Impact of Extended Access on Primary Care Sensitive Emergency Department Visits in a Michigan Patient-centered Medical Home Program

INTRODUCTION Patient-centered medical home (PCMH) encourages patients and physicians to actively engage in care coordination resulting in potential cost savings and improvements in quality of care. Blue Cross Blue Shield of Michigan has one of the nation's largest PCMH program with 1,800 designated primary care physicians (PCPs). Our objective was to estimate the impact of providing extended access, a tenet of the PCMH program, on Primary Care Sensitive (PCS) emergency department (ED) visits among participating PCPs. MATERIALS / METHODS We analyzed 2009 paid claims for 1,514,215 commercially-enrolled members (0-64) attributed to 5,325 PCPs within 2,407 practices eligible for PCMH participation. Five capabilities quantifying extended access were measured for each practice. PCS ED visits were defined using the New York University ED Algorithm as visits amendable to primary care intervention. RESULTS Controlling for members' age and gender, PCS ED visit rates were significantly lower for practices offering any of the five BCBSM-defined extended access capabilities. Practices offering 24-hour telephone access had a 14% lower PCS visit rate (<0.0001). Practices offering a systematic approach to fully inform patients about after-hours care availability and locations had 11% lower rates (<0.0001). Those practices that provided additional arrangements for patients to have access to non-ED after-hours providers for urgent care needs during at least 8 after-hours per weekend had 9% lower PCS ED rates. We found that practices that offered an additional four weekend hours (12 hours) did not reduce their PCS ED visit rates more than those offering 8 after-hours. Practices that offered advanced access scheduling that reserved 30% of same-day appointments for acute and routine care had 14% fewer visits (<0.0001) than practices without this capability. The difference in PCS ED visit rates between practices did not increase for those who reserved 50% of same-day appointments for acute and routine care. DISCUSSION Our results highlight the importance of providing extended access for PCP practices working to reduce emergency department use, particularly those potentially preventable. While we found that providing additional weekend after-hours or additional same-day appointments reduce ED use, practices should be aware of the threshold to not limit their scheduling to an extent that may negatively impact them financially.