Effects of a Medical Home and Shared Savings Intervention on Quality and Utilization of Care

IMPORTANCE: Published evaluations of medical home interventions have found limited effects on quality and utilization of care. OBJECTIVE: To measure associations between participation in the Northeastern Pennsylvania Chronic Care Initiative and changes in quality and utilization of care. DESIGN, SETTING, AND PARTICIPANTS: The northeast region of the Pennsylvania Chronic Care Initiative began in October 2009, included 2 commercial health plans and 27 volunteering small primary care practice sites, and was designed to run for 36 months. Both participating health plans provided medical claims and enrollment data spanning October 1, 2007, to September 30, 2012 (2 years prior to and 3 years after the pilot inception date). We analyzed medical claims for 17,363 patients attributed to 27 pilot and 29 comparison practices, using difference-in-difference methods to estimate changes in quality and utilization of care associated with pilot participation. EXPOSURES: The intervention included learning collaboratives, disease registries, practice coaching, payments to support care manager salaries and practice transformation, and shared savings incentives (bonuses of up to 50% of any savings generated, contingent on meeting quality targets). As a condition of participation, pilot practices were required to attain recognition by the National Committee for Quality Assurance as medical homes. MAIN OUTCOMES AND MEASURES: Performance on 6 quality measures for diabetes and preventive care; utilization of hospital, emergency department, and ambulatory care. RESULTS: All pilot practices received recognition as medical homes during the intervention. By intervention year 3, relative to comparison practices, pilot practices had statistically significantly better performance on 4 process measures of diabetes care and breast cancer screening; lower rates of all-cause hospitalization (8.5 vs 10.2 per 1000 patients per month; difference, -1.7 95% CI, -3.2 to -0.03), lower rates of all-cause emergency department visits (29.5 vs 34.2 per 1000 patients per month; difference, -4.7 95% CI, -8.7 to -0.9), lower rates of ambulatory care-sensitive emergency department visits (16.2 vs 19.4 per 1000 patients per month; difference, -3.2 95% CI, -5.7 to -0.9), lower rates of ambulatory visits to specialists (104.9 vs 122.2 per 1000 patients per month; difference, -17.3 95% CI, -26.6 to -8.0); and higher rates of ambulatory primary care visits (349.0 vs 271.5 per 1000 patients per month; difference, 77.5 95% CI, 37.3 to 120.5). CONCLUSIONS AND RELEVANCE: During a 3-year period, this medical home intervention, which included shared savings for participating practices, was associated with relative improvements in quality, increased primary care utilization, and lower use of emergency department, hospital, and specialty care. With further experimentation and evaluation, such interventions may continue to become more effective.