Sickle Cell Disease in an Older Adult Population: A Retrospective Review of Health Care Resource Utilization.

Sickle cell disease (SCD) has a history of health inequity, as patients with SCD are primarily Black and often marginalized from the health care system. Although recent health care and treatment advancements have prolonged life expectancy, it may be insufficient to support the complex needs of the growing population of older adults with SCD. This retrospective study used a cohort (N = 812) of Medicare Advantage beneficiaries 45 years and older (ages: 45-54, 55-64, 65-74, 75-89) with SCD to identify associations of SCD-related complications and comorbidities with emergency department (ED) visits, potentially avoidable ED visits, all-cause hospitalization, and potentially avoidable hospitalizations, 2018-2020. The 75-89 age group had lower odds of an ED visit (OR 0.56; 95% CI 0.32-1.00), 65-74 age group had lower odds of an ED visit (OR 0.49; 95% CI 0.31-0.78) and hospitalization (OR 0.50; 95% CI 0.31-0.79), compared with the 45-54 age group. Acute chest syndrome was associated with increased odds of an ED visit (OR 2.02; 95% CI 1.10-3.71), avoidable ED visit (OR 1.87; 95% CI 1.14-3.06), and hospitalization (OR 3.61; 95% CI 2.06-6.31). Pain was associated with increased odds of an ED visit (OR 2.64; 95% CI 1.85-3.76), an avoidable ED visit (OR 3.08; 95% CI 1.90-4.98), hospitalization (OR 1.51; 95% CI 1.02-2.24), and avoidable hospitalization (OR 6.42; 95% CI 1.74-23.74). Older adults with SCD have been living with SCD for decades, often while managing pain crises and complications associated increased incidence of an ED visit and hospitalization. The characteristics and needs of this population must continue to be examined to increase preventative care and reduce costly emergent health care resource utilization.

Effects of Primary Care-Led, Integrated Palliative Care for Medicare Patients in a Value-Based Model.

CONTEXT: Faced with a projected shortage of specialized palliative care physicians, scalable palliative solutions are required to better meet the aging population's needs. OBJECTIVES: To determine whether a multi-site, primary care-led, integrated palliative care model improves clinical, utilization, and economic outcomes. METHODS: Propensity score-matched comparison group formed from participants who were Medicare beneficiaries, died January 1, 2021-January 31, 2023, were patients of eight primary care practices that partner with agilon health, and enrolled in palliative care for at least seven days. Each practice operates in a value-based model, where primary care providers (PCPs) take on full-risk for the cost and quality of patient outcomes. Each program includes symptom management, defining goals of care/advance directives, PCP care coordination, and assistance with care transitions if patients enroll in hospice. RESULTS: Final sample included 1778 decedents, with 889 in both enrolled and matched cohorts, average age 83. Palliative care is associated with improved patient outcomes from palliative care enrollment until death, including 5.4 more days at home (p < 0.001), 0.4 fewer hospitalizations (p < 0.001), 17% fewer deaths in a hospital (p < 0.001), and $10,393 lower overall healthcare costs (p < 0.001). CONCLUSION: A primary care-led, integrated approach of delivering palliative care within a full-risk model can be an effective care delivery mechanism to meet the healthcare needs of an aging population by impacting patient outcomes and reducing avoidable utilization and cost at the end of life. These findings demonstrate that PCPs in a scaled, full-risk model can simultaneously improve care for patients while reducing costs to the healthcare system.

Burden Of Health-Related Social Needs Among Dual- And Non-Dual-Eligible Medicare Advantage Beneficiaries.

Little information exists to inform stakeholders' efforts to screen for, address, and risk-adjust for the health-related social needs (HRSNs) of Medicare Advantage (MA) enrollees, particularly those not dually Medicaid-Medicare eligible and those younger than age sixty-five. HRSNs can include food insecurity, housing instability, transportation issues, and other factors. We examined the prevalence of HRSNs in 2019 among 61,779 enrollees in a large, national MA plan. Although HRSNs were more common among dual-eligible beneficiaries, with 80 percent reporting at least one (average, 2.2 per beneficiary), 48 percent of non-dual-eligible beneficiaries reported one or more, indicating that dual eligibility alone would have inadequately captured HRSN risk. HRSN burden was unequally distributed across multiple beneficiary characteristics, notably with beneficiaries younger than age sixty-five more likely than those ages sixty-five and older to report having an HRSN. We also found that some HRSNs were more strongly associated with hospitalizations, emergency department visits, and physician visits than others. These findings suggest the importance of considering the HRSNs of dual- and non-dual-eligible beneficiaries, as well as those of beneficiaries of all ages, when exploring how to address HRSNs in the MA population.

