FORMATIVE EVALUATIONS OF HEALTH EXPENDITURE, QUALITY OF CARE, AND ACCESS WITHIN A STATEWIDE MULTI-PAYER PATIENT-CENTERED MEDICAL HOME PROGRAM

Background: The patient-centered medical home (PCMH) is an innovative, primary care delivery model with potential to enhance population health. However, evaluations report mixed impact on health expenditure and have not adequately assessed the model’s effect on socioeconomic disparities, or determinants of access to PCMH care. Objective: This dissertation aims to: 1.) evaluate the impact of medical home care on expenditure and utilization of recurrently expensive patients; 2.) evaluate disparities in clinical performance among medical homes by proportion of low-income patients; and, 3.) describe temporal changes in the characteristics of patients served by medical homes. Methods: The context is a statewide PCMH demonstration program, the Maryland Multi-Payer PCMH Program (MMPP). Participating practices were matched to comparator primary care practices in Maryland. The first study used panel-data regression models to evaluate changes in outcomes for consistently high-cost patients during the program. In the second study, I used logistic models to compare performance on six quality-of-care outcomes among participating practices, categorized by proportion of their patients insured by Medicaid. In the third study, I examined changes in characteristics of continuing and new patients in participating practices. Results: Relative to non-PCMH practices, odds of remaining consistently high-cost during the MMPP were lower by 35% (OR = 0.65 [0.41—0.89], P = 0.02) in participating practices. In the final year, participating practices with the highest proportions of Medicaid patients had lower performance on most quality measures compared to practices with the lowest proportions of Medicaid patients. Patients in participating practices had greater odds of remaining attributed to their practice than counterparts in non-PCMH sites. New patients joining medical homes were less medically complex than new patients joining non-PCMH practices. Conclusions: The PCMH demonstrated favorable outcomes for consistently expensive patients, practices with low proportions of Medicaid-insured patients, and established patients. The model’s benefits are not fully realized by practices majorly serving vulnerable populations or by potential patients with complex conditions. This dissertation provides guidance on profiles of patients who need greater integration into the medical home, and types of practices that need stronger support, toward maximizing the gains of the PCMH for all