Abstract
Our analysis presents a case study on the impacts of Health Care Home (HCH) – a large-scale technology-based healthcare innovation in New Zealand’s primary healthcare system. For our analysis, we link the registered population of health practices within the Wellington region to administrative hospital admission data for quarterly periods between 2014 and 2017. By employing variation in the timing of HCH implementation across practices (selected via propensity score matching), we estimate differences-in-differences models to investigate the effects of the intervention on multiple patient outcomes. Additionally, we incorporate a number of empirical specifications to test the robustness of estimates. HCH results in a statistically significant reduction in the likelihood of emergency department (ED) presentations by 6–8 %, with no significant impacts on other health outcomes. The impact on ED presentations aligns with the expectation that the HCH intervention would produce downstream effects of a reduced economic burden on public hospital services.
Appendix
Number of registered individuals per practice-quarter.
2014 Quarters | 2015 Quarters | 2016 Quarters | 2017 Quarters | ||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
HCH implementation quarter | Practice | 1st | 2nd | 3rd | 4th | 1st | 2nd | 3rd | 4th | 1st | 2nd | 3rd | 4th | 1st | 2nd | 3rd | 4th |
1 | 1,773 | 1,781 | 1,803 | 1,822 | 1,829 | 1,835 | 1,864 | 1,874 | 1,888 | 1,893 | 1,924 | 1,947 | 1,968 | 1,995 | 2,040 | 2,079 | |
2016q3 | 2 | 8,302 | 8,488 | 8,641 | 8,841 | 9,005 | 9,183 | 9,360 | 9,609 | 9,805 | 9,975 | 10,244 | 10,471 | 10,742 | 10,987 | 11,257 | 11,645 |
3 | 1,403 | 1,428 | 1,472 | 1,507 | 1,537 | 1,557 | 1,594 | 1,622 | 1,696 | 1,683 | 1,750 | 1,792 | 1,864 | 1,925 | 2,004 | 2,104 | |
4 | 373 | 387 | 395 | 412 | 420 | 429 | 442 | 457 | 462 | 471 | 476 | 490 | 514 | 531 | 549 | 587 | |
5 | 2,567 | 2,607 | 2,646 | 2,700 | 2,732 | 2,769 | 2,833 | 2,847 | 2,901 | 2,946 | 3,001 | 3,077 | 3,159 | 3,240 | 3,316 | 3,414 | |
2017q4 | 6 | 3,201 | 3,246 | 3,305 | 3,370 | 3,442 | 3,541 | 3,650 | 3,727 | 3,863 | 3,947 | 4,073 | 4,212 | 4,355 | 4,503 | 4,659 | 4,850 |
2016q4 | 7 | 1,759 | 1,808 | 1,826 | 1,843 | 1,867 | 1,911 | 1,952 | 1,985 | 2,023 | 2,044 | 2,108 | 2,136 | 2,205 | 2,257 | 2,287 | 2,357 |
8 | 6,584 | 6,726 | 6,872 | 7,066 | 7,287 | 7,436 | 7,632 | 7,797 | 7,976 | 8,136 | 8,430 | 8,638 | 8,860 | 9,090 | 9,333 | 9,683 | |
9 | 693 | 713 | 724 | 732 | 757 | 767 | 784 | 799 | 811 | 830 | 849 | 860 | 877 | 901 | 923 | 954 | |
2017q3 | 10 | 5,737 | 5,844 | 5,974 | 6,121 | 6,237 | 6,390 | 6,553 | 6,703 | 6,953 | 7,153 | 7,406 | 7,633 | 7,815 | 8,112 | 8,350 | 8,673 |
11 | 855 | 880 | 892 | 921 | 952 | 972 | 1,001 | 1,043 | 1,070 | 1,115 | 1,152 | 1,177 | 1,218 | 1,279 | 1,353 | 1,421 | |
12 | 641 | 651 | 665 | 681 | 725 | 756 | 799 | 829 | 847 | 881 | 910 | 939 | 971 | 996 | 1,025 | 1,056 | |
2018q2 | 13 | 1,892 | 1,922 | 1,975 | 2,032 | 2,105 | 2,179 | 2,296 | 2,408 | 2,556 | 2,661 | 2,847 | 2,977 | 3,154 | 3,322 | 3,485 | 3,666 |