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.

Long-Term Effects of the Comprehensive Primary Care Model on Health Care Spending and Utilization.

BACKGROUND: The Centers for Medicare & Medicaid Services launched the 4-year Comprehensive Primary Care Initiative (CPC Classic) in 2012 and its 5-year successor, CPC Plus (CPC+), in 2017 to test whether improving primary care delivery in five areas-and providing practices with financial and technical support-reduced spending and improved quality. This is the first study to examine long-term effects of a primary care practice transformation model. OBJECTIVE: To test whether long-term primary care transformation-the 4-year CPC Classic and the first 2 years of its successor, CPC+-reduced hospitalizations, emergency department (ED) visits, and spending over 6 years. DESIGN: We used a difference-in-differences analysis to compare outcomes for beneficiaries attributed to CPC Classic practices with outcomes for beneficiaries attributed to comparison practices during the year before and 6 years after CPC Classic began. PARTICIPANTS: The study involved 565,674 Medicare fee-for-service beneficiaries attributed to 502 CPC Classic practices and 1,165,284 beneficiaries attributed to 908 comparison practices, with similar beneficiary-, practice-, and market-level characteristics as the CPC Classic practices. INTERVENTIONS: The interventions required primary care practices to improve 5 care areas and supported their transformation with substantially enhanced payment, data feedback, and learning support and, for CPC+, added health information technology support. MAIN MEASURES: Hospitalizations (all-cause), ED visits (outpatient and total), and Medicare Part A and B expenditures. KEY RESULTS: Relative to comparison practices, beneficiaries in intervention practices experienced slower growth in hospitalizations-3.1% less in year 5 and 3.5% less in year 6 (P < 0.01) and roughly 2% (P < 0.1) slower growth each year in total ED visits during years 3 through 6. Medicare Part A and B expenditures (excluding care management fees) did not change appreciably. CONCLUSIONS: The emergence of favorable effects on hospitalizations in years 5 and 6 suggests primary care transformation takes time to translate into lower hospitalizations. Longer tests of models are needed.

Measuring physician practice site characteristics: A comparison of data from SK&A and a practice site survey.

OBJECTIVE: To evaluate the comparability of commercially available practice site data from SK&A with survey data to understand the implications of using SK&A data for health services research. DATA SOURCES: Responses to the Comprehensive Primary Care Plus (CPC+) Practice Survey and SK&A data. STUDY DESIGN: Comparison of CPC + Practice Survey responses to SK&A information for 2698 primary care practice sites. DATA COLLECTION: CPC + Practice Survey data collected through a web-only survey from April through September 2017, and SK&A data purchased in November 2016. PRINCIPAL FINDINGS: Information was similar across data sources, although some discrepancies were common. For example, 56% of practice sites had differences in the reported number of practitioners, and larger sites tended to have larger differences. Among practice sites with 1 practitioner in the survey, only 1.3% had a difference of 3 or more practitioners between the data sources, whereas 63% of practice sites with 11 or more practitioners had a difference of 3 or more practitioners. CONCLUSIONS: Discrepancies between data sources could reflect differences of interpretation when defining practice site characteristics, changes over time in those characteristics, or data errors in either SK&A or the survey. Researchers using SK&A data should consider possible ramifications for their studies.

Practice-site-level measures of primary care comprehensiveness and their associations with patient outcomes.

