Health care savings with the patient-centered medical home: Community Care of North Carolina's experience

Opioid Use Among Children and Adults With Sickle Cell Disease in North Carolina Medicaid Enrollees in the Era of Opioid Harm Reduction

Adults and children with sickle cell disease (SCD) are predominantly African American, with pain-related health disparities. We examined opioid prescription fill patterns in adults and children with SCD and compared factors associated with fills in North Carolina Medicaid enrollees. Our retrospective cohort study included 955 enrollees diagnosed with SCD having at least one opioid fill. Associations were measured between two cohorts (12 and 24 mo of continuous enrollment) for the following characteristics: sex, age, enrollee residence, hydroxyurea adherence, comanagement, enrollment in Community Care North Carolina, prescription for short versus short and long-acting opioids, and emergency department reliance. The majority of individuals did not have an opioid claim over a 12 or 24-month period. Claims increased at ages 10 to 17, peaking at ages 18 to 30. The increased number of claims was associated with the following factors: increasing age, male, short versus long-acting opioids, and Medicaid enrollment for 24 versus 12 months. Community Care North Carolina enrollees in the 12-month cohort had higher opioid days of supply per month; the inverse was true of the 24-month cohort.

Revitalizing Primary Care, Part 2: Hopes for the Future

Part 1 of this essay argued that the root causes of primary care's problems lie in (1) the low percent of national health expenditures dedicated to primary care and (2) overly large patient panels that clinicians without a team are unable to manage, leading to widespread burnout and poor patient access. Part 2 explores policies and practice changes that could solve or mitigate these primary care problems.Initiatives attempting to improve primary care are discussed. Diffuse multi-component initiatives-patient-centered medical homes (PCMHs), accountable care organizations (ACOs), and Comprehensive Primary Care Plus (CPC+)-have had limited success in addressing primary care's core problems. More focused initiatives-care management, open access, and telehealth-offer more promise.To truly revitalize primary care, 2 fundamental changes are needed: (1) a substantially greater percent of health expenditures dedicated to primary care, and (2) the building of powerful teams that add capacity to care for large panels while reducing burnout.Part 2 of the essay reviews 3 approaches to increasing primary care spending: state-level legislation, eliminating Medicare's disparity between primary care and procedural specialty reimbursement, and efforts by health systems. The final section of Part 2 addresses the building of powerful core and interprofessional teams.

Dissemination of Evidence-Based Recommendations for Sickle Cell Disease to Primary Care and Emergency Department Providers in North Carolina: A Cost Benefit Analysis

Background: Sickle cell disease (SCD) is a genetic condition affecting primarily individuals of African descent, who happen to be disproportionately impacted by poverty and who lack access to health care. Individuals with SCD are at high likelihood of high acute care utilization and chronic pain episodes. The multiple complications seen in SCD contribute to significant morbidity and premature mortality, as well as substantial costs to the healthcare system. Objectives: SCD is a complex chronic disease resulting in the need for primary, specialty and emergency care. Many providers do not feel prepared to care for individuals with SCD, despite the existence of evidence-based guidelines. We report the development of a SCD toolbox and the dissemination process to primary care and emergency department (ED) providers in North Carolina (NC). We report the effect of this dissemination on health-care utilization, cost of care, and overall cost-benefit. Methods: The SCD toolbox was adapted from the National Heart, Lung, and Blood Institute recommendations. Toolbox training was provided to quality improvement specialists who then disseminated the toolbox to primary care providers (PCPs) affiliated with the only NC managed care coordination system and ED providers. Tools were made available in paper, online, and in app formats to participating managed care network practices (n=1 800). Medicaid claims data were analyzed for total costs and benefits of the toolbox dissemination for a 24-month pre- and 18-month post-intervention period. Results: There was no statistically significant shift in the number of outpatient specialty visits, ED visits or hospitalizations. There was a small decrease in the number of PCP visits in the post-implementation period. The dissemination resulted in a net cost-savings of $361 414 ($14.03 per-enrollee per-month on average). However, the estimated financial benefit associated with the dissemination of the SCD toolbox was not statistically significant. Conclusions: Although we did not find the expected shift to increased PCP visits and decreased ED visits and hospitalizations, there were many lessons learned.

