Association of the Range of Outpatient Services Provided by Primary Care Physicians with Subsequent Health Care Costs and Utilization.

BACKGROUND: Broader primary care practice range of services (ROS), defined as the diversity of professional services delivered, is associated with lower utilization. ROS provided by individual primary care physicians (PCPs) varies considerably with unclear implications for patients. OBJECTIVES: Create a PCP-ROS measure covering six categories of outpatient services, including expanded codes for mental health counseling services and point of care ultrasound (POCUS) technology in physician offices. Determine whether PCP-ROS is associated with total Medicare expenditures, inpatient admissions, acute hospital utilization (AHU), and emergency department (ED) visits. Examine physician and practice characteristics associated with PCP-ROS. DESIGN: Retrospective cohort study. PARTICIPANTS: 4,569,711 Medicare fee-for-service beneficiaries and 27,008 PCPs observed during the evaluation of the Comprehensive Primary Care Plus (CPC +) initiative. MEASUREMENTS: PCP-ROS, hospitalizations, AHU (includes observation stays as well as inpatient admissions), ED visits, and total Medicare expenditures. RESULTS: Physicians varied substantially in the range of services provided. Broader PCP-ROS was significantly, independently associated with 1 - 3% lower Medicare expenditures (p ≤ 0.01), inpatient admissions (p ≤ 0.027), AHU (p ≤ 0.025), and ED visit rates (p ≤ 0.000). PCP-ROS score was associated with improved patient outcomes, independent of physician provision of procedures (such as laceration repair or skin excisions). Physicians in practice sites affiliated with a hospital or health system had narrower PCP-ROS than independent physicians by 0.3 to 0.4 (p < 0.001). Internal medicine specialty was associated with narrower PCP-ROS than family medicine by 0.3 (p < 0.001). CONCLUSIONS: Patients cared for by primary care physicians who provide a broader range of services subsequently experience lower acute care utilization and expenditures than do those cared for by physicians with narrower ROS. Practice leaders and professional associations should consider how best to ensure that primary care physicians efficiently and effectively provide the office-based professional services most needed by their patients.

Reducing Acute Hospitalizations at High-Performing CPC+ Primary Care Practice Sites: Strategies, Activities, and Facilitators.

PURPOSE: Despite evidence suggesting that high-quality primary care can prevent unnecessary hospitalizations, many primary care practices face challenges in achieving this goal, and there is little guidance identifying effective strategies for reducing hospitalization rates. We aimed to understand how practices in the Comprehensive Primary Care Plus (CPC+) program substantially reduced their acute hospitalization rate (AHR) over 2 years. METHODS: We used Bayesian analyses to identify the CPC+ practice sites having the highest probability of achieving a substantial reduction in the adjusted Medicare AHR between 2016 and 2018 (referred to here as AHR high performers). We then conducted telephone interviews with 64 respondents at 14 AHR high-performer sites and undertook within- and cross-case comparative analysis. RESULTS: The 14 AHR high performers experienced a 6% average decrease (range, 4% to 11%) in their Medicare AHR over the 2-year period. They credited various care delivery activities aligned with 3 strategies for reducing AHR: (1) improving and promoting prompt access to primary care, (2) identifying patients at high risk for hospitalization and addressing their needs with enhanced care management, and (3) expanding the breadth and depth of services offered at the practice site. They also identified facilitators of these strategies: enhanced payments through CPC+, prior primary care practice transformation experience, use of data to identify high-value activities for patient subgroups, teamwork, and organizational support for innovation. CONCLUSIONS: The AHR high performers observed that strengthening the local primary care infrastructure through practice-driven, targeted changes in access, care management, and comprehensiveness of care can meaningfully reduce acute hospitalizations. Other primary care practices taking on the challenging work of reducing hospitalizations can learn from CPC+ practices and may consider similar strategies, selecting activities that fit their context, personnel, patient population, and available resources.

A systematic review of vertical integration and quality of care, efficiency, and patient-centered outcomes.

