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

Importance: Implemented in 18 regions, Comprehensive Primary Care Plus (CPC+) was the largest US primary care delivery model ever tested. Understanding its association with health outcomes is critical in designing future transformation models. Objective: To test whether CPC+ was associated with lower health care spending and utilization and improved quality of care. Design, Setting, and Participants: Difference-in-differences regression models compared changes in outcomes between the year before CPC+ and 5 intervention years for Medicare fee-for-service beneficiaries attributed to CPC+ and comparison practices. Participants included 1373 track 1 (1 549 585 beneficiaries) and 1515 track 2 (5 347 499 beneficiaries) primary care practices that applied to start CPC+ in 2017 and met minimum care delivery and other eligibility requirements. Comparison groups included 5243 track 1 (5 347 499 beneficiaries) and 3783 track 2 (4 507 499 beneficiaries) practices, matched, and weighted to have similar beneficiary-, practice-, and market-level characteristics as CPC+ practices. Interventions: Two-track design involving enhanced (higher for track 2) and alternative payments (track 2 only), care delivery requirements (greater for track 2), data feedback, learning, and health information technology support. Main Outcomes and Measures: The prespecified primary outcome was annualized Medicare Part A and B expenditures per beneficiary per month (PBPM). Secondary outcomes included expenditure categories, utilization (eg, hospitalizations), and claims-based quality-of-care process and outcome measures (eg, recommended tests for patients with diabetes and unplanned readmissions). Results: Among the CPC+ patients, 5% were Black, 3% were Hispanic, 87% were White, and 5% were of other races (including Asian/Other Pacific Islander and American Indian); 85% of CPC+ patients were older than 65 years and 58% were female. CPC+ was associated with no discernible changes in the total expenditures (track 1: $1.1 PBPM [90% CI, -$4.3 to $6.6], P = .74; track 2: $1.3 [90% CI, -$5 to $7.7], P = .73), and with increases in expenditures including enhanced payments (track 1: $13 [90% CI, $7 to $18], P < .001; track 2: $24 [90% CI, $18 to $31], P < .001). Among secondary outcomes, CPC+ was associated with decreases in emergency department visits starting in year 1, and in acute hospitalizations and acute inpatient expenditures in later years. Associations were more favorable for practices also participating in the Medicare Shared Savings Program and independent practices. CPC+ was not associated with meaningful changes in claims-based quality-of-care measures. Conclusions and Relevance: Although the timing of the associations of CPC+ with reduced utilization and acute inpatient expenditures was consistent with the theory of change and early focus on episodic care management of CPC+, CPC+ was not associated with a reduction in total expenditures over 5 years. Positive interaction between CPC+ and the Shared Savings Program suggests transformation models might be more successful when provider cost-reduction incentives are aligned across specialties. Further adaptations and testing of primary care transformation models, as well as consideration of the larger context in which they operate, are needed.

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.

Communication Gaps Persist Between Primary Care and Specialist Physicians.

A survey conducted with data from 2008 found that physicians often do not communicate with each other at the time of referral or after consultation. Communication between physicians might have improved since then, with the dissemination of electronic health records (EHRs), but this is not known. We used 2019 survey data to measure primary care physicians' perceptions of communication at the time of referral and after consultation. We found that large gaps in communication persist. The similarity between these survey results suggests that despite the dissemination of EHRs, physicians still do not consistently communicate with each other about the patients they share.

Exploring and Overcoming the Challenges Primary Care Practices Face with Care Management of High-Risk Patients in CPC+: a Mixed-Methods Study.

