Association Between the Implementation of a Population-Based Primary Care Payment System and Achievement on Quality Measures in Hawaii

The COVID-19 Pandemic Led To A Large Decline In Physician Gross Revenue Across All Specialties In 2020

US health care use declined during the initial phase of the COVID-19 pandemic in 2020. Although utilization is known to have recovered in 2021 and 2022, it is unknown how revenue in 2020-22 varied by physician specialty and practice setting. This study linked medical claims from a large national federation of commercial health plans to physician and practice data to estimate pandemic-associated impacts on physician revenue (defined as payments to eligible physicians) by specialty and practice characteristics. Surgical specialties, emergency medicine, and medical subspecialties each experienced a greater than 9 percent adjusted gross revenue decline in 2020 relative to prepandemic baselines. By 2022, pathology and psychiatry revenue experienced robust recovery, whereas surgical and oncology revenue remained at or below baseline. Revenue recovery in 2022 was greater for physicians practicing in hospital-owned practices and in practices participating in accountable care organizations. Pandemic-associated revenue recovery in 2021 and 2022 varied by specialty and practice type. Given that physician financial instability is associated with health care consolidation and leaving practice, policy makers should closely monitor revenue trends among physicians in specialties or practice settings with sustained gross revenue reductions during the pandemic.

Disentangling the impact of alternative payment models and associated service delivery models on quality of chronic care: A scoping review

Payment reforms are frequently implemented alongside service delivery reforms, thus rendering it difficult to disentangle their impact. This scoping review aims to link alternative payment arrangements within their context of service delivery, to assess their impact on quality of chronic care, and to disentangle, where possible, the impact of payment reforms from changes to service delivery. A search of literature published between 2013 and 2022 resulted in 34 relevant articles across five types of payment models: capitation/global budget (n = 13), pay-for-coordination (n = 10), shared savings/shared risk (n = 6), blended capitation (n = 3), and bundled payments (n = 1). The certainty of evidence was generally low due to biases associated with voluntary participation in reforms. This scoping review finds that population-based payment reforms are better suited for collaborative, person-centred approaches of service delivery spanning settings and providers, but also highlights the need for a wider evidence base of studies disentangling the impact of financing from service delivery reforms. Limited evidence disentangling the two suggests that transforming service delivery to a team-based model of care alongside a purchasing reform shifting to blended capitation was more impactful in improving quality of chronic care, than the individual components of payment and service delivery. Further comparative studies employing causal inference methods, accounting for biases and quantifying aspects of service delivery, are needed to better disentangle the mechanisms impacting quality of care.

Association Between Capitated Payments and Preventive Care Among U.S. Adults

Introduction

There is increasing interest in using capitation rather than fee for service to promote primary care and population health. The goal of this study was to examine the association between practice reimbursement mix (majority fee for service versus majority capitation versus other) and receipt of common preventive screening examinations and health counseling from 2012 to 2018.

Methods

Using the National Ambulatory Medical Care Survey, a retrospective cross-sectional study of 24,864 visits with primary care clinicians among patients aged 18-75 years without a cancer diagnosis was conducted. The main dependent measures were age- and sex-appropriate receipt of breast cancer screening, osteoporosis screening, cervical cancer screening, chlamydia testing, colon cancer screening, diabetes screening, and hyperlipidemia screening as well as 3 health counseling items. Multivariable logistic regression was performed to assess the association between reimbursement mix and receipt of preventive care, adjusted for patient, visit, and practice characteristics.

Results

Majority capitation reimbursement was associated with a greater likelihood of receiving breast cancer screening (AOR=2.11, 95% CI=1.16, 3.84, p=0.014) and osteoporosis screening (AOR=4.34, 95% CI=1.74, 10.8, p=0.0017) than majority fee-for-service or other reimbursement mixes. Reimbursement mix was not associated with the likelihood of receiving 9 other preventive care or health counseling services.

Conclusions

Larger amounts of capitation reimbursement may improve some but not all aspects of preventive care compared with fee for service.

What contributes to Primary Health Care effectiveness? Integrative literature review, 2010-2020

Primary Health Care (PHC) intends to rearrange services to make it more effective. Nevertheless, effectiveness in PHC is quite a challenge. This study reviews several articles regarding the effectiveness improvements in PHC between 2010 and 2020. Ninety out of 8,369 articles found in PubMed and the Virtual Health Library databases search were selected for thematic analysis using the Atlas.ti® 9.0 software. There were four categories identified: strategies for monitoring and evaluating health services, organizational arrangements, models and technologies applied to PHC. Studies concerning the sensitive conditions indicators were predominant. Institutional assessment programs, PHC as a structuring policy, appropriate workforce, measures to increase access and digital technologies showed positive effects. However, payment for performance is still controversial. The expressive number of Brazilian publications reveals the broad diffusion of PHC in the country and the concern on its performance. These findings reassure well-known aspects, but it also points to the need for a logical model to better define what is intended as effectiveness within primary health care as well as clarify the polysemy that surrounds the concept. We also suggest substituting the term "resolvability", commonly used in Brazil, for "effectiveness".