14 | 2,056 | 2,086 | 2,116 | 2,145 | 2,161 | 2,190 | 2,237 | 2,281 | 2,308 | 2,330 | 2,386 | 2,411 | 2,440 | 2,485 | 2,535 | 2,609 | |
15 | 3,796 | 3,822 | 3,887 | 3,981 | 4,073 | 4,138 | 4,191 | 4,211 | 4,273 | 4,340 | 4,367 | 4,384 | 4,441 | 4,522 | 4,561 | 4,656 | |
16 | 2,489 | 2,532 | 2,558 | 2,623 | 2,654 | 2,679 | 2,723 | 2,754 | 2,789 | 2,831 | 2,857 | 2,913 | 2,962 | 3,020 | 3,107 | 3,185 | |
2017q4 | 17 | 7,005 | 7,114 | 7,236 | 7,355 | 7,481 | 7,599 | 7,705 | 8,068 | 8,196 | 8,338 | 8,486 | 8,612 | 8,779 | 9,009 | 9,198 | 9,344 |
2018q1 | 18 | 6,326 | 6,381 | 6,447 | 6,568 | 6,644 | 6,714 | 6,807 | 6,879 | 6,976 | 7,086 | 7,188 | 7,260 | 7,347 | 7,458 | 7,590 | 7,720 |
2017q4 | 19 | 5,360 | 5,509 | ||||||||||||||
20 | 373 | 381 | 382 | 387 | 401 | 410 | 418 | 433 | 437 | 438 | 441 | 453 | 468 | 485 | 497 | 501 | |
21 | 2,603 | 2,654 | 2,699 | 2,749 | 2,781 | 2,862 | 2,910 | 2,961 | 3,038 | 3,124 | 3,202 | 3,299 | 3,398 | 3,486 | 3,582 | 3,712 | |
22 | 1,850 | 1,883 | 1,886 | 1,907 | 1,919 | 1,956 | 1,972 | 1,995 | 2,015 | 2,028 | 2,060 | 2,079 | 2,093 | 2,111 | 2,144 | 2,180 | |
23 | 4,683 | 4,729 | 4,801 | 4,891 | 5,004 | 5,148 | 5,270 | 5,427 | 5,589 | 5,691 | 5,940 | 6,119 | 6,379 | 6,628 | 6,814 | 7,056 | |
24 | 3,522 | 3,569 | 3,636 | 3,691 | 3,723 | 3,767 | 3,813 | 3,890 | 3,929 | 3,977 | 3,993 | 4,087 | 4,164 | 4,285 | 4,348 | 4,429 | |
25 | 5,031 | 5,116 | 5,190 | 5,283 | 5,378 | 5,468 | 5,567 | 5,662 | 5,750 | 5,849 | 6,005 | 6,116 | 6,230 | 6,398 | 6,531 | 6,698 | |
26 | 3,539 | 3,600 | 3,631 | 3,657 | 3,688 | 3,744 | 3,813 | 3,862 | 4,006 | 4,093 | 4,211 | 4,323 | 4,421 | 4,608 | 4,723 | 4,902 | |
2017q3 | 27 | 8,146 | 8,248 | 8,353 | 8,463 | 8,639 | 8,756 | 8,871 | 8,938 | 9,048 | 9,167 | 9,336 | 9,454 | 9,596 | 9,813 | 10,002 | 10,207 |
2018q1 | 28 | 1,598 | 1,616 | 1,634 | 1,649 | 1,666 | 1,684 | 1,701 | 1,712 | 1,733 | 1,756 | 1,782 | 1,817 | 1,860 | 1,903 | 1,932 | 1,991 |
29 | 1,248 | 1,261 | 1,281 | 1,298 | 1,305 | 1,348 | 1,386 | 1,420 | 1,442 | 1,466 | 1,490 | 1,503 | 1,513 | 1,544 | 1,582 | 1,607 | |
2018q3 | 30 | 4,600 | 4,655 | 4,724 | 4,798 | 4,863 | 4,924 | 5,093 | 5,157 | 5,220 | 5,310 | 5,404 | 5,507 | 5,615 | 5,734 | 5,850 | 5,988 |
31 | 1,609 | 1,631 | 1,672 | 1,704 | 1,721 | 1,741 | 1,763 | 1,770 | 1,774 | 1,780 | 1,807 | 1,830 | 1,855 | 1,864 | 1,886 | 1,913 | |
32 | 6,626 | 6,731 | 6,817 | 6,903 | 7,011 | 7,098 | 7,170 | 7,257 | 7,332 | 7,463 | 7,585 | 7,699 | 7,828 | 7,969 | 8,122 | 8,293 | |
33 | 4,232 | 4,366 | 4,409 | 4,490 | 4,552 | 4,622 | 4,712 | 4,776 | 4,869 | 4,962 | 5,043 | 5,103 | 5,203 | 5,321 | 5,462 | 5,586 | |
34 | 1,874 | 1,883 | 1,919 | 1,965 | 1,991 | 2,036 | 2,140 | 2,172 | 2,239 | 2,245 | 2,307 | 2,354 | 2,394 | 2,468 | 2,506 | 2,574 | |
2016q3 | 35 | 2,198 | 2,240 | 2,301 | 2,327 | 2,362 | 2,372 | 2,401 | 2,426 | 2,474 | 2,508 | 2,548 | 2,597 | 2,631 | 2,680 | 2,745 | 2,822 |
36 | 2,251 | 2,276 | 2,298 | 2,322 | 2,364 | 2,413 | 2,481 | 2,542 | 2,592 | 2,641 | 2,703 | 2,750 | 2,816 | 2,868 | 2,933 | 3,012 | |
