|PI Name, Project Title, Grant Number, Institution
|PCMH Transformation Effort Studied
|Paul Fishman, PhD; Estimating the Cost of a Medical Home Transformation
Group Health Cooperative
|26 primary care clinics belonging to an integrated health system located in Washington State
|A systemwide initiative to transform Group Health's primary care clinics into PCMHs. The Group Health PCMH model included four practice change modules: virtual medicine (including after-hours nurse consultations and increased virtual visits via secure messaging), chronic disease management, previsit preparation, and outreach. These were accompanied by additional systems changes. All 26 clinics achieved Level 3 NCQA PCMH recognition.
|Document the costs of conducting a systemwide PCMH transformation of an integrated health care system and to estimate the change in direct health care costs attributable to the transformation. The study examined direct and indirect costs of designing, developing, implementing, and refining a transformation model.
|Total health care costs, costs associated with primary and other types of care, and costs for all patients with chronic conditions
|A gross-costing method was used. Cost data were obtained from general ledger data and assigned to health care production costs based on two methods, an internal cost model and the Resource Based Relative Value Scale. The change in total direct health care costs and in categories of use attributable to transformation were determined using regression analyses. Two different empirical models, both using interrupted time series regression, were used to estimate the change in cost over time.
|Neil Fleming, PhD; Costs of Transforming Established Primary Care Practices to Patient-Centered Medical Homes
Baylor Research Institute
|60 primary care practices within a large ambulatory care medical group practice in the greater Dallas/Fort Worth area
|All primary care practices within the HealthTexas Provider Network were required to meet NCQA criteria for PCMH recognition. Practice changes included improved processes to assign a primary care physician to each patient; improved care coordination, scheduling, and team-based care; using health information technology to identify patients who are overdue for services; and others. 57 practices were recognized as NCQA Level 3 PCMHs and three practices as Level 2 PCMHs.
|Estimate the costs of a primary care practice's initial PCMH transformation and application for formal recognition under 2008 NCQA criteria and to estimate the additional costs of renewing PCMH recognition and opportunity costs (forgone revenue)
|Corporate and practice-level infrastructure or capital expenditures, costs of applying for PCMH certification, and recertification
|An activity-based costing method was used. Data were collected from various sources, including payroll data, expenditure data, and qualitative data from interviews. Direct costs were calculated based on observed expenditures and staff wages multiplied by the estimated number of hours spent on transformation activities. Costs were estimated separately for transformation and for applying for NCQA recognition
|Jacqueline Halladay, MD, MPH; Understanding the Direct and Indirect Costs of Transformation to Medical Homes
University of North Carolina at Chapel Hill
|Four small- to medium-sized primary care practices (three pediatric and one family practice) that participated in the North Carolina Practice Support Program
|Practices participated in the North Carolina Practice Support Program, a statewide initiative to help primary care practices transform into PCMHs. Practices focused on improving the care of patients with asthma or diabetes, including use of patient registries, planned care templates, disease-specific care protocols, patient self-management tools, and regular care team meetings. Out of 76 practices participating in the program, 25 (33%) achieved 2008 NCQA PCMH recognition; 22 practices were recognized at Level 3, and three at Level 1. Practices with PCMH recognition benefited from provider incentives in the form of enhanced payments from some regional payers.
|Estimate the incremental costs of PCMH transformation; specifically, costs that are attributed to new activities required for NCQA PCMH recognition and that are above and beyond previous or baseline costs
|Costs by phase of PCMH transformation (development, implementation, and maintenance), costs per FTE clinician, cost per element specified in the NCQA application, costs of applying for PCMH recognition, and total costs
|An activity-based costing method was used. Data were obtained primarily through qualitative, semistructured interviews and practice documents and then categorized and analyzed. Costs of staff time were computed using mean hourly salaries for 2012 obtained from the U.S. Bureau of Labor Statistics
|Elbert Huang, MD, MPH; Case Studies on the Cost of Medical Home Transformation and Maintenance in the Safety Net
University of Chicago
|Nine safety net practices in five States (Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania)
|Practices participated in a demonstration project to transform safety net practices into PCMHs. The practice transformation effort was structured along eight "change concepts": 1) engaged leadership, 2) quality improvement strategy, 3) empanelment, 4) continuous and team-based healing relationships, 5) patient-centered interactions, 6) organized evidence-based care, 7) enhanced access, and 8) care coordination. Diabetes care was a common focus for practice transformation efforts.