BACKGROUND: Longitudinal care management (LCM) for high-risk patients is a cornerstone of primary care models aiming to improve quality and reduce costs. OBJECTIVE: Describe the extent to which LCM was implemented in the second year of Comprehensive Primary Care Plus (CPC+), and barriers to and facilitators of implementation. DESIGN: Mixed-methods. PARTICIPANTS: Quantitative: 2715 practices participating in CPC+ in 2018. Qualitative: Interviews with practitioners and staff in 23 representative CPC+ practices. MAIN MEASURES: Across all CPC+ practices, we report median percentages of empaneled patients placed in the highest-risk tiers and, of those, the median percentage receiving LCM. Across 23 CPC+ practices, we report qualitative findings on LCM implementation. KEY RESULTS: While practices reported benefits of LCM, a small proportion of patients received LCM. Practices placed 2.4% (median) of patients in the highest-risk tier; of these, 30% (median) received LCM. Practices placed 10% (median) of patients in the second-highest-risk tier; of these, 7% (median) received LCM. Interviews revealed LCM uptake across tiers was low because of insufficient care manager staffing. Other challenges included lack of practitioner buy-in to using risk stratification to identify high-risk patients, patients' reluctance to engage in LCM or change behaviors, and limited health information technology functionality for developing, maintaining, and accessing high-risk patients' care plans. Facilitators included embedding care managers within practices and electronic health record functionalities that support LCM. CONCLUSIONS: Despite substantial financial and other supports, and practices' perceived benefits of LCM, insufficient care manager staffing and other barriers have limited its potential in CPC+ to date. To expand LCM's reach, practices need additional care managers, training to overcome barriers to patient engagement, better identification of patients who might benefit from LCM, improved information technology tools for risk stratification and care plans, and more practitioner buy-in to risk stratification.

Barriers, facilitators, and opportunities to optimize care engagement in a diverse sample of older low-income women: A qualitative study.

The growing population of aging women in the United States is disproportionately at-risk for adverse physical, behavioral, mental, and psychosocial health conditions. Engagement with preventive care is critical to address these risk factors. A qualitative descriptive approach was used to explore patterns of healthcare use, facilitators, barriers, and opportunities to optimize primary/preventive care engagement among low-income midlife and older women. Themes were deductively derived from the Behavioral Model for Vulnerable Populations. Categories were inductively determined: barriers to care engagement; facilitators of care engagement; opportunities to optimize primary/preventive care engagement. Themes emerging from this study suggest that experiences related to discrimination, psychological health, trauma, and prioritizing care of others negatively influence care engagement; while respect, continuity, and clinician gender and racial/ethnic concordance enhance care participation. Efforts aiming to engage low-income aging women in care should focus on addressing barriers, building on facilitators, and leveraging contemporary telehealth-outreach solutions.

Two-Year Costs and Quality in the Comprehensive Primary Care Initiative.

BACKGROUND: The 4-year, multipayer Comprehensive Primary Care Initiative was started in October 2012 to determine whether several forms of support would produce changes in care delivery that would improve the quality and reduce the costs of care at 497 primary care practices in seven regions across the United States. Support included the provision of care-management fees, the opportunity to earn shared savings, and the provision of data feedback and learning support. METHODS: We tracked changes in the delivery of care by practices participating in the initiative and used difference-in-differences regressions to compare changes over the first 2 years of the initiative in Medicare expenditures, health care utilization, claims-based measures of quality, and patient experience for Medicare fee-for-service beneficiaries attributed to initiative practices and a group of matched comparison practices. RESULTS: During the first 2 years, initiative practices received a median of $115,000 per clinician in care-management fees. The practices reported improvements in approaches to the delivery of primary care in areas such as management of the care of high-risk patients and enhanced access to care. Changes in average monthly Medicare expenditures per beneficiary did not differ significantly between initiative and comparison practices when care-management fees were not taken into account (-$11; 95% confidence interval [CI], -$23 to $1; P=0.07; negative values indicate less growth in spending at initiative practices) or when these fees were taken into account ($7; 95% CI, -$5 to $19; P=0.27). The only significant differences in other measures were a 3% reduction in primary care visits for initiative practices relative to comparison practices (P<0.001) and changes in two of the six domains of patient experience--discussion of decisions regarding medication with patients and the provision of support for patients taking care of their own health--both of which showed a small improvement in initiative practices relative to comparison practices (P=0.006 and P<0.001, respectively). CONCLUSIONS: Midway through this 4-year intervention, practices participating in the initiative have reported progress in transforming the delivery of primary care. However, at this point these practices have not yet shown savings in expenditures for Medicare Parts A and B after accounting for care-management fees, nor have they shown an appreciable improvement in the quality of care or patient experience. (Funded by the Department of Health and Human Services, Centers for Medicare and Medicaid Services; ClinicalTrials.gov number, NCT02320591.).

