The CareFirst Patient-Centered Medical Home Program: Cost and Utilization Effects in Its First Three Years

The Comprehensive Primary Care Plus Model and Health Care Spending, Service Use, and Quality

Importance

Implemented in 18 regions, Comprehensive Primary Care Plus (CPC+) was the largest US primary care delivery model ever tested. Understanding its association with health outcomes is critical in designing future transformation models.

Objective

To test whether CPC+ was associated with lower health care spending and utilization and improved quality of care.

Design, Setting, and Participants

Difference-in-differences regression models compared changes in outcomes between the year before CPC+ and 5 intervention years for Medicare fee-for-service beneficiaries attributed to CPC+ and comparison practices. Participants included 1373 track 1 (1 549 585 beneficiaries) and 1515 track 2 (5 347 499 beneficiaries) primary care practices that applied to start CPC+ in 2017 and met minimum care delivery and other eligibility requirements. Comparison groups included 5243 track 1 (5 347 499 beneficiaries) and 3783 track 2 (4 507 499 beneficiaries) practices, matched, and weighted to have similar beneficiary-, practice-, and market-level characteristics as CPC+ practices.

Interventions

Two-track design involving enhanced (higher for track 2) and alternative payments (track 2 only), care delivery requirements (greater for track 2), data feedback, learning, and health information technology support.

Main Outcomes and Measures

The prespecified primary outcome was annualized Medicare Part A and B expenditures per beneficiary per month (PBPM). Secondary outcomes included expenditure categories, utilization (eg, hospitalizations), and claims-based quality-of-care process and outcome measures (eg, recommended tests for patients with diabetes and unplanned readmissions).

Results

Among the CPC+ patients, 5% were Black, 3% were Hispanic, 87% were White, and 5% were of other races (including Asian/Other Pacific Islander and American Indian); 85% of CPC+ patients were older than 65 years and 58% were female. CPC+ was associated with no discernible changes in the total expenditures (track 1: $1.1 PBPM [90% CI, -$4.3 to $6.6], P = .74; track 2: $1.3 [90% CI, -$5 to $7.7], P = .73), and with increases in expenditures including enhanced payments (track 1: $13 [90% CI, $7 to $18], P < .001; track 2: $24 [90% CI, $18 to $31], P < .001). Among secondary outcomes, CPC+ was associated with decreases in emergency department visits starting in year 1, and in acute hospitalizations and acute inpatient expenditures in later years. Associations were more favorable for practices also participating in the Medicare Shared Savings Program and independent practices. CPC+ was not associated with meaningful changes in claims-based quality-of-care measures.

Conclusions and Relevance

Although the timing of the associations of CPC+ with reduced utilization and acute inpatient expenditures was consistent with the theory of change and early focus on episodic care management of CPC+, CPC+ was not associated with a reduction in total expenditures over 5 years. Positive interaction between CPC+ and the Shared Savings Program suggests transformation models might be more successful when provider cost-reduction incentives are aligned across specialties. Further adaptations and testing of primary care transformation models, as well as consideration of the larger context in which they operate, are needed.

Value-Based Purchasing Design And Effect: A Systematic Review And Analysis

During the past two decades in the United States, all major payer types-commercial, Medicare, Medicaid, and multipayer coalitions-have introduced value-based purchasing (VBP) contracts to reward providers for improving health care quality while reducing spending. This systematic review qualitatively characterized the financial and nonfinancial features of VBP programs and examined how such features combine to create a level of program intensity that relates to desired quality and spending outcomes. Higher-intensity VBP programs are more frequently associated with desired quality processes, utilization measures, and spending reductions than lower-intensity programs. Thus, although there may be reasons for payers and providers to opt for lower-intensity programs (for example, to increase voluntary participation), these choices apparently have consequences for spending and quality outcomes.

Who gets access to an interprofessional team-based primary care programme for patients with complex health and social needs? A cross-sectional analysis

OBJECTIVES

To determine whether a voluntary referral-based interprofessional team-based primary care programme reached its target population and to assess the representativeness of referring primary care physicians.

DESIGN

Cross-sectional analysis of administrative health data.

SETTING

Ontario, Canada.