Beyond demonstrations: implementing a primary care hybrid payment model in Medicare

The National Academies of Sciences, Engineering, and Medicine's (NASEM's) 2021 report on primary care called for a hybrid payment approach-a mix of fee-for-service and population-based payment-with performance accountability to strike the proper balance for desired practice transformation and to support primary care's important and expanding role. The NASEM report also proposed substantial increases to primary care payment and reforms to the Medicare Physician Fee Schedule. This paper addresses pragmatic ways to implement these recommendations, describing and proposing solutions to the main implementation challenges. The urgent need for primary care payment reform calls for adopting a hybrid model within the Medicare fee schedule rather than engaging in another round of demonstrations, despite legal and practical obstacles to adoption. The paper explores reasons for adopting a roughly 50:50 blend of fee-for-service and population-based payment and addresses other design features, presenting reasons why spending accountability should rely on utilization measures under primary care control rather than performance on total cost of care, and proposes a fresh approach to quality, emphasizing that quality measures should be parsimonious, focused on important outcomes with demonstrated quality improvement.

Comprehensive Primary Care Plus Did Not Improve Quality Or Lower Spending For The Privately Insured

Comprehensive Primary Care Plus (CPC+) was a multipayer payment reform model that provided incentives for primary care practices to lower spending and improve quality performance. Although CPC+ has been evaluated in Medicare, little is known about its impact in the private sector. Using claims and enrollment data from the period 2013-20 from two large insurers in Michigan, we performed difference-in-differences analyses and found that CPC+ was not associated with changes in total spending (-$44.70 per year) or overall quality performance (-0.1 percentage point). These changes did not vary systematically across CPC+ cohorts, tracks, regions, or participation in prior primary care innovations. We conclude that CPC+ did not improve spending or quality for private-plan enrollees in Michigan, even before accounting for payouts to providers. This analysis adds to existing evidence that CPC+ may cost payers money in the short term, without concomitant improvements to care quality.

Evaluation of Payment Transformation in Hawai'i Based on Physician Perspective

The Hawai'i Medical Service Association's (HMSA) Population-based Payments for Primary Care (3PC) system has been in effect since 2016. There is limited literature regarding physician opinions on this payment transformation policy change. The objective of this study was to evaluate physician responses to a survey regarding the 3PC payment transformation system and identify methods to support physicians in Hawai'i. An online survey was sent to 2478 Hawai'i physicians and yielded 250 responses. A total of 77% respondents reported being unhappy with payment transformation, while 12.9% and 10.1% reported being indifferent and happy, respectively. Of responding physicians, 60.6% reported a decrease in overall income, whereas 24.9% and 14.5% reported no change or an overall increase, respectively. Open-ended responses were categorized into theme clusters: negative impact on primary care, increased administrative burdens, decreased quality of patient care, decreased physician reimbursement, preference to treat healthier patients, harm to private practice, harm to newer practices, ignored physician sentiments, and worsened physician shortage in Hawai'i. Respondents, especially those working in primary care, are dissatisfied with payment transformation. Future research is needed to compare the thematic clusters identified in the current study with relevant literature.

Value-Based Payment Models In The Commercial Insurance Sector: A Systematic Review

Value-based payment models are a prominent strategy in health reform. Although Medicare payment models have been extensively evaluated, much less is known about value-based payment models in the commercial insurance sector. We performed the first systematic review of the quality, spending, and utilization effects of commercial models, extracting results from fifty-nine studies. Forty-one of these studies evaluated outcomes. More studies had positive results for quality outcomes (81 percent of studies) than for spending (56 percent) and utilization (58 percent). Less rigorous studies were more likely to find positive results. Given the mixed nature of the findings, commercial insurers should identify ways to strengthen value-based payment programs or leverage other strategies to improve health care value.

Bundled Payment Episodes Initiated by Physician Group Practices: Medicare Beneficiary Perceptions of Care Quality

BACKGROUND

The Bundled Payments for Care Improvement (BPCI) initiative incentivizes participating providers to reduce total Medicare payments for an episode of care. However, there are concerns that reducing payments could reduce quality of care.

OBJECTIVE

To assess the association of BPCI with patient-reported functional status and care experiences.

DESIGN

We surveyed a stratified random sample of Medicare beneficiaries with BPCI episodes attributed to participating physician group practices, and matched comparison beneficiaries, after hospitalization for one of the 18 highest volume clinical episodes. The sample included beneficiaries discharged from the hospital from February 2017 through September 2017. Beneficiaries were surveyed approximately 90 days after their hospital discharge. We estimated risk-adjusted differences between the BPCI and comparison groups, pooled across all 18 clinical episodes and separately for the five largest clinical episodes.