37 | 3,074 | 3,113 | 3,135 | 3,169 | 3,199 | 3,229 | 3,253 | 3,273 | 3,319 | 3,345 | 3,418 | 3,491 | 3,543 | 3,600 | 3,650 | 3,731 | |
38 | 5,584 | 5,641 | 5,734 | 5,853 | 5,948 | 6,060 | 6,147 | 6,259 | 6,373 | 6,481 | 6,641 | 6,751 | 6,873 | 7,052 | 7,231 | 7,440 | |
39 | 4,417 | 4,451 | 4,517 | 4,598 | 4,718 | 4,770 | 4,866 | 4,985 | 5,072 | 5,180 | 5,305 | 5,421 | 5,522 | 5,653 | 5,811 | 5,943 | |
2017q4 | 40 | 3,137 | 3,204 | 3,252 | 3,336 | 3,417 | 3,475 | 3,513 | 3,542 | 3,598 | 3,634 | 3,768 | 3,826 | 3,890 | 3,950 | 4,028 | 4,148 |
41 | 269 | 278 | 276 | 286 | 283 | 295 | 313 | 331 | 344 | 351 | 360 | 373 | 387 | 411 | 431 | 452 | |
42 | 1,576 | 1,623 | 1,668 | 1,728 | 1,750 | 1,774 | 1,816 | 1,851 | 1,876 | 1,912 | 1,958 | 1,992 | 2,032 | 2,090 | 2,152 | 2,289 | |
2018q1 | 43 | 4,143 | 4,201 | 4,258 | 4,292 | 4,328 | 4,371 | 4,443 | 4,469 | 4,549 | 4,623 | 4,712 | 4,771 | 4,872 | 4,965 | 5,054 | 5,173 |
2018q2 | 44 | 3,859 | 3,967 | 4,055 | 4,131 | 4,172 | 4,255 | 4,363 | 4,435 | 4,508 | 4,596 | 4,659 | 4,734 | 4,842 | 4,955 | 5,066 | 5,231 |
2016q3 | 45 | 6,676 | 6,751 | 6,805 | 6,860 | 6,939 | 7,063 | 7,176 | 7,281 | 7,413 | 7,501 | 7,618 | 7,720 | 7,870 | 8,063 | 8,257 | 8,452 |
Notes: The practice identifiers marked in bold implemented the health care homes model.
Difference-in-differences model with binary health events using all practices.
Dependent variables (binary indicator of health events) | |||||
---|---|---|---|---|---|
Excess stay | Acute admission | ED admission | ASH event | Readmission | |
Sample mean | 0.011 | 0.017 | 0.015 | 0.006 | 0.002 |
Model 1: Time and practice-specific fixed effects | |||||
HCH implementation | −0.00035 | −0.00013 | −0.00120** | −0.00024 | −0.00010 |
(0.00022) | (0.00032) | (0.00048) | (0.00028) | (0.00020) | |
Model 2: Model 1 + demographic controls (age, sex, ethnicity, quintile) | |||||
HCH implementation | −0.00033 | −0.00010 | −0.00118** | −0.00023 | −0.00009 |
(0.00023) | (0.00032) | (0.00050) | (0.00029) | (0.00016) | |
Model 3: Model 2 + practice-specific linear time trends | |||||
HCH implementation | −0.00018 | 0.00011 | −0.00111*** | −0.00002 | 0.00011 |
(0.00030) | (0.00034) | (0.00033) | (0.00018) | (0.00027) | |
Model 4: Model 2 + event study | |||||
HCH implementation | −0.00028 | 0.00002 | −0.00135*** | −0.00011 | −0.00003 |
(0.00029) | (0.00031) | (0.00038) | (0.00023) | (0.00022) | |
Pre-treatment ( | 0.00000 | 0.00006 | 0.00003 | 0.00004 | 0.00001 |
(0.00004) | (0.00005) | (0.00005) | (0.00003) | (0.00002) | |
−0.00004 | −0.00027* | 0.00001 | −0.00021** | −0.00008 | |
(0.00014) | (0.00016) | (0.00017) | (0.00010) | (0.00006) | |
Observations | 2,819,751 | 2,819,751 | 2,659,260 | 2,819,751 | 2,819,751 |
Individuals | 235,457 |
Notes: The marginal effects from probit regressions using all the matched practices along with the respective standard errors (in parentheses) are reported in the above table. The standard errors are corrected for clustering at the practice-level. ***, **, * denote statistical significance at the 1 %, 5 %, and 10 % levels, respectively. We estimate probit regressions for Models 1–4.
