Capsule commentary on Timbie et al., association between patient-centered medical home capabilities and outcomes for Medicare beneficiaries seeking care from federally qualified health centers

Abstract

Timbie et al. report on the association between patient-centered medical home capabilities and various outcomes for Medicare beneficiaries receiving care from 804 Federally Qualified Health Centers (FQHCs) participating in the Centers for Medicare & Medicaid Services (CMS) FQHC Advanced Primary Care Practice Demonstration.1 As part of this demonstration, in the summer of 2011, FQHCs completed the National Committee for Quality Assurance (NCQA) application for patient-centered medical home (PCMH) recognition as a baseline assessment of PCMH capabilities. Using a cross-sectional design, the study authors examined the relationship between PCMH capabilities and outcomes using claims for Medicare beneficiaries seen between November 2010 and October 2011. Eighty-eight percent of FQHCs reported PCMH capabilities that would qualify them for NCQA PCMH recognition. Medicare beneficiaries seen in PCMH-certified sites had higher numbers of outpatient visits and Medicare expenditures, but no differences in non-FQHC primary care visits or inpatient costs, compared to non-PCMH sites. Quality-of-care measure outcomes were mixed, with significant increases found for LDL cholesterol and nephropathy testing, but no differences in HbA1c test or eye exam. A very high proportion of FQHCs were purportedly operating with PCMH capabilities. Defining and measuring PCMH capabilities will continue to be one of the most challenging aspects of primary care delivery system research, because formal recognition as a PCMH and actually delivering care guided by PCMH principles may not be equivalent.2 PCMH research has demonstrated mixed findings with respect to whether such interventions offer meaningful value;3 findings confirmed by this study would suggest that small increases in quality come with a higher cost, and the largest known drivers of cost (inpatient utilization) are not associated with PCMH capabilities. Primary Care is a non-linear, complex adaptive system,4 and evaluating broad delivery system innovations such as PCMH presents large challenges. The field is poised to move beyond simplistic comparisons of PCMH vs. non-PCMH, to identifying specific primary care features, functions, and processes that lead to meaningful changes in quality, health outcomes, patient experience, and cost.5