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.

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.

The Impact of a Health Information Technology-Focused Patient-centered Medical Neighborhood Program Among Medicare Beneficiaries in Primary Care Practices: The Effect on Patient Outcomes and Spending.

BACKGROUND: The Center for Medicare & Medicaid Innovation (CMMI) tests new models of paying for or delivering health care services and expands models that improve health outcomes while lowering medical spending. CMMI gave TransforMED, a national learning and dissemination contractor, a 3-year Health Care Innovation Award (HCIA) to integrate health information technology systems into physician practices. This paper estimates impacts of TransforMED's HCIA-funded program on patient outcomes and Medicare parts A and B spending. RESEARCH DESIGN: We compared outcomes for Medicare fee-for-service (FFS) beneficiaries served by 87 treatment practices to outcomes for Medicare FFS beneficiaries served by 286 matched comparison practices, adjusting for differences in outcomes between the 2 groups during a 1-year baseline period. We estimated impacts in 3 evaluation outcome domains: quality-of-care processes, service use, and spending. RESULTS: We estimated the program led to a 7.1% reduction in inpatient admissions and a 5.7% decrease in the outpatient emergency department visits. However, there was no evidence of statistically significant effects in outcomes in either the quality-of-care processes or spending domains. CONCLUSIONS: These results indicate that TransforMED's program reduced service use for Medicare FFS beneficiaries, but also show that the program did not have statistically significant favorable impacts in the quality-of-care processes or spending domains. These results suggest that providing practices with population health management and cost-reporting software-along with technical assistance for how to use them-can complement practices' own patient-centered medical home transformation efforts and add meaningfully to their impacts on service use.

The Affordable Care Act and Access to Care for People Changing Coverage Sources.

OBJECTIVES: We investigated how access to and continuity of care might be affected by transitions between health insurance coverage sources, including the Marketplace (also called the Exchange), Medicaid, and the Children's Health Insurance Program (CHIP). METHODS: From January to February 2014 and from August to September 2014, we searched provider directories for networks of primary care physicians and selected pediatric specialists participating in Marketplace, Medicaid, and CHIP in 6 market areas of the United States and calculated the degree to which networks overlapped. RESULTS: Networks of physicians in Medicaid and CHIP were nearly identical, meaning transitions between those programs may not result in much physician disruption. This was not the case for Marketplace and Medicaid and CHIP networks. CONCLUSIONS: Transitions from the Marketplace to Medicaid or CHIP may result in different degrees of physician disruption for consumers depending on where they live and what type of Marketplace product they purchase.

Effects of a Behavioral Health and Chronic Illness Care Intervention on Patient Outcomes in Primary Care Practices in the Dakotas.

From 2012 to 2015, Sanford Health, a large health care system, integrated behavioral health services and chronic condition care management in some of its primary care practices in the Dakotas and rural Minnesota. Using difference-in-differences analyses for fee-for-service Medicare beneficiaries attributed to 22 participating practices and 91 matched comparison practices, we found that the program increased the receipt of four recommended diabetes care processes by 8.6% (p=.048) and, by slowing the increase in emergency department (ED) visits, reduced them by 4.9% (p=.07) relative to the comparison group. However, the findings are mixed: the program did not affect hospital admissions, readmissions, or Medicare spending. In addition, the program increased admissions for ambulatory care-sensitive conditions by 13.6% (p=.07) relative to the comparison group. Sanford's program provides a concrete example of how to incorporate behavioral health services in primary care in underserved areas with some positive results on quality-of-care processes and ED utilization.

Rural hospital transitional care program reduces Medicare spending.

OBJECTIVES: To evaluate impacts of a telephonic transitional care program on service use and spending for Medicare fee-for-service beneficiaries at a rural hospital. STUDY DESIGN: Observational cohort study. METHODS: Patients discharged from Atlantic General Hospital (AGH) with an AGH primary care provider were assigned a nurse care coordinator for 30 days. The nurse reviewed the patient's conditions, assessed needs for transition support, conducted weekly telephone calls (beginning 24-72 hours after discharge) to monitor adherence to treatment plans, and scheduled follow-up appointments. Using claims data, we evaluated impacts on service use and spending using a difference-in-differences design with a matched comparison group. RESULTS: The intervention reduced Medicare spending in the 6-month period after discharge by 30.8%, or $1333 per beneficiary per month (90% CI, -$2078 to -$589), which was partly driven by a 39.4% reduction in spending for inpatient claims (difference, -$729; 90% CI, -$1234 to -$225). There were no statistically significant changes in the 14-day ambulatory care follow-up rate, 30-day unplanned readmission rate, number of inpatient admissions, or number of emergency department visits, although this may be due to modest statistical power to detect effects. CONCLUSIONS: The estimated $5.4 million in savings from this intervention more than offset the costs of the $1.1 million funding for the award. Although other studies have found that care transitions programs can improve outcomes, this study was unique in the size of the impacts relative to the low-touch intervention and the location in a small rural healthcare system.

Association Between Extending CareFirst's Medical Home Program to Medicare Patients and Quality of Care, Utilization, and Spending.

