Assessing the Cost-Effectiveness of the Chronic Care Model as Implemented in Two Health Centers

The Chronic Care Model (CCM) has been implemented in a variety of settings, including Federally Qualified Health Centers (FQHCs)--key sources of care for underserved populations that have striven to improve the delivery of care. Little research has followed cohorts of patients over time in FQHCs that have implemented expanded or enhanced services consistent with the CCM. This research seeks to describe the implementation, costs, and long-term clinical effects associated with running ”enhanced diabetes care” in two health centers that participated in the Health Disparities Collaboratives, participated in the Robert Wood Johnson Foundations' Diabetes Initiative, and used the CCM as a framework for improving care processes. The paper focuses on the methods used and the implication of the results for other providers or programs.

This is a quasi-experimental longitudinal study with comparison groups constructed from patients. Clinical values were collected from patient registers and include almost all adults with type II diabetes served by the health centers over multiple years both before and after enhanced services were offered. Life years gained and adverse events avoided are estimated by using a cost–effectiveness simulation model based on the Framingham Heart Study.

Some elements of the CCM, like reminder calls or use of electronic systems, are implemented in clinics as part of the normal evolution of “usual care.” The similarities between what has become “usual care” and “enhanced care” under the CCM framework can make it difficult to attribute clinical improvements to specific care processes implemented. In addition, FQHCs serve inherently challenging populations with portions of patient panels having gaps in care or clinical measures over time.

Providers reported that the expanded or enhanced services cost about $700 per-person per-year. After receiving data from electronic registers over multiple years, we (1) conducted a pre-post analysis of patients reported to have been exposed to the CCM (participants) and (2) compared these changes to those observed in a similar group of patients that did not receive the expanded services implemented. Systolic BP improved by 1.5 – 5 mmHg, depending on the method used; and lipid levels improved by 1-18 mg/dL. We also observed clinically and statistically significant improvements in HbA1c levels (about .8%). The cost-effectiveness estimates suggest that under some assumptions the enhanced care services are cost-effective when compared with other medical treatments and programs. Results are sensitive to the inclusion and exclusion criteria applied, to the follow-up time used, and to the methods employed.