OBJECTIVES: To develop two practice-site-level measures of comprehensiveness and examine their associations with patient outcomes, and how their performance differs from physician-level measures. DATA SOURCES: Medicare fee-for-service claims. STUDY DESIGN: We calculated practice-site-level comprehensiveness measures (new problem management and involvement in patient conditions) across 5286 primary care physicians (PCPs) at 1339 practices in the Comprehensive Primary Care initiative evaluation in 2013. We assessed their associations with practices' attributed beneficiaries' 2014 total Medicare expenditures, hospitalization rates, ED visit rates. We also examined variation in PCPs' comprehensiveness across PCPs within practices versus between primary care practices. Finally, we compared associations of practice-site and PCP-level measures with outcomes. PRINCIPAL FINDINGS: The measures had good variation across primary care practices, strong validity, and high reliability. Receiving primary care from a practice at the 75th versus 25th percentile on the involvement in patient conditions measure was associated with $21.93 (2.8%) lower total Medicare expenditures per beneficiary per month (P < .01). Receiving primary care from a practice at the 75th versus 25th percentile on the new problem management measure was associated with $14.77 (1.9%) lower total Medicare expenditures per beneficiary per month (P < .05); 8.84 (3.0%) fewer hospitalizations (P < .001), and 21.27 (3.1%) fewer ED visits per thousand beneficiaries per year (P < .01). PCP comprehensiveness varied more within than between practices. CONCLUSIONS: More comprehensive primary care practices had lower Medicare FFS expenditures, hospitalization, and ED visit rates. Both PCP and practice-site level comprehensiveness measures had strong construct and predictive validity; PCP-level measures were more precise.

Pathways to reduced emergency department and urgent care center use: Lessons from the comprehensive primary care initiative.

OBJECTIVE: To determine the association between a large-scale, multi-payer primary care redesign-the Comprehensive Primary Care (CPC) Initiative-on outpatient emergency department (ED) and urgent care center (UCC) use and to identify the types of visits that drive the overall trends observed. DATA SOURCES: Medicare claims data capturing characteristics and outcomes of 565 674 Medicare fee-for-service (FFS) beneficiaries attributed to 497 CPC practices and 1 165 284 beneficiaries attributed to 908 comparison practices. STUDY DESIGN: We used an adjusted difference-in-differences framework to test the association between CPC and beneficiaries' ED and UCC use from October 2012 through December 2016. Regression models controlled for baseline practice and patient characteristics and practice-level clustering of standard errors. Our key outcomes were all-cause and primary care substitutable (PC substitutable) outpatient ED and UCC visits, and potentially primary care preventable (PPC preventable) ED visits, categorized by the New York University Emergency Department Algorithm. We used a propensity score-matched comparison group of practices that were similar to CPC practices before CPC on multiple dimensions. Both groups of practices had similar growth in ED and UCC visits in the two-year period before CPC. PRINCIPAL FINDINGS: Comprehensive Primary Care practices had 2% (P = .06) lower growth in all-cause ED visits than comparison practices. They had 3% (P = .02) lower growth in PC substitutable ED visits, driven by lower growth in weekday PC substitutable visits (4%, P = .002). There was 3% (P = .04) lower growth in PPC preventable ED visits with no weekday/nonweekday differential. As expected, our falsification test showed no difference in ED visits for injuries. UCC visits had 9% lower growth for both all-cause (P = .08) and PC substitutable visits (P = .07). CONCLUSIONS: Our results suggest that greater access to the practice and more effective primary care both contributed to the lower growth in ED and UCC visits during the initiative.

Participation in the Comprehensive Primary Care Plus Initiative.

PURPOSE: Comprehensive Primary Care Plus (CPC+) is the largest test of primary care payment and delivery reform. This program aims to strengthen primary care via enhanced and alternative payment, data feedback, learning, and health information technology support for practice transformation for more than 3,000 practices. We analyzed participation rates and how CPC+ practices differ from other primary care practices in CPC+ regions. METHODS: We assembled a unique data set describing all US primary care practices and compared primary care practices in CPC+ regions, CPC+ applicants, and CPC+ participants. Among CPC+ participants, we compared across 2 model tracks. RESULTS: Of the primary care practices in CPC+ regions, 22% applied for CPC+ and 15% participated. Practices that applied to CPC+ were diverse, but they were generally larger, more sophisticated electronic health record users, more likely to be owned by a hospital or health system, more likely to have experience with transformation efforts, and more likely to be in urban areas than practices that did not apply. Applicants also generally served slightly healthier and more advantaged Medicare fee-for-service beneficiaries. Differences between practices that applied but did not join CPC+ and CPC+ participants were smaller yet systematic. CONCLUSIONS: Participants in CPC+ are diverse but not representative of all primary care practices, underscoring the need to further engage practices that are small, independent, in rural areas, and lack experience with practice and payment transformation models, as well as the need to extrapolate evaluation results carefully.

Primary Care Practice Transformation Introduces Different Staff Roles.