BACKGROUND: Small independent practices are increasingly giving way to more complex affiliations between provider organizations and hospital systems. There are several ways in which vertically integrated health systems could improve quality and lower the costs of care. But there are also concerns that integrated systems may increase the price and costs of care without commensurate improvements in quality and outcomes. PURPOSE: Despite a growing body of research on vertically integrated health systems, no systematic review that we know of compares vertically integrated health systems (defined as shared ownership or joint management of hospitals and physician practices) to nonintegrated hospitals or physician practices. METHODS: We conducted a systematic search of the literature published from January 1996 to November 2016. We considered articles for review if they compared the performance of a vertically integrated health system and examined an outcome related to quality of care, efficiency, or patient-centered outcomes. RESULTS: Database searches generated 7,559 articles, with 29 articles included in this review. Vertical integration was associated with better quality, often measured as optimal care for specific conditions, but showed either no differences or lower efficiency as measured by utilization, spending, and prices. Few studies evaluated a patient-centered outcome; among those, most examined mortality and did not identify any effects. Across domains, most studies were observational and did not address the issue of selection bias. PRACTICE IMPLICATIONS: Recent evidence suggests the trend toward vertical integration will likely continue as providers respond to changing payment models and market factors. A growing body of research on comparative health system performance suggests that integration of physician practices with hospitals might not be enough to achieve higher-value care. More information is needed to identify the health system attributes that contribute to improved outcomes, as well as which policy levers can minimize anticompetitive effects and maximize the benefits of these affiliations.

How Accountable Care Organizations Use Population Segmentation to Care for High-Need, High-Cost Patients.

Issue: New payment and care delivery models such as accountable care organizations (ACOs) have prompted health care delivery systems to better meet the requirements of their high-need, high-cost (HNHC) patients. Goal: To explore how a group of mature ACOs are seeking to match patients with appropriate interventions by segmenting HNHC populations with similar needs into smaller subgroups. Methods: Semistructured telephone interviews with 34 leaders from 18 mature ACOs and 10 national experts knowledgeable about risk stratification and segmentation. Key Findings and Conclusions: ACOs use a range of approaches to segment their HNHC patients. Although there was no consistent set of subgroups for HNHC patients across ACOs, there were some common ones. Respondents noted that when primary care clinicians were engaged in refining segmentation approaches, there was an increase in both the clinical relevance of the results as well as the willingness of frontline providers to use them. Population segmentation results informed ACOs' understanding of program needs, for example, by helping them better understand what skill sets and staff were needed to deliver enhanced care management. Findings on how mature ACOs are segmenting their HNHC population can improve the future development of more systematic approaches.

Measuring Comprehensiveness of Primary Care: Challenges and Opportunities.

Comprehensiveness of primary care (the extent to which the clinician, as part of the primary care team, recognizes and meets the majority of each patient's physical and mental health care needs) is an important element of primary care, but seems to be declining in the U.S. This is concerning, because more comprehensive primary care is associated with greater equity and efficiency in health care, improved continuity, less care fragmentation and better health outcomes. Without measurement and support for its improvement, comprehensiveness may further decline as other measured aspects of primary care (e.g. access, coordination) improve. To track, support and improve comprehensiveness, it is useful to have valid and reliable ways to measure it. This paper discusses challenges to measuring comprehensiveness for a primary care team's patient panel, presents survey and claims-based measures of comprehensiveness, and provides suggestions for future research.

Factors Contributing to Variations in Physicians' Use of Evidence at The Point of Care: A Conceptual Model.

There is ample evidence that many clinical decisions made by physicians are inconsistent with current and generally accepted evidence. This leads to the underuse of some efficacious diagnostic, preventive or therapeutic services, and the overuse of others of marginal or no value to the patient. Evolving new payment and delivery models place greater emphasis on the provision of evidence-based services at the point of care. However, changing physician clinical behaviors is likely to be difficult and slow. Policy makers therefore need to design interventions that are most effective in promoting greater evidence-based care. To help identify modifiable factors that can influence clinical decisions at the point of care, we present a conceptual model and literature review of physician decision making. We describe the multitude of factors--drawn from different disciplines--that have been shown to influence physician point-of-care decisions. We present a conceptual framework for organizing these factors, dividing them into patient, physician, practice site, physician organization, network, market, and public policy influences. In doing so, we review some of the literature that speak to these factors. We then identify areas where additional research is especially needed, and discuss the challenges and opportunities for health services and policy researchers to gain a better understanding of these factors, particularly those that are potentially modifiable by policymakers and organizational leaders.