Patient Experiences with Chronic Care Management Services and Fees: a Qualitative Study.

BACKGROUND: As of 2015, the Centers for Medicare & Medicaid Services (CMS) pays for chronic care management (CCM) services for Medicare beneficiaries with two or more chronic conditions. CMS requires eligible providers to first obtain patients' verbal (and, prior to 2017, written) consent, to ensure that patients who participate in CCM services understand their rights and agree to any applicable cost sharing. CCM providers must also enhance patients' access to continuous and coordinated care, including ongoing care management. OBJECTIVE: To understand patients' perceptions of the consent process, their reasons for choosing to participate, and their experiences receiving CCM services. DESIGN: Qualitative study using semi-structured interviews with Medicare beneficiaries who had two or more CCM claims submitted by an eligible provider. Beneficiaries were selected from a sampling frame of Medicare claims submitted between January and September 2015. KEY RESULTS: Most patients reported no concerns about being asked to participate in CCM. The majority of patients had secondary insurance (or Medicaid) that covered any coinsurance for CCM and therefore could not say with certainty whether they would participate if they had to pay for CCM services out-of-pocket. Reasons for participating included having insurance that covered the copay and peace of mind about having access to the CCM team. Patients reported multiple benefits of participating in CCM services, including better access to their primary care team, improved continuity of care, and improved care coordination. Most patients reported no downside to participating in CCM services, although some felt they were relatively healthy and questioned whether they needed CCM services. CONCLUSIONS: These findings on patients' experiences participating in CCM services during the first 9 months of the policy's implementation can help providers and policymakers understand their perceived benefits and unintended consequences. Our findings also have implications for providers when approaching patients about CCM services.

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.

A qualitative study of older adults' and family caregivers' perspectives regarding their preoperative care transitions.

AIMS AND OBJECTIVES: To explore how older patients with multiple chronic conditions and their family caregivers perceive their engagement and overall care experience throughout the preoperative phase of elective orthopaedic hip or knee joint replacement. BACKGROUND: Patient engagement is a critical component of care necessary for improving patient outcomes. Little is known about how older adults with multiple chronic conditions and their family caregivers engage in preoperative care transitions and the subsequent impact of this experience on postoperative health outcomes. DESIGN: Prospective qualitative descriptive design was used. METHODS: Semi-structured telephone interviews with a convenience sample of older adults coping with multiple chronic conditions and their family caregivers. Interviews were conducted prior to surgery and, again 21 days postsurgery, were audio-recorded and transcribed for qualitative content analysis. The Quality Health Outcomes Model was used to categorise study findings. RESULTS: Eleven patients and five family caregivers participated. Guided by the Quality Health Outcomes Model, four major themes were identified. (i) Older adults perceive that joint replacement is about quality of life. (ii) Standardised interventions often fail to address the unique needs of complex older adults. (iii) Family caregivers perceive they are the primary care coordinators. (iv) Postoperative outcomes and resource utilisation vary widely in complex older adults. CONCLUSION: Findings suggest that current preoperative care interventions are often not designed to effectively engage complex older patients and their family caregivers. Coordinated patient-centred preoperative care that reflects the needs and goals of complex older patients and their family caregivers may positively influence perioperative care transitions and outcomes beyond this episode of care. RELEVANCE TO CLINICAL PRACTICE: The current research documents the need for more in-depth knowledge about the relationship between older adults' and their family caregivers' engagement preoperatively and postoperative outcomes and resource utilisation.

