Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care

How the Gender Wage Gap for Primary Care Physicians Differs by Compensation Approach : A Microsimulation Study

BACKGROUND

The physician gender wage gap may be due, in part, to productivity-based compensation models that undervalue female practice patterns.

OBJECTIVE

To determine how primary care physician (PCP) compensation by gender differs when applying existing productivity-based and alternative compensation models.

DESIGN

Microsimulation.

SETTING

2016 to 2019 national clinical registry of 1222 primary care practices.

PARTICIPANTS

Male and female PCPs matched on specialty, years since medical school graduation, practice site, and sessions worked.

MEASUREMENTS

Net annual, full-time-equivalent compensation for male versus female PCPs, under productivity-based fee-for-service, panel size-based capitation without or with risk adjustment, and hybrid payment models. Microsimulation inputs included patient and visit characteristics and overhead expenses.

RESULTS

Among 1435 matched male (n = 881) and female (n = 554) PCPs, female PCP panels included patients who were, on average, younger, had lower diagnosis-based risk scores, were more often female, and were more often uninsured or insured by Medicaid rather than by Medicare. Under productivity-based payment, female PCPs earned a median of $58 829 (interquartile range [IQR], $39 553 to $120 353; 21%) less than male PCPs. This gap was similar under capitation ($58 723 [IQR, $42 141 to $140 192]). It was larger under capitation risk-adjusted for age alone ($74 695 [IQR, $42 884 to $152 423]), for diagnosis-based scores alone ($114 792 [IQR, $49 080 to $215 326] and $89 974 [IQR, $26 175 to $173 760]), and for age-, sex-, and diagnosis-based scores ($83 438 [IQR, $28 927 to $129 414] and $66 195 [IQR, $11 899 to $96 566]). The gap was smaller and nonsignificant under capitation risk-adjusted for age and sex ($36 631 [IQR, $12 743 to $73 898]).

LIMITATION

Panel attribution based on office visits.

CONCLUSION

The gender wage gap varied by compensation model, with capitation risk-adjusted for patient age and sex resulting in a smaller gap. Future models might better align with primary care effort and outcomes.

PRIMARY FUNDING SOURCE

None.

Understanding Geographic Variation in Systemic Overuse Among the Privately Insured

BACKGROUND

Medical care overuse is a significant source of patient harm and wasteful spending. Understanding the drivers of overuse is essential to the design of effective interventions.

OBJECTIVE

We tested the association between structural factors of the health care delivery system and regional differences systemic overuse.

RESEARCH DESIGN

We conducted a retrospective analysis of deidentified claims for 18- to 64-year-old adults from the IBM MarketScan Commercial Claims and Encounters Database. We calculated a semiannual Johns Hopkins Overuse Index for each of the 375 Metropolitan Statistical Areas in the United States, from January 2011 to June 2015. We fit an ordinary least squares regression to model the Johns Hopkins Overuse Index as a function of regional characteristics of the health care system, adjusted for confounders and time.

RESULTS

The supply of regional health care resources was associated with systemic overuse in commercially insured beneficiaries. Regional characteristics associated with systemic overuse included number of physicians per 1000 residents (P=0.001) and higher Medicare malpractice geographic price cost index (P<0.001). Regions with a higher density of primary care physicians (P=0.008) and a higher proportion of hospital-based providers (P=0.016) had less systemic overuse. Differences in hospital and insurer market power were inversely associated with systemic overuse.

CONCLUSIONS

Systemic overuse is associated with observable, structural characteristics of the regional health care system. These findings suggest that interventions that aim to improve care efficiency via reductions in overuse should focus on the structural drivers of this phenomenon, rather than on the eradication of individual overused procedures.

Clinical audit as a tool to optimize contracted private healthcare provision: Testing the waters in resource-deprived Greece

BACKGROUND AND AIMS

Clinical audit is applied to optimize clinical practice and quality of healthcare services while controlling for money spent, critically in resource-deprived settings. This case study reports on the outcomes of a retrospective clinical audit on private hospitalizations, for which reimbursement had been pending by the Health Care Organization for Public Servants (OPAD) in Greece. This case study is the first effort by a social insurance organization in Greece to employ external clinical audit before settling contracted private healthcare charges.

METHODS

One thousand two hundred hospitalization records were reviewed retrospectively and a fully anonymized clinical audit summary report created for each one of them by a team of clinical audit experts, proposing evidence-based cuts in pending charges where medical services were deemed clinically unnecessary. These audit reports were then collated and analysed to test trends in overcharges among hospitalized insureds per reason for hospitalization.

RESULTS

The clinical audit report concluded that 17.4% of a total reimbursement claim of €12,387,702.18 should not be reimbursed, as it corresponded to unnecessary or not fully justifiable according to evidence-based, best practice, medical service provision. The majority of proposed cuts were related to charges for medical devices, which are borne directly by social insurance with no patient or private insurance co-payment.

CONCLUSION

Clinical audit of hospital practice may be a key tool to optimize care provision, address supplier-induced demand and effectively manage costs for national health insurance, especially in circumstances of budgetary constraints, such as in austerity-stricken settings or developing national healthcare systems.

Workforce Configurations to Provide High-Quality, Comprehensive Primary Care: a Mixed-Method Exploration of Staffing for Four Types of Primary Care Practices

BACKGROUND

Broad consensus exists about the value and principles of primary care; however, little is known about the workforce configurations required to deliver it.

OBJECTIVE

The aim of this study was to explore the team configurations and associated costs required to deliver high-quality, comprehensive primary care.

METHODS

We used a mixed-method and consensus-building process to develop staffing models based on data from 73 exemplary practices, findings from 8 site visits, and input from an expert panel. We first defined high-quality, comprehensive primary care and explicated the specific functions needed to deliver it. We translated the functions into full-time-equivalent staffing requirements for a practice serving a panel of 10,000 adults and then revised the models to reflect the divergent needs of practices serving older adults, patients with higher social needs, and a rural community. Finally, we estimated the labor and overhead costs associated with each model.

