American Journal of Managed Care Study of Empire Members Demonstrates Better Health Outcomes, Lower Costs in PCMH Practices

Health care costs were 15 percent lower in adult population treated by PCMH practices

Empire BlueCross BlueShieldSally Kweskin, (720) 373-4836orLori McLaughlin, (317) 407-7403

Physicians working in patient-centered medical homes in New York City and surrounding suburbs better managed their patients’ diseases, ordered fewer high-cost imaging tests, reduced patient emergency room visits and hospitalizations and reduced costs of care for patients overall, according to a new baseline study published in the September edition of the

Total health care costs in the PCMH adult population were $93 – or 15 percent – less per-member, per-month than in the non-PCMH adult population. Health care costs to treat children were also less in the PCMH population by 8.6 percent. The numbers are risk-adjusted and include medical and pharmacy spending.

“Empire BlueCross BlueShield was adamant that a study of its PCMH pilots should go beyond just measuring whether patients were having their cholesterol levels taken, receiving their HbA1c testing and reporting their values, and actually measure whether patients with diabetes and cardiovascular disease had better health outcomes,” said Dr. Scott Breidbart, chief medical director, Empire BlueCross BlueShield.

The study, conducted by HealthCore Inc., a clinical outcomes research company, is unique in that the study includes a control group of commercially insured patients not treated by PCMH practices to draw more accurate comparisons. The comprehensive study—incorporated Healthcare Effectiveness and Data Information Set measures, utilization and laboratory data, in combination with outcomes and cost data—making it a hallmark study in PCMH research.

“We were pleased to find that not only were health outcomes much stronger in PCMH practices, but that they also had lower costs in the early stages of their development into a full-fledged PCMH practice,” Breidbart said. “These findings and others gave us the confidence to boost fees for primary care physicians and further support them through technology and staff so that practices within our network are properly supported to spend as much time as possible with patients and keep them as healthy as possible.”

Patient-centered medical homes are physician practices that use cross-disciplinary teams of professionals who put the patient at the center of the health care delivery system by focusing on improving outcomes while reducing costs associated with inconsistent, duplicate or fragmented care. Typically, patient-centered medical home practices are open beyond traditional office hours and use technology to be more proactive in managing and communicating with their patients.

“I describe my practice as a Norman Rockwell practice that follows an old-fashioned approach in taking care of people, which is basically holistic medicine,” said Dr. Salvatore Volpe, whose practice in Staten Island, New York, was the first solo practice nationally to receive the highest level of PCMH recognition from the National Committee for Quality Assurance in 2012. “If you can understand the patient in a continuum and not a 15-20 minute encounter, you’re more likely to make a difference in their lives.”

Volpe uses a patient Internet portal and paper copies to make sure patients can view their medical records and specific notes about their diagnoses. Specialists and hospital staff appreciate having patients bring this information with them, he said. Patients also use the portal to order prescription re-fills and make appointments, which saves a lot of administrative time.

In addition to using portals to communicate with patients, WestMed Medical Group, another PCMH practice in the study, also aims to get patients treated in one place on the same day. For example, women who discover they have an abnormal mammogram will see a surgeon that same day for a biopsy and receive a diagnosis and a treatment plan by the next day. This one-to-two day process would typically take six to seven weeks.

“To place the patient at the center of care, you have to educate the patient and the patient needs one place to go for care,” said Dr. Simeon Schwartz, CEO, for Westchester-based WestMed Medical Group, which received its first medical home recognition in 2009. “Coordinated care leads to efficiency and quality and if you don’t measure quality and efficiency you don’t get results.”

Empire raised participating primary care physician fees this year to further support physicians in focusing on patient outcomes. To place further emphasis on health outcomes, rather than fee-for-services, participating practices also are expected in 2014 to share in the health care savings generated, as long as quality is maintained.

The patient-centered medical homes in this study, including WestMed and Volpe’s practice, were in the process of receiving their NCQA recognition, which they all achieved by 2010, while the measurement period for the study took place during the entire year of 2009.

The study evaluated prevention and care for chronic conditions, including laboratory tests for HbA1c and cholesterol (LDL-C screening), eye examinations, medical attention for nephropathy in patients with diabetes, imaging procedures for low-back pain not supported by appropriate diagnoses and appropriate testing for children with pharyngitis.

Other assessments included: appropriate medication use, including antibiotic use in children with viral upper-respiratory infections and adults with acute bronchitis and the use of long-term controller medications among patients with persistent asthma. The study also evaluated the rates of inpatient hospitalizations and emergency department services and costs for PCMH and non-PCMH patients.

“While there were a few measures that showed non-PCMH patients faring slightly better, overwhelmingly those patients treated in PCMH practices were screened at higher rates, received more appropriate treatment and had fewer hospital and emergency room visits,” said Andrea DeVries, HealthCore director of research operations.

Specifically, the study found:

The study compared commercially insured patients treated by physician practices located in five boroughs of New York City and its suburbs in Nassau County, Suffolk County and Westchester County that were part of the Empire BlueCross BlueShield provider networks. The study included 31,032 PCMH and 350,015 non-PCMH patients.

Study authors include Andrea DeVries, PhD, HealthCore, Chia-husan Winnie Li of HealthCore, MS, Gayathri Sridhar, PhD of HealthCore, Jill Hummel, JD, of WellPoint, Scott Breidbart, MD, of Empire BlueCross BlueShield and John Barron, PharmD, of HealthCore.

Serving New Yorkers for over 75 years, Empire BlueCross BlueShield is the largest health insurer in New York supporting nearly six million members and more than 38,000 business, union and small employers in New York. Empire BlueCross BlueShield (Empire) is the trade name of Empire HealthChoice Assurance, Inc., and Empire Blue Cross Blue Shield HMO is the trade name of Empire HealthChoice HMO, Inc., independent licensees of the Blue Cross Blue Shield Association, serving residents and businesses in the 28 eastern and southeastern counties of New York State. Additional information about Empire is available at . Also, follow us on Twitter at , on Facebook at , or visit our YouTube channel at .