INTERVENTION

TeamCare provides access to Community Health Centre services for patients of non-team physicians with complex health and social needs.

PARTICIPANTS

All adult patients who participated in TeamCare between 1 April 2015 and 31 March 2017 (n=1148), and as comparators, all non-referred adult patients of the primary care providers who shared patients in TeamCare (n=546 989), and a 1% random sample of the adult Ontario population (n=117 753).

RESULTS

TeamCare patients were more likely to live in lower income neighbourhoods with a higher degree of marginalisation relative to comparison groups. TeamCare patients had a higher mean number of diagnoses, higher prevalence of all chronic conditions and had more frequent encounters with the healthcare system in the year prior to participation.

CONCLUSIONS

TeamCare reached a target population and fills an important gap in the Ontario primary care landscape, serving a population of patients with complex needs that did not previously have access to interprofessional team-based care.

STRENGTHS AND LIMITATIONS

This study used population-level administrative health data. Data constraints limited the ability to identify patients referred to the programme but did not receive services, and data could not capture all relevant patient characteristics.

To What Extent Are ACO and PCMH Models Advancing the Triple Aim Objective? Implications and Considerations for Primary Care Medical Practices

Accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) have emerged to advance the health care system by achieving the Triple Aim of improving population health, reducing costs, and enhancing the patient experience. This review examines evidence regarding the relationship between these innovative care models and care outcomes, costs, and patient experiences. The 28 articles summarized in this review show that ACO and PCMH models play an important role in achieving the Triple Aim, when compared with conventional care models. However, there can be drawbacks associated with model implementation. The long-term success of these models still merits further investigation.

The Medical Home Initiative in Italy: an Analysis of Changes in Healthcare Utilization

BACKGROUND

Seventeen medical homes (MHs) were established in the Local Health Authority (LHA) of Parma (about 450,000 residents), Emilia Romagna, Italy, between 2011 and 2016.

OBJECTIVE

To estimate the effects of MH implementation on healthcare utilization.

DESIGN

We conducted a longitudinal cohort study (01/2011-12/2017) using the Parma LHA administrative healthcare database.

PARTICIPANTS

Residents for ≥1 year and older than 14 years of age with a documented primary care physician (PCP) in Parma LHA.

INTERVENTION

MH exposure status was classified for each resident as either receiving care from a PCP that (1) eventually practices in an MH (pre-MH), (2) is currently in an MH (post-MH), or (3) does not join an MH (non-MH).

MAIN OUTCOME MEASURES

Risks of ordinary inpatient hospital admissions, day hospital admissions, admissions for ambulatory care sensitive conditions (ACSCs), all-cause emergency department (ED) visits, and deferrable ED visits were compared using Cox proportional hazards regression and risks of all-cause 30- and 90-day readmissions for congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD) were compared using logistic regression.

KEY RESULTS

Prior to MH implementation, the risk of all-cause ED visits for pre-MH residents was 0.93 (95% CI: 0.92-0.94) that of non-MH residents. After MH implementation, the relative risk for post-MH versus non-MH was 0.86 (95% CI: 0.85-0.87) and, over time, post-MH versus pre-MH was 0.93 (95% CI: 0.92-0.94). Hospitalization risks were generally lower among the pre-MH and post-MH, compared to non-MH. However, hospitalizations and HF or COPD readmissions were not generally lower post-MH compared to pre-MH.

CONCLUSIONS

This MH initiative was associated with a 7% reduction in risk of ED visits. More research is necessary to understand if ED visit risk will continue to improve and how other aspects of healthcare utilization might change as more MHs open and the length of exposure to MHs increases.