PURPOSE: Practices in the 4-year Comprehensive Primary Care (CPC) initiative changed staffing patterns during 2012-2016 to improve care delivery. We sought to characterize these changes and to compare practice patterns with those in similar non-CPC practices in 2016. METHODS: We conducted an online survey among selected US primary care practices. We statistically tested 2012-2016 changes in practice-reported staff composition among 461 CPC practices using 2-tailed t tests. Using logistic regression analysis, we compared differences in staff types between the CPC practices and 358 comparison practices that participated in the survey in 2016. RESULTS: In 2012, most CPC practices reported having physicians (100%), administrative staff (99%), and medical assistants (90%). By 2016, 84% reported having care managers/care coordinators (up from 24% in 2012), and 29% reported having behavioral health professionals, clinical psychologists, or social workers (up from 19% in 2014). There were also smaller increases (of less than 10 percentage points) in the share of practices having pharmacists, nutritionists, registered nurses, quality improvement specialists, and health educators. Larger and system-affiliated practices were more likely to report having care managers/care coordinators and behavioral health professionals. In 2016, relative to comparison practices, CPC practices were more likely to report having various staff types-notably, care managers/care coordinators (84% of CPC vs 36% of comparison practices), behavioral health professionals (29% vs 12%), and pharmacists (18% vs 4%). CONCLUSIONS: During the CPC initiative, CPC practices added different staff types to a fairly traditional staffing model of physicians with medical assistants. They most commonly added care managers/care coordinators and behavioral health staff to support the CPC model and, at the end of CPC, were more likely to have these staff members than comparison practices.

The Changing Landscape Of Primary Care: Effects Of The ACA And Other Efforts Over The Past Decade.

Providing high-quality primary care is key to improving health care in the United States. The Affordable Care Act sharpened the emerging focus on primary care as a critical lever to use in improving health care delivery, lowering costs, and improving the quality of care. We describe primary care delivery system reform models that were developed and tested over the past decade by the Center for Medicare and Medicaid Innovation-which was created by the Affordable Care Act-and reflect on key lessons and remaining challenges. Considerable progress has been made in understanding how to implement and support different approaches to improving primary care delivery in that decade, though evaluations showed little progress in spending or quality outcomes. This may be because none of the models was able to test substantial increases in primary care payment or strong incentives for other providers to coordinate with primary care to reduce costs and improve quality.

Aggregating Claims Data Across Payers: Approaches, Challenges, and Lessons Learned From the Comprehensive Primary Care Initiative.

The Comprehensive Primary Care (CPC) initiative fueled the emergence of new organizational alliances and financial commitments among payers and primary care practices to use data for performance improvement. In most regions of the country, practices received separate confidential feedback reports of claims-based measures from multiple payers, which varied in content and provided an incomplete picture of a practice's patient panel. Over CPC's last few years, participating payers in several regions resisted the tendency to guard data as a proprietary asset, instead working collaboratively to produce aggregated performance feedback for practices. Aggregating claims data across payers is a potential game changer in improving practice performance because doing so potentially makes the data more accessible, comprehensive, and useful. Understanding lessons learned and key challenges can help other initiatives that are aggregating claims or clinical data across payers for primary care practices or other types of providers.

New approaches to measuring the comprehensiveness of primary care physicians.

OBJECTIVE: To develop claims-based measures of comprehensiveness of primary care physicians (PCPs) and summarize their associations with health care utilization and cost. DATA SOURCES AND STUDY SETTING: A total of 5359 PCPs caring for over 1 million Medicare fee-for-service beneficiaries from 1404 practices. STUDY DESIGN: We developed Medicare claims-based measures of physician comprehensiveness (involvement in patient conditions and new problem management) and used a previously developed range of services measure. We analyzed the association of PCPs' comprehensiveness in 2013 with their beneficiaries' emergency department, hospitalizations rates, and ambulatory care-sensitive condition (ACSC) admissions (each per 1000 beneficiaries per year), and Medicare expenditures (per beneficiary per month) in 2014, adjusting for beneficiary, physician, practice, and market characteristics, and clustering. PRINCIPAL FINDINGS: Each measure varied across PCPs and had low correlation with the other measures-as intended, they capture different aspects of comprehensiveness. For patients whose PCPs' comprehensiveness score was at the 75th vs 25th percentile (more vs less comprehensive), patients had lower service use (P < 0.05) in one or more measures: involvement with patient conditions: total Medicare expenditures, -$17.4 (-2.2 percent); hospitalizations, -5.5 (-1.9 percent); emergency department (ED) visits, -16.3 (-2.4 percent); new problem management: total Medicare expenditures, -$13.3 (-1.7 percent); hospitalizations, -7.0 (-2.4 percent); ED visits, -19.7 (-2.9 percent); range of services: ED visits, -17.1 (-2.5 percent). There were no significant associations between the comprehensiveness measures and ACSC admission rates. CONCLUSIONS: These measures demonstrate strong content and predictive validity and reliability. Medicare beneficiaries of PCPs providing more comprehensive care had lower hospitalization rates, ED visits, and total Medicare expenditures.