Provider Experiences with Chronic Care Management (CCM) Services and Fees: A Qualitative Research Study.

BACKGROUND: Support for ongoing care management and coordination between office visits for patients with multiple chronic conditions has been inadequate. In January 2015, Medicare introduced the Chronic Care Management (CCM) payment policy, which reimburses providers for CCM activities for Medicare beneficiaries occurring outside of office visits. OBJECTIVE: To explore the experiences, facilitators, and challenges of practices providing CCM services, and their implications going forward. DESIGN: Semi-structured telephone interviews from January to April 2016 with 71 respondents. PARTICIPANTS: Sixty billing and non-billing providers and practice staff knowledgeable about their practices' CCM services, and 11 professional society representatives. KEY RESULTS: Practice respondents noted that most patients expressed positive views of CCM services. Practice respondents also perceived several patient benefits, including improved adherence to treatment, access to care team members, satisfaction, care continuity, and care coordination. Facilitators of CCM provision included having an in-practice care manager, patient-centered medical home recognition, experience developing care plans, patient trust in their provider, and supplemental insurance to cover CCM copayments. Most billing practices reported few problems obtaining patients' consent for CCM, though providers felt that CMS could better facilitate consent by marketing CCM's goals to beneficiaries. Barriers reported by professional society representatives and by billing and non-billing providers included inadequacy of CCM payments to cover upfront investments for staffing, workflow modification, and time needed to manage complex patients. Other barriers included inadequate infrastructure for health information exchange with other providers and limited electronic health record capabilities for documenting and updating care plans. Practices owned by hospital systems and large medical groups faced greater bureaucracy in implementing CCM than did smaller, independent practices. CONCLUSIONS: Improving providers' experiences with and uptake of CCM will require addressing several challenges, including the upfront investment for CCM set-up and the time required to provide CCM to more complex patients.

A qualitative study of patient and provider experiences during preoperative care transitions.

AIMS AND OBJECTIVES: To explore the issues and challenges of care transitions in the preoperative environment. BACKGROUND: Ineffective transitions play a role in a majority of serious medical errors. There is a paucity of research related to the preoperative arena and the multiple inherent transitions in care that occur there. DESIGN: Qualitative descriptive design was used. METHODS: Semistructured interviews were conducted in a 975-bed academic medical centre. RESULTS: A total of 30 providers and 10 preoperative patients participated. Themes that arose were as follows: (1) need for clarity of purpose of preoperative care, (2) care coordination, (3) interprofessional boundaries of care and (4) inadequate time and resources. CONCLUSION: Effective transitions in the preoperative environment require that providers bridge scope of practice barriers to promote good teamwork. Preoperative care that is a product of well-informed providers and patients can improve the entire perioperative care process and potentially influence postoperative patient outcomes. RELEVANCE TO CLINICAL PRACTICE: Nurses are well positioned to bridge the gaps within transitions of care and accordingly affect health outcomes.

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.

Overcoming challenges to teamwork in patient-centered medical homes: a qualitative study.