Impact of a Statewide Multi-Payer Patient-Centered Medical Home Program on Antihypertensive Medication Adherence

Evidence suggests that the patient-centered medical home (PCMH) model of primary care improves management of chronic disease, but there is limited research contrasting this model's effect when financed by a single payer versus multiple payers, and among patients with different types of health insurance. This study evaluates the impact of a statewide medical home demonstration, the Maryland Multi-Payer PCMH Program (MMPP), on adherence to antihypertensive medication therapy relative to non-PCMH primary care and to the PCMH model when financed by a single payer. The authors used a difference-in-differences analytic design to analyze changes in medication possession ratio for antihypertensive medications among Medicaid-insured and privately insured non-elderly adult patients attributed to primary care practices in the MMPP ("multi-payer PCMHs"), medical homes in Maryland that participated in a regional PCMH program funded by a single private payer ("single-payer PCMHs"), and non-PCMH practices in Maryland. Comparison sites were matched to multi-payer PCMHs using propensity scores based on practice characteristics, location, and aggregated provider characteristics. Multi-payer PCMHs performed better on antihypertensive medication adherence for both Medicaid-insured and privately insured patients relative to single-payer PCMHs. Statistically significant effects were not observed consistently until the second year of the demonstration. There were negligible differences in outcome trends between multi-payer medical homes and matched non-PCMH practices. Findings indicate that health care delivery innovations may yield superior population health outcomes under multi-payer financing compared to when such initiatives are financed by a single payer.

Comparative Effectiveness of a Complex Care Program for High-Cost/High-Need Patients: a Retrospective Cohort Study

BACKGROUND

High-cost/high-need (HCHN) adults and the healthcare systems that provide their care may benefit from a new patient-centered model of care involving a dedicated physician and nurse team who coordinate both clinical and social services for a small patient panel.

OBJECTIVE

Evaluate the impact of a Complex Care Program (CCP) on likelihood of patient survival and hospital admission in 180 days following empanelment to the CCP.

DESIGN

Retrospective cohort study using a quasi-experimental design with CCP patients propensity score matched to a concurrent control group of eligible but unempaneled patients.

SETTING

Kaiser Permanente Mid-Atlantic States (KPMAS) during 2017-2018.

PARTICIPANTS

Nine hundred twenty-nine CCP patients empaneled January 2017-June 2018, 929 matched control patients for the same period.

INTERVENTIONS

The KPMAS CCP is a new program consisting of 8 teams each staffed by a physician and nurse who coordinate care across a continuum of specialty care, tertiary care, and community services for a panel of 200 patients with advanced clinical disease and recent hospitalizations.

MAIN OUTCOMES

Time to death and time to first hospital admission in the 180 days following empanelment or eligibility.

RESULTS

Compared to matched control patients, CCP patients had prolonged time to death (hazard ratio [HR]: 0.577, 95% CI: 0.474, 0.704), and CCP decedents had longer survival (median days 69.5 vs. 53.0, p=0.03). CCP patients had similar time to hospital admission (HR: 1.081, 95% CI: 0.930, 1.258), with similar results when adjusting for competing risk of death (HR: 1.062, 95% CI: 0.914, 1.084).

LIMITATIONS

Non-randomized intervention; single healthcare system; patient eligibility limited to specific conditions.

CONCLUSION

The KPMAS CCP was associated with significantly reduced short-term mortality risk for eligible patients who volunteered to participate in this intervention.

Reducing Emergency Department Visits Among Patients With Diabetes by Embedding Clinical Pharmacists in the Primary Care Teams

BACKGROUND

Pharmacists are effective at improving control of cardiovascular risk factors, but it less clear whether these improvements translate into less emergency department (ED) use and fewer hospitalizations. The UCMyRx program embed pharmacists in primary care.

OBJECTIVE

The objective of this study was to examine if the integration of pharmacists into primary care was associated with lower ED and hospital use for patients with diabetes.

DESIGN

This was a quasi-experimental study with a comparator group.

SUBJECTS

The analytic sample included patients with diabetes with uncontrolled cardiovascular risk factors (A1C >9%, blood pressure >140/90 mm Hg, low-density lipoprotein-cholesterol >130 mg/dL) who had 1 or more visits in either a UCMyRx (648 patients, 14 practices) or usual care practice (1944 patients, 14 practices).

MEASURES

Our outcomes were ED and hospitalization rates as measured before and after the consultations between UCMyRx and usual care. Our predictor variable was the pharmacist consultation. Poisson generalized estimating equations model was used to estimate the adjusted predicted change in utilization before and after the pharmacist consultation. The Average Treatment Effect on the Treated was estimated.