Effect of the Patient-Centered Medical Home on Racial Disparities in Quality of Care

BACKGROUND

Research demonstrates that the patient-centered medical home (PCMH) is associated with improved clinical outcomes and quality of care, and the populations that can most benefit from this model require long-term management, e.g., persons with chronic illness and behavioral health conditions. However, different populations may not benefit equally from the PCMH, and empirical evidence about the effects of this model on racial disparities is limited.

OBJECTIVE

Estimate the association between enrollment in National Committee for Quality Assurance (NCQA)-recognized PCMHs and racial disparities in quality of care for adults with major depressive disorder (MDD) and comorbid medical conditions.

DESIGN

Applying a quasi-experimental instrumental variable design to account for differential selection into the PCMH, we used generalized estimating equations to determine the probability of receiving eight disease-specific quality measures.

SUBJECTS

Medicaid enrollees in three states not dually enrolled in Medicare, ages 18-64 with MDD and > 1 other chronic condition. A subgroup analysis was conducted for enrollees with comorbid diabetes.

INTERVENTIONS

Enrollment in an NCQA-recognized PCMH.

MAIN MEASURES

Disease-specific quality indicators for MDD (e.g., antidepressant use, receipt of psychotherapy), and for diabetes, (e.g. A1c testing, LDL-C testing, retinal exams, and medical attention for nephropathy).

KEY RESULTS

PCMH enrollment was associated with an increase in the overall likelihood of receiving six of eight recommended services and a decrease in the likelihood of receiving any psychotherapy (4.94 percentage points, p < 0.01) and retinal exams (5.51 percentage points, p < 0.05). Although both groups improved, PCMH enrollment was associated with an exacerbation of the Black-white disparity in adequate antidepressant use by 4.20 percentage points (p < 0.01).

CONCLUSIONS

While PCMH enrollment may improve the overall quality of care, the effect is inconsistent across racial groups and not always associated with reductions in racial disparities in quality.

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.

Do Medical Homes Improve Quality of Care for Persons with Multiple Chronic Conditions?

OBJECTIVE

To examine the association between medical home enrollment and receipt of recommended care for Medicaid beneficiaries with multiple chronic conditions (MCC).

DATA SOURCES/STUDY SETTING

Secondary claims data from fiscal years 2008-2010. The sample included nonelderly Medicaid beneficiaries with at least two of eight target conditions (asthma, chronic obstructive pulmonary disease, diabetes, hypertension, hyperlipidemia, seizure disorder, major depressive disorder, and schizophrenia).

STUDY DESIGN

We used linear probability models with person- and year-level fixed effects to examine the association between patient-centered medical home (PCMH) enrollment and nine disease-specific quality-of-care metrics, controlling for selection bias and time-invariant differences between enrollees.

DATA COLLECTION METHODS

This study uses a dataset that links Medicaid claims with other administrative data sources.

PRINCIPAL FINDINGS

Patient-centered medical home enrollment was associated with an increased likelihood of receiving eight recommended mental and physical health services, including A1C testing for persons with diabetes, lipid profiles for persons with diabetes and/or hyperlipidemia, and psychotherapy for persons with major depression and persons with schizophrenia. PCMH enrollment was associated with overuse of short-acting β-agonists among beneficiaries with asthma.

CONCLUSIONS

The PCMH model can improve quality of care for patients with multiple chronic conditions.

Toward a National Conversation on Health: The Transformative Power of Deregulated Markets and Market-Driven Innovation

The U.S. health care system is broken. Unhealthy behaviors, misaligned incentives, excessive regulations, and a reactive care delivery system have created an unsustainable situation for the American people. Health care reform efforts to date have focused primarily on costs, insurance coverage, and policies and regulations in an attempt to increase access, improve quality and control costs. In addition, the Affordable Care Act has created so much complexity that it is nearly impossible to determine how elements in the health care system interact or impact health outcomes. Health care is more complex than ever, with a myriad of new government regulations that must be considered when designing new models of health.New care delivery models that increase consumer choice, encourage competition through free markets, and accelerate innovation are urgently needed. The longstanding fee-for-service model of health care, which is driven by government regulation and the insurance industry, must be abandoned. In its place, the authors provide examples of several emerging market-driven innovations that are currently being implemented and evaluated for viability, replicability, and scalability. They also recommend specific environments for piloting innovative, consumer-focused models of health care, and for helping the government define a process for eventually backing out of health care in order to create a truly deregulated system.