RESULTS

A primary care practice needs a mix of 37 team members, including 8 primary care providers (PCPs), at a cost of $45 per patient per month (PPPM), to provide comprehensive primary care to a panel of 10,000 actively managed adults. A practice requires a team of 52 staff (including 12 PCPs) at $64 PPPM to care for a panel of 10,000 adults with a high proportion of older patients, and 50 staff (with 10 PCPs) at $56 PPPM for a panel of 10,000 with high social needs. In rural areas, a practice needs 22 team members (with 4 PCPs) at $46 PPPM to serve a panel of 5000 adults.

CONCLUSIONS

Our estimates provide health care decision-makers with needed guideposts for considering primary care staffing and financing and inform broader discussions on primary care innovations and the necessary resources to provide high-quality, comprehensive primary care in the USA.

Funding models and medical dominance in interdisciplinary primary care teams: qualitative evidence from three Canadian provinces

BACKGROUND

Primary care in Canada is the first point of entry for patients needing specialized services, the fundamental source of care for those living with chronic illness, and the main supplier of preventive services. Increased pressures on the system lead to changes such as an increased reliance on interdisciplinary teams, which are advocated to have numerous advantages. The functioning of teams largely depends on inter-professional relationships that can be supported or strained by the financial arrangements within teams. We assess which types of financial environments perpetuate and which reduce the challenge of medical dominance.

METHODS

Using qualitative interview data from 19 interdisciplinary teams/networks in three Canadian provinces, as well as related policy documents, we develop a typology of financial environments along two dimensions, financial hierarchy and multiplicity of funding sources. A financial hierarchy is created when the incomes of some providers are a function of the incomes of other providers. A multiplicity of funding sources is created when team funding is provided by several funders and a team faces multiple lines of accountability.

RESULTS

We argue that medical dominance is perpetuated with higher degrees of financial hierarchy and higher degrees of multiplicity. We show that the financial environments created in the three provinces have not supported a reduction in medical dominance. The longstanding Community Health Centre model, however, displays the least financial hierarchy and the least multiplicity-an environment least fertile for medical dominance.

CONCLUSIONS

The functioning of interdisciplinary primary care teams can be negatively affected by the unique positioning of the medical profession. The financial environment created for teams is an important consideration in policy development, as it plays an important role in establishing inter-professional relationships. Policies that reduce financial hierarchies and funding multiplicities are optimal in this regard.

Outcomes For High-Needs Patients: Practices With A Higher Proportion Of These Patients Have An Edge

High-value primary care for high-needs patients-those with multiple physical, mental, or behavioral health conditions-is critical to improving health system performance. However, little is known about what types of physician practices perform best for high-needs patients. We examined two scale-related characteristics that could predict how well physician practices delivered care to this population: the proportion of patients in the practice that were high-needs and practice size (number of physicians). Using four years of data on commercially insured, high-needs patients in Michigan primary care practices, we found lower spending and utilization among practices with a higher proportion of high-needs patients (more than 10 percent of the practice's panel) compared to practices with smaller proportions. Small practices (those with one or two physicians) had lower overall spending, but not less utilization, compared to large practices. However, practices with a substantial proportion of high-needs patients, as well as small practices, performed slightly worse on a composite measure of process quality than their associated reference group. Practices that treat a high proportion of high-needs patients might have structural advantages or have developed specialized approaches to serve this population. If so, this raises questions about how best to make use of this knowledge to foster high-value care for high-needs patients.

Payment and Care for Hematopoietic Cell Transplantation Patients: Toward a Specialized Medical Home for Complex Care Patients

Patient-centered medical home models are fundamental to the advanced alternative payment models defined in the Medicare Access and Children's Health Insurance Plan Reauthorization Act (MACRA). The patient-centered medical home is a model of healthcare delivery supported by alternative payment mechanisms and designed to promote coordinated medical care that is simultaneously patient-centric and population-oriented. This transformative care model requires shifting reimbursement to include a per-patient payment intended to cover services not previously reimbursed such as disease management over time. Payment is linked to quality measures, including proportion of care delivered according to predefined pathways and demonstrated impact on outcomes. Some medical homes also include opportunities for shared savings by reducing overall costs of care. Recent proposals have suggested expanding the medical home model to specialized populations with complex needs because primary care teams may not have the facilities or the requisite expertise for their unique needs. An example of a successful care model that may provide valuable lessons for those creating specialty medical home models already exists in many hematopoietic cell transplantation (HCT) centers that deliver multidisciplinary, coordinated, and highly specialized care. The integration of care delivery in HCT centers has been driven by the specialty care their patients require and by the payment methodology preferred by the commercial payers, which has included bundling of both inpatient and outpatient care in the peritransplant interval. Commercial payers identify qualified HCT centers based on accreditation status and comparative performance, enabled in part by center-level comparative performance data available within a national outcomes database mandated by the Stem Cell Therapeutic and Research Act of 2005. Standardization across centers has been facilitated via voluntary accreditation implemented by Foundation for the Accreditation of Cell Therapy. Payers have built on these community-established programs and use public outcomes and program accreditation as standards necessary for inclusion in specialty care networks and contracts. Although HCT centers have not been described as medical homes, most HCT providers have already developed the structures that address critical requirements of MACRA for medical homes.

The Collaborative Payer Provider Model Enhances Primary Care, Producing Triple Aim Plus One Outcomes: A Cohort Study

Rising health care costs are threatening the fiscal solvency of patients, employers, payers, and governments. The Collaborative Payer Provider Model (CPPM) addresses this challenge by reinventing the role of the payer into a full-service collaborative ally of the physician. From 2010 through 2014, a Medicare Advantage plan prospectively deployed the CPPM, averaging 30,561 members with costs that were 73.6% of fee-for-service (FFS) Medicare (p < 0.001). The health plan was not part of an integrated delivery system. After allocating $80 per member per month (PMPM) for primary care costs, the health plan had medical cost ratios averaging 75.1% before surplus distribution. Member benefits were the best in the market. The health plan was rated 4.5 Stars by the Centers for Medicare and Medicaid Services for years 1–4, and 5 Stars in study year 5 for quality, patient experience, access to care, and care process metrics. Primary care and specialist satisfaction were significantly better than national benchmarks. Savings resulted from shifts in spending from inpatient to outpatient settings, and from specialists to primary care physicians when appropriate. The CPPM is a scalable model that enables a win-win-win system for patients, providers, and payers.

