Department of Health Law, Policy, and Management Boston University School of Public Health, Boston, MA.
Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI.
Med Care. 2019 Oct;57(10):801-808. doi: 10.1097/MLR.0000000000001194.
To estimate the effect of patient-centered medical home (PCMH) participation on cost and utilization of care for patients in Rhode Island's statewide, multipayer PCMH program, which serves over one-third of the state population.
DATA SOURCES/STUDY SETTING: 2009-2014 claims data from all payers in Rhode Island, representing >743,000 unique patients.
A propensity score-matched difference-in-differences framework was used to separately estimate the effect of the PCMH on 3 patient cohorts, which were defined by their intervention start dates and amounts of implementation time. Outcomes included patient costs (total, inpatient, outpatient, professional, pharmacy) and utilization [emergency department (ED) visits, preventable ED visits, inpatient admissions, preventable inpatient admissions, all-cause 30-day readmissions]. Interaction effects were estimated to assess heterogeneity among clinical risk groups and payers.
There was no evidence of a PCMH effect on total costs, though we observed evidence of an increase in the odds of PCMH patients having outpatient and professional costs, and in one cohort, a decrease in inpatient costs for those with an inpatient visit. We also observed evidence of reduced ED visits, preventable ED visits, and inpatient admissions for PCMH patients. While subgroup effects varied by cohort and measure, high-risk patients often experienced the largest reductions in ED visits.
All PCMH cohorts experienced statistically significant reductions in some types of utilization in as little as 1.25 years. Reductions were greatest for measures included in the PCMH contractual agreement. While PCMH programs may not expect cost savings in the short-term, costs could potentially be reduced in the longer-term through avoided ED and inpatient expenses.
评估参与以患者为中心的医疗之家（PCMH）对罗德岛全州范围内多付款人 PCMH 计划中患者的医疗成本和利用的影响，该计划为该州三分之一以上的人口提供服务。
数据来源/研究环境：来自罗德岛所有付款人的 2009-2014 年索赔数据，代表超过 743,000 个独特患者。
使用倾向评分匹配的差分差异框架，分别估计 PCMH 对 3 个患者队列的影响，这些队列根据干预开始日期和实施时间的多少来定义。结果包括患者成本（总、住院、门诊、专业、药房）和利用[急诊部（ED）就诊、可预防 ED 就诊、住院入院、可预防住院入院、全因 30 天再入院]。估计交互效应以评估临床风险组和付款人之间的异质性。
没有证据表明 PCMH 对总费用有影响，但我们观察到 PCMH 患者门诊和专业费用增加的证据，在一个队列中，对于有住院就诊的患者，住院费用减少。我们还观察到 PCMH 患者的 ED 就诊、可预防 ED 就诊和住院入院减少。虽然亚组效应因队列和措施而异，但高危患者通常经历最大的 ED 就诊减少。
所有 PCMH 队列在短短 1.25 年内都经历了某些类型的利用的统计学显著减少。在 PCMH 合同协议中包含的措施中，减少幅度最大。虽然 PCMH 计划可能不会在短期内节省成本，但通过避免 ED 和住院费用，成本可能会在长期内降低。