|Evaluate the long-term sustainability and maintenance costs of PCMH transformation and to compare the costs of PCMH transformation and maintenance by type of practice
|Direct clinical and administrative costs and indirect costs related to PCMH transformation and maintenance
|An activity-based costing method was used. Data was collected from a self-administered survey, clinic-level billing data, and qualitative interviews. In-depth case studies were conducted. The study reported descriptive statistics on differences in costs and revenue
|John Kralewski, PhD; Transition of Primary Care Medical Group Practices to Next Generation Models
Medica Research Institute
|Two high-performing, midsized family medicine clinics owned by a large, hospital-based, integrated health care system in the Minneapolis-St. Paul metropolitan area, Minnesota
|Clinics transitioned from traditional fee-for-service, illness-oriented, physician-centric health care to a patient-centered population health model. A health insurance plan provided compensation for 2 years while the clinics developed, implemented, and tested the model. The goal of the transformation was to position the clinics to participate in Total Cost of Care contracts being developed by insurance companies. Both clinics received a State medical home certification based on the NCQA model.
|Document practice changes to patient care processes and programs and experiences implementing the transformations; document initial implementation costs and costs to maintain transformation; and document patient-level savings to insurance plans (per member/per year costs from the insurance company's perspective)
|Direct and indirect and initial and ongoing costs related to primary care transformation efforts, including staff time, consultant fees, administrative expenses, capital outlays, training costs, lost revenue from fewer clinic visits and provision of unbillable services, and patient-level costs
|Both activity-based costing and gross-costing methods were used. The study used an in-depth, mixed methods, case study approach. Data were collected through interviews, surveys, and document reviews and comparison ratios and tables were used to estimate costs for each transformation component. Multivariate regressions were used to analyze patient-level costs and compared with a control group of 28 clinics.
|Michael K. Magill, MD; Tool to Assess Ongoing Costs of Patient-Centered Medical Homes
University of Utah, School of Medicine, Department of Family and Preventive Medicine
|20 primary care practices, including independent practices, FQHCs, and clinics belonging to a university-owned network in Utah and Colorado
|Participating practices redesigned systems and implemented changes consistent with mature PCMH practices. Eight clinics belonging to a university-owned network implemented Care by Design™, a model that emphasizes timely access, team-based care, and care planning and yielded improvements in clinical quality as well as patient and provider satisfaction. Five FQHCs implemented changes to enhance access, continuity of care, and teamwork. Seven independent practices participated in a PCMH pilot and achieved significant improvements in cardiovascular and diabetes care, smoking cessation, depression screening, and preventive care. Of the 20 clinics, 12 obtained Level 3 NCQA recognition and eight opted not to pursue NCQA recognition.
|Understand the cost structure associated with ongoing maintenance of PCMH services and to correlate practice characteristics with the cost of ongoing maintenance of PCMH services, as well as estimate per patient per month costs for practices while accounting for the variation in practice-level characteristics
|Direct costs of maintaining PCMH services were estimated, including: cost per FTE clinician, costs per patient per month, and costs per element of NCQA PCMH recognition
|An activity-based costing method was used. A cost analysis was conducted in primary care practices that varied in terms of NCQA recognition. The analysis focused on estimating the direct costs (primarily salaries and benefits) of maintaining PCMH services. The PCMH Cost Dimensions Tool was used to estimate costs. Data were collected through structured interviews and financial and administrative data sources. The study team also collected data on practice characteristics to be used in aggregate cost analyses.
|Grant R. Martsolf, PhD, MPH, RN; Estimating Costs Associated With Patient-Centered Medical Home Transformation
|81 primary care practices in Pennsylvania, including general internal medicine and pediatric practices and nurse-managed health centers
|Practices participated in a 3-year demonstration project, which engaged primary care practices in improving the care of patients with chronic diseases through implementation of the PCMH model. Practices that achieved NCQA PCMH recognition also received enhanced payments from a coalition of regional payers. The extent of PCMH transformation varied across practices.
|Describe the costs associated with PCMH transformation across practices with varying levels of transformation
|One-time costs, ongoing costs, total costs, costs per clinician, costs per provider FTE, category-specific costs, and costs per patient
|An activity-based costing method was used. Survey and claims data were used to identify a sample of 81 practices and used to compute quality index scores for each practice. Practices were then ranked and three from each region (12 in total) were selected for case studies, which included semistructured interviews. Interviews were used to obtain estimates of initial and ongoing costs of transformation.