Funding and remuneration of interdisciplinary primary care teams in Canada: a conceptual framework and application

Background

Reliance on interdisciplinary teams in the delivery of primary care is on the rise. Funding bodies strive to design financial environments that support collaboration between providers. At present, the design of financial arrangements has been fragmented and not based on evidence. The root of the problem is a lack of systematic evidence demonstrating the superiority of any particular financial arrangement, or a solid understanding of options. In this study we develop a framework for the conceptualization and analysis of financial arrangements in interdisciplinary primary care teams.

Methods

We use qualitative data from three sources: (i) interviews with 19 primary care decision makers representing 215 clinics in three Canadian provinces, (ii) a research roundtable with 14 primary care decision makers and/or researchers, and (iii) policy documents. Transcripts from interviews and the roundtable were coded thematically and a framework synthesis approach was applied.

Results

Our conceptual framework differentiates between team level funding and provider level remuneration, and characterizes the interplay and consonance between them. Particularly the notions of hierarchy, segregation, and dependence of provider incomes, and the link between funding and team activities are introduced as new clarifying concepts, and their implications explored. The framework is applied to the analysis of collaboration incentives, which appear strongest when provider incomes are interdependent, funding is linked to the team as a whole, and accountability does not have multiple lines. Emergent implementation issues discussed by respondents include: (i) centrality of budget negotiations; (ii) approaches to patient rostering; (iii) unclear funding sources for space and equipment; and (iv) challenges with community engagement. The creation of patient rosters is perceived as a surprisingly contentious issue, and the challenges of funding for space and equipment remain unresolved.

Conclusions

The development and application of a conceptual framework is an important step to the systematic study of the best performing financial models in the context of interdisciplinary primary care. The identification of optimal financial arrangements must be contextualized in terms of feasibility and the implementation environment. In general, financial hierarchy, both overt and covert, is considered a barrier to collaboration.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2290-4) contains supplementary material, which is available to authorized users.

Defining Team Effort Involved in Patient Care from the Primary Care Physician's Perspective

BACKGROUND

A better understanding of the attributes of patients who require more effort to manage may improve risk adjustment approaches and lead to more efficient resource allocation, improved patient care and health outcomes, and reduced burnout in primary care clinicians.

OBJECTIVE

To identify and characterize high-effort patients from the physician's perspective.

DESIGN

Cohort study.

PARTICIPANTS

Ninety-nine primary care physicians in an academic primary care network.

MAIN MEASURES

From a list of 100 randomly selected patients in their panels, PCPs identified patients who required a high level of team-based effort and patients they considered complex. For high-effort patients, PCPs indicated which factors influenced their decision: medical/care coordination, behavioral health, and/or socioeconomic factors. We examined differences in patient characteristics based on PCP-defined effort and complexity.

KEY RESULTS

Among 9594 eligible patients, PCPs classified 2277 (23.7 %) as high-effort and 2676 (27.9 %) as complex. Behavioral health issues were the major driver of effort in younger patients, while medical/care coordination issues predominated in older patients. Compared to low-effort patients, high-effort patients were significantly (P < 0.01 for all) more likely to have higher rates of medical (e.g. 23.2 % vs. 6.3 % for diabetes) and behavioral health problems (e.g. 9.8 % vs. 2.9 % for substance use disorder), more frequent primary care visits (10.9 vs. 6.0 visits), and higher acute care utilization rates (25.8 % vs. 7.7 % for emergency department [ED] visits and 15.0 % vs. 3.9 % for hospitalization). Almost one in five (18 %) patients who were considered high-effort were not deemed complex by the same PCPs.

CONCLUSIONS

Patients defined as high-effort by their primary care physicians, not all of whom were medically complex, appear to have a high burden of psychosocial issues that may not be accounted for in current chronic disease-focused risk adjustment approaches.

Allocation of Residency Training Positions in Spain: Contextual Effects on Specialty Preferences

In Spain's 'MIR' system, medical school graduates are ranked by their performance on a national exam and then sequentially choose from the available residency training positions. We took advantage of a unique survey of participants in the 2012 annual MIR cycle to analyze preferences under two different choice scenarios: the residency program actually chosen by each participant when it came her turn (the 'real') and the program that she would have chosen if all residency training programs had been available (the 'counterfactual'). Utilizing conditional logit models with random coefficients, we found significant differences in medical graduates' preferences between the two scenarios, particularly with respect to three specialty attributes: work hours/lifestyle, prestige among colleagues, and annual remuneration. In the counterfactual world, these attributes were valued preferentially by those nearer to the top, while in the real world, they were valued preferentially by graduates nearer to the bottom of the national ranking. Medical graduates' specialty preferences, which we conclude, are not intrinsically stable but depend critically on the 'rules of the game'. The MIR assignment system, by restricting choice, effectively creates an externality in which those at the bottom, who have fewer choices, want what those at the top already have. Copyright © 2016 John Wiley & Sons, Ltd.

The Impact of Alternative Payment in Chronically Ill and Older Patients in the Patient-centered Medical Home

BACKGROUND

Patient-centered medical home (PCMH) has gained prominence as a promising model to encourage improved primary care delivery. There is a paucity of studies that evaluate the impact of payment models in the PCMH.

OBJECTIVES

We sought to examine whether coupling coordinated, team-based care transformation plan with a novel reimbursement model affects outcomes related to expenditures and utilization.

RESEARCH DESIGN

Interrupted time-series model with a difference-in-differences approach to assess differences between intervention and control groups, across time periods attributable to PCMH transformation and/or payment change.