RESULTS

In models adjusted, the adjusted mean predicted number of emergency department visits/month during the year before the consultation was 0.09 among UCMyRx patients. During the year after initiating the care with the pharmacists, this rate decreased to an adjusted mean monthly rate of 0.07, with an Average Treatment Effect on the Treated=0.021 (P=0.035), a predicted reduction of 21% in emergency department visits associated with the clinical pharmacist consults. There was a nonsignificant predicted 3.2% reduction in hospitalizations over time for patients in the UCMyRx program.

CONCLUSION

Clinical pharmacists are an important addition to clinical care teams in primary care practices and significantly decreased utilization of the ED among patients with poorly controlled diabetes.

Quality of Care and Preventive Screening Use in the CareFirst Patient-Centered Medical Home Program

Despite their value, comprehensive diabetes care and screening for common cancers remain underutilized. We examined the association between participation in a patient-centered medical home (PCMH) program with strong financial incentives and receipt of preventive care in the first 5 years after program launch. Using multivariate regression analysis, we compared outcomes for adults under the care of participating primary care providers (PCPs) with adults under the care of nonparticipating PCPs. Outcomes were breast, cervical and colorectal cancer screenings, and elements of diabetes care. The analytic sample included 818,623 adults living in Maryland, Virginia, or the District of Columbia, and enrolled with CareFirst for at least 1 year during 2010-2015. By Year 5, enrollees in the intervention group were 7.9 (95% confidence interval [CI]: 2.8-13.0), 6.1 (95% CI: 1.4-10.7), 3.1 (95% CI: 2.1-4.0), and 7.6 (95% CI: 7.0-8.2) percentage points more likely to undergo HbA1c tests, nephropathy examinations, breast, and cervical cancer screenings, respectively. We found no significant change in the propensity to receive colorectal cancer screening or an eye examination. Our study shows that a PCMH program with strong financial incentives can raise the provision of preventive care but could require additional adjustment.

Impact of Healthcare Delivery System Type on Clinical, Utilization, and Cost Outcomes of Patient-Centered Medical Homes: a Systematic Review

BACKGROUND

As healthcare reimbursement shifts from being volume to value-focused, new delivery models aim to coordinate care and improve quality. The patient-centered medical home (PCMH) model is one such model that aims to deliver coordinated, accessible healthcare to improve outcomes and decrease costs. It is unclear how the types of delivery systems in which PCMHs operate differentially impact outcomes. We aim to describe economic, utilization, quality, clinical, and patient satisfaction outcomes resulting from PCMH interventions operating within integrated delivery and finance systems (IDFS), government systems including Veterans Administration, and non-integrated delivery systems.

METHODS

We searched PubMed, the Cochrane Library, and Embase from 2004 to 2017. Observational studies and clinical trials occurring within the USA that met PCMH criteria (as defined by the Agency for Healthcare Research and Quality), addressed ambulatory adults, and reported utilization, economic, clinical, processes and quality of care, or patient satisfaction outcomes.

RESULTS

Sixty-four studies were included. Twenty-four percent were within IDFS, 29% were within government systems, and 47% were within non-IDFS. IDFS studies reported decreased emergency department use, primary care use, and cost relative to other systems after PCMH implementation. Government systems reported increased primary care use relative to other systems after PCMH implementation. Clinical outcomes, processes and quality of care, and patient satisfaction were assessed heterogeneously or infrequently.

DISCUSSION

Published articles assessing PCMH interventions generally report improved outcomes related to utilization and cost. IDFS and government systems exhibit different outcomes relative to non-integrated systems, demonstrating that different health systems and populations may be particularly sensitive to PCMH interventions. Both the definition of PCMH interventions and outcomes measured are heterogeneous, limiting the ability to perform direct comparisons or meta-analysis.

