News & Commentary

5 Questions: A Discussion with Primary Care Expert, Marci Nielsen

Tuesday, February 16, 2016
ThinkAnthem
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This month the Patient-Centered Primary Care Collaborative (PCPCC) released their annual report, The Patient-Centered Medical Home’s Impact on Cost and Quality: Annual Review of Evidence, highlighting the cost and quality impact of patient-centered medical home initiatives throughout the country. We talked with PCPCC’s CEO, Dr. Marci Nielsen about the report’s key findings, how medical home initiatives have evolved over time, and her expectations for the medical home in 2016.

1. This is your fifth year of the report — what surprised you most about this year’s results?

The report evolves substantially with each edition. This year, we summarized the latest PCMH evidence within the context of payment reform, and we were pleased, although not surprised, about the results coming out of multi-payer PCMH initiatives. They clearly made a greater impact on outcomes than single payer programs. Another finding that may surprise some is the diversity in payment arrangements that are being tested to support and sustain the PCMH across various markets. That said, the evidence does not yet clearly point to a single payment strategy that is most successful in delivering advanced primary care.

2. You say in the report that more ‘mature’ medical home projects demonstrated more favorable results; do you have any perspective on why this might be true?”

Health system transformation is a lengthy process that can take 18 months to 3 years (depending on a myriad of factors) and requires a focus on continuous improvement and learning. It is hard work; it is expensive work; and it is slow work. But our new report suggests that it is worth the investment. Medical home programs that have been implemented for a longer period of time have had the opportunity to identify best practices and learn from their mistakes, and therefore have been able to adjust, adapt, and evolve to deliver care more efficiently and continuously improve quality of care. The authors of the Pennsylvania Chronic Care Initiative studies and their analysis “nature” versus “nurture” characteristics have a lot to teach us.

3. It seems that the biggest potential for savings are the low-hanging fruit, as in reduced ER visits, inpatient visits, readmissions, etc. Is this a trend that will last over time for practices and healthcare systems? 

Indeed the PCMH is demonstrating favorable reductions in ER visits, hospitalizations, and readmissions. These “low-hanging fruit” are helpful in achieving cost savings in the initial PCMH implementation years because they can offset some of the upfront costs of PCMH transformation. However, they are not the only avenues by which to achieve cost savings. As referenced in this year’s report, the model is also associated with reducing costly specialist visits and spending on prescription drugs, as well as reductions in total cost of care. As far as the longevity of this trend, it’s hard to say, but the PCMH offers sophisticated primary care that includes diligent care coordination, continuity, and efficiency that can improve quality of care and effectively reduce the need for return or follow-up visits.

4. How is the role of payers evolving in medical home initiatives? (private, public, etc.)

Since our inception in 2006, the PCMH has gained significant traction in both the public and private markets, and we’ve seen a proliferation in PCMH initiatives nationwide. As more and more payers have engaged in value-based payment to support this model, it has fostered a need to standardize cost, quality, performance, and meaningful patient experience metrics across multiple payers. This is a significant evolution, and now multi-payer collaboratives are beginning to learn how to best align local, regional, and national payer and provider interests in order to scale and spread best practices and optimize both delivery and payment reform. As we mention in our report, the PCMH programs with multi-payer alignment are generally showing more impressive cost and utilization outcomes. 

5. What are you most excited to see for the PCMH in 2016?

This will be a big year for the PCMH in terms of regulatory policy. Last year, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA), which creates two new innovative payment pathways for PCMH (the Merit-based Incentive Program System and Alternative Payment Models), both of which acknowledge advanced primary care as critical to advancing system-wide transformation. Pretty exciting, right? It gets better. This year, through the regulatory process CMS will define PCMH certification for the purpose of payment incentives, which further underscores the importance of having a unified vision of the PCMH model. We think that better aligning PCMH certification with what it actually takes to transform a practice will be increasingly important if we want patients, payers, and providers to value the model.

 

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