RESULTS

Although results were modest and mixed overall, PCMH with payment reform is associated with a reduction of $1.04 (P=0.0347) per member per month (PMPM) in pharmacy expenditures. Patients with hypertension, hyperlipidemia, diabetes, and coronary atherosclerosis enrolled in PCMH without payment reform experienced reductions in emergency department visits of 2.16 (P<0.0001), 2.42 (P<0.0001), 3.98 (P<0.0001), and 3.61 (P<0.0001) per 1000 per month. Modest increases in inpatient admission were seen among these patients in PCMH either with or without payment reform. Patients 65 and older enrolled in PMCH without payment reform experienced reductions in pharmacy expenditures $2.35 (P=0.0077) PMPM with a parallel reduction in pharmacy standardized cost of $2.81 (P=0.0174) PMPM indicative of a reduction in the intensity of drug utilization.

CONCLUSIONS

We conclude that PCMH implementation coupled with an innovative payment arrangement generated mixed results with modest improvements with respect to pharmacy expenditures, but no overall financial improvement. However, we did see improvement within specific groups, especially older patients and those with chronic conditions.

Patient-Centered Specialty Practice: Defining the Role of Specialists in Value-Based Health Care

Health care is at a crossroads and under pressure to add value by improving patient experience and health outcomes and reducing costs to the system. Efforts to improve the care model in primary care, such as the patient-centered medical home, have enjoyed some success. However, primary care accounts for only a small portion of total health-care spending, and there is a need for policies and frameworks to support high-quality, cost-efficient care in specialty practices of the medical neighborhood. The Patient-Centered Specialty Practice (PCSP) model offers ambulatory-based specialty practices one such framework, supported by a formal recognition program through the National Committee for Quality Assurance. The key elements of the PCSP model include processes to support timely access to referral requests, improved communication and coordination with patients and referring clinicians, reduced unnecessary and duplicative testing, and an emphasis on continuous measurement of quality, safety, and performance improvement for a population of patients. Evidence to support the model remains limited, and estimates of net costs and value to practices are not fully understood. The PCSP model holds promise for promoting value-based health care in specialty practices. The continued development of appropriate incentives is required to ensure widespread adoption.

What is Patient-Centered Care? A Typology of Models and Missions

Recently adopted health care practices and policies describe themselves as "patient-centered care." The meaning of the term, however, remains contested and obscure. This paper offers a typology of "patient-centered care" models that aims to contribute to greater clarity about, continuing discussion of, and further advances in patient-centered care. The paper imposes an original analytic framework on extensive material covering mostly US health care and health policy topics over several decades. It finds that four models of patient-centered care emphasize: patients versus their parts; patients versus providers; patients/providers/states versus "the system"; and patients and providers as persons. Each type is distinguishable along three dimensions: epistemological orientations, practical accommodations, and policy tools. Based on this analysis, the paper recommends that four questions be asked of any proposal that claims to provide patient-centered care: Is this care a means to an end or an end in itself? Are patients here subjects or objects? Are patients here individuals or aggregates? How do we know what patients want and need? The typology reveals that models are neither entirely compatible nor entirely incompatible and may be usefully combined in certain practices and policies. In other instances, internal contradictions may jeopardize the realization of coherent patient-centered care.

Primary Care: Medicine's Gordian Knot

Primary care is the cornerstone of effective and efficient healthcare systems. Patients prefer a trusted primary care provider to serve as the first contact for all of their healthcare questions, to help them make important health decisions, to help guide them through an expanding amount of medical information and to help coordinate their care with all other providers. Patients also prefer to establish an ongoing, continuous relationship with their primary care provider. However, fewer and fewer physicians are choosing primary care as a career, threatening the foundation of the health system. We explore the central challenges of primary care defined by work-force controversies about who can best deliver primary care. We also explore the current challenging reimbursement model for primary care that often results in fragmenting care for patients and providers. Finally, we explore new models of primary care health delivery that may serve as partial solutions to the current challenges.

Recruiting Quarterbacks: Strategies for Revitalizing Training in Primary Care Internal Medicine

Current U.S. primary care workforce shortages and trainees' declining interest in primary care residency training, especially regarding primary care internal medicine, have many parallels with circumstances in the early 1970s, when modern adult primary care first emerged. Rediscovery of the lessons learned and the solutions developed at that time and applying them to the current situation have the potential to help engage a new generation of young physicians in the primary care mission.The author compares the internal medicine residency primary care track at the University of New Mexico, described by Brislen and colleagues in this issue, with the nation's first three-year primary care internal medicine residency track introduced at Massachusetts General Hospital in 1973. Strategies for addressing the challenges of primary care practice and improving learner attitudes toward the field are discussed. The author suggests that primary care physicians should be likened to "quarterbacks" rather than "gatekeepers" or "providers" to underscore the intensity of training, level of responsibility, degree of professionalism, and amount of compensation required for this profession. The advent of multidisciplinary team practice, modern health information technology, and fundamental payment reform promises to dramatically alter the picture of primary care, restoring its standing as one of the best job descriptions in medicine.

Development and Impact of a Novel Academic Primary Care Compensation Model

BACKGROUND

Traditional productivity-based compensation models do not align well with newer population-based approaches to primary care. There are few published examples of academic general internal medicine compensation models that explicitly reward population health management, including care for patients between visits.

OBJECTIVE

To describe the development and implementation of an academic general internal medicine compensation plan based upon actual work performed, compare satisfaction across primary care specialties, and evaluate work-related outcomes.

DESIGN

Observational study.

PARTICIPANTS

Forty-seven general internists who practice in affiliated academic and community clinics.

MAIN MEASURES

Clinician satisfaction with compensation plan, workforce stability, panel data, and productivity.

KEY RESULTS

The compensation plan change was associated with higher provider satisfaction. Sixty-five percent (31/47) of participants within general internal medicine reported being satisfied or very satisfied, as compared to 24 % (22/90 participants) for family medicine and 22 % (5/23 participants) for general pediatrics (p < 0.05). In the first 4 years of the compensation plan change, no general internists left to join other local groups. General internal medicine increased its number of physicians by 19 %. The number of established general internists accepting new patients increased from 17 to 48 %, while the relative value units per full-time equivalent declined by 3 %.