Conflict of Interest: The authors hereby acknowledge that the analysis does not involve any conflict of interest, as per the journal requirements.
References
Amarasingham, R., B. J. Moore, Y. P. Tabak, M. H. Drazner, C. A. Clark, S. Zhang, W. G. Reed, et al. 2010. “An Automated Model to Identify Heart Failure Patients at Risk for 30-Day Readmission or Death Using Electronic Medical Record Data.” Medical Care 48 (11): 981–88.10.1097/MLR.0b013e3181ef60d9Search in Google Scholar
Angrist, J., and S. Pischke. 2013. Mostly Harmless Econometrics: An Empiricists’ Companion. Princeton, NJ: Princeton University Press.Search in Google Scholar
Autor, D. H. 2003. “Outsourcing at Will: The Contribution of Unjust Dismissal Doctrine to the Growth of Employment Outsourcing.” Journal of Labor Economics 21 (1): 1–42.10.1086/344122Search in Google Scholar
Becker, S. O., and A. Ichino. 2002. “Estimation of Average Treatment Effects Based on Propensity Scores.” The Stata Journal 2 (4): 358–77.10.1177/1536867X0200200403Search in Google Scholar
Compass Health. 2017a. Compass Health Annual Report 2017. Wellington, New Zealand. Accessed July 17, 2018. http://annualreport.compasshealth.org.nz/2017/docs/Compass_Health_2017_Annual_Report.pdf.Search in Google Scholar
Compass Health. 2017b. “Health Care Home first year: Achievements and reflections.” Wellington, New Zealand. Accessed 25 June, 2018. http://www.compasshealth.org.nz/Portals/0/HCH/HCH-year-1-reflections.pdf.Search in Google Scholar
Compass Health. 2018. “Health Care Home Practices.” Wellington, New Zealand. Accessed 10 June, 2018. http://www.compasshealth.org.nz/PracticesandFees/HealthCareHomePractices.aspx.Search in Google Scholar
Downs, A. 2017. “From theory to practice: The promise of primary care in New Zealand.” Accessed 5 July, 2018. http://www.fulbright.org.nz/wp-content/uploads/2017/09/DOWNS-From-Theory-to-Practice-The-Promise-of-Primary-Care-in-New-Zealand-.pdf.Search in Google Scholar
Ernst & Young. 2018. Health Care Home Evaluation: Updated Analysis April-September 2017. New Zealand: Ernst & Young.Search in Google Scholar
Gilfillan, R. J., J. Tomcavage, M. B. Rosenthal, D. E. Davis, J. Graham, J. A. Roy, S. B. Pierdon, et al. 2010. “Value and the Medical Home: Effects of Transformed Primary Care.” The American Journal of Managed Care 16 (8): 607–14.Search in Google Scholar
Grant, R., and D. Greene. 2012. “The Health Care Home Model: Primary Health Care Meeting Public Health Goals.” American Journal of Public Health 102 (6): 1096–103.10.2105/AJPH.2011.300397Search in Google Scholar
Grumbach, K., and P. Grundy. 2010. Outcomes of Implementing Patient Centered Medical Home Interventions. Washington, DC: Patient-Centered Primary Care Collaborative.Search in Google Scholar
Health Care Home Collaborative. 2017. “Health Care Home model of care requirements.” Wellington, New Zealand. Accessed June 10, 2018. http://www.healthcarehome.co.nz/wp-content/uploads/2017/07/Health-Care-Home-Model-of-Care-Requirements.pdf.Search in Google Scholar
Health Care Home Collaborative. 2019. “An integrated care management model that benefits patients and practices.” Accessed April 20, 2019. https://www.healthcarehome.org.nz/integrated-health-care-management-nz.Search in Google Scholar
Hefford, M. 2017. “From Good to Great: The Potential for the Health Care Home Model to Improve Primary Health Care Quality in New Zealand.” Journal of Primary Health Care 9 (3): 230–33.10.1071/HC17045Search in Google Scholar
Jackson, G., and M. Tobias. 2001. “Potentially Avoidable Hospitalisations in New Zealand, 1989–98.” Australian and New Zealand Journal of Public Health 25 (3): 212–21.10.1111/j.1467-842X.2001.tb00565.xSearch in Google Scholar
