Importance: Since 2008, National Committee for Quality Assurance (NCQA) has offered patient-centered medical home (PCMH) recognition to practices that meet its requirements. Few studies have assessed the relationship between such recognition and health care use among children with special health care needs (CSHCN).
Objective: To evaluate whether Medicaid-enrolled CSHCN treated by NCQA-recognized providers (the "treatment group") had better utilization-related outcomes compared to similar children seeing other providers.
Design: Cross-sectional analyses versus two comparison groups. We identified CSHCN using Medicaid eligibility and claims data. We flagged NCQA-certified providers in Medicaid claims data using National Provider Identifier numbers obtained via NCQA. We attributed children to providers based on the volume of well-child, preventive care, evaluation and management services and other services. Children attributed to providers who received NCQA-recognition between 2008 and 2010 comprised the treatment group. Children attributed to providers who received NCQA-recognition in 2011 comprised the non-matched, "late recognition" comparison group. Children not attributed to recognized providers who were exact-matched to the treatment group children on demographics, diagnoses, prescription drugs, and number of months enrolled in Medicaid comprised a matched comparison group.
Setting: Louisiana, New Hampshire and Texas Medicaid.
Participants: CSHCN ages 0-18 years in fee-for-service Medicaid in 2010.
Exposure(s): Attribution to providers who received NCQA-recognition between 2008 and 2010.
Main Outcome Measures: Well-child visits, any emergency department (ED) and avoidable ED visits, hospitalizations and ambulatory care-sensitive hospitalizations, and follow-up after ED visits and hospitalizations.
Results: In Louisiana, there were no statistically significant differences in outcomes between the treatment group showing treatment group children received better care than either of the comparison groups. Furthermore, outcomes were actually significantly worse for the treatment group than for the matched comparison group for the three measures related to ED use or follow-up. In Texas, we found substantially higher rates of well-child visits and follow-up after ED visits for treatment group children than for children in the "late recognition" comparison group, but no differences between the treatment group and the matched comparison group for any outcomes. In New Hampshire, treatment group children were more likely to have follow-up after ED visits and well-child visits than children in either the matched or late recognition comparison groups. The treatment-comparison group odds ratios for any ED visits and preventable ED visits were less than 1.0 using either comparison group in New Hampshire, but neither difference was statistically significant. However, treatment group children in New Hampshire had a significantly higher rate of hospitalizations than the late recognition comparison group.
Conclusions and Relevance: We found no evidence to suggest that Medicaid-covered CSHCN attributed to NCQA PCMH-recognized providers had more favorable hospital or ED utilization patterns than comparison groups in any of the three states. However, in two of the three states (Texas and New Hampshire) CSHCN attributed to these recognized providers did have significantly higher probabilities of well-child visits and post-ED follow-up visits than comparison groups. NCQA-recognition may not signal high-quality primary care for Medicaid-covered CSHCN in all states, based on the measures used in this study, and parents and payers may need to assess other factors to identify high-quality providers.