Health Savings Come with Quality Standards

July brought encouraging news from the Medicare Board of Trustees and the Congressional Budget Office.  Each announced that they were extending Medicare’s projected solvency by several years due to a slowdown in the pace of spending.  Some of the decline is clearly due to the economic downturn, although how much remains a subject of vigorous debate.  Regardless, recent delivery system reforms have also contributed significantly to the trend.

 A new, independent study illuminates the role that one piece of the reform puzzle, the patient-centered medical home (PCMH) model, has played in putting health care spending on a more sustainable track.  The study, conducted by RTI International and published in the journal Health Services Research, identified demonstrably greater declines in total Medicare payments, acute care payments and emergency room visits among those being treated in PCMHs recognized by the National Committee for Quality Assurance (NCQA), of which I am president.

The research focused on participants in the Medicare Fee-for-Service (FFS) program, comparing the performance of 308 NCQA-recognized PCMHs against that of a matched sample of nearly 2,000 primary care practices across three years, beginning in July of 2008.  It adds to a growing body of evidence that a team-based approach putting patients’ needs first can deliver lower overall costs and drive more appropriate health care utilization, while increasing satisfaction with the health care experience.

In the RTI study, practices receiving NCQA recognition saw a 5 percent greater reduction in the trend of total Medicare payments than their non-recognized counterparts, with a full 62 percent of the difference attributed to lower payments to acute care hospitals.  And overall emergency room visit declined by 6 percent once a practice was recognized.  The greatest gains were realized among what were described in the study as “sicker than average” patients – for whom hospitalizations fell by 4 percent more than the comparison group and emergency room utilization by 10 percent more.

It is hardly surprising that providing enhanced access to after hours and on-line care, encouraging patient engagement and shared decision-making, and coordinating the care an individual receives from multiple providers would lead to the type of results seen in the RTI study.  These are some of the key facets of the PCMH model.  Beyond the statistical evidence of cost and quality gains, we hear regularly from primary care clinicians who tell us that they are rejuvenated by the ability to practice the way they had imagined when they first entered the field – no small thing at a time when the health care system is struggling to train and maintain a sufficient primary care workforce.

While we take great pride in the results, NCQA did not commission this study.  But we are familiar with the story the study tells, based on our work over the last decade with clinicians striving to offer superior, coordinated care to their patients.  Today, almost 8,000 practices, and the 40,000 individual clinicians they employ, hold NCQA recognition.

It is also important to note that most studies, including this latest from RTI, are based on results from the earliest versions of the PCMH recognition process.  We have learned a great deal about what works in this setting since NCQA first launched our recognition program and have incorporated these lessons into the periodic updates of the standards and measures we use.  For example, we have expanded requirements to include a focus on integrating care for behavioral health and special needs populations, as well as the increasing role of health information technology in the modern medical practice.  As encouraging as the early results are, we believe they are just the beginning of a revolutionary change in health care delivery.

Challenges remain, of course.  Most primary care clinicians are not part of a recognized patient-centered practice at this point.  PCMH transformation requires a long-term commitment on the part of every medical team member, as well as significant investments in training and technology.  A number of public and private payers have begun to align incentives to reward the better value and greater coordination PCMHs can yield and make these investments more feasible for providers.  These developments are encouraging, but they must proliferate if we are to realize the promise of a truly patient-centered health care system that we can, as a nation, afford.  Otherwise, we may look back on the recent good fiscal news as merely a blip on the path to Medicare insolvency.

Margaret O’Kane is the President of the National Committee for Quality Assurance (NCQA.

Morning Consult