The Effects of a Primary Care Transformation Initiative on Primary Care Physician Burnout and Workplace Experience.

BACKGROUND: Physician burnout is associated with deleterious effects for physicians and their patients and might be exacerbated by practice transformation. OBJECTIVE: Assess the effect of the Comprehensive Primary Care (CPC) initiative on primary care physician experience. DESIGN: Prospective cohort study conducted with about 500 CPC and 900 matched comparison practices. Mail surveys of primary care physicians, selected using cross-sectional stratified random selection 11 months into CPC, and a longitudinal design with sample replacement 44 months into CPC. PARTICIPANTS: Primary care physicians in study practices. INTERVENTION: A multipayer primary care transformation initiative (October 2012-December 2016) that required care delivery changes and provided enhanced payment, data feedback, and learning support. MAIN MEASURES: Burnout, control over work, job satisfaction, likelihood of leaving current practice within 2 years. KEY RESULTS: More than 1000 physicians responded (over 630 of these in CPC practices) in each round (response rates 70-81%, depending on round and research group). Physician experience outcomes were similar for physicians in CPC and comparison practices. About one third of physician respondents in CPC and comparison practices reported high levels of burnout in each round (32 and 29% in 2013 [P = 0.59], and 34 and 36% in 2016 [P = 0.63]). Physicians in CPC and comparison practices reported some to moderate control over work, with an average score from 0.50 to 0.55 out of 1 in 2013 and 2016 (CPC-comparison differences of - 0.04 in 2013 [95% CI - 0.08-0.00, P = 0.07], and - 0.03 in 2016 [95% CI - 0.03-0.02, P = 0.19]). In 2016, roughly three quarters of CPC and comparison physicians were satisfied with their current job (77 and 74%, P = 0.77) and about 15% planned to leave their practice within 2 years (14 and 15%, P = 0.17). CONCLUSIONS: Despite requiring substantial practice transformation, CPC did not affect physician experience. Research should track effects of other transformation initiatives on physicians and test new ways to address burnout. TRIAL REGISTRATION: ClinicalTrials.gov number, NCT02320591.

Patient experience during a large primary care practice transformation initiative.

OBJECTIVES: To determine how the multipayer Comprehensive Primary Care (CPC) initiative that transformed primary care delivery affected patient experience of Medicare fee-for-service beneficiaries. The study examines whether patient experience changed during the 4-year initiative, whether ratings of CPC practices changed relative to ratings of comparison practices, and areas in which practices still have an opportunity to improve patient experience. STUDY DESIGN: Prospective study using 2 cross-sectional samples of more than 25,000 Medicare fee-for-service beneficiaries attributed to 490 CPC practices and more than 8000 beneficiaries attributed to 736 comparison practices. METHODS: We analyzed patient experience 8 to 12 months and 45 to 48 months after CPC began, measured using 5 domains of the Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey with Patient-Centered Medical Home items, version 2.0. A regression-adjusted analysis compared differences in the proportion of beneficiaries giving the best responses (and, as a sensitivity test, mean responses) to survey questions over time and between CPC and comparison practices. RESULTS: Patient ratings of care over time were generally comparable for CPC and comparison practices. CPC had favorable effects on measures of follow-up care after hospitalizations and emergency department visits. CONCLUSIONS: Practice transformation did not alter patient experience. The lack of favorable findings raises questions about how future efforts in primary care can succeed in improving patient experience.

The Comprehensive Primary Care Initiative: Effects On Spending, Quality, Patients, And Physicians.

