Article Figures & Data
Tables
Characteristic Utah Practices Colorado Practices Number and type 8 university-owned primary care 7 private primary care practices 5 FQHC network practices Medical home model Care by Design (medical home) NCQA PCMH 2011 (Level III) NCQA PCMH 2011 (Level III) Number of annual primary care visits/practice, range 12,912–38,076 7,206–29,880 10,433–47,777 Number of primary care physicians/practice, range 3–13 2–8 2–7 Number of primary care physician assistants and nurse practitioners/practice, range 1–4 1–6 2–12 Number of care managers, range 1–2 0–1 1.5–6 Payers Primarily commercial insurance; 2 practices with ≥30% Medicaid Primarily commercial insurance ≥69% Medicaid, Medicare, SCHIP Urgent care and/or extended hours 2 evening/weekend urgent care Weekend and after hours Weekend and after hours 3 extended hours Context 3 suburban, 3 urban, 2 rural 4 suburban, 3 urban Urban and suburban FQHC = Federally Qualified Health Center; NCQA = National Committee for Quality Assurance; PCMH = patient-centered medical home; SCHIP = State Children’s Health Insurance Program.
Notes: Study practices in Utah were primary care practices including family medicine, internal medicine, and internal medicine/pediatrics. Colorado practices were full-spectrum family medicine practices; 6 did not include obstetrics. Colorado FQHC practices were full-spectrum family medicine practices and included obstetrics, pediatrics, and geriatrics. They also included on-site behavioral health and dental care and hospital care.
Outcome Value Utah practices A B C D E F G H Mean Cost ratios Cost per clinician FTE, $ 8,366 5,001 8,568 9,066 7,247 8,423 5,079 5,176 7,698 Cost per encounter, $ 30.04 30.36 33.01 31.86 30.31 74.02 25.72 23.83 32.71 Cost PMPM, $ 5.02 2.50 4.40 4.05 3.65 4.21 3.06 2.59 3.85 Staffing ratios MA per physician FTE 2.35 1.35 1.71 2.33 3.24 1.81 1.94 2.52 2.16 Other staff per physician FTE 1.15 0.64 1.19 1.62 0.95 0.73 0.42 0.98 0.96 NP or PA per physician FTE 0.34 0.11 0.08 0.33 0.61 0.08 0.48 0.14 0.27 Practice staff Physician FTE 8.7 9.3 6.3 11.2 4.5 12.4 8.5 7.2 8.5 NP and PA FTE 3.0 1.0 0.5 3.7 2.8 1.0 4.1 1.0 2.1 Resident FTE 0 3.6 0 0 0 0 3.6 0 0.9 Nurse (PRN or manager) FTE 2.0 2.0 1.0 5.3 1.0 4.0 2.5 1.0 2.5 MA FTE 22.6 12.6 10.8 26.0 14.6 22.5 16.5 18.0 17.7 Care manager FTE 1.0 1.0 1.0 2.0 1.0 1.0 1.0 1.0 1.1 Other support staff FTE 10.0 4.0 6.0 14.5 5.0 5.0 4.2 6.0 6.8 Colorado practices A B C D E F G H Mean Cost ratios Cost per clinician FTE, $ 7,529 5,437 13,055 10,190 13,929 9,295 6,558 7,464 9,658 Cost per encounter, $ 34.12 19.65 50.06 36.32 59.34 37.18 23.57 19.04 36.68 Cost PMPM, $ 3.80 2.71 6.08 4.96 6.96 4.65 3.28 3.73 4.83 Staffing ratios MA per physician FTE 2.00 1.76 3.16 1.67 4.98 3.08 4.00 3.00 2.96 Other staff per physician FTE 3.25 1.50 8.97 2.97 3.85 2.13 1.72 2.92 3.41 NP or PA per physician FTE 1.50 0.63 1.02 0.20 1.30 0.46 2.60 1.65 1.17 Practice staffa Physician FTE 2.0 8.0 22.5 3.0 3.0 1.3 1.5 2.0 3.6 NP and PA FTE 3.0 5.0 23.0 0.6 4.0 0.6 4.0 3.3 3.7 Resident FTE 0 0 0 0 0 0 0 0 0 Nurse (PRN or manager) FTE 0 4.6 21.0 0 0 0 0 0 2.1 MA FTE 4.0 14.0 71.0 5.0 15.0 4.0 6.0 6.0 10.4 Care manager FTE 1.0 0 21.0 1.0 1.0 0.4 0 1.0 2.1 Other support staff FTE 8.5 12.4 205.5 8.5 14.5 3.0 6.6 8.0 22.3 FTE = full-time equivalent; MA = medical assistant; NP = nurse practitioner; PA = physician assistant; PMPM = per member per month; PRN = pro re nata.
↵a Weighted means.
Note: Key cost and staffing ratios are presented for individual study practices with averages calculated for each state. Numbers of staff by category are presented by practice with averages calculated for each state. Clinicians include physicians, residents, nurse practitioners, and physician assistants. Other support staff include nurses, nurse managers, care managers, front desk staff, call center staff, information technology developers, and dieticians.
PCMH Standards and Elements Annual Cost per FTE Clinician, $ Utah Practices Colorado Practices All Study Practices 1. Enhance Access and Continuity 25,658 30,059 28,076 After-hours, same-day access, urgent care, electronic access, practice care team 2. Identify and Manage Populations 5,603 5,688 5,646 Comprehensive health assessment, proactive outreach, use data/registries for population management 3. Plan and Manage Care 31,935 38,431 35,248 Previsit planning/huddles, implement evidence-based guidelines, identify high-risk patients, care management, medication reconciliation 4. Provide Self-Care Support and Community Resources 5,710 14,124 10,172 Support self-care processes (self-management, activation, education), provide referrals to community resources 5. Track and Coordinate Care 10,503 18,602 14,663 Referral and test tracking, follow-up, care transitions/coordination 6. Measure and Improve Performance 12,884 8,990 10,994 Measure, report performance; measure patient, family experience; implement continuous quality improvement; report externally Total annual cost per clinician FTE 92,293 115,894 104,799 FTE = full-time equivalent; PCMH = patient-centered medical home.
Notes: Not all practices reported costs for each of the Factors for each of the Standards. Because average cost calculations are sensitive to the denominator used, in computing the average cost at the NCQA Standard level we excluded Factors for which no costs were reported to ensure that only actual practice costs incurred in support of each Standard were reflected in the results. Annual costs per FTE clinician for all study practices are therefore not means of Utah and Colorado practices.
Additional Files
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Supplemental Appendix
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The Article in Brief
The Cost of Sustaining a Patient-Centered Medical Home: Experience From 2 States
Michael K. Magill , and colleagues
Background Transformation of a practice to a patient-centered medical home (PCMH) requires many changes, including new workflows, systems to improve patient access and manage patient health, and potentially added staff to perform new services. This study examines personnel costs necessary to deliver PCMH functions in a diverse group of practices in 2 states.
What This Study Found Even partial PCMH implementation costs approximately $105,000 per full time equivalent (FTE) physician annually. PCMH costs per physician FTE were $7,691 in Utah and $9,658 in Colorado, and PCMH incremental costs per patient encounter were $32.30 and $36.68, respectively. For an assumed panel of 2,000 patients, average estimated costs per member per month were $3.85 in Utah and $4.83 in Colorado.
Implications
- Maintenance and ongoing support of PCMH functions require additional time and new skills, which may be provided by existing staff, additional staff or both.
- The authors conclude that adequate compensation for ongoing and substantial incremental costs is critical for practices to sustain PCMH functions. Payment reform, they assert, is essential for primary care practices to sustain medical home services.
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