BACKGROUND: There is emerging consensus that enhanced inter-professional teamwork is necessary for the effective and efficient delivery of primary care, but there is less practical information specific to primary care available to guide practices on how to better work as teams. OBJECTIVE: The purpose of this study was to describe how primary care practices have overcome challenges to providing team-based primary care and the implications for care delivery and policy. APPROACH: Practices for this qualitative study were selected from those recognized as patient-centered medical homes (PCMHs) via the most recent National Committee for Quality Assurance PCMH tool, which included a domain on practice teamwork. PARTICIPANTS: Sixty-three respondents, ranging from physicians to front-desk staff, were interviewed from May through December of 2013. Practice respondents came from 27 primary care practices ranging in size, type, geography, and population served. KEY RESULTS: Practices emphasizing teamwork overcame common challenges through the incremental delegation of non-clinical tasks away from physicians. The roles of medical assistants and nurses are expanding to include template-guided information collection from patients prior to the physician office visit as well as many other tasks. The inclusion of staff input in care workflow redesign and the use of data to demonstrate how team care process changes improved patient care were helpful in gaining staff buy-in. Team "huddles" guided by pre-visit planning were reported to assist in role delegation, consistency of information collected from patients, and structured communication among team members. Nurse care managers were found to be important team members in working with patients and their physicians on care plan design and execution. Most practices had not participated in formal teamwork training, but respondents expressed a desire for training for key team members, particularly if they could access it on-site (e.g., via practice coaches or the Internet). CONCLUSIONS: Participants who adopted new forms of delegation and care processes using teamwork approaches, and who were supported with resources, system support, and data feedback, reported improved provider satisfaction and productivity. There appears to be a need for more on-site teamwork training.

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.

Incorporating health IT into primary care transformation.

OBJECTIVES: To understand the role of health information technology (IT) vendors and health IT functionality in supporting advanced primary care. STUDY DESIGN: We synthesized multiple rounds of surveys and interviews (2017-2022) from a mixed-methods evaluation of Comprehensive Primary Care Plus (CPC+), a multipayer model developed by CMS. CPC+ was the first federal advanced primary care reform effort that formalized health IT vendors' roles in supporting health IT implementation and specified detailed health IT requirements for practices. METHODS: We conducted content analysis to identify cross-cutting themes related to health IT for both practices and vendors, comparing similarities and differences across participants and (when possible) over time. RESULTS: Vendors and practices reported advances in registries and dashboards for improved information management within the practice as well as strengthened relationships between vendors and practices that supported health IT implementation. However, CPC+ practices noted several gaps or challenges using existing functionalities, and both vendors and practices reported broader challenges for more transformative health IT change, particularly the lack of interoperable health information exchange needed to support care management and care coordination. Key factors constraining vendors' investment in further advances included long product development schedules, making it difficult to respond to rapidly evolving model requirements. Vendors also shared that CPC+ practices represented a small fraction of their client base, so investing in developing new functionality was not strategic unless it was more broadly relevant outside CPC+. CONCLUSIONS: Continued collaboration among health IT vendors, practices, policy makers, and payers could support continued technological improvements, particularly related to information exchange and communication. Aligning requirements more closely with other federal and private models could also help mitigate the risk for vendors.

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.

How CPC+ supported patient care during the COVID-19 pandemic: Lessons for alternative payment models.

BACKGROUND: A growing literature documents how primary care practices adapted to the COVID-19 pandemic. We examine a topic that has received less attention-how participants in an advanced alternative payment model perceive the model influenced their ability to meet patients' care needs during the pandemic. METHODS: Analysis of closed- and open-ended questions from a 2021 survey of 2496 practices participating in the Comprehensive Primary Care Plus (CPC+) model (92% response rate) and a 2021 survey of 993 randomly selected primary care physicians from these practices (55% response rate). Both surveys asked whether respondents agreed or disagreed that they or their practice was "better positioned to meet patients' care needs during the coronavirus pandemic" because of participation in CPC+. Both also included an open-ended question about CPC+'s effects. RESULTS: Half of practices and one-third of physicians agreed or strongly agreed that participating in CPC+ better positioned them to meet patients' care needs during the pandemic. One in 10 practices and 2 in 10 physicians, disagreed or strongly disagreed, while 4 in 10 practices and slightly more than half of physicians neither agreed nor disagreed (or, for physicians, didn't know). The most commonly identified CPC+ activities that facilitated meeting patient care needs related to practices' work on care management (e.g., risk stratification), access (e.g., telehealth), payment outside of fee-for-service (FFS), and staffing (e.g., supporting care managers). CONCLUSIONS: Most CPC+ practices and physicians were positive or neutral about participating in CPC+ in the context of COVID-19, indicating more benefit than risk to payment alternatives to FFS.