The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative's effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions. The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures. As CMS and other payers increasingly use alternative payment models that reward quality and value, CPC provides important lessons about supporting practices in transforming care.

Development and Validation of the Modified Patient-Centered Medical Home Assessment for the Comprehensive Primary Care Initiative.

OBJECTIVE: To describe the modified Patient-Centered Medical Home Assessment (M-PCMH-A) survey module developed to track primary care practices' care delivery approaches over time, assess whether its underlying factor structure is reliable, and produce factor scores that provide a more reliable summary measure of the practice's care delivery than would a simple average of question responses. DATA SOURCES/STUDY SETTING: Survey data collected from diverse practices participating in the Comprehensive Primary Care (CPC) initiative in 2012 (n = 497) and 2014 (n = 493) and matched comparison practices in 2014 (n = 423). STUDY DESIGN: Confirmatory factor analysis. DATA COLLECTION: Thirty-eight questions organized in six domains: Access and Continuity of Care, Planned Care for Chronic Conditions and Preventive Care, Risk-Stratified Care Management, Patient and Caregiver Engagement, Coordination of Care across the Medical Neighborhood, and Continuous Data-Driven Improvement. PRINCIPAL FINDINGS: Confirmatory factor analysis suggested using seven factors (splitting one domain into two), reassigning two questions to different domain factors, and removing one question, resulting in high reliability, construct validity, and stability in all but one factor. The seven factors together formed a single higher-order factor summary measure. Factor scores guard against potential biases from equal weighting. CONCLUSIONS: The M-PCMH-A can validly and reliably track primary care delivery across practices and over time using factors representing seven key components of care as well as an overall score. Researchers should calculate factor loadings for their specific data if possible, but average scores may be suitable if they cannot use factor analysis due to resource or sample constraints.

Uses and Limitations of Claims-based Performance Feedback Reports: Lessons From the Comprehensive Primary Care Initiative.

BACKGROUND: Performance feedback is central to data-driven models of quality improvement, but the use of claims-based data for feedback has received little attention. PURPOSE: To examine the challenges, uses, and limitations of quarterly Medicare claims-based performance feedback reports generated for practices participating in the Comprehensive Primary Care (CPC) initiative from 2012 to 2015. METHODS: Mixed methods study of nearly 500 CPC practices in seven regions, combining pilot testing; systematic monitoring; surveys; in-depth interviews; user feedback; and input from data feedback team. RESULTS: Designing reports required addressing issues about timing, data completeness and reliability, variations in patient risk across practices, and use of benchmarks and metrics understandable to users. Practices' ability to use reports constructively depended on their experience, analytic resources, expectations, and perceptions about the role of primary care in improving reported outcomes. CONCLUSIONS: Generating claims-based feedback reports that support practices' quality improvement efforts requires a significant investment of analytic expertise, time, resources, continuous improvement, and technical assistance. IMPLICATIONS: Claims-based performance feedback can provide insight into patterns of patients' care across provider settings and opportunities for improvement, but practices need data from other sources to manage patients in real time or assess the short-term effects of specific changes in care delivery.

Patients' perspectives of care management: a qualitative study.

OBJECTIVES: Risk-stratified care management is a cornerstone of patient-centered medical home models, but studies on patients' perspectives of care management are scarce. We explored patients' experiences with care management, what they found useful, and what needs improvement. STUDY DESIGN: Semi-structured qualitative telephone interviews. METHODS: We interviewed 43 high-risk patients or their caregivers who were receiving care management from 11 practices in CMS' Comprehensive Primary Care initiative, provided by nurse care managers (9 practices) or the physician (2 [solo] practices). RESULTS: Patients' perceptions of care management were mixed. Patients who had regular contact with, and a desire to work with, their care manager valued the care management services provided. These patients valued care managers who listened to them and explained their conditions and options in lay terms, helped them navigate the healthcare system and community resources, and followed up after hospitalizations. However, one-fifth of the patients in practices that used nurse care managers could not identify their care manager although we: 1) sampled patients who had recent contact with their care manager and 2) defined the care manager's roles and provided examples of typical care management activities. Patients' interactions with care managers from health plans and hospitals contributed to confusion. CONCLUSIONS: Practices can improve patient buy-in for care management through in-person introductions to care managers by their physicians, offering care management to patients who need and are interested in it, broader agreement about terminology and the role of care managers and care plans, and better coordination with care management from insurers and hospitals.