Care Experiences of Patients with Multiple Chronic Conditions in a Payer-Based Patient-Centered Medical Home

Individuals with multiple chronic health conditions require additional support and medical services, incur higher health care costs, and often have a higher risk of hospitalization. The goal of this study was to examine care experiences of patients with multiple chronic conditions in the CareFirst patient-centered medical home (PCMH). The study used a repeated cross-sectional research design and included 1308 adult CareFirst plan members with multiple chronic conditions. Patient care experiences were collected using a structured telephone survey in 2015 and 2017. Composite scores and individual question responses for patient-provider communication, coordination of care, access to care, and self-management support were analyzed to determine differences between survey years. Overall, patients reported positive care experiences with communication, self-management support, and care coordination. Access to care indicators received lower composite scores. Between 2015 and 2017, patients reported higher ratings for appointment reminders, communicating test results, providers listening carefully, and care plan effectiveness. Patients who completed their CareFirst PCMH care plan had higher care experience scores than patients who did not. A key finding of this study is that care plan completion is associated with positive care experiences, indicating the importance of the care plan to this PCMH model. Lower scores on access to care measures suggest a need for improved pathways for patients to obtain care during nontraditional office hours. Payer-based PCMH models that include enhanced care coordination and additional provider payments to support these activities may be beneficial to patients with multiple chronic conditions.

Provider Experiences with a Payer-Based PCMH Program

BACKGROUND

The patient-centered medical home (PCMH) is an enhanced primary care model that aims to improve quality of care. Over the past several years, the PCMH model has been adopted by Medicare and private payers, which offer financial resources and technical assistance to participating practices. However, few studies have examined provider experiences and perspectives on the adoption of payer-based PCMH models in different practice settings.

OBJECTIVE

The goal of this qualitative study was to analyze how providers experienced specific elements of a payer-based PCMH model and identify cross-cutting themes that can be applied to other payer-based PCMH initiatives.

DESIGN

Observational qualitative study.

PARTICIPANTS

A total of 65 individuals (which includes 57 primary care physicians) participated in focus group sessions. Telephone interviews were conducted with an additional 14 physicians and 2 practice administrators.

APPROACH

Interviews and focus groups were recorded after obtaining the informed consent of participants. Written transcripts from the recordings were then imported into NVivo 11 for subsequent coding and qualitative analysis of themes.

KEY RESULTS

We found that nurse care coordinators (NCCs) were the single most valuable and visible program element. Individual care plans served as effective tools of communication between the NCC and physician on patient care management goals and issues. The online data portal was viewed as the least valuable element. With regard to cross-cutting themes, some providers expressed a strained relationship with CareFirst due to communication challenges, a lack of trust, and differing priorities in selecting patients for care plans.

CONCLUSION

Nurse care coordinators and the targeted use of individualized care plans are essential components in a payer-based PCMH program. Improving communication and trust in data reports are critical for effective implementation. Future research should examine provider experiences in other payer-based PCMH programs to see how interactions with payers affect program implementation.

The Impact of Rhode Island's Multipayer Patient-centered Medical Home Program on Utilization and Cost of Care

OBJECTIVE

To estimate the effect of patient-centered medical home (PCMH) participation on cost and utilization of care for patients in Rhode Island's statewide, multipayer PCMH program, which serves over one-third of the state population.

DATA SOURCES/STUDY SETTING

2009-2014 claims data from all payers in Rhode Island, representing >743,000 unique patients.

STUDY DESIGN

A propensity score-matched difference-in-differences framework was used to separately estimate the effect of the PCMH on 3 patient cohorts, which were defined by their intervention start dates and amounts of implementation time. Outcomes included patient costs (total, inpatient, outpatient, professional, pharmacy) and utilization [emergency department (ED) visits, preventable ED visits, inpatient admissions, preventable inpatient admissions, all-cause 30-day readmissions]. Interaction effects were estimated to assess heterogeneity among clinical risk groups and payers.

PRINCIPAL FINDINGS

There was no evidence of a PCMH effect on total costs, though we observed evidence of an increase in the odds of PCMH patients having outpatient and professional costs, and in one cohort, a decrease in inpatient costs for those with an inpatient visit. We also observed evidence of reduced ED visits, preventable ED visits, and inpatient admissions for PCMH patients. While subgroup effects varied by cohort and measure, high-risk patients often experienced the largest reductions in ED visits.

CONCLUSIONS

All PCMH cohorts experienced statistically significant reductions in some types of utilization in as little as 1.25 years. Reductions were greatest for measures included in the PCMH contractual agreement. While PCMH programs may not expect cost savings in the short-term, costs could potentially be reduced in the longer-term through avoided ED and inpatient expenses.

