1. Neal Wallace, Ph.D. Shauna Petchel, MPH Portland State University
Oregon’s Patient Centered Primary Care Home Model after Three Years: Use and Expenditures
Neal Wallace, Ph.D.
Shauna Petchel, MPH
Portland State University
Research Support from the Oregon Health Authority (PI: Sherril Gelmon, DrPH)

2. Background
The Oregon Legislature established the Patient-Centered Primary Care Home (PCPCH) Program in 2009 to create access to patient-centered, high quality care and reduce costs by supporting practice transformation.
The PCPCH model is Oregon’s characterization of a “medical home,” and is defined by six core attributes each with a number of corresponding standards and measures.
The attributes include: Access to Care; Accountability; Comprehensive Whole-Person Care; Continuity; Coordination and Integration; and Person and Family Centered Care.
The Program is responsible for defining the model, administering the application process to recognize practices that have achieved the model, and providing technical assistance to clinics.
As of December 2015, over 600 practices across the state had been formally recognized by the OHA as a PCPCH.

3. Research Objective
To assess the impact of Oregon’s Patient Centered Primary Care Home (PCPCH) program on use and expenditures:
For all PCPCH designated clinics through the first three years of the program
Across all covered services and key service types
For the program overall and by PCPCH duration of designation.

4. Study Design
Generalized difference-in-difference design to accommodate staggered PCPCH implementation:
Compare patients empirically attributed to PCPCH or non-PCPCH primary care providers in each study year
Minimum one year pre-PCPCH data and maximum three years post PCPCH designation
Applied to a two part model to assess probability of use, expenditures per user and per person

5. Study Data
Four years of Oregon All Payer All Claims (APAC) claims, eligibility and provider data:
October 2010 through September 2014 (first PCPCH designations October 1, 2011)
APAC contains all claims for commercial, self- insured, Medicaid, and Medicare Advantage
Does not include Medicare FFS, VA claims
Excludes substance use and some sensitive condition (e.g. AIDS/HIV) related service claims

6. Study Population - Individuals
1,192,435 individuals were initially identified who during a study year had:
Consistent residence in Oregon
Consistent, full year insurance coverage
At least one primary care visit to an Oregon provider
These individuals were empirically attributed to a provider billing unit during each study year based on plurality of visits or last visit (tie)
The final study population consists of 1,128,234 individuals solely (100%) attributed to either PCPCH or non-PCPCH primary care provider billing units (606,881 PCPCH and 599,990 non-PCPCH)

7. Study Population - Providers
510 PCPCH practices continuously designated within the study period (on or after October 2011)
PCPCH related claims were initially identified using practice and/or organizational National Provider Identifiers (NPIs).
NPI-based claims were grouped using a “provider crosswalk key”:
Practice billing units reflecting common/linking billing information (e.g. name, address, secondary NPI, etc).
Links practitioners billing under individual NPI but otherwise identifying as part of larger practice group
Practices may have multiple “billing units”

8. Study Population - Observations
The unit of analysis for the study was a provider billing unit quarter.
Individual use, expenditure and demographic characteristics were aggregated to provider billing unit by quarter
100,084 observations (7,380 PCPCH/92,704non-PCPCH) representing 510 PCPCH and 8,435 non-PCPCH billing units

9. Outcome Measures
Main outcome measures are percentage of subjects using service in a quarter, expenditures per service user, and expenditures per subject
The outcome measures are applied to all covered services and eight specific service types:
Primary care office visits and procedures
Specialty office visits and procedures
Outpatient mental health care
Non-therapeutic radiation
Lab
Pharmacy
Emergency Department
Inpatient

10. Subject Characteristics
Subject characteristics aggregated to the practice billing unit quarter as percentages include:
Gender
Age group (9)
Specific insurance type (16)
Physical and behavioral condition markers (10) including diabetes, COPD/asthma, chronic heart failure, chronic kidney disease, coronary heart disease, cerebrovascular disease, obesity, schizophrenia, affective disorders, and other behavioral health conditions

11. Analytic Methods
Two-way fixed effects (practice billing unit and quarter) weighted (individuals) OLS regression
Inclusion of all subject characteristics measures
Samples are not matched but >99% support found across PCPCH and non-PCPCH observations
PCPCH effects identified by a binary variable(s):
For all PCPCH related quarterly observations on or after PCPCH designation date, or
PCPCH designated quarters by year of designation (1-3)
Standard errors adjusted for clustering on practice billing unit

12. Results: Subject Characteristics
non-PCPCH
PCPCH
Observations
3,717,920
3,977,248
Insurance Type
Private
71.0%
41.3%
Gender
Medicare
10.9%
5.0%
Female
44.3%
46.7%
Medicaid
18.1%
53.7%
Male
55.7%
53.3%
Chronic Disease
None
59.4%
56.3%
Age Group
Diabetes
8.2%
6.2%
0-1
2.0%
5.5%
COPD/Asthma
10.8%
13.6%
2-5
6.8%
15.4%
Chronic Heart Failure
0.6%
0.4%
6-11
15.6%
Chronic Kidney Disease
0.5%
12-17
8.4%
13.4%
Cerebrovascular Disease
1.5%
1.0%
18-25
7.5%
7.0%
Coronary Heart Disease
0.8%
26-40
23.1%
16.5%
Obesity
1.3%
2.5%
41-64
31.8%
20.2%
Schizophrenia
0.2%
65-80
11.2%
5.8%
Affective Disorder
3.3%
3.9%
81+
1.1%
0.7%
Other Behavioral Health
12.6%
14.2%