Disentangling the Linkage of Primary Care Features to Patient Outcomes: A Review of Current Literature, Data Sources, and Measurement Needs.

Primary care plays a central role in the provision of health care, and is an organizing feature for health care delivery systems in most Western industrialized democracies. For a variety of reasons, however, the practice of primary care has been in decline in the U.S. This paper reviews key primary care concepts and their definitions, notes the increasingly complex interplay between primary care and the broader health care system, and offers research priorities to support future measurement, delivery and understanding of the role of primary care features on health care costs and quality.

The Results Are Only as Good as the Sample: Assessing Three National Physician Sampling Frames.

BACKGROUND: Databases of practicing physicians are important for studies that require sampling physicians or counting the physician population in a given area. However, little is known about how the three main sampling frames differ from each other. OBJECTIVE: Our purpose was to compare the National Provider and Plan Enumeration System (NPPES), the American Medical Association Masterfile and the SK&A physician file. METHODS: We randomly sampled 3000 physicians from the NPPES (500 in six specialties). We conducted two- and three-way comparisons across three databases to determine the extent to which they matched on address and specialty. In addition, we randomly selected 1200 physicians (200 per specialty) for telephone verification. KEY RESULTS: One thousand, six hundred and fifty-five physicians (55 %) were found in all three data files. The SK&A data file had the highest rate of missing physicians when compared to the NPPES, and varied by specialty (50 % in radiology vs. 28 % in cardiology). NPPES and SK&A had the highest rates of matching mailing address information, while the AMA Masterfile had low rates compared with the NPPES. We were able to confirm 65 % of physicians' address information by phone. The NPPES and SK&A had similar rates of correct address information in phone verification (72-94 % and 79-92 %, respectively, across specialties), while the AMA Masterfile had significantly lower rates of correct address information across all specialties (32-54 % across specialties). CONCLUSIONS: None of the data files in this study were perfect; the fact that we were unable to reach one-third of our telephone verification sample is troubling. However, the study offers some encouragement for researchers conducting physician surveys. The NPPES and to a lesser extent, the SK&A file, appear to provide reasonably accurate, up-to-date address information for physicians billing public and provider insurers.

Advancing geriatrics research, education, and practice: policy challenges after the great recession.

The series of articles in this JGIM issue provides a number of policy-relevant recommendations for advancing geriatrics research, education and practice. Despite the unprecedented pressure to reduce state and federal spending, policymakers must concurrently address the challenges of a growing population of older individuals with increasingly complex health care problems. Thus, there may be opportunities to advance this agenda in creative ways. For example, without new spending, federal research agencies can make changes to encourage needed new directions in aging research, and the ACA provides new funding opportunities such as the Patient Centered Outcomes Research Institute. States and the federal government have an increasing need for the health professions workforce to have collaborative care skills and geriatrics clinical competencies, and are finding ways to invest in relevant initiatives. On the clinical program side, state and federal governments are initiating programs to promote delivery system changes that improve the care of older adults. Nonetheless, in the face of the policy challenges that have persisted after the "great recession," academic geriatrics and general internal medicine will need to join forces with public and private interests to secure the resources needed to advance this ambitious agenda for geriatrics research, education and practice.

Structuring payment to medical homes after the affordable care act.

The Patient-Centered Medical Home (PCMH) is a leading model of primary care reform, a critical element of which is payment reform for primary care services. With the passage of the Affordable Care Act, the Accountable Care Organization (ACO) has emerged as a model of delivery system reform, and while there is theoretical alignment between the PCMH and ACOs, the discussion of physician payment within each model has remained distinct. Here we compare payment for medical homes with that for accountable care organizations, consider opportunities for integration, and discuss implications for policy makers and payers considering ACO models. The PCMH and ACO are complementary approaches to reformed care delivery: the PCMH ultimately requires strong integration with specialists and hospitals as seen under ACOs, and ACOs likely will require a high functioning primary care system as embodied by the PCMH. Aligning payment incentives within the ACO will be critical to achieving this integration and enhancing the care coordination role of primary care in these settings.