Offsetting Patient-Centered Medical Homes Investment Costs Through Per-Member-Per-Month or Medicare Merit-based Incentive Payment System Incentive Payments

Primary care practices become patient-centered medical homes (PCMHs) to improve care. However, investment costs and opportunities to offset those costs are critical to the decision. We examined potential offsets through commercial payer per-member-per-month (PMPM) payments and the Medicare Merit-based Incentive Payment System (MIPS) for a network that spent $4 818 260 over 4 years obtaining and renewing PCMH recognition for 57 practices. With PMPM payments of $3.37 to $8.98, "breakeven" requires that 2.4% to 6.4% of the network's 1645 commercially insured patients per physician be covered, while applying MIPS incentive payments of half the maximum available each year to the network's average 2016 Medicare reimbursement of $196 812 per physician showed they would exceed PCMH costs by 2022.

Payment Reform, Medication Use, and Costs: Can We Afford to Leave Out Drugs?

Medications are one of the fastest growing sources of costs in the health system and the cornerstone of disease management. Despite extensive attention around drug pricing, medications have largely been excluded from CMS-derived, value-based payment models. In this perspective, we synthesize evidence about the impact of three prominent models-primary care-based redesign, ACOs, and bundled payment programs-on medication use, adherence, and costs. We also examine the literature describing similar models implemented by private payors and their relationship with medication use and costs. The exclusion of drug costs from payment reform model design has led to missed opportunities for payors and providers to prioritize effective medication management strategies and has limited our learning about the effects on cost and quality. New CMS-based models are starting to allow greater flexibility in pharmacy benefit design and reward improved medication therapy management. Additionally, health plans, pharmacies, and pharmacy benefit managers are beginning to partner on collaborative value-based pharmacy initiatives. Taken together, these efforts encourage a paradigm shift around drug cost management that more deeply integrates pharmacy into payment and delivery reform with the goal of improving quality and reducing the total cost of care.

Key Design Considerations When Calculating Cost Savings for Population Health Management Programs in an Observational Setting

OBJECTIVE

To illustrate the impact of key quasi-experimental design elements on cost savings measurement for population health management (PHM) programs.

DATA SOURCES

Population health management program records and Medicaid claims and enrollment data from December 2011 through March 2016.

STUDY DESIGN

The study uses a difference-in-difference design to compare changes in cost and utilization outcomes between program participants and propensity score-matched nonparticipants. Comparisons of measured savings are made based on (1) stable versus dynamic population enrollment and (2) all eligible versus enrolled-only participant definitions. Options for the operationalization of time are also discussed.

DATA COLLECTION/EXTRACTION METHODS

Individual-level Medicaid administrative and claims data and PHM program records are used to match study groups on baseline risk factors and assess changes in costs and utilization.

PRINCIPAL FINDINGS

Savings estimates are statistically similar but smaller in magnitude when eliminating variability based on duration of population enrollment and when evaluating program impact on the entire target population. Measurement in calendar time, when possible, simplifies interpretability.

CONCLUSION

Program evaluation design elements, including population stability and participant definitions, can influence the estimated magnitude of program savings for the payer and should be considered carefully. Time specifications can also affect interpretability and usefulness.

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

Background

The NHS policy of constructing multispecialty community providers (MCPs) rests on a complex set of assumptions about how health systems can replace hospital use with enhanced primary care for people with complex, chronic or multiple health problems, while contributing savings to health-care budgets.

Objectives

To use policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and to compare this with published secondary evidence and revise the programme theory accordingly.

Design

Realist synthesis with a three-stage method: (1) for policy documents, elicit the IPT underlying the MCP policy, (2) review and synthesise secondary evidence relevant to those assumptions and (3) compare the programme theory with the secondary evidence and, when necessary, reformulate the programme theory in a more evidence-based way.

Data sources

Systematic searches and data extraction using (1) the Health Management Information Consortium (HMIC) database for policy statements and (2) topically appropriate databases, including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Applied Social Sciences Index and Abstracts (ASSIA). A total of 1319 titles and abstracts were reviewed in two rounds and 116 were selected for full-text data extraction. We extracted data using a formal data extraction tool and synthesised them using a framework reflecting the main policy assumptions.