Jiang, N., and G. Pacheco. 2014. “Demand in New Zealand Hospitals: Expect the Unexpected?” Applied Economics 46 (36): 4475–89.10.1080/00036846.2014.964830Search in Google Scholar
Khandker, S., G. B. Koolwal, and H. Samad. 2010. Handbook on Impact Evaluation: Quantitative Methods and Practices. Washington, DC: The World Bank.10.1596/978-0-8213-8028-4Search in Google Scholar
Larson, E. B., and R. Reid. 2010. “The Patient-Centered Medical Home Movement: Why Now?” Jama 303 (16): 1644–45.10.1001/jama.2010.524Search in Google Scholar
Maeng, D. D., J. Graham, T. R. Graf, J. N. Liberman, N. B. Dermes, J. Tomcavage, D. E. Davis, F. J. Bloom Jr., G. D. Steele. 2012. “Reducing Long-Term Cost by Transforming Primary Care: Evidence from Geisinger’s Medical Home Model.” The American Journal of Managed Care 18 (3): 149–55.Search in Google Scholar
Martsolf, G. R., J. A. Alexander, Y. Shi, L. P. Casalino, D. R. Rittenhouse, D. P. Scanlon, and S. M. Shortell. 2012. “The Patient‐Centered Medical Home and Patient Experience.” Health Services Research 47 (6): 2273–95.10.1111/j.1475-6773.2012.01429.xSearch in Google Scholar
McCarthy, D., K. Mueller, and I. Tillmann. 2009. Group Health Cooperative: Reinventing Primary Care by Connecting Patients with a Medical Home. New York: The Commonwealth Fund.Search in Google Scholar
McClelland, M., B. Asplin, S. K. Epstein, K. E. Kocher, R. Pilgrim, J. Pines, E. J. Rabin, N. K. Rathlev. 2014. “The Affordable Care Act and Emergency Care.” American Journal of Public Health 104 (10): e8–e10.10.2105/AJPH.2014.302052Search in Google Scholar
McHugh, M. D., and C. Ma. 2013. “Hospital Nursing and 30-Day Readmissions among Medicare Patients with Heart Failure, Acute Myocardial Infarction, and Pneumonia.” Medical Care 51 (1): 52.10.1097/MLR.0b013e3182763284Search in Google Scholar
Middleton, L., P. Dunn, C. O’Loughlin, and J. Cumming. 2018. Taking Stock: Primary Care Innovation. Wellington, New Zealand: Productivity Commission. Accessed August 2, 2018. https://www.productivity.govt.nz/sites/default/files/Taking%20Stock%20Primary%20Care%20Innovation_Victoria%20University%20Wellington.pdf.Search in Google Scholar
Ministry of Health NZ. 2018. “Enrolment in a primary health organisation.” Accessed August 17, 2018. https://www.health.govt.nz/our-work/primary-health-care/about-primary-health-organisations/enrolment-primary-health-organisation.Search in Google Scholar
Mutter, R. L., M. D. Rosko, and H. S. Wong. 2008. “Measuring Hospital Inefficiency: The Effects of Controlling for Quality and Patient Burden of Illness.” Health Services Research 43 (6): 1992–2013.10.1111/j.1475-6773.2008.00892.xSearch in Google Scholar
Pinnacle Midlands Health Network. 2018. “Our Health Care Home Journey.” Health Care Home. Accessed July 17, 2018. http://www.healthcarehome.co.nz/model-overview/.Search in Google Scholar
Rosenberg, C. N., P. Peele, D. Keyser, S. McAnallen, and D. Holder. 2012. “Results from a Patient-Centered Medical Home Pilot at UPMC Health Plan Hold Lessons for Broader Adoption of the Model.” Health Affairs 31 (11): 2423–31.10.1377/hlthaff.2011.1002Search in Google Scholar
Werner, R. M., A. Canamucio, J. A. Shea, and G. True. 2014. “The Medical Home Transformation in the Veterans Health Administration: An Evaluation of Early Changes in Primary Care Delivery.” Health Services Research 49 (4): 1329–47.10.1111/1475-6773.12155Search in Google Scholar
Zhan, C., and M. R. Miller. 2003. “Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries during Hospitalization.” Jama 290 (14): 1868–74.10.1001/jama.290.14.1868Search in Google Scholar
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