Can Medical Home Assignment Lead to Appropriate Health Care Utilization?

The efforts to implement the medical home (MH) model are relatively new and occur primarily among insured populations and within specific health systems. The California Health Care Coverage Initiative (HCCI) demonstration project implements the MH within the safetynet structure of 10 California Counties. Programmatic and service variations by county are allowed but all counties are required to establish a MH, defined as a provider or facility that provides primary medical care and prevention services and maintains all of the enrollee's medical information. Despite this broad definition, the MH implementation in HCCI is more in line with the Patient-Centered Medical Home (PCMH) model. This study examines if implementation of MH in the HCCI counties corresponds to changes in utilization patterns and outcomes. It is hypothesized that MH assignment reduces hospitalizations and emergency room visits and increases appropriate physician visits and medication use and improved patient outcomes. A limited pre-post evaluation design is selected using enrollment and claims data on program enrollees. Data from the year prior to HCCI implementation and two years of program data are included. The pre period data includes health care utilization of the program enrollees under the county indigent programs. Uninsured adult ages 18-64, with incomes up to 200% of the Federal Poverty Level, legal U.S. citizens and residents, and residents of participating counties are enrolled and included. Our preliminary analyses revealed changes in utilization in two counties. In county 1 emergency room and mean outpatient visits declined, but the percentage of patients with 1-4 outpatient visits and the average number of prescriptions per person increased. The percentage of diabetes patients with HgbA1C tests increased and the mean HgbA1C scores declined. In county 2, the length of inpatient hospitalizations and the percent with more than one ER visit increased and the mean outpatient visits and the percent with 1-4 visits declined. The changes in county 2 are likely due to pent-up demand of new enrollees. Our findings indicate that medical home assignment corresponds to more appropriate levels of care in at least one of the two participating counties. The results indicate that MH can be successfully implemented within the safteynet and it has the potential to improve patient care and outcomes. PCMH is considered to be the panacea to the major shortcomings of the U.S. health care system particularly to address the difficulties in improving appropriateness and quality of care within a fragmented delivery system.