SEATTLE – Patient-centered medical homes will improve care and reduce costs only if patients use them.
To make that happen, a California demonstration project, the Health Care Coverage Initiative, had to deny claims for nonurgent care when patients sought help outside of their medical home, according to researchers from the University of California, Los Angeles, Health Policy Research Center.
The HCCI is a Medicaid demonstration project that provides care for low income, uninsured adults.
"You’re talking about a population that has historically been underserved. When they get sick, they go to the [emergency department]; that’s what they’ve done their whole lives. One of major challenges was convincing people that they have [their own] doctor and should go to that doctor when they’re sick," said Gerald Kominski, Ph.D., the center’s associate director.
He and his colleagues analyzed claims data for more than 37,700 enrollees in Orange County, where the policy was tried. In the year before the claims were denied, about 60% of outpatient primary care visits were at patients’ medical homes. "Folks were not being turned away" when they sought care elsewhere, said Anna Davis, MPH, a senior research associate at the center.
That number increased to about 80% in the year after the policy took effect; the change was driven by those who hadn’t been using their assigned homes.
"Primary care visits were almost six times as likely to be [medical home] adherent" once nonadherent claims were denied, Ms. Davis said.
The likelihood of any emergency department visits being followed by admission and the likelihood of any inpatient stay both declined significantly after the policy change, she added.
Primary care use of the medical home also increased after the policy change, and specialty and urgent care decreased.
"Enforcing adherence to the medical home may be a way to strengthen the impact of the medical home model. It’s likely to lead to reductions in cost, particularly among low-income populations," she said.
About half the patients in the study were older than age 50 years and had two or more chronic conditions. To be eligible for the demonstration project, they had to have incomes below 200% of the federal poverty level.
Every patient was assigned a primary care provider when they enrolled in HCCI, and they were allowed to change their provider every 6 months. They were informed of the claims-denial policy by letter; the same letter explained that they would have a copayment of $5 for office visits and $25 for emergency department visits.
The researchers haven’t looked yet to see what impact the changes had on enrollee health, but "we did look at ambulatory care sensitive inpatient admissions and didn’t see any significant findings," Ms. Davis said.
Dr. Kominski and Ms. Davis said they have no relevant disclosures.