Synthesis Of Research On Patient-Centered Medical Homes Brings Systematic Differences Into Relief

The patient-centered medical home (PCMH) model emphasizes comprehensive, coordinated, patient-centered care, with the goals of reducing spending and improving quality. To evaluate the impact of PCMH initiatives on utilization, cost, and quality, we conducted a meta-analysis of methodologically standardized findings from evaluations of eleven major PCMH initiatives. There was significant heterogeneity across individual evaluations in many outcomes. Across evaluations, PCMH initiatives were not associated with changes in the majority of outcomes studied, including primary care, emergency department, and inpatient visits and four quality measures. The initiatives were associated with a 1.5 percent reduction in the use of specialty visits and a 1.2 percent increase in cervical cancer screening among all patients, and a 4.2 percent reduction in total spending (excluding pharmacy spending) and a 1.4 percent increase in breast cancer screening among higher-morbidity patients. These associations were significant. Identification of the components of PCMHs likely to improve outcomes is critical to decisions about investing resources in primary care.

Physician perceptions of integrating advanced practice pharmacists into practice

OBJECTIVES

Barriers have prevented full integration of advanced practice pharmacists (APPs) into collaborative practice in some areas despite evidence describing their value. APPs in North Carolina can be recognized as Clinical Pharmacist Practitioners (CPPs) under a collaborative practice agreement and provide comprehensive medication management under physician supervision. This study describes the perceptions of physicians regarding the barriers and benefits of integrating CPPs into interprofessional teams and compares physician and CPP perceptions.

METHODS

This prospective descriptive study surveyed CPP supervising physicians in North Carolina. The questionnaire consisted of 17 multiple-choice and free-response questions. Questions included demographics, perceived benefits and challenges of incorporating CPPs into health care teams, and services provided by CPPs. Findings were compared with previously published data that assessed CPP perceptions about the same topics to gain insight into common perspectives of team members.

RESULTS

Fifty-six physicians (23.1%) responded, identifying enhanced clinical outcomes (87.5%), access to drug knowledge (58.9%), and creation of a multidisciplinary model for learners (57.1%) as the top benefits of working with CPPs. Primary barriers included limited reimbursement (60.7%) and billing difficulties (51.8%). More CPPs acknowledged provider acceptance as a barrier (25.9% vs. 3.6%; P = 0.001). Twelve physicians (21.4%) and no CPPs identified space as a barrier.

CONCLUSION

Physicians identified enhanced clinical outcomes, access to drug knowledge, and creation of a multidisciplinary model for learners as the top benefits of incorporating CPPs into teams, and billing difficulties and limited reimbursement were the primary barriers. These findings were similar to the perceptions of CPPs, with exceptions being that physicians were more concerned about space limitations and CPPs noted that provider acceptance may be difficult. These findings may provide guidance to providers desiring to establish collaborative practice.

Active Redesign of a Medicaid Care Management Strategy for Greater Return on Investment: Predicting Impactability

Care management of high-cost/high-needs patients is an increasingly common strategy to reduce health care costs. A variety of targeting methodologies have emerged to identify patients with high historical or predicted health care utilization, but the more pertinent question for program planners is how to identify those who are most likely to benefit from care management intervention. This paper describes the evolution of complex care management targeting strategies in Community Care of North Carolina's (CCNC) work with the statewide non-dual Medicaid population, culminating in the development of an “Impactability Score” that uses administrative data to predict achievable savings. It describes CCNC's pragmatic approach for estimating intervention effects in a historical cohort of 23,455 individuals, using a control population of 14,839 to determine expected spending at an individual level, against which actual spending could be compared. The actual-to-expected spending difference was then used as the dependent variable in a multivariate model to determine the predictive contribution of a multitude of demographic, clinical, and utilization characteristics. The coefficients from this model yielded the information required to build predictive models for prospective use. Model variables related to medication adherence and historical utilization unexplained by disease burden proved to be more important predictors of impactability than any given diagnosis or event, disease profile, or overall costs of care. Comparison of this approach to alternative targeting strategies (emergency department super-utilizers, inpatient super-utilizers, or patients with highest Hierarchical Condition Category risk scores) suggests a 2- to 3-fold higher return on investment using impactability-based targeting.