CONCLUSIONS

An equitable compensation model that aligns with population management goals and work performed outside the clinical visit can lead to improved satisfaction and retention of faculty in an academic general internal medicine division, along with improved access for the patient population.

Assessment of systems for paying health care providers in Vietnam: implications for equity, efficiency and expanding effective health coverage

Provider payment arrangements are currently a core concern for Vietnam's health sector and a key lever for expanding effective coverage and improving the efficiency and equity of the health system. This study describes how different provider payment systems are designed and implemented in practice across a sample of provinces and districts in Vietnam. Key informant interviews were conducted with over 100 health policy-makers, purchasers and providers using a structured interview guide. The results of the different payment methods were scored by respondents and assessed against a set of health system performance criteria. Overall, the public health insurance agency, Vietnam Social Security (VSS), is focused on managing expenditures through a complicated set of reimbursement policies and caps, but the incentives for providers are unclear and do not consistently support Vietnam's health system objectives. The results of this study are being used by the Ministry of Health and VSS to reform the provider payment systems to be more consistent with international definitions and good practices and to better support Vietnam's health system objectives.

Health is primary: Family medicine for America's health

PURPOSE

More than a decade ago the American Academy of Family Physicians, American Academy of Family Physicians Foundation, American Board of Family Medicine, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, North American Primary Care Research Group, and Society of Teachers of Family Medicine came together in the Future of Family Medicine (FFM) to launch a series of strategic efforts to "renew the specialty to meet the needs of people and society," some of which bore important fruit. Family Medicine for America's Health was launched in 2013 to revisit the role of family medicine in view of these changes and to position family medicine with new strategic and communication plans to create better health, better health care, and lower cost for patients and communities (the Triple Aim).

METHODS

Family Medicine for America's Health was preceded and guided by the development of a family physician role definition. A consulting group facilitated systematic strategic plan development over 9 months that included key informant interviews, formal stakeholder surveys, future scenario testing, a retreat for family medicine organizations and stakeholder representatives to review strategy options, further strategy refinement, and finally a formal strategic plan with draft tactics and design for an implementation plan. A second communications consulting group surveyed diverse stakeholders in coordination with strategic planning to develop a communication plan. The American College of Osteopathic Family Physicians joined the effort, and students, residents, and young physicians were included.

RESULTS

The core strategies identified include working to ensure broad access to sustained, primary care relationships; accountability for increasing primary care value in terms of cost and quality; a commitment to helping reduce health care disparities; moving to comprehensive payment and away from fee-for-service; transformation of training; technology to support effective care; improving research underpinning primary care; and actively engaging patients, policy makers, and payers to develop an understanding of the value of primary care. The communications plan, called Health is Primary, will complement these strategies. Eight family medicine organizations have pledged nearly $20 million and committed representatives to a multiyear implementation team that will coordinate these plans in a much more systematic way than occurred with FFM.

CONCLUSIONS

Family Medicine for America's Health is a new commitment by 8 family medicine organizations to strategically align work to improve practice models, payment, technology, workforce and education, and research to support the Triple Aim. It is also a humble invitation to patients and to clinical and policy partners to collaborate in making family medicine even more effective.

Keep it simple? Predicting primary health care costs with clinical morbidity measures

Models of the determinants of individuals' primary care costs can be used to set capitation payments to providers and to test for horizontal equity. We compare the ability of eight measures of patient morbidity and multimorbidity to predict future primary care costs and examine capitation payments based on them. The measures were derived from four morbidity descriptive systems: 17 chronic diseases in the Quality and Outcomes Framework (QOF); 17 chronic diseases in the Charlson scheme; 114 Expanded Diagnosis Clusters (EDCs); and 68 Adjusted Clinical Groups (ACGs). These were applied to patient records of 86,100 individuals in 174 English practices. For a given disease description system, counts of diseases and sets of disease dummy variables had similar explanatory power. The EDC measures performed best followed by the QOF and ACG measures. The Charlson measures had the worst performance but still improved markedly on models containing only age, gender, deprivation and practice effects. Comparisons of predictive power for different morbidity measures were similar for linear and exponential models, but the relative predictive power of the models varied with the morbidity measure. Capitation payments for an individual patient vary considerably with the different morbidity measures included in the cost model. Even for the best fitting model large differences between expected cost and capitation for some types of patient suggest incentives for patient selection. Models with any of the morbidity measures show higher cost for more deprived patients but the positive effect of deprivation on cost was smaller in better fitting models.

The impact of global budgets on pharmaceutical spending and utilization: early experience from the alternative quality contract

In 2009, Blue Cross Blue Shield of Massachusetts implemented a global budget-based payment system, the Alternative Quality Contract (AQC), in which provider groups assumed accountability for spending. We investigate the impact of global budgets on the utilization of prescription drugs and related expenditures. Our analyses indicate no statistically significant evidence that the AQC reduced the use of drugs. Although the impact may change over time, early evidence suggests that it is premature to conclude that global budget systems may reduce access to medications.

Bending the cost curve? Results from a comprehensive primary care payment pilot

BACKGROUND

There is much interest in understanding how using bundled primary care payments to support a patient-centered medical home (PCMH) affects total medical costs.

RESEARCH DESIGN AND SUBJECTS

We compare 2008-2010 claims and eligibility records on about 10,000 patients in practices transforming to a PCMH and receiving risk-adjusted base payments and bonuses, with similar data on approximately 200,000 patients of nontransformed practices remaining under fee-for-service reimbursement.

METHODS

We estimate the treatment effect using difference-in-differences, controlling for trend, payer type, plan type, and fixed effects. We weight to account for partial-year eligibility, use propensity weights to address differences in exogenous variables between control and treatment patients, and use the Massachusetts Health Quality Project algorithm to assign patients to practices.