Results

The IPT of MCPs contained 28 interconnected context–mechanism–outcome relationships. Few policy statements specified what contexts the policy mechanisms required. We found strong evidence supporting the IPT assumptions concerning organisational culture, interorganisational network management, multidisciplinary teams (MDTs), the uses and effects of health information technology (HIT) in MCP-like settings, planned referral networks, care planning for individual patients and the diversion of patients from inpatient to primary care. The evidence was weaker, or mixed (supporting some of the constituent assumptions but not others), concerning voluntary sector involvement, the effects of preventative care on hospital admissions and patient experience, planned referral networks and demand management systems. The evidence about the effects of referral reductions on costs was equivocal. We found no studies confirming that the development of preventative care would reduce demands on inpatient services. The IPT had overlooked certain mechanisms relevant to MCPs, mostly concerning MDTs and the uses of HITs.

Limitations

The studies reviewed were limited to Organisation for Economic Co-operation and Development countries and, because of the large amount of published material, the period 2014–16, assuming that later studies, especially systematic reviews, already include important earlier findings. No empirical studies of MCPs yet existed.

Conclusions

Multidisciplinary teams are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. Further primary research would be required to test elements of the revised logic model, in particular about (1) how MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks and (2) under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience.

Study registration

This study is registered as PROSPERO CRD42016038900.

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery Research programme and supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Maryland Multipayor Patient-centered Medical Home Program: A 4-Year Quasiexperimental Evaluation of Quality, Utilization, Patient Satisfaction, and Provider Perceptions

OBJECTIVE

To evaluate impact of the Maryland Multipayor Patient-centered Medical Home Program (MMPP) on: (1) quality, utilization, and costs of care; (2) beneficiaries' experiences and satisfaction with care; and (3) perceptions of providers.

DESIGN

4-year quasiexperimental design with a difference-in-differences analytic approach to compare changes in outcomes between MMPP practices and propensity score-matched comparisons; pre-post design for patient-reported outcomes among MMPP beneficiaries.

SUBJECTS

Beneficiaries (Medicaid-insured and privately insured) and providers in 52 MMPP practices and 104 matched comparisons in Maryland.

INTERVENTION

Participating practices received unconditional financial support and coaching to facilitate functioning as medical homes, membership in a learning collaborative to promote education and dissemination of best practices, and performance-based payments.

MEASURES

Sixteen quality, 20 utilization, and 13 cost measures from administrative data; patient-reported outcomes on care delivery, trust in provider, access to care, and chronic illness management; and provider perceptions of team operation, team culture, satisfaction with care provided, and patient-centered medical home transformation.

RESULTS

The MMPP had mixed impact on site-level quality and utilization measures. Participation was significantly associated with lower inpatient and outpatient payments in the first year among privately insured beneficiaries, and for the entire duration among Medicaid beneficiaries. There was indication that MMPP practices shifted responsibility for certain administrative tasks from clinicians to medical assistants or care managers. The program had limited effect on measures of patient satisfaction (although response rates were low) and on provider perceptions.

CONCLUSIONS

The MMPP demonstrated mixed results of its impact and indicated differential program effects for privately insured and Medicaid beneficiaries.

Navigating payer heterogeneity in the United States: lessons for primary care

With most providers accepting private and public funding, the US exemplifies hybridization, which results in both systemic benefits and harms. While this practice stimulates innovation, encourages practices to be efficient, and increases choice, it has also been linked to gaps in patient safety and overtreatment. We propose three lessons from the US for navigating a public and private system: hybridization allows for innovation; hybridization leads to administrative complexity; and if the costs of participation outweigh the benefits, practices may undergo dehybridization.

Association Between Extending CareFirst's Medical Home Program to Medicare Patients and Quality of Care, Utilization, and Spending

Importance

CareFirst, the largest commercial insurer in the mid-Atlantic Region of the United States, runs a medical home program focusing on financial incentives for primary care practices and care coordination for high-risk patients. From 2013 to 2015, CareFirst extended the program to Medicare fee-for-service (FFS) beneficiaries in participating practices. If the model extension improved quality while reducing spending, the Centers for Medicare and Medicaid Services could expand the program to Medicare beneficiaries broadly.

