Evaluation of multipayer medical home is under way

A formal scientific assessment of Pennsylvania's multipayer medical home program is under way, reports David K. Kelley, MD, MPA, chief medical officer for the Pennsylvania Department of Public Welfare Office of Medical Assistance Programs.

"We have done a less formal, less robust assessment," he says. "Anecdotally, we can say we think things look good, that we saved some money, but we can't objectively do that at this point. We just don't have the data."

During the first year or so, adds Dr. Kelley, the program's focus was mostly on practice transformation, with less emphasis on direct care management and transition of care activity. If significant cost savings aren't found, he adds, this may be the reason.

"Those are two things that we didn't make key pillars right out of the gate," he says. "We didn't require all of the higher-volume practice to embed care management nurses, and we didn't add a transition of care component."

Focus on transition of care

A first-year analysis by Keystone Mercy, one of the participating Medicaid health plans, did find some reductions in hospitalizations and ED visits, however, adds Dr. Kelley. "The same payer did another pilot with embedded nurses with a transition of care program, and found significant per member/per month savings," he says.

Last year, a transition of care program was added to the Access Plus Enhanced Primary Care Case Management program, says Dr. Kelley, involving nurses seeing patients while they are still in the hospital and following up with them after discharge.

"The whole goal is to get our consumers home safely, on the right medicines, and to see their specialists and primary care physicians," says Dr. Kelley. "Obviously, we are hoping to see some cost savings on avoiding readmissions."

A Pittsburgh-based Medicaid health plan, UPMC for You, has implemented a very similar program, adds Dr. Kelley, with embedded nurses and a transition of care program.

Dr. Kelley adds that it's worth noting that Keystone Mercy's assessment did show cost savings within a year. "It can be done within a year," he says. "But I don't want to put all eggs in one basket with the multipayer approach, and say that if we don't see cost savings then it was worthless."

In addition, Dr. Kelley notes that Geisinger Health System has published some encouraging results on their medical home initiatives in the Medicare population in the same 42 counties that Access Plus programs are in.

"There is a growing body of published literature, some of it maybe not as rigorous as we'd like it to be, that points to the fact that medical homes do add value, and save money and improve quality," says Dr. Kelley. The Access Plus program has clearly demonstrated that quality has improved, he says, and staff are now trying to translate that into cost savings.

Future directions

Enhanced funding available from the Affordable Care Act could motivate states to proceed with medical home initiatives, "but these are very challenging budgetary times. Coming up with that up-front cash is not easy to do," says Dr. Kelley.

While enhanced funding is a great "carrot" for states, says Dr. Kelley, there are also a lot of requirements attached to it. Pennsylvania's current approach, he says, is to continue to improve its medical home programs already in place.

One question, says Dr. Kelley, is whether this can be done with the participating managed care organization's existing capitation payments. "We think that it can be done," he says. "If we ask for the 90/10 [enhanced funding], then we are addicted to the 90/10 for two years. Our approach is to work within our current construct, but to really take it to the next level."

This will be accomplished, says Dr. Kelley by increasing the focus on transition of care and embedded nurses. "In the meantime, we are going to leverage our existing programs," he says. "We think we can do that without the 90/10, and without all of the strings attached to that."