RESULTS

Estimated treatment effects are sensitive to: control variables, propensity weighting, the algorithm used to assign patients to practices, how we address differences in health risk, and whether/how we use data from enrollees who join, leave, or change practices. Unadjusted PCMH spending reductions are 1.5% in year 1 and 1.8% in year 2. With fixed patient assignment and other adjustments, medical spending in the treatment group seems to be 5.8% (P=0.20) lower in year 1 and 8.7% (P=0.14) lower in year 2 than for propensity-weighted, continuously enrolled controls; the largest proportional 2-year reduction in spending occurs in laboratory test use (16.5%, P=0.02).

CONCLUSIONS

Although estimates are imprecise because of limited data and quasi-experimental design, risk-adjusted bundled payment for primary care may have dampened spending growth in 3 practices implementing a PCMH.

A case study of a team-based, quality-focused compensation model for primary care providers

In 2011, Fairview Health Services began replacing their fee-for-service compensation model for primary care providers (PCPs), which included an annual pay-for-performance bonus, with a team-based model designed to improve quality of care, patient experience, and (eventually) cost containment. In-depth interviews and an online survey of PCPs early after implementation of the new model suggest that it quickly changed the way many PCPs practiced. Most PCPs reported a shift in orientation toward quality of care, working more collaboratively with their colleagues and focusing on their full panel of patients. The majority reported that their quality of care had improved because of the model and that their colleagues' quality had to. The comprehensive change did, however, result in lower fee-for-service billing and reductions in PCP satisfaction. While Fairview's compensation model is still a work in progress, their early experiences can provide lessons for other delivery systems seeking to reform PCP compensation.

Risk selection, risk adjustment and choice: concepts and lessons from the Americas

Interest has grown worldwide in risk adjustment and risk sharing due to their potential to contain costs, improve fairness, and reduce selection problems in health care markets. Significant steps have been made in the empirical development of risk adjustment models, and in the theoretical foundations of risk adjustment and risk sharing. This literature has often modeled the effects of risk adjustment without highlighting the institutional setting, regulations, and diverse selection problems that risk adjustment is intended to fix. Perhaps because of this, the existing literature and their recommendations for optimal risk adjustment or optimal payment systems are sometimes confusing. In this paper, we present a unified way of thinking about the organizational structure of health care systems, which enables us to focus on two key dimensions of markets that have received less attention: what choices are available that may lead to selection problems, and what financial or regulatory tools other than risk adjustment are used to influence these choices. We specifically examine the health care systems, choices, and problems in four countries: the US, Canada, Chile, and Colombia, and examine the relationship between selection-related efficiency and fairness problems and the choices that are allowed in each country, and discuss recent regulatory reforms that affect choices and selection problems. In this sample, countries and insurance programs with more choices have more selection problems.

Aligning provider incentives to improve primary healthcare delivery in the United States

BACKGROUND

The United States (US) is reforming primary care delivery systems, including the implementation of 'patient-centered medical homes.' Alignment of provider incentives with desired outcomes will likely be important to the success of these delivery system reforms.

METHODS

This critical review uses a theoretical framework from game-theory models to discuss some of the dominant primary care provider payment models and how they create 'prisoner's dilemmas' that have stalled past reform efforts. It then uses this framework to illustrate, hypothetically, how advantages from different models could be blended together to encourage cooperation and improve the quality of primary care services delivered, thus providing an escape from current prisoner's dilemmas faced by providers.

FINDINGS

Improvements in primary care delivery will largely hinge on blended payment mechanisms that can effectively combine the advantageous elements of fee-for-service, capitation, and incentive payments into a balanced equation that enables providers to escape the perverse financial incentives of current payment mechanisms and overcome collective action problems.

CONCLUSIONS

If balanced appropriately, a blend of guaranteed payment and selective incentives designed to encourage primary care providers to deliver high quality care, efficient and equitable care and to eliminate incentives towards over-servicing could reach outcomes leading to shared benefits for everyone involved.

Personalized medicine in women's obesity prevention and treatment: implications for research, policy and practice

The prevalence of obesity in America has reached epidemic proportions, and obesity among women is particularly concerning. Severe obesity (body mass index ≥35 kg m(-2) ) is more prevalent in women than men. Further, women have sex-specific risk factors that must be considered when developing preventive and therapeutic interventions. This review presents personalized medicine as a dynamic approach to obesity prevention, management and treatment for women. First, we review obesity as a complex health issue, with contributing sex-specific, demographic, psychosocial, behavioural, environmental, epigenetic and genetic/genomic risk factors. Second, we present personalized medicine as a rapidly advancing field of health care that seeks to quantify these complex risk factors to develop more targeted and effective strategies that can improve disease management and/or better minimize an individual's likelihood of developing obesity. Third, we discuss how personalized medicine can be applied in a clinical setting with current and emerging tools, including health risk assessments, personalized health plans, and strategies for increasing patient engagement. Finally, we discuss the need for additional research, training and policy that can enhance the practice of personalized medicine in women's obesity, including further advancements in the '-omics' sciences, physician training in personalized medicine, and additional development and standardization of innovative targeted therapies and clinical tools.

Transforming primary care: from past practice to the practice of the future

The gap between the supply of primary care physicians and the demand for primary care continues to grow. Primary care practices must find a way to increase their patient capacity without sacrificing quality of care or adding more work to already overburdened physicians. A transformed primary care practice addressing these issues must redefine the physician role such that the physician no longer sees all patients assigned to the practice but acts as a leader for a well-trained, highly functioning primary care team. The team's overall goal would be to advance the health of an entire patient panel. New payment models are among changes that will be central to this transformation.

Why pharmacists belong in the medical home

Pharmacists can affect the delivery of primary care by addressing the challenges of medication therapy management. Most office visits involve medications for chronic conditions and require assessment of medication effectiveness, the cost of therapies, and patients' adherence with medication regimens. Pharmacists are often underused in conducting these activities. They perform comprehensive therapy reviews of prescribed and self-care medications, resolve medication-related problems, optimize complex regimens, design adherence programs, and recommend cost-effective therapies. Pharmacists should play key roles as team members in medical homes, and their potential to serve effectively in this role should be evaluated as part of medical home demonstration projects.