13. Results: Expenditures per Person
Years of PCPCH Designation
Service Type
Overall
Year 1
Year 2
Year 3
Total
-$40.73 *
-$33.85
-$48.85
-$84.58
-4.2%
-3.5%
-5.0%
-8.6%
Primary Care
$3.33
$2.93
$3.70
$6.48
3.1%
2.7%
3.4%
6.0%
Speciality Care
-$1.60
-$0.35
-$3.90
-$5.01
-3.6%
-0.8%
-8.7%
-11.1%
Mental Health
-$3.11
-$2.52
-$3.63
-$7.79
-13.3%
-10.6%
-15.3%
-32.7%
Radiology
-$0.01
-$0.10
-$0.31
$2.78
0.0%
-0.3%
7.5%
Lab
$0.21
-$1.10
-$2.82
-1.0%
0.7%
-9.2%
Pharmacy
$9.49
$7.87
$10.91
$22.51
5.1%
4.3%
5.9%
12.2%
Emergency Department
-$2.04
-$0.99
-$3.49
-$7.48
-5.3%
-2.5%
-9.0%
-19.2%
Inpatient
-$29.21
-$26.07
-$32.96
-$48.99
-15.9%
-14.1%
-17.8%
-26.4%
* = p < .05

14. Results: Expenditures per User
Years of PCPCH Designation
Service Type
Overall
Year 1
Year 2
Year 3
Total
-$61.44 *
-$52.52
-$70.67
-$128.02
-4.8%
-4.1%
-5.5%
-10.0%
Primary Care
-$3.37
-$2.62
-$4.85
-$5.38
-1.6%
-1.2%
-2.3%
-2.5%
Speciality Care
-$3.14
-$3.24
-$2.50
-$5.78
-1.5%
-2.8%
Mental Health
$58.41
$35.28
$121.12
$128.15
7.2%
4.4%
15.2%
16.0%
Radiology
-$7.89
-$7.15
-$10.20
-$4.40
-3.2%
-2.9%
-1.8%
Lab
-$3.16
-$2.70
-$3.91
-$5.73
-2.4%
-3.5%
-5.1%
Pharmacy
$13.26
$10.58
$16.74
$30.25
3.7%
3.0%
4.8%
8.6%
Emergency Department
-$75.83
-$59.75
-$114.22
-$159.18
-8.6%
-6.7%
-12.9%
-17.9%
Inpatient
-$757
-$485
-$1,718
-$3,322
-4.7%
-3.0%
-10.7%
-20.6%
* = p < .05

15. Results: Percent Service Use
Years of PCPCH Designation
Service Type
Overall
Year 1
Year 2
Year 3
Total
0.72% *
0.65%
0.73%
1.56%
0.97%
0.88%
0.98%
2.10%
Primary Care
2.19%
1.70%
2.95%
4.24%
4.27%
3.35%
5.80%
8.33%
Speciality Care
-0.60%
0.25%
-2.21%
-2.58%
-2.90%
1.16%
-10.46%
-12.20%
Mental Health
-0.42%
-0.22%
-0.74%
-1.15%
-13.69%
-6.99%
-23.27%
-36.22%
Radiology
0.12%
0.16%
-0.03%
0.51%
0.87%
1.10%
-0.18%
3.63%
Lab
0.79%
0.74%
0.78%
1.48%
3.21%
3.02%
3.16%
6.01%
Pharmacy
0.50%
1.11%
2.80%
1.61%
1.02%
2.28%
5.73%
Emergency Department
0.27%
0.26%
0.30%
4.96%
4.77%
5.44%
4.90%
Inpatient
-0.02%
-0.01%
0.05%
-1.87%
-2.88%
-0.63%
4.10%
* = p < .05

16. Results: Summary
Total expenditures were reduced by 4% overall with progressive reductions to 8% for PCPCHs in the third year of designation:
Progressive decreases in overall expenditure per user coupled with progressive increases in overall service use
Increases in primary care expenditure and use
Reductions in specialty care expenditures and use
No or inconsistent change in lab and radiology
Increases in expenditure and use of pharmacy
Decreases in expenditures for ED and inpatient:
All due to decreases in expenditures per user – use up (ED) or unchanged (IP)

17. Study Limitations
PCPCH program effects may be Oregon specific (e.g. culture of “transformation”)
PCPCH practices have different characteristics than non-PCPCH and may reflect unique capabilities/motivations of practices that chose to participate
APAC data missing some key services (e.g. substance abuse) and insurance groups (e.g. Medicare FFS)
Observational, natural experiment design may fail to capture “unobservables” that influence outcomes
Current design does not adjust for potential differences in reimbursement rates across insurance types over time
Anticipatory behavior by PCPCHs (changes prior to designation) detected

18. Conclusions
Oregon’s Patient Centered Primary Care Home Program appears to be incurring expected (or hoped for) system transformative effects – reducing expenditures in a “treatment positive” manner
Findings are consistent with other large state level implementation efforts – e.g. Colorado and Michigan
Apparent progressive effects among PCPCHs over time from designation may be important to understand from a policy, programmatic and evaluation standpoint:
Policy makers may actually have to wait for large(r) results
Progressive effects could be practice maturation (consistent with Oregon’s multi-level designation approach) and/or “dose response” as patients get more exposure to program.
Some effects may not be apparent in short-term or “average” effect evaluations

19. Thank You Questions? nwallace@pdx.edu
Mark O. Hatfield School of Government
OHSU/PSU Joint School of Public Health
Portland State University