|Richard T. Meenan, PhD, MPH, MBA; Estimating the Costs of Primary Care Renewal
Center for Health Research–Kaiser Permanente Northwest
|Eight clinic systems with more than 40 primary care practices, including neighborhood health centers, school-based clinics, and primary care practices serving primarily low- income patients in western Oregon
|Practices implemented a PCMH through a training collaborative based on the Primary Care Renewal (PCR) experience. PCR encourages practices to provide multidisciplinary, coordinated, and comprehensive care. Practices implementing PCR agree to establish team-based and customer-driven care, barrier-free access, proactive health improvement for patient panels, and onsite or otherwise integrated behavioral health services. The participating organizations have adopted formal improvement methods, redesigned practices to increase patient empanelment, and introduced care teams.
|Quantify the true resource and cost burden that similar clinics are likely to bear in successful PCMH transformation by using process improvement theory as a framework, and to apply costing methodology and qualitative research methods to the identification, categorization, and quantification of the direct and indirect costs of successful PCMH practice transformation within a safety net–based medical care system
|Direct and indirect costs of PCMH implementation, including costs of specific implementation activities, total costs, costs per service, and costs per member
|An activity-based costing method was used. Data were collected from project reports and semistructured interviews, including financial information. Information was then used to develop a model of the implementation process. Activity- based costing methods were used to identify costs associated with each activity.
|Benjamin Miller, PsyD; Cost Assessment of Collaborative Healthcare (CoACH)
University of Colorado Denver, Department of Family Medicine
|Six primary care practices in Grand Junction, Colorado, ranging from solo rural practices to large, urban, multispecialty primary care practices
|The six participating practices were already providing or considering whether to offer onsite integrated behavioral health care. The practices were part of the Sustaining Healthcare Across Integrated Primary-Care Efforts project, which studied whether a global budget for primary care, including mental health, is sustainable.
|Develop and test a Web-based tool to both prospectively and retrospectively estimate the annual incremental expenditure of integrating mental and behavioral health services into primary care practices through the PCMH
|Both initial and ongoing costs were estimated, including staff salaries and benefits, training costs, and operational costs such as space, equipment, and software
|An activity-based costing method was used. The Web-based data collection tool developed includes a practice intake questionnaire and an integration activities graphic workflow. Respondents can then edit workflow assumptions to model the total cost of different scenarios. The six participating practices piloted the tool to assess and improve its usability and accuracy.
|Linzheng Shi, PhD; Estimating Costs of Supporting Safety Net Patient-Centered Medical Home Transformation in New Orleans
|110 safety net clinics (75 primary care clinics and 35 behavioral health clinics) from 24 health care organizations in New Orleans
|A systemwide effort to rebuild and transform primary care using the PCMH model and supported by a Primary Care Access and Stabilization Grant (PCASG). Participating clinics were required to implement PCMH quality standards and many clinics also improved care management for patients with diabetes and depression, in some cases by integrating primary care and behavioral health care services. PCASG offered incentives for PCMH transformation through bonus payments to clinics with NCQA recognition. Of the 110 clinics, 39 primary care and two behavioral health clinics attained NCQA PCMH recognition.
|Understand the differences between PCASG clinics that attained NCQA PCMH recognition and those that did not
|Baseline and incremental costs of the PCMH transformation process, including total costs, costs per visit, and costs per FTE physician
|A gross-costing approach was used. The study team used program data to estimate costs by tracking actual program expenditures in various categories. Trend analyses were conducted to understand cost trends for clinics that attained recognition and those that did not. Econometric modeling was used to estimate incremental costs of transformation.
|Sarah Shih, MPH; What Are the Costs to Small Practices and Community Health Centers to Maintain Comprehensive Primary Care in New York City?
New York City Department of Health and Mental Hygiene
|45 small, office- based practices and CHCs serving lower income neighborhoods in New York City
|Practices participated in the Primary Care Information Project to help primary care practices and CHCs implement electronic health record systems; the project also helped practices and CHCs optimize their workflows and adopt changes reflecting NCQA PCMH standards. The practices generally used a combination of informal and structured techniques to achieve PCMH goals related to improving access, coordinating care, improving the care of patients with chronic conditions, and assessing improvement efforts.
|Quantify the time and resources utilized by practices for new activities or revised workflows as part of maintaining primary care medical home services relating to patient engagement and care coordination, to translate the time and resources spent into costs, and to examine the range of costs by organizational attributes
|Costs of time and resources to maintain PCMH activities related to patient engagement and care coordination, including total costs per practice, average costs per provider and administrative staff, and costs per patient per encounter
|An activity-based costing approach was used. The study team used a multistep data collection process that included a survey and structured interviews. Data obtained from interviews were translated into costs using salary data from the practices. Program data about practice characteristics were used to examine the relationship between costs and organizational attributes.
