1. Evaluation Issues: NH Multi-Payer Medical Home Pilot
October 28, 2008

2. Major Evaluation Questions
If payers and providers make the investment in patient-centered medical homes, can it create value (as defined by cost savings or higher quality of care)?
Will there be sufficient value created to cover costs of investment?
What are the metrics that are best correlated to value creation?

3. Possible Secondary Evaluation Questions
Is there a dose-response (better outcomes with higher levels of Medical Home)
Are there specific elements of PCMH that are better correlated with outcomes
How did practices transform

4. Methods Overview
Qualitative and descriptive. Best suited for process improvement, and sharing lessons learned regarding infrastructure issues, support teams etc…
Quantitative. Quasi-experimental design involving simple pre-post comparisons, contemporaneous controls and interrupted time series. Metrics include: cost, quality (structural efficiency measures and process), patient experience, and provider satisfaction.

5. What Cost Outcomes? Prior consensus: Standard utilization metrics
Avoidable in-patient stays
ED utilization
Office visits (specialty, primary care)
Pharmacy
Outpatient procedures and diagnostics
Total cost
Risk adjustment
CHIS data and software available

6. Which Quality Outcomes Measures?
Recommend:
CMS Group Practice Demo Metrics
Clinical outcomes consistent with other pilots

7. Quality Measures: Diabetes % of patients in performance year with
Claims Based
Hgb-A1c tests
LDL test
Microalbumin testing or Dx/Tx for nephropathy
Retinal exam by MD/OD:
1year/high risk,
2 years/low risk
Chart/Hybrid Based
HgbA1c ≤ 9.0%
BP< 140/90
LDL<130
Complete foot exam documented
Influenza vaccine
Pneumoccocal vaccine

8. Quality Measures: CAD % of patients in performance year with
Claims Based
Lipid profile
Chart/Hybrid Based
LDL<130
Antiplatelet Rx
Lipid Rx
Hx MI, on ß-blockers
last visit
DM &/or LVSD on ACEI

9. Quality Measures: HF % of patients in performance year with
Claims Based
LV-EF in same year if hospitalized for HF
Chart/Hybrid Based
Qualitative/quantitative LVF Assessment
Visits Weight documented
Visits BP documented
HF Education documented in last 6 months
LVSD on ß-blocker
LVSD on ACEI
HF/AF on Warfarin
Influenza vaccine
Pneumococcal vaccine

10. Quality Measures: Preventive Care % of patients in performance year with
Claims Based
♀ y.o. w/ mammogram in current or prior year
Chart/Hybrid Based
“Screened” for colon Cancer
BP documented
Last BP<140/90
If BP is >140/>90  documented plan of care

11. Which P4P Measures? Recommend PQRI Measures :
(up to 4% Medicare payment)
Electronic prescribing
Chronic care management
Diabetes: HgbA1c Control, LDL Control, BP Control, Dilated Eye Exam, Urine Microalbumin
CHF: ACEI/ARB, betablocker
Asthma: pharmacologic therapy
CAD: antiplatelet therapy, betablocker post MI, ASA post MI
Care coordination: Medication reconciliation
Prevention
Flu vaccine
Pneumovax

12. Outcomes: Infrastructure
Assessing Level of Medical Home
Pre-post design
Validation of practice transformation
Determination of what makes a difference
Correlation issues
Instruments:
NCQA (a priori, therefore predictor not an outcome)
Medical Home Index
TransforMed
Starfield survey
Primary Care Assessment Survey (PCAS)

13. Which Infrastructure Tools?
Recommend:
Medical Home Index
Starfield survey
Primary Care Assessment Survey (PCAS)
TransforMed

14. Other Domains Recommend: Patient perspective:
PCAS (based on CG-CAHPS)
Practice culture, teamwork, staff satisfaction:
Assessing the culture of Medial Group Practice (Krelewski)
Practice staff Questionnaire (PSQ) (Stange, Crabtree, et al)
Microsystems Assessment Tool (Nutting)
Leadership capacity (MHIQ subsection)
Community Linkages section of Assessing Chronic Illness survey (Wagner)

15. Unresolved Analytic Issues
Sample size and power calculations
How many comparisons can we make?
Unit of analysis
Practices vs Practitioners
Individual patients vs Patient panels
Will P4P confound outcomes measurement and does it matter

16. Next Steps Recommend: Select principal investigator
David Laflamme, UNH ?
Andy Coburn, Muskie ?
PCMH evaluation consultation
Meredith Rosenthal, HSPH
PI writes evaluation plan before start of pilot
Evaluation plan agreed upon by practices
PI and workgroup seeks evaluation funding
Consider collaboration with Maine (RWJF)