RISQy business (Relationships, Incentives, Supports, and Quality): evolution of the British Columbia Model of Primary Care (patient-centered medical home)

Learning from health system reform trajectories in seven Canadian provinces

In publicly funded health systems, reform efforts have proliferated to adapt to increasingly complex demands. In Canada, prior research (Lazar et al., 2013, Paradigm Freeze: Why is it so Hard to Reform Health Care in Canada?, McGill-Queen's Press) found that reforms at the end of the 20th century failed to change the fundamentals of the Canadian system based on physician independence and assured universal coverage only for medical and hospital services. This paper focuses on reforms since the turn of the millennium to explore the transformative capacities developed in seven provinces within this system architecture. Longitudinal case studies, based on scientific and grey literature, and interviews with key informants, trace the patterns of reform in each province and reveal five objectives that, to varying degrees, preoccupied reformers: (1) address chronic disease, (2) align health system actors with provincial objectives, (3) shift from hospital to community-based care, (4) integrate physicians, and (5) develop improvement capacities. The range of strategies adopted to achieve these objectives in different provinces is compared to identify emerging pathways of reform and extract lessons for future reformers. We find significant cross-learning between provinces, but also note an emergent dimension to reforms, where multiple strategies aggregate through time to create unique patterns, presenting their own set of possibilities and limitations for the future.

Physician Incentives and Sex/Gender Differences in Depression Care: An Interrupted Time Series Analysis

Introduction: Physician incentives have been shown to reduce socioeconomic disparities in health care. The impact on sex/gender inequalities, however, has rarely been investigated. Using population-based data, this study investigated sex/gender differences in depression care and the impact of physician incentives.

Methods: Deidentified health data from physician claims, hospitals, vital statistics, prescription database, and insurance plan registries in British Columbia, Canada, were examined, retrospectively. Individuals with depression were identified and their use of mental health services was tracked for 12 months following initial diagnosis. The following indicators were assessed: (1) counseling/psychotherapy (CP), (2) minimally adequate counseling/psychotherapy (MACP), (3) antidepressant therapy (AT), and (4) minimally adequate antidepressant therapy (MAAT). Sex/gender differences in these indicators before (January 2005–December 2007) and after (January 2008–December 2012) the introduction of physician incentives were estimated using interrupted time series analysis.

Results: Preintervention, the percentage of individuals with depression who received CP was higher among males (CP: 58.4%, MACP: 13.6%) than females (CP: 57.1%, MACP: 10.9%). In contrast, the percentage who received AT was higher among females (AT: 57.7%, MAAT: 47.4%) than males (AT: 53.6%, MAAT: 41.9%). These statistically significant sex/gender differences remain unchanged postintervention.

Conclusions: Sex/gender differences in depression care persist despite the introduction of physician incentives.

Is the Road to Mental Health Paved With Good Incentives? Estimating the Population Impact of Physician Incentives on Mental Health Care Using Linked Administrative Data

OBJECTIVES

The use of physician incentives to improve health care, in general, has been extensively studied but its value in mental health care has rarely been demonstrated. In this study the population-level impact of physician incentives on mental health care was estimated using indicators for receipt of counseling/psychotherapy (CP); antidepressant therapy (AT); minimally adequate counseling/psychotherapy; and minimally adequate antidepressant therapy. The incentives' impacts on overall continuity of care and of mental health care were also examined.

MATERIALS AND METHODS

Monthly cohorts of individuals diagnosed with major depression were identified between January 2005 and December 2012 and their use of mental health services tracked for 12 months following initial diagnosis. Linked health administrative data were used to ascertain cases and measure health service use. Pre-post changes associated with the introduction of physician incentives were estimated using segmented regression analyses, after adjusting for seasonal variation.

RESULTS

Physician incentives reversed the downward and upward trends in CP and AT. Five years postintervention, the estimated impacts in percentage points for CP, AT, minimally adequate counseling/psychotherapy, and minimally adequate antidepressant therapy were +3.28 [95% confidence interval (CI), 2.05-4.52], -4.47 (95% CI, -6.06 to -2.87), +1.77 (95% CI, 0.94-2.59), and -2.24 (95% CI, -4.04 to -0.45). Postintervention, the downward trends in continuity of care failed to reverse, but were disrupted, netting estimated impacts of +7.53 (95% CI, 4.54-10.53) and +4.37 (95% CI, 2.64-6.09) for continuity of care and of mental health care.

CONCLUSIONS

The impact of physician incentives on mental health care was modest at best. Other policy interventions are needed to close existing gaps in mental health care.

