Objective: To study the cost and utilization performance of primary care physicians (PCPs) with and without a patient-centered medical home (PCMH) designation or a Bridges to Excellence (BTE) Diabetes Recognition.
Methods: We performed a retrospective analysis of claims data using the PROMETHEUS Evidence-informed Case Rate (ECR) analytic software on an aggregated claims database, consisting of data from several health plans across the nation. We defined cohorts of PCPs within the database, with and without a PCMH or BTE Diabetes recognition, and either participating in a payment pilot or not, and analyzed the total costs and utilization of services for chronic care episodes attributed to each of those cohorts.
Results: When looking at costs associated with patients with certain chronic illness, we observed that PCMH-recognized physicians participating in a payment pilot and BTE Diabetes recognized physicians had lower cost and utilization performance than the other cohorts. PCMH pilot and PCMH non-pilot participating physicians had similar results.
Conclusions: PCMH-recognized physicians participating in pilots had a favorable cost performance amounting to approximately $12.10 per chronically ill member per month, translating to an overall cost advantage of $4.23 per plan member per month. BTE Diabetes recognized physicians had a favorable cost performance of approximately $36.50 per diabetic member per month, translating to an overall cost advantage of $4.38 per plan member per month. The better performance was tightly associated with the management of certain patients for which quality measures were reported and did not extend to other patients with chronic illness for whom quality metrics were not reported. These amounts are not negligible and undoubtedly underestimate the full potential effect of PCMH practices on total plan member costs. Also, they call into question the size of the current per member per month payments that private and public sector plans make to recognized practices.