Evaluating the potential for primary care to serve as a mental health home for people with schizophrenia

OBJECTIVE

Primary care-based medical homes could improve the coordination of mental health care for individuals with schizophrenia and comorbid chronic conditions. The objective of this paper is to examine whether persons with schizophrenia and comorbid chronic conditions engage in primary care regularly, such that primary care settings have the potential to serve as a mental health home.

METHOD

We examined the annual primary care and specialty mental health service utilization of adult North Carolina Medicaid enrollees with schizophrenia and at least one comorbid chronic condition who were in a medical home during 2007-2010. Using a fixed-effects regression approach, we also assessed the effect of medical home enrollment on utilization of primary care and specialty mental health care and medication adherence.

RESULTS

A substantial majority (78.5%) of person-years had at least one primary care visit, and 17.9% had at least one primary care visit but no specialty mental health services use. Medical home enrollment was associated with increased use of primary care and specialty mental health care, as well as increased medication adherence.

CONCLUSIONS

Medical home enrollees with schizophrenia and comorbid chronic conditions exhibited significant engagement in primary care, suggesting that primary-care-based medical homes could serve a care coordination function for persons with schizophrenia.

Many Medicaid Beneficiaries Receive Care Consistent With Attributes Of Patient-Centered Medical Homes

The patient-centered medical home (PCMH) is being embraced as a way to improve access to and quality of care and to control health care costs. However, it is not known what proportion of the Medicaid population receives care from practices that incorporate PCMH goals. Nationally representative data for 2008-12 indicate that the majority of Medicaid beneficiaries with no other coverage who reported having a usual source of care described it as consistent with at least three of five key PCMH attributes: serving multiple health needs, ease of phone contact, extended office hours, coordination of prescriptions, and shared decision making. Younger, healthier, and higher-income Medicaid beneficiaries tended to report care sources with multiple attributes, compared to the older, sicker, and lower-income beneficiaries, who may be more likely to benefit from access to such care. Most attributes were associated with higher perceived quality of care and greater access, although the findings regarding health care expenditures were inconclusive. Challenges to widespread adoption of PCMH principles in Medicaid programs include targeting delivery of care consistent with those principles to high-need, high-cost populations and ensuring an adequate supply of usual sources of primary care.

Effects of New Funding Models for Patient-Centered Medical Homes on Primary Care Practice Finances and Services: Results of a Microsimulation Model

PURPOSE

We assess the financial implications for primary care practices of participating in patient-centered medical home (PCMH) funding initiatives.

METHODS

We estimated practices' changes in net revenue under 3 PCMH funding initiatives: increased fee-for-service (FFS) payments, traditional FFS with additional per-member-per-month (PMPM) payments, or traditional FFS with PMPM and pay-for-performance (P4P) payments. Net revenue estimates were based on a validated microsimulation model utilizing national practice surveys. Simulated practices reflecting the national range of practice size, location, and patient population were examined under several potential changes in clinical services: investments in patient tracking, communications, and quality improvement; increased support staff; altered visit templates to accommodate longer visits, telephone visits or electronic visits; and extended service delivery hours.

RESULTS

Under the status quo of traditional FFS payments, clinics operate near their maximum estimated possible net revenue levels, suggesting they respond strongly to existing financial incentives. Practices gained substantial additional net annual revenue per full-time physician under PMPM or PMPM plus P4P payments ($113,300 per year, 95% CI, $28,500 to $198,200) but not under increased FFS payments (-$53,500, 95% CI, -$69,700 to -$37,200), after accounting for costs of meeting PCMH funding requirements. Expanding services beyond minimum required levels decreased net revenue, because traditional FFS revenues decreased.

CONCLUSIONS

PCMH funding through PMPM payments could substantially improve practice finances but will not offer sufficient financial incentives to expand services beyond minimum requirements for PCMH funding.

