1. THE COMMONWEALTH FUND Melinda Abrams, MS The Commonwealth Fund Patient-Centered Primary Care Collaborative Stakeholders Workshop Meeting Washington, DC July 16, 2008 www.commonwealthfund.org Evaluating Systems of the Patient- Centered Medical Home Agenda Item: IV

2. THE COMMONWEALTH FUND Why Are Evaluations Important? Considerable information suggests the patient-centered medical home will result in better quality, patient experience and greater efficiency However, gaps in the evidence exist Need to rigorously evaluate demonstrations to improve health care and health policy Need information that is useful to policymakers, purchasers, payers, clinicians and patients How many evaluations are enough?

3. THE COMMONWEALTH FUND Patient-Centered Medical Home Evaluations: Key Research Questions –Do Patient-Centered Medical Homes provide better clinical quality, patient experience and more efficient care? Does the degree a practice embrace PCMH principles correlate with these improvements? –Do physician offices that receive technical assistance and revised payment structure improve their performance on measures of clinical quality, patient experience and efficiency? Are physician practices able to make the changes necessary to function as patient-centered medical homes? –Do the processes or outcomes work any differently for safety net clinics or providers?

4. THE COMMONWEALTH FUND Marshal Chin, MD University of Chicago Medical Center Judith Fifield, PhD University of Connecticut Health Center Meredith Rosenthal, PhD Harvard School of Public Health Diane Rittenhouse, MD, MPH University of California, San Francisco Carlos Jaén, MD, PhD University of Texas Health Science Center

5. Key Design Features: In the commercial setting… Location New YorkRhode Island Locations across the country Comparison Group Random assignment Matched control group Random assignment # of payers 1 4-5 (including Medicaid) NA # of practices (intervention) ~40 (20 intervention) 536 (18 intervention) # of beneficiaries ~24,000-30,00026,000? Payment Method Hybrid payment (PMPM, FFS and P4P) PMPM w/ FFS NA

6. Location 4 regions throughout USNew Orleans # of payers 11+ # of beneficiaries TBD~103,000 # of practices (intervention) ~50 safety net clinics 67 clinical sites (25 organizations) Payment Method small payment to regions to support medical home transformation activities 1.Every six months based on # of patients under care 2.Performance payments (3 levels) Key Design Features: In the safety-net setting…

7. Comparison of Research Questions DO PCMHs IMPROVE: CLINICAL QUALITY? XXXX PATIENT EXPERIENCE? XXXXX EFFICIENCY/ HEALTH SYTEM COSTS? XXXX

8. Comparison of Research Questions (continued) Practices Transform? XXXXX MD/ Staff experience XX Practice financially stable? X What are costs to practice? X

9. Comparison of Measures In the commercial setting… Office Systems NCQA PPC-PMCHNCQA PPC-PCMH Case study approach Clinical HEDIS, PQRI ACQA starter set (plus new depression measures) Patient Experience Modified C-G CAHPS TransforMED Patient Outcomes Survey Cost Comparison of projected versus actual costs (claims data) Changes in utilization (claims) Total PMPM spending Rx spending Analysis of practice cost and revenues

10. Measures: In the safety-net setting… Office Systems Modified NCQA PPC-PCMH National Survey of Small and Medium Physician Practices Clinical HEDIS/ AHRQ Quality Indicator-type general and disease-specific measures Clinic level: Processes of care System level: ACS Patient Experience Modified C-G CAHPS and CMWF survey Modified C-G CAHPS and CMWF survey (Melissa Herrmann, ICR) Cost Trends in Medicaid claims over 4-5 years between Tx and Control Community hospital discharge data Trends in Medicaid claims (utilization, ACS)

11. THE COMMONWEALTH FUND Challenges/ Concerns Complex interventions Short time horizons Small sample sizes Randomization challenges Standardizing measurement across pilot projects High level of enthusiasm among payers and employers Potentially underfinanced… more funding partners needed E. Schneider, M. Rosenthal, “Another Chasm to Cross? Evaluating the PCMH”, presentation at AcademyHealth Annual Research meeting, invitational breakout session (June 2008).

12. THE COMMONWEALTH FUND Considerations for Future Medical Home Evaluations What will we learn that’s new? –Need variation in demonstration design (e.g., payment, TA) –Multi-payer strongly preferred Standardization of metrics to enable cross-project comparisons Keeping patients at the center – without patient perspective, it’s not a patient-centered medical home Co-funding –Must assure independence of investigator to publish results regardless of outcome Robust design Clarity about implications for key audiences