Primary care and why it matters for U.S. health system reform

The term primary care is widely used as if it were consistently defined or well understood. In fact, neither is the case. This paper offers a definition of primary care derived from historical perspectives-from both the United States and abroad. We discuss the evidence for primary care's important functions and international experiences with primary care. We also describe how and why the United States has deviated from this fuller realization of primary care, as well as the steps needed to achieve primary care and health outcomes on a par with those of other developed countries. These include doubling primary care financing to 10-12 percent of total health care spending--a step that would be likely to pay for itself via resulting reductions in overall health spending.

Structuring payment for medical homes

Despite widespread interest in the medical home model, there has been a lack of careful assessment of alternative methods to pay practices that serve as medical homes. This paper examines four specific payment approaches: enhanced fee-for-service payments for evaluation and management; additional codes for medical home activities within fee-for-service payments; per patient per month medical home payments to augment fee-for-service visit payments; and risk-adjusted, comprehensive per patient per month payments. Payment policies selected will affect both the adoption of the model and its longer-term evaluation. Evaluations of ongoing demonstrations should focus on payment design as well as on care--and cost.

Primary care: a critical review of the evidence on quality and costs of health care

Despite contentious debate over the new national health care reform law, there is an emerging consensus that strengthening primary care will improve health outcomes and restrain the growth of health care spending. Policy discussions imply three general definitions of primary care: a specialty of medical providers, a set of functions served by a usual source of care, and an orientation of health systems. We review the empirical evidence linking each definition of primary care to health care quality, outcomes, and costs. The available evidence most directly supports initiatives to increase providers' ability to serve primary care functions and to reorient health systems to emphasize delivery of primary care.

Off the hamster wheel? Qualitative evaluation of a payment-linked patient-centered medical home (PCMH) pilot

CONTEXT

Many primary care practices are moving toward the patient-centered medical home (PCMH) model and increasingly are offering payment incentives linked to PCMH changes. Despite widespread acceptance of general PCMH concepts, there is still a pressing need to examine carefully and critically what transformation means for primary care practices and their patients and the experience of undergoing such change in a practice.

METHODS

We used a qualitative case study approach to explore the underlying dynamics of change at five practices participating in PCMH transformation efforts linked to payment reform. The evaluation consisted of structured site visits, interviews, observations, and artifact reviews followed by a structured review of transcripts and documents for patterns, themes, and insights related to PCMH implementation.

FINDINGS

We describe both the detailed components of each practice's transformation efforts and a grounded taxonomy of eight insights stemming from the experiences of these medical homes. We identified specific contextual factors related to wide variations in change tactics. We also observed widely varying approaches to catalyzing change using (or not) external consultants, specific challenges regarding health information technology implementation, team and staff role restructuring, compensation, and change fatigue, and several unexpected potential confounders or alternative explanations for practice success.

CONCLUSIONS

Our evaluation affirms the value and necessity of qualitative methods for understanding primary care practice transformation, and it should encourage ongoing and future pilots to include assessments of the PCMH change process beyond clinical markers and claims data. The results raise insights into the heterogeneity of medical home transformation, the central but complex role of payment reform in creating a space for change, the ability of small practices to achieve substantial change in a short time period, and the challenges of sustaining it.

Risk-adjusted payment and performance assessment for primary care

BACKGROUND

Many wish to change incentives for primary care practices through bundled population-based payments and substantial performance feedback and bonus payments. Recognizing patient differences in costs and outcomes is crucial, but customized risk adjustment for such purposes is underdeveloped.

RESEARCH DESIGN

Using MarketScan's claims-based data on 17.4 million commercially insured lives, we modeled bundled payment to support expected primary care activity levels (PCAL) and 9 patient outcomes for performance assessment. We evaluated models using 457,000 people assigned to 436 primary care physician panels, and among 13,000 people in a distinct multipayer medical home implementation with commercially insured, Medicare, and Medicaid patients.

METHODS

Each outcome is separately predicted from age, sex, and diagnoses. We define the PCAL outcome as a subset of all costs that proxies the bundled payment needed for comprehensive primary care. Other expected outcomes are used to establish targets against which actual performance can be fairly judged. We evaluate model performance using R(2)'s at patient and practice levels, and within policy-relevant subgroups.

RESULTS

The PCAL model explains 67% of variation in its outcome, performing well across diverse patient ages, payers, plan types, and provider specialties; it explains 72% of practice-level variation. In 9 performance measures, the outcome-specific models explain 17%-86% of variation at the practice level, often substantially outperforming a generic score like the one used for full capitation payments in Medicare: for example, with grouped R(2)'s of 47% versus 5% for predicting "prescriptions for antibiotics of concern."

CONCLUSIONS

Existing data can support the risk-adjusted bundled payment calculations and performance assessments needed to encourage desired transformations in primary care.

Time is up: increasing shadow price of time in primary-care office visits

A physician's own time is a scarce resource in primary care, and the physician must constantly evaluate the gain from spending more time with the current patient against moving to address the health-care needs of the next. We formulate and test two alternative hypotheses. The first hypothesis is based on the premise that with time so scarce, physicians equalize the marginal value of time across patients. The second, alternative hypothesis states that physicians allocate the same time to each patient, regardless of how much the patient benefits from the time at the margin. For our empirical work, we examine the presence of a sharply increasing subjective shadow price of time around the 'target' time using video recordings of 385 visits by elderly patients to their primary care physician. We structure the data at the 'topic' level and find evidence consistent with the alternative hypothesis. Specifically, time elapsed within a visit is a very strong determinant of the current topic being the 'last topic'. This finding implies the physician's shadow price of time is rising during the course of a visit. We consider whether dislodging a target-time mentality from physicians (and patients) might contribute to more productive primary care practice.