Collaborative drug therapy management and comprehensive medication management-2015

The American College of Clinical Pharmacy (ACCP) previously published position statements on collaborative drug therapy management (CDTM) in 1997 and 2003. Since 2003, significant federal and state legislation addressing CDTM has evolved and expanded throughout the United States. CDTM is well suited to facilitate the delivery of comprehensive medication management (CMM) by clinical pharmacists. CMM, defined by ACCP as a core component of the standards of practice for clinical pharmacists, is designed to optimize medication-related outcomes in collaborative practice environments. New models of care delivery emphasize patient-centered, team-based care and increasingly link payment to the achievement of positive economic, clinical, and humanistic outcomes. Hence clinical pharmacists practicing under CDTM agreements or through other privileging processes are well positioned to provide CMM. The economic value of clinical pharmacists in team-based settings is well documented. However, patient access to CMM remains limited due to lack of payer recognition of the value of clinical pharmacists in collaborative care settings and current health care payment policy. Therefore, the clinical pharmacy discipline must continue to establish and expand its use of CDTM agreements and other collaborative privileging mechanisms to provide CMM. Continued growth in the provision of CMM by appropriately qualified clinical pharmacists in collaborative practice settings will enhance recognition of their positive impact on medication-related outcomes.

Assessment of School-Based Quasi-Experimental Nutrition and Food Safety Health Education for Primary School Students in Two Poverty-Stricken Counties of West China

BACKGROUND

Few studies on nutrition and food safety education intervention for students in remote areas of China were reported. The study aimed to assess the questionnaire used to measure the knowledge, attitude and behavior with respect to nutrition and food safety, and to evaluate the effectiveness of a quasi-experimental nutrition and food safety education intervention among primary school students in poverty-stricken counties of west China.

METHODS

Twelve primary schools in west China were randomly selected from Zhen'an of Shaanxi province and Huize of Yunnan province. Six geographically dispersed schools were assigned to the intervention group in a nonrandom way. Knowledge, attitude and behavior questionnaire was developed, assessed, and used for outcome measurement. Students were investigated at baseline and the end of the study respectively without follow-up. Students in intervention group received targeted nutrition and food safety lectures 0.5 hour per week for two semesters. Item response theory was applied for assessment of questionnaire, and a two-level difference-in-differences model was applied to assess the effectiveness of the intervention.

RESULTS

The Cronbach's alpha of the original questionnaire was 0.84. According to item response model, 22 knowledge items, 6 attitude items and 8 behavior items showed adequate discrimination parameter and were retained. 378 and 478 valid questionnaires were collected at baseline and the end point. Differences of demographic characteristics were statistically insignificant between the two groups. Two-level difference-in-differences models showed that health education improved 2.92 (95% CI: 2.06-3.78) and 2.92 (95% CI: 1.37-4.47) in knowledge and behavior scores respectively, but had no effect on attitude.

CONCLUSION

The questionnaire met the psychometric standards and showed good internal consistence and discrimination power. The nutrition and food safety education was effective in improving the knowledge and behavior of primary school students in the two poverty-stricken counties of China.

Medicaid Managed Care in an Integrated Health Care Delivery System: Lessons from Geisinger's Early Experience

Many states in the United States, including Pennsylvania, have opted to rely on private managed care organizations to provide health insurance coverage for their Medicaid population in recent years. Geisinger Health System has been one such organization since 2013. Based on its existing care management model involving data-driven population management, advanced patient-centered medical homes, and targeted case management, Geisinger's Medicaid management efforts have been redesigned specifically to accommodate those with complex health care issues and social service needs to facilitate early intervention, effective and efficient care support, and ultimately, a positive impact on health care outcomes. An analysis of Geisinger's claims data suggests that during the first 19 months since beginning Medicaid member enrollment, Geisinger's Medicaid members, particularly those eligible for the supplemental security income benefits, have incurred lower inpatient, outpatient, and professional costs of care compared to expected levels. However, the total cost savings were partially offset by the higher prescription drug costs. These early data suggest that an integrated Medicaid care management effort may achieve significant cost of care savings. (Population Health Management 2016;19:257-263).

Medicare Chronic Care Management Payments and Financial Returns to Primary Care Practices: A Modeling Study

BACKGROUND

Physicians have traditionally been reimbursed for face-to-face visits. A new non-visit-based payment for chronic care management (CCM) of Medicare patients took effect in January 2015.

OBJECTIVE

To estimate financial implications of CCM payment for primary care practices.

DESIGN

Microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements.

DATA SOURCES

National Ambulatory Medical Care Survey and other published sources.

TARGET POPULATION

Medicare patients.

TIME HORIZON

10 years.

PERSPECTIVE

Practice-level.

INTERVENTION

Comparison of CCM delivery approaches by staff and physicians.

OUTCOME MEASURES

Net revenue per full-time equivalent (FTE) physician; time spent delivering CCM services.

