), and 0.07 (P ‫؍‬ .12), respectively. In univariate analyses, lower National Commission on Quality Assurance PCMH level was associated with higher QC for the mental health care domain, whereas case mix severity did not correlate with QC. In multivariate analyses, higher QC correlated with larger practices, greater proportion of older patients, and readmission visits. Rural practices had higher proportions of Medicaid patients, lower QC, and higher QC improvement in interaction analyses with time.Conclusions: The gains in QC in the chronic disease domain, the preventive care domain, and, most significantly, the mental health care domain were observed over time regardless of patient case mix severity. QC improvement was generally not modified by practice characteristics, except for rurality.

Are We Learning More about Patient-centered Medical Homes (PCMHs), or Learning More about Primary Care?

“…The study by Khanna et al 7 confirms my own experience as a PCMH physician, and as a chief medical executive for a 600-physician network, that quality improvements and cost reductions often are not evident until the third year of PCMH recognition. Cost of care may increase in the first year as reorganized practices improve access, update preventive services, and stabilize chronic disease.…”

The impact of patient‐centered medical home certification on quality of care for patients with diabetes

“…When clinical outcomes data are available, often the population scope is constrained 22 or the population is missing a suitable control group. 23 The analytic methods used to evaluate the impact of PCMH certification vary widely from simple comparisons of PCMH versus non-PCMH populations to carefully designed difference-in-differences models. 14,24 In the former case, the analytic methods may have no correction for estimation bias resulting from the nonrandom nature of a primary care practices' decision to pursue certification.…”

“…It is harder to capture clinical outcomes, such as cholesterol or blood pressure control, because these must be extracted from health records. When clinical outcomes data are available, often the population scope is constrained 22 or the population is missing a suitable control group 23 …”

Evaluation of PCMH Model Adoption on Teamwork and Impact on Patient Access and Safety

“…8 Although most PCMH care delivery teams are lead by physicians and some by nurse practitioners, there is an evolving trend to delegate leadership and care coordination to the designated members of staff. 9,10 In addition, optimization of health information technology (HIT) has provided communication channels and ease of communication within teams in the health care system. 11 The Maryland Multi-Payer Program (MMPP) for PCMH was established by the Maryland Health Care Commission (MHCC), pursuant to Maryland Legislative Resolution HB929/SB855 enacted in April 2010.…”