|Ming Tai-Seale, PhD, MPH; Estimating the Costs of Supporting Primary Care Practice Transformation
Palo Alto Medical Foundation Research Institute
|17 primary care practices affiliated with a community-based, multispecialty group practice in northern California
|Redesign efforts were guided by the core principles of team-based care, whole person orientation, integrated care, enhanced access, quality and safety, and appropriate reimbursement for services. Between 2007 and 2010, 10 of the 17 primary care practices affiliated with the Palo Alto Medical Foundation applied for and received NCQA PCMH recognition; five practices were recognized at Level 2 and five at Level 3.
|Identify the key components of the transformation process and sources of indirect costs and determine the costs of the identified key components. The study focused on costs associated with several specific interventions and examined the activities and costs associated with the early planning stage of each intervention and the initial rollout of the interventions in the clinics.
|Indirect costs (estimated at the physician, practice, division, and organization level) of planning and introducing PCMH interventions, including shared medical appointments, team-based care, and automatic laboratory test ordering
|An activity-based costing approach was used to calculate indirect costs associated with each intervention as determined through a multistep process. Data were primarily collected through interviews, with additional data obtained from electronic calendars used by staff members, meeting minutes, and project tracking and payroll data. Costs were examined at the physician, practice, division, and organizational levels.
|George Valko, MD; Patient-Centered Medical Home Cost of Sustaining and Transforming
Thomas Jefferson University
|11 rural, urban, and suburban primary care practices located in southeastern Pennsylvania
|Participating practices achieved NCQA PCMH recognition as the result of a statewide demonstration program, which brought together family medicine, general internal medicine, and pediatric practices to implement the chronic care model. Major insurers in the State offered ongoing payment incentives to practices with NCQA recognition. The 11 practices participating in this study implemented a variety of transformation activities, including expanding patient access and continuity, improving care coordination and care transitions, and increased shared decisionmaking.
|Estimate the cost of transforming a small primary care practice into a PCMH and to create a structured tool to provide practices with a way to estimate the costs of transforming into a PCMH
|Direct and indirect costs of achieving NCQA recognition and costs of maintaining recognition, including staff salaries, training costs, costs associated with patient care, and space and equipment costs
|An activity-based costing approach was used. Data were collected from each practice and costs were classified according to whether or not they were one-time or ongoing. The net cost of achieving recognition was computed for each practice. A structured cost tool was developed to estimate and report the cost of practice transformation.
|Arturo Vargas-Bustamante, PhD, MPP, MA; Examining the Costs of a Medical Home Transformation for Seniors
University of California, Los Angeles
|A large integrated medical group with 31 practice sites and 213 IPAs in three geographic regions in the greater Los Angeles area
|Practices participated in a wellness care redesign for older adult patients in an ACO. The primary goals of the redesign were to improve the quality of patient-primary care team interactions, support shared decisionmaking, and help coordinate preventive and chronic patient care needs.
|Develop a cost capture template to retrospectively quantify startup and incremental expenses for senior care redesign in the integrated medical group and IPA primary care practice sites and compare startup and incremental practice expenses for site-level implementation of the PCMH redesign between integrated group primary care and IPA practice sites
|Startup (initial) and incremental practice expenses for PCMH transformation, including training material development, staff costs, equipment costs, and incidental costs (transportation and incentives)
|An activity-based costing approach was used. Data were collected using a customized cost-capture template completed by program administrators and was then coded and aggregated to enable cost comparisons across time, presented in 2012 dollars.
|Benjamin Yarnoff, PhD; Estimating the Costs of Supporting Primary Care Practice Transformation
Research Triangle Institute
|Study includes all primary care practices in the United States that attained PCMH recognition between December 2014 and February 2015, a total of 467 practices
|All participating practices received recognition from NCQA as a PCMH
|Estimate the cost of primary care transformation through a survey of primary care practices
|Direct costs of attaining PCMH certification, including labor, equipment, materials, travel, and contracted services
|An activity-based costing approach was used. The study examined the direct costs of NCQA recognition and used an activity-based costing approach to collect costs data. Respondents were asked to retrospectively report only on the costs of the transformation effort itself, not the ongoing costs. Practice managers were surveyed to examine the average cost of transformation for each practice transformation element, the distribution of costs across resource components for each element, and how costs vary by practice characteristics. Costs were captured by resource component and activity using a Web-based survey/cost data collection tool.
Abbreviations: ACO = Accountable Care Organization; CHCs = Community Health Centers; FQHCs = Federally Qualified Health Centers; FTE = full-time equivalent; IPA = Independent Practice Association; NCQA = National Committee for Quality Assurance; PCMH = patient-centered medical home.