RESULTS OF BASE-CASE ANALYSIS

If nonphysician staff were to deliver CCM services, net revenue to practices would increase despite opportunity and staffing costs. Practices could expect approximately $332 per enrolled patient per year (95% CI, $234 to $429) if CCM services were delivered by registered nurses (RNs), approximately $372 (CI, $276 to $468) if services were delivered by licensed practical nurses, and approximately $385 (CI, $286 to $485) if services were delivered by medical assistants. For a typical practice, this equates to more than $75 ,00 of net annual revenue per FTE physician and 12 hours of nursing service time per week if 50% of eligible patients enroll. At a minimum, 131 Medicare patients (CI, 115 to 140 patients) must enroll for practices to recoup the salary and overhead costs of hiring a full-time RN to provide CCM services.

RESULTS OF SENSITIVITY ANALYSIS

If physicians were to deliver all CCM services, approximately 25% of practices nationwide could expect net revenue losses due to opportunity costs of face-to-face visit time.

LIMITATION

The CCM program may alter long-term primary care use, which is difficult to predict.

CONCLUSION

Practices that rely on nonphysician team members to deliver CCM services will probably experience substantial net revenue gains but must enroll a sufficient number of eligible patients to recoup costs.

PRIMARY FUNDING SOURCE

None.

Practice adaptive reserve and colorectal cancer screening best practices at community health center clinics in 7 states

BACKGROUND

Enhancing the capability of community health centers to implement best practices (BPs) may mitigate health disparities. This study investigated the association of practice adaptive reserve (PAR) with the implementation of patient-centered medical home (PCMH) colorectal cancer (CRC) screening BPs at community health center clinics in 7 states.

METHODS

A convenience sample of clinic staff participated in a self-administered, online survey. Eight PCMH CRC screening BPs were scored as a composite ranging from 0 to 32. The PAR composite score was scaled from 0 to 1 and then categorized into 3 levels. Multilevel analyses examined the relation between PAR and self-reported implementation of PCMH BPs.

RESULTS

There were 296 respondents, and 59% reported 6 or more PCMH BPs at their clinics. The mean PAR score was 0.66 (standard deviation, 0.18), and the PCMH BP mean scores were significantly higher for respondents who reported higher clinic PAR categories. In comparison with the lowest PAR level, adjusted PCMH BP means were 25.0% higher at the middle PAR level (difference, 3.2; standard error, 1.3; t = 2.44; P = .015) and 63.2% higher at the highest PAR level (difference, 8.0; standard error, 1.9; t = 4.86; P < .0001).

CONCLUSIONS

A higher adaptive reserve, as measured by the PAR score, was positively associated with self-reported implementation of PCMH CRC screening BPs by clinic staff. Future research is needed to determine the PAR levels most conducive to implementing CRC screening and to develop interventions that enhance PAR in primary care settings.

Conflicting Readmission Rate Trends in a High-Risk Population: Implications for Performance Measurement

The 30-day readmission rate is a common performance indicator for hospitals and accountable care entities. There is reason to question whether measuring readmissions as a function of hospital discharges is an appropriate measure of performance for initiatives that aim to improve overall cost and quality outcomes in a population. The objectives of this study were to compare trends in 30-day readmission rates per discharge to population-based measures of hospital admission and readmission frequency in a high-risk statewide Medicaid population over a 5-year period of quality improvement and care management intervention. Further, this study aimed to examine case-mix changes among hospitalized beneficiaries over time. This was a retrospective analysis of North Carolina Medicaid paid claims 2008 through 2012 for beneficiaries with multiple chronic or catastrophic conditions. Thirty-day readmission rates per discharge trended upward from 18.3% in 2008 to 18.7% in 2012. However, the rate of 30-day readmissions per 1000 beneficiaries declined from 123.3 to 110.7. Overall inpatient admissions per 1000 beneficiaries decreased from 579.4 to 518.5. The clinical complexity of hospitalized patients increased over the 5-year period. Although rates of hospital admissions and readmissions fell substantially in this high-risk population over 5 years, the 30-day readmission rate trend appeared unfavorable when measured as a percent of hospital discharges. This may be explained by more complex patients requiring hospitalization over time. The choice of metrics significantly affects the perceived effectiveness of improvement initiatives. Emphasis on readmission rates per discharge may be misguided for entities with a population health management focus.