PARTICIPANTS

Medicare beneficiaries with BPCI episodes (n=16,898, response rate=44.5%) and comparison beneficiaries hospitalized for similar conditions selected using coarsened exact matching (n=14,652, response rate=46.2%).

MAIN MEASURES

Patient-reported functional status, care experiences, and overall satisfaction with recovery.

KEY RESULTS

Overall, we did not find differences between the BPCI and comparison respondents across seven measures of change in functional status or overall satisfaction with recovery. Both BPCI and comparison respondents reported generally positive care experiences, but BPCI respondents were less likely to report positive care experience for 3 of 8 measures (discharged at the right time, -1.2 percentage points (pp); appropriate level of care, -1.8 pp; preferences for post-discharge care taken into account, -0.9 pp; p<0.05 for all three measures).

CONCLUSIONS

The proportion of respondents with favorable care experiences was smaller for BPCI than comparison respondents. However, we did not detect differences in self-reported change in functional status approximately 90 days after hospital discharge, indicating that differences in care experiences did not affect functional recovery.

Capitated versus fee-for-service reimbursement and quality of care for chronic disease: a US cross-sectional analysis

BACKGROUND

Upcoming alternative payment models Primary Care First (PCF) and Kidney Care Choices (KCC) incorporate capitated payments for chronic disease management. Prior research on the effect of capitated payments on chronic disease management has shown mixed results. We assessed the patient, physician, and practice characteristics of practices with capitation as the majority of revenue, and evaluated the association of capitated reimbursement with quality of chronic disease care.

METHODS

We performed a cross-sectional analysis of visits in the United States' National Ambulatory Medical Care Survey (NAMCS) for patients with hypertension, diabetes, or chronic kidney disease (CKD). Our predictor was practice reimbursement type, classified as 1) majority capitation, 2) majority FFS, or 3) other reimbursement mix. Outcomes were quality indicators of hypertension control, diabetes control, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use, and statin use.

RESULTS

About 9% of visits were to practices with majority capitation revenue. Capitated practices, compared with FFS and other practices, had lower visit frequency (3.7 vs. 5.2 vs. 5.2, p = 0.006), were more likely to be located in the West Census Region (55% vs. 18% vs. 17%, p < 0.001), less likely to be solo practice (21% vs. 37% vs. 35%, p = 0.005), more likely to be owned by an insurance company, health plan or HMO (24% vs. 13% vs. 13%, p = 0.033), and more likely to have private insurance (43% vs. 25% vs. 19%, p = 0.004) and managed care payments (69% vs. 23% vs. 26%, p < 0.001) as the majority of revenue. The prevalence of controlled hypertension, controlled diabetes, ACEi/ARB use, and statin use was suboptimal across practice reimbursement types. Capitated reimbursement was not associated with differences in hypertension, diabetes, or CKD quality indicators, in multivariable models adjusting for patient, physician, and practice characteristics.

CONCLUSIONS

Practices with majority capitation revenue differed substantially from FFS and other practices in patient, physician, and practice characteristics, but were not associated with consistent quality differences. Our findings establish baseline estimates of chronic disease quality of care performance by practice reimbursement composition, informing chronic disease care delivery within upcoming payment models.

Osteoporosis treatment rates after hip fracture 2011-2019 in Hawaii: Undertreatment of men after hip fractures

Objectives

To investigate trends of osteoporosis treatment rates, and factors affecting osteoporosis treatment after hip fracture admission within a single health care system in Hawaii.

Methods

A retrospective chart review was conducted of patients aged 50 years or older and hospitalized for hip fractures between January 1, 2011 and December 31, 2019 at Hawaii Pacific Health, a large health care system in Hawaii. We collected data on basic demographics and osteoporosis medication prescription from electronic medical records. We evaluated trends of osteoporosis treatment rates and performed logistic regression to determine factors associated with osteoporosis treatment.

Results

The mean for treatment rates for osteoporosis from 2011 to 2019 was 17.2% (range 8.8%–26.0%). From 2011 to 2019 there was a small increase in treatment rates from 16.3% in 2011 to 24.1% in 2019. Men were less likely to receive osteoporosis treatment after admission for hip fracture. Patients discharged to a facility were more likely to receive osteoporosis treatment. As compared to women, men who had a hip fracture were less likely to receive dual-energy X-ray absorptiometry scan, and osteoporosis medication before hip fracture admission.

Conclusions

The use of osteoporosis medication for secondary prevention after admission for hip fracture in Hawaii from 2011 to 2019 was low. However, there was a small increase in treatment rates from 2011 to 2019. Disparities in treatment of osteoporosis after hip fracture were noted in men. Significant work is needed to increase treatment rates further, and to address the disparity in osteoporosis treatment between men and women.