Objective

To test whether extending CareFirst's program to Medicare FFS patients improves care processes and reduces hospitalizations, emergency department visits, and spending.

Design, Setting, and Participants

This difference-in-differences analysis compared outcomes for roughly 35 000 Medicare FFS patients attributed to 52 intervention practices (grouped by CareFirst into 14 "medical panels") to outcomes for 69 000 Medicare patients attributed to 42 matched comparison panels during a 1-year baseline period and 2.5-year intervention at Maryland primary care practices.

Main Outcomes and Measures

Hospitalizations (all-cause and ambulatory-care sensitive), emergency department visits, Medicare Part A and B spending, and 3 quality-of-care process measures: ambulatory care within 14 days of a hospital stay, cholesterol testing for those with ischemic vascular disease, and a composite measure for those with diabetes.

Interventions

CareFirst hired nurses who worked with patients' usual primary care practitioners to coordinate care for 3656 high-risk Medicare patients. CareFirst paid panels rewards for meeting cost and quality targets for their Medicare patients and advised panels on how to meet these targets based on analyses of claims data.

Results

On average, each of the 14 intervention panels had 9.3 primary care practitioners and was attributed 2202 Medicare FFS patients in the baseline period. The panels' attributed Medicare patients were, on average, 73.8 years old, 59.2% female, and 85.1% white. The extension of CareFirst's program to Medicare patients was not statistically associated with improvements in any outcomes, either for the full Medicare population or for a high-risk subgroup in which impacts were expected to be largest. For the full population, the difference-in-differences estimates were 1.4 hospitalizations per 1000 patients per quarter (P = .54; 90% CI, -2.1 to 5.0), -2.5 outpatient ED visits per 1000 patients per quarter (P = .26; 90% CI, -6.2 to 1.1), and -$1 per patient per month in Medicare Part A and B spending (P = .98; 90% CI, -$40 to $39). For hospitalizations and Medicare spending, the 90% CIs did not span CareFirst's expected impacts. Hospitalizations for the intervention group declined by 10% from baseline year to the final 18 months of the intervention, but this was matched by similar declines in the comparison group.

Conclusion and Relevance

The extension of CareFirst's program to Medicare did not measurably improve quality-of-care processes or reduce service use or spending for Medicare patients. Further program refinement and testing would be needed to support scaling the program more broadly to Medicare patients.

Using Statewide Data on Health Care Quality to Assess the Effect of a Patient-Centered Medical Home Initiative on Quality of Care

Patient-centered medical homes comprise a large portion of modern health care redesign. However, most efforts have reflected rigid, limited models of transformation. In addition, evaluations of their impact on quality of care have relied on data designed for other purposes. Minnesota's Health Care Home (HCH) initiative is a statewide medical home model relying on state-run, adaptive certification and supportive data infrastructure. This longitudinal study leverages a unique statewide system of clinic-reported, patient-level quality data (2010-2013) to assess the effect of being in a HCH clinic on health care quality. Measures included optimal quality (meeting all targets) and average quality (number of targets met) for asthma, vascular, and diabetes care; colorectal cancer screening; depression follow-up; and depression remission. Depending on measure and year, the analytic sample included 246,023 - 3,335,994 child and adult patients in 404-651 clinics. Using endogenous treatment effects models to address endogeneity, and including patient- and clinic-level covariates and clinic-level selection bias corrections, the authors produced potential outcomes means and average treatment effects (ATEs). HCH patients received better quality versus non-HCH patients for most outcomes. For example, the adjusted rate receiving optimal diabetes care was 453.7/1000 adult HCH patients versus 327.2/1000 non-HCH adult patients (ATE = 126.5; P < .001). By contrast, depression remission showed no HCH-related benefit. Findings on average care quality generally echoed optimal care findings. These findings indicate the usefulness of statewide quality data and support the effectiveness of adaptive, state-run medical home programs. Additional integration of services may be needed for mental health conditions.