Importance: CareFirst, the largest commercial insurer in the mid-Atlantic Region of the United States, runs a medical home program focusing on financial incentives for primary care practices and care coordination for high-risk patients. From 2013 to 2015, CareFirst extended the program to Medicare fee-for-service (FFS) beneficiaries in participating practices. If the model extension improved quality while reducing spending, the Centers for Medicare and Medicaid Services could expand the program to Medicare beneficiaries broadly. Objective: To test whether extending CareFirst's program to Medicare FFS patients improves care processes and reduces hospitalizations, emergency department visits, and spending. Design, Setting, and Participants: This difference-in-differences analysis compared outcomes for roughly 35 000 Medicare FFS patients attributed to 52 intervention practices (grouped by CareFirst into 14 "medical panels") to outcomes for 69 000 Medicare patients attributed to 42 matched comparison panels during a 1-year baseline period and 2.5-year intervention at Maryland primary care practices. Main Outcomes and Measures: Hospitalizations (all-cause and ambulatory-care sensitive), emergency department visits, Medicare Part A and B spending, and 3 quality-of-care process measures: ambulatory care within 14 days of a hospital stay, cholesterol testing for those with ischemic vascular disease, and a composite measure for those with diabetes. Interventions: CareFirst hired nurses who worked with patients' usual primary care practitioners to coordinate care for 3656 high-risk Medicare patients. CareFirst paid panels rewards for meeting cost and quality targets for their Medicare patients and advised panels on how to meet these targets based on analyses of claims data. Results: On average, each of the 14 intervention panels had 9.3 primary care practitioners and was attributed 2202 Medicare FFS patients in the baseline period. The panels' attributed Medicare patients were, on average, 73.8 years old, 59.2% female, and 85.1% white. The extension of CareFirst's program to Medicare patients was not statistically associated with improvements in any outcomes, either for the full Medicare population or for a high-risk subgroup in which impacts were expected to be largest. For the full population, the difference-in-differences estimates were 1.4 hospitalizations per 1000 patients per quarter (P = .54; 90% CI, -2.1 to 5.0), -2.5 outpatient ED visits per 1000 patients per quarter (P = .26; 90% CI, -6.2 to 1.1), and -$1 per patient per month in Medicare Part A and B spending (P = .98; 90% CI, -$40 to $39). For hospitalizations and Medicare spending, the 90% CIs did not span CareFirst's expected impacts. Hospitalizations for the intervention group declined by 10% from baseline year to the final 18 months of the intervention, but this was matched by similar declines in the comparison group. Conclusion and Relevance: The extension of CareFirst's program to Medicare did not measurably improve quality-of-care processes or reduce service use or spending for Medicare patients. Further program refinement and testing would be needed to support scaling the program more broadly to Medicare patients.

Spotlight on Express Lane Eligibility (ELE): A Tool to Improve Enrollment and Renewal.

OBJECTIVE: We examine a new simplification policy, Express Lane Eligibility (ELE), introduced by the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), to understand ELE's effects on enrollment, renewal, and administrative costs. METHODS: Beginning in January 2012 and lasting through June 2013, we conducted 2 rounds of phone interviews with 38 state administrators and staff in 8 states that implemented ELE in Medicaid, Children's Health Insurance Program (CHIP), or both; we also conducted case studies in these same states, resulting in 136 in-person interviews. We collected administrative data on enrollments and renewals processed through ELE methods from the 8 states. RESULTS: ELE was adopted in different ways; the method of adoption influenced how many children were served and administrative savings. Automatic ELE processes, which enable states to use eligibility findings from partner agencies to automatically enroll or renew children, serve the most children and generate, on average, $1 million annually in administrative savings. Given the size of renewal caseloads and the recurring nature of renewal, using ELE for renewals holds substantial promise for administrative savings and keeping children covered. CONCLUSIONS: Automatic ELE processes are a best practice for using ELE. However, because Congress has not yet made ELE a permanent policy option, states are discouraged from adopting this more efficient method of eligibility determination and redeterminations. Making ELE permanent would support states that have already adopted the policy; in addition, ELE could support the transition of children to Medicaid or exchanges should CHIP not be funded after September 30, 2015.

CHIP and Medicaid: Evolving to Meet the Needs of Children.

OBJECTIVE: To examine the evolution of Children's Health Insurance Program (CHIP) and Medicaid programs after passage of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), focusing on policies affecting eligibility, enrollment, renewal, benefits, access to care, cost sharing, and preparation for health care reform. METHODS: Case studies were conducted in 10 states during 2012-which included key informant interviews and consumer focus groups-and a national survey of state CHIP program administrators was conducted in early 2013. RESULTS: Despite the recession that persisted during much of the study period, many states expanded children's coverage by raising upper income eligibility limits or by covering new groups made eligible by CHIPRA. Simplifying rules and procedures for enrollment and renewal continued to be a major priority for CHIP and Medicaid, and CHIPRA played a direct role in spurring innovation. CHIPRA's outreach grants played an important role in supporting and supplementing state outreach efforts. Important legacies of CHIPRA are the law's mandatory requirements for comprehensive dental benefits coverage and mental health parity for all types of CHIP programs. Although most states already offered generous coverage of these benefits, the mandate may have protected them from cuts during the economic downturn. Federal Maintenance of Effort rules were a crucial protection for CHIP, especially during the recession when state budget shortfalls could have led to program cuts. CONCLUSIONS: Passage of the Affordable Care Act has raised questions surrounding the future role of CHIP in a reformed health care system. A growing number of stakeholders have recommended a 2-year extension of federal CHIP funding to allow complex transition issues to be resolved.