Hospital outpatient department billing is a poor indicator of primary care practice integration with hospital systems.

OBJECTIVE: To test the reliability of Medicare claims in measuring vertical integration. We assess the accuracy of a commonly used measure of integration, primary care physician (PCP) practices billing Medicare as a hospital outpatient department (HOPD) in claims. DATA SOURCES AND STUDY SETTING: Medicare fee-for-service claims, IQVIA, and CPC+ practice surveys for this study. STUDY DESIGN: We compare measures of integration from Medicare claims to self-reported indicators of integration from IQVIA and a survey of CPC+ participating practice sites. DATA COLLECTION/EXTRACTION METHODS: We measure integration by using site-of-service billing in the 100% sample of Medicare Carrier claims from 2017-2020. In the IQVIA SK&A (2017-2018), OneKey (2019-2020), and practice survey data (2017-2019), we use self-reported responses to measure integration. PRINCIPAL FINDINGS: We find that currently most PCP practices sites that report themselves as being integrated with a health system do not bill as an HOPD. In 2017, 11% of CPC+ practices were identified as being vertically integrated in claims, while the equivalent numbers in SK&A and surveys were 52% and 54% integration, respectively. A t-test found that both datasets significantly differed from claims (Survey: 41.3%-45.1%; SK&A: 45.3%-51.1%); this gap persists in 2018-2019. CONCLUSION: Measuring physician-hospital vertical integration accurately is integral to determining consolidation. The overwhelming majority of PCP practice sites not billing as an HOPD may reflect Medicare regulatory changes that have reduced the financial incentives for doing so. These findings have implications for researchers that study the growth in PCP-hospital integration in health care markets.

Medicare beneficiaries with more comprehensive primary care physicians report better primary care.

OBJECTIVE: To examine whether primary care physician (PCP) comprehensiveness is associated with Medicare beneficiaries' overall rating of care from their PCP and staff. DATA SOURCES: We linked Medicare claims with survey data from Medicare beneficiaries attributed to Comprehensive Primary Care Plus (CPC+) physicians and practices. STUDY DESIGN: We performed regression analyses of the associations between two claims-based measures of PCP comprehensiveness in 2017 and beneficiaries' rating of care from their PCP and practice staff in 2018. DATA COLLECTION/EXTRACTION METHODS: The analytic sample included 6228 beneficiaries cared for by 3898 PCPs. Regressions controlled for beneficiary, physician, practice, and market characteristics. PRINCIPAL FINDINGS: Beneficiaries with more comprehensive PCPs rated care from their PCP and practice staff higher than did those with less comprehensive PCPs. For each comprehensiveness measure, beneficiaries whose PCP was in the 75th percentile were more likely than beneficiaries whose PCP was in the 25th percentile to rate their care highly (2 percentage point difference, p = 0.02). CONCLUSIONS: Medicare beneficiaries with more comprehensive PCPs rate overall care from their PCPs and staff higher than those with less comprehensive PCPs.

From comparative effectiveness research to patient-centered outcomes research: policy history and future directions.

Containing growth in health care expenditures is considered to be essential to improving both the long-term fiscal outlook of the federal government and the future affordability of health care in the US. As health care expenditures have increased, so too have concerns about the quality of health care. Better information on the clinical effectiveness of alternative treatments and other interventions is needed to improve the quality of care and restrain growth in expenditures. This article explains the key role played by the federal government in defining the context and process of comparative effectiveness research as well as its funding. Subsequently, the article explores the mission, priorities, and research agenda of the Patient-Centered Outcomes Research Institute, which is an independent, nonprofit corporation established in 2010 by the Patient Protection and Affordable Care Act.

Geographic Variation In The Consolidation Of Physicians Into Health Systems, 2016-18.

Physician consolidation into health systems increased in nearly all metropolitan statistical areas (MSAs) from 2016 to 2018. Of the 382 US MSAs, 113 had more than half of their physicians in health systems in 2018. Consolidation of physicians was most notable in the Midwest and Northeast and in small-to-midsize MSAs.