Health care spending and quality in year 1 of the alternative quality contract

BACKGROUND

In 2009, Blue Cross Blue Shield of Massachusetts (BCBS) implemented a global payment system called the Alternative Quality Contract (AQC). Provider groups in the AQC system assume accountability for spending, similar to accountable care organizations that bear financial risk. Moreover, groups are eligible to receive bonuses for quality.

METHODS

Seven provider organizations began 5-year contracts as part of the AQC system in 2009. We analyzed 2006-2009 claims for 380,142 enrollees whose primary care physicians (PCPs) were in the AQC system (intervention group) and for 1,351,446 enrollees whose PCPs were not in the system (control group). We used a propensity-weighted difference-in-differences approach, adjusting for age, sex, health status, and secular trends to isolate the treatment effect of the AQC in comparisons of spending and quality between the intervention group and the control group.

RESULTS

Average spending increased for enrollees in both the intervention and control groups in 2009, but the increase was smaller for enrollees in the intervention group--$15.51 (1.9%) less per quarter (P=0.007). Savings derived largely from shifts in outpatient care toward facilities with lower fees; from lower expenditures for procedures, imaging, and testing; and from a reduction in spending for enrollees with the highest expected spending. The AQC system was associated with an improvement in performance on measures of the quality of the management of chronic conditions in adults (P<0.001) and of pediatric care (P=0.001), but not of adult preventive care. All AQC groups met 2009 budget targets and earned surpluses. Total BCBS payments to AQC groups, including bonuses for quality, are likely to have exceeded the estimated savings in year 1.

CONCLUSIONS

The AQC system was associated with a modest slowing of spending growth and improved quality of care in 2009. Savings were achieved through changes in referral patterns rather than through changes in utilization. The long-term effect of the AQC system on spending growth depends on future budget targets and providers' ability to further improve efficiencies in practice. (Funded by the Commonwealth Fund and others.).

The case for synergy between a usual source of care and health insurance coverage

BACKGROUND

In 2010, the United States (US) passed health insurance reforms aimed at expanding coverage to the uninsured. Yet, disparities persist in access to health care services, even among the insured.

OBJECTIVE

To examine the separate and combined association between having health insurance and/or a usual source of care (USC) and self-reported receipt of health care services.

DESIGN/SETTING

Two-tailed, chi-square analyses and logistic regression models were used to analyze nationally representative pooled 2002-2007 data from the Medical Expenditure Panel Survey (MEPS).

PARTICIPANTS

US adults (≥18 years of age) in the MEPS population who had at least one health care visit and who needed any care, tests, or treatment in the past year (n = 62,067).

MAIN OUTCOME MEASURES

We assessed the likelihood of an adult reporting unmet medical needs; unmet prescription needs; a problem getting care, tests, or treatment; and delayed care based on whether each individual had health insurance, a USC, both, or neither one.

KEY RESULTS

Among adults who reported a doctor visit and a need for services in the past year, having both health insurance and a USC was associated with the lowest percentage of unmet medical needs, problems and delays in getting care while having neither one was associated with the highest unmet medical needs, problems and delays in care. After adjusting for potentially confounding covariates (age, race, ethnicity, employment, geographic residence, education, household income as a percent of federal poverty level, health status, and marital status), compared with insured adults who also had a USC, insured adults without a USC were more likely to have problems getting care, tests or treatment (adjusted relative risk [aRR] 1.27; 95% confidence interval [CI] 1.18-1.37); and also had a higher likelihood of experiencing a delay in urgent care (aRR 1.12; 95% CI 1.05-1.20).

CONCLUSIONS

Amidst ongoing health care reform, these findings suggest the important role that both health insurance coverage and a usual source of care may play in facilitating individuals' access to care.

Family medicine training--the international experience

Family medicine is undergoing dramatic transformation around the world. Its organisation, delivery, and funding are changing in profound ways. While the specifics of primary care reform vary, a common emerging strategy involves establishment of primary health care teams that provide improved access, use electronic records, are networked with other teams, and are paid using blended payment schemes. More family doctors are needed in all countries. New approaches beyond the traditional apprenticeships or residency programs will be required to meet global demand. Training of family doctors must change to prepare tomorrow's family physician for a different practice reality. Curricula are more competency-oriented, rather than time-focused. Today's trainees can anticipate a career that includes periodic reassessment of their knowledge base and competency. This article explores these trends and offers some strategies that have proved effective in various parts of the world for training increased numbers of qualified family doctors.

From volume to value: better ways to pay for health care

Payment systems for health care today are based on rewarding volume, not value for the money spent. Two proposed methods of payment, "episode-of-care payment" and "comprehensive care payment" (condition-adjusted capitation), could facilitate higher quality and lower cost by avoiding the problems of both fee-for-service payment and traditional capitation. The most appropriate payment systems for different types of patient conditions and some methods of addressing design and implementation issues are discussed. Although the new payment systems are desirable, many providers are not organized to accept or use them, so transitional approaches such as "virtual bundling," described in this paper, will be needed.

A house is not a home: keeping patients at the center of practice redesign

The "patient-centered medical home" has been promoted as an enhanced model of primary care. Based on a literature review and interviews with practicing physicians, we find that medical home advocates and physicians have somewhat different, although not necessarily inconsistent, expectations of what the medical home should accomplish-from greater responsiveness to the needs of all patients to increased focus on care management for patients with chronic conditions. As the medical home concept is further developed, it will be important to not overemphasize redesign of practices at the expense of patient-centered care, which is the hallmark of excellent primary care.

The political economy of U.S. primary care

Compelling evidence suggests that the United States lags behind other developed nations in the health of its population and the performance of its health care system, partly as a result of a decades-long decline in primary care. This paper outlines the political, economic, policy, and institutional factors behind this decline. A large-scale, multifaceted effort--a new Charter for Primary Care--is required to overcome these forces. There are grounds for optimism for the success of this effort, which is essential to achieving health outcomes and health system performance comparable to those of other industrialized nations.