The impact of the State Innovation Models Initiative on population health

In this paper, we examine the effects of the State Innovation Models Initiative (SIM) on population-level health status. SIM provided $250 million to six states in 2013 for broad delivery system reforms. We use data from the Behavioral Risk Factor Surveillance System for the years 2010-2016. Our sample is restricted to individuals ages 45 and older residing in 6 SIM and 15 control states. Treatment effects in a difference-in-difference design are estimated using a latent factor model for multiple indicators of health status. In addition to estimates for the primary sample, we obtain estimates for six subsamples based on strata of age, education, income, race and urban/rural status. We find that individuals in states that implemented SIM show significant improvements in health status. The effects of SIM are greater among older, Medicare eligible individuals, including those living in rural areas. The State Innovation Models Initiative, which provided financial incentives for states to implement health care delivery system reforms, led to population-level improvements in health status.

A Comparative Analysis of the Place of Death of Older Adults in Hawai'i, 2003-2018

Studies from around the world have found that the preferred place of death is at home. Although desired, the ability to die at home requires personal, social, and structural factors to be in place. In the United States, between 2003 and 2017, there were decreased hospital and nursing facility deaths and increased home and hospice facility deaths. This study aims to determine whether a change in the place of death in those greater than 65 years of age in Hawai'i is similar to the overall United States data and if these changes in place of death are similar across islands/counties in the state of Hawai'i. Data from the Centers for Disease Control and Prevention database were analyzed for natural deaths between 2003 and 2018 in Hawai'i. Between 2003 and 2018, there were 120 115 natural deaths in Hawai'i, with a decrease in the overall percentage of deaths in hospitals from 53% in 2003 to 33% in 2018. During the same period, home deaths increased from 23% to 33%, and nursing facility deaths increased from 14% to 16%. This study found that the change in the place of death in those greater than 65 years in Hawai'i is similar to the overall United States data as a whole, but not within individual Hawai'i counties.

Does Provider Gender Affect the Quality of Primary Care?

BACKGROUND

Women providers have a more patient-centered communication style than men, and some studies have found women primary care providers are more likely to meet quality performance measures.

OBJECTIVE

To explore gender differences in the quality of primary care process and outcome measures.

DESIGN

Retrospective analysis of primary care performance data from 1 year (2018-2019).

PARTICIPANTS

A total of 586 primary care providers (311 women and 275 men) who cared for 241,428 primary care patients at 96 primary care clinics at 8 Veterans Affairs (VA) medical centers.

MAIN MEASURES

Our primary outcome was a composite quality measure that averaged all thirty-four primary care performance measures that assessed performance in cancer screening, diabetes care, cardiovascular care, tobacco counseling, risky alcohol screening, immunizations, HIV testing, opiate care, and continuity. Our secondary outcomes were performance on each of the 34 measures.

KEY RESULTS

There was no difference in the average performance on our composite measure between men and women (75.8% vs. 76.6%, p = 0.17). Among the 34 primary care quality measures collected, there was no difference between male and female providers' performance. Using a more conservative cut-point, women were more likely to screen at-risk diabetic patients for hypoglycemia and document follow-up on risky alcohol behavior noted during patient check-in. These differences were clinically small and likely due to chance, given the multiple measures evaluated in this study.

CONCLUSIONS

We found little evidence of difference in the performance on primary care quality measures between male and female providers.

Satisfaction of octogenarians with Primary Health Care services

Abstract Objective: To evaluate the satisfaction of octogenarians with Primary Health Care services. Method: a descriptive study, with a quantitative approach, was carried out with 30 older users of the Family Health Strategy, selected by a non-probabilistic sample. Data were collected at home, using the following questionnaires: the mini-mental state exam, a questionnaire on sociodemographic factors, health conditions and access to services, and a questionnaire on satisfaction with Primary Health Care. Data were analyzed using descriptive statistics. Results: The satisfaction analysis showed that the elderly octogenarians are satisfied in terms of care ( X ´ = 6,0 ; ± 1,5) and the interest that community agents demonstrate in them ( X ´ = 5,9 ; ± 1,6) and the availability of nurses for their treatment ( X ´ = 5,9 ; ± 1,1). Aspects related to the waiting time for nurses ( X ´ = 4,6 ; ± 1,6) and doctors ( X ´ = 4,9 ; ± 1,6), facilities for the disabled ( X ´ = 4,6 ; ± 1,4) and the perception that the unit is close to a perfect health unit ( X ´ = 4,6 ; ± 1,8). Conclusion: The services were positively evaluated, reflecting the importance of considering the perspective of octogenarian users in the planning of healthcare actions, since the evaluation of the quality of these services can lead to changes and guide actions in a way that is coherent with the lives of users, increasing their effectiveness, especially regarding actions aimed at the octogenarian population.