Assessing the Effectiveness of Policies to Reduce Diabetes Hospitalizations Before and After the Reforms of Physician Payment and Primary Care Organization in British Columbia and Alberta

OBJECTIVE

Diabetes is one of the most common chronic conditions in Canada. Appropriate care management, particularly in primary care settings, has been demonstrated to improve the outcomes of people with this condition. Policies have been implemented to support primary care providers in providing appropriate diabetes management. This study aimed to evaluate whether policy changes related to improving care have impacted diabetes hospitalizations in British Columbia and Alberta, Canada.

METHODS

This study used a before-and-after evaluation design based on longitudinal administrative data including physicians' claims and hospitalizations from 1998-1999 to 2009-2010. We performed ordinary least squares regressions to assess the variations in diabetes hospitalization rates following the implementation of policies in primary care settings in each province.

RESULTS

Diabetes-related hospitalization rates have been decreasing since 1998 and continued to decrease after the reforms in both provinces. In 1998, the adjusted hospitalization rate for diabetes was 2.9% in Alberta and 1.7% in British Columbia compared to, respectively, 1.1% and 0.8% in 2009. Regression results suggest that the changes in policy in 2003 have had limited impact on outcomes for those with diabetes.

CONCLUSIONS

The hospitalization rates were already declining in both provinces over time, before and after the reform, so it is challenging to disentangle the decrease that could be attributable to policy changes. More research is needed to better understand the impact of changes in primary care on outcomes such as hospitalizations for diabetes.

Incentive-Based Primary Care: Cost and Utilization Analysis

CONTEXT

In its fee-for-service funding model for primary care, British Columbia, Canada, introduced incentive payments to general practitioners as pay for performance for providing enhanced, guidelines-based care to patients with chronic conditions. Evaluation of the program was conducted at the health care system level.

OBJECTIVE

To examine the impact of the incentive payments on annual health care costs and hospital utilization patterns in British Columbia.

DESIGN

The study used Ministry of Health administrative data for Fiscal Year 2010-2011 for patients with diabetes, congestive heart failure, chronic obstructive pulmonary disease, and/or hypertension. In each disease group, cost and utilization were compared across patients who did, and did not, receive incentive-based care.

MAIN OUTCOME MEASURES

Health care costs (eg, primary care, hospital) and utilization measures (eg, hospital days, readmissions).

RESULTS

After controlling for patients' age, sex, service needs level, and continuity of care (defined as attachment to a general practice), the incentives reduced the net annual health care costs, in Canadian dollars, for patients with hypertension (by approximately Can$308 per patient), chronic obstructive pulmonary disease (by Can$496), and congestive heart failure (by Can$96), but not diabetes (incentives cost about Can$148 more per patient). The incentives were also associated with fewer hospital days, fewer admissions and readmissions, and shorter lengths of hospital stays for all 4 groups.

CONCLUSION

Although the available literature on pay for performance shows mixed results, we showed that the funding model used in British Columbia using incentive payments for primary care might reduce health care costs and hospital utilization.

Financial implications of the continuity of primary care

BACKGROUND

The objective of this study was to assess the financial implications of the continuity of care, for patients with high care needs, by examining the cost of government-funded health care services in British Columbia, Canada.

METHODS

Using British Columbia Ministry of Health administrative databases for fiscal year 2010-2011 and generalized linear models, we estimated cost ratios for 10 cost-related predictor variables, including patients' attachment to the practice. Patients were selected and divided into groups on the basis of their Resource Utilization Band (RUB) and placement in provincial registries for 8 chronic conditions (1,619,941 patients). The final dataset included all high- and very-high-care-needs patients in British Columbia (ie, RUB categories 4 and 5) in 1 or more of the 8 registries who met the screening criteria (222,779 patients).

RESULTS

Of the 10 predictors, across 8 medical conditions and both RUBs, patients' attachment to the practice had the strongest relationship to costs (correlations = -0.168 to -0.322). Higher attachment was associated with lower costs. Extrapolation of the findings indicated that an increase of 5% in the overall attachment level, for the selected high-care-needs patients, could have resulted in an estimated cost avoidance of $142 million Canadian for fiscal year 2010-2011.

CONCLUSIONS

Continuity of care, defined as a patient's attachment to his/her primary care practice, can reduce health care costs over time and across chronic conditions. Health care policy makers may wish to consider creating opportunities for primary care physicians to increase the attachment that their high-care-needs patients have to their practices.