A Salzberg Claudia, Bitton Asaf, Lipsitz Stuart R, Franz Cal, Shaykevich Shimon, Newmark Lisa P, Kwatra Japneet, Bates David W
*Division of General Medicine, Brigham and Women's Hospital, Boston, MA †Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health ‡Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD §Harvard T.H. Chan School of Public Health ∥Harvard Medical School Center for Primary Care ¶Ariadne Labs, A Joint Center Between Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health #Department of Health Care Policy, Harvard Medical School, Boston **Eastern Research Group, Lexington ††Information Systems, Partners HealthCare System, Wellesley ‡‡Harvard School of Dental Medicine, Boston, MA.
Med Care. 2017 May;55(5):483-492. doi: 10.1097/MLR.0000000000000694.
Patient-centered medical home (PCMH) has gained prominence as a promising model to encourage improved primary care delivery. There is a paucity of studies that evaluate the impact of payment models in the PCMH.
We sought to examine whether coupling coordinated, team-based care transformation plan with a novel reimbursement model affects outcomes related to expenditures and utilization.
Interrupted time-series model with a difference-in-differences approach to assess differences between intervention and control groups, across time periods attributable to PCMH transformation and/or payment change.
Although results were modest and mixed overall, PCMH with payment reform is associated with a reduction of $1.04 (P=0.0347) per member per month (PMPM) in pharmacy expenditures. Patients with hypertension, hyperlipidemia, diabetes, and coronary atherosclerosis enrolled in PCMH without payment reform experienced reductions in emergency department visits of 2.16 (P<0.0001), 2.42 (P<0.0001), 3.98 (P<0.0001), and 3.61 (P<0.0001) per 1000 per month. Modest increases in inpatient admission were seen among these patients in PCMH either with or without payment reform. Patients 65 and older enrolled in PMCH without payment reform experienced reductions in pharmacy expenditures $2.35 (P=0.0077) PMPM with a parallel reduction in pharmacy standardized cost of $2.81 (P=0.0174) PMPM indicative of a reduction in the intensity of drug utilization.
We conclude that PCMH implementation coupled with an innovative payment arrangement generated mixed results with modest improvements with respect to pharmacy expenditures, but no overall financial improvement. However, we did see improvement within specific groups, especially older patients and those with chronic conditions.
以患者为中心的医疗之家（PCMH）作为一种有望改善初级医疗服务的模式已备受关注。评估支付模式对PCMH影响的研究较少。
我们试图研究将协调的、基于团队的护理转型计划与一种新型报销模式相结合是否会影响与支出和利用相关的结果。
采用中断时间序列模型和差异分析方法，以评估干预组和对照组在因PCMH转型和/或支付变化而导致的不同时间段内的差异。
尽管总体结果不显著且好坏参半，但实施支付改革的PCMH与每位成员每月（PMPM）药房支出减少1.04美元（P = 0.0347）相关联。未进行支付改革的PCMH中，患有高血压、高脂血症、糖尿病和冠状动脉粥样硬化的患者每月每1000人急诊就诊次数分别减少2.16次（P < 0.0001）、2.42次（P < 0.0001）、3.98次（P < 0.0001）和3.61次（P < 0.0001）。无论有无支付改革，这些患者在PCMH中的住院人数均有适度增加。未进行支付改革的65岁及以上参保PCMH患者的药房支出减少了2.35美元（P = 0.0077）/PMPM，药房标准化成本同时减少了2.81美元（P = 0.0174）/PMPM，这表明药物使用强度有所降低。
我们得出结论，实施PCMH并结合创新支付安排产生了好坏参半的结果，药房支出有适度改善，但总体财务状况未得到改善。然而，我们确实在特定群体中看到了改善，尤其是老年患者和慢性病患者。
