Health facility management and primary health care performance in Uganda.

BACKGROUND: Primary health care is a critical foundation of high-quality health systems. Health facility management has been studied in high-income countries, but there are significant measurement gaps about facility management and primary health care performance in low and middle-income countries. A primary health care facility management evaluation tool (PRIME-Tool) was initially piloted in Ghana where better facility management was associated with higher performance on select primary health care outcomes such as essential drug availability, trust in providers, ease of following a provider's advice, and overall patient-reported quality rating. In this study, we sought to understand health facility management within Uganda's decentralized primary health care system. METHODS: We administered and analyzed a cross-sectional household and health facility survey conducted in Uganda in 2019, assessing facility management using the PRIME-Tool. RESULTS: Better facility management was associated with better essential drug availability but not better performance on measures of stocking equipment. Facilities with better PRIME-Tool management scores trended towards better performance on a number of experiential quality measures. We found significant disparities in the management performance of primary health care facilities. In particular, patients with greater wealth and education and those living in urban areas sought care at facilities that performed better on management. Private facilities and hospitals performed better on the management index than public facilities and health centers and clinics. CONCLUSIONS: These results suggest that investments in stronger facility management in Uganda may strengthen key aspects of facility readiness such as essential drug availability and potentially could affect experiential quality of care. Nevertheless, the stark disparities demonstrate that Uganda policymakers need to target investments strategically in order to improve primary health care equitably across socioeconomic status and geography. Moreover, other low and middle-income countries may benefit from the use of the PRIME-Tool to rapidly assess facility management with the goal of understanding and improving primary health care performance.

Trends in Outpatient Care for Medicare Beneficiaries and Implications for Primary Care, 2000 to 2019.

BACKGROUND: Despite the central role of primary care in improving health system performance, there are little recent data on how use of primary care and specialists has evolved over time and its implications for the range of care coordination needed in primary care. OBJECTIVE: To describe trends in outpatient care delivery and the implications for primary care provider (PCP) care coordination. DESIGN: Descriptive, repeated, cross-sectional study using Medicare claims from 2000 to 2019, with direct standardization used to control for changes in beneficiary characteristics over time. SETTING: Traditional fee-for-service Medicare. PATIENTS: 20% sample of Medicare beneficiaries. MEASUREMENTS: Annual counts of outpatient visits and procedures, the number of distinct physicians seen, and the number of other physicians seen by a PCP's assigned Medicare patients. RESULTS: The proportion of Medicare beneficiaries with any PCP visit annually only slightly increased from 61.2% in 2000 to 65.7% in 2019. The mean annual number of primary care office visits per beneficiary also changed little from 2000 to 2019 (2.99 to 3.00), although the mean number of PCPs seen increased from 0.89 to 1.21 (36.0% increase). In contrast, the mean annual number of visits to specialists increased 20% from 4.05 to 4.87, whereas the mean number of unique specialists seen increased 34.2% from 1.63 to 2.18. The proportion of beneficiaries seeing 5 or more physicians annually increased from 17.5% to 30.1%. In 2000, a PCP's Medicare patient panel saw a median of 52 other physicians (interquartile range, 23 to 87), increasing to 95 (interquartile range, 40 to 164) in 2019. LIMITATION: Data were limited to Medicare beneficiaries and, because of the use of a 20% sample, may underestimate the number of other physicians seen across a PCP's entire panel. CONCLUSION: Outpatient care for Medicare beneficiaries has shifted toward more specialist care received from more physicians without increased primary care contact. This represents a substantial expansion of the coordination burden faced by PCPs. PRIMARY FUNDING SOURCE: National Institute on Aging.

Implementing sustainable primary healthcare reforms: strategies from Costa Rica.

As the world strives to achieve universal health coverage by 2030, countries must build robust healthcare systems founded on strong primary healthcare (PHC). In order to strengthen PHC, country governments need actionable guidance about how to implement health reform. Costa Rica is an example of a country that has taken concrete steps towards successfully improving PHC over the last two decades. In the 1990s, Costa Rica implemented three key reforms: governance restructuring, geographic empanelment, and multidisciplinary teams. To understand how Costa Rica implemented these reforms, we conducted a process evaluation based on a validated implementation science framework. We interviewed 39 key informants from across Costa Rica's healthcare system in order to understand how these reforms were implemented. Using the Exploration Preparation Implementation Sustainment (EPIS) framework, we coded the results to identify Costa Rica's key implementation strategies and explore underlying reasons for Costa Rica's success as well as ongoing challenges. We found that Costa Rica implemented PHC reforms through strong leadership, a compelling vision and deliberate implementation strategies such as building on existing knowledge, resources and infrastructure; bringing together key stakeholders and engaging deeply with communities. These reforms have led to dramatic improvements in health outcomes in the past 25 years. Our in-depth analysis of Costa Rica's specific implementation strategies offers tangible lessons and examples for other countries as they navigate the important but difficult work of strengthening PHC.

Assessment of Bypass of the Nearest Primary Health Care Facility Among Women in Ghana.

Importance: Recent reports have highlighted that expanding access to health care is ineffective at meeting the goal of universal health coverage if the care offered does not meet a minimum level of quality. Health care facilities nearest to patient's homes that are perceived to offer inadequate or inappropriate care are frequently bypassed in favor of more distant private or tertiary-level hospital facilities that are perceived to offer higher-quality care. Objective: To estimate the frequency with which women in Ghana bypass the nearest primary health care facility and describe patient experiences, costs, and other factors associated with this choice. Design, Setting, and Participants: This nationally representative survey study was conducted in 2017 and included 4203 households to identify women in Ghana aged 15 to 49 years (ie, reproductive age) who sought primary care within the last 6 months. Women who sought care within the past 6 months were included in the study. Data were analyzed from 2018 to 2019. Exposures: Bypass was defined as a woman's report that she sought care at a health facility other than the nearest facility. Main Outcomes and Measures: Sociodemographic characteristics, reasons why women sought care, reasons why women bypassed their nearest facility, ratings for responsiveness of care, patient experience, and out-of-pocket costs. All numbers and percentages were survey-weighted to account for survey design. Results: A total of 4289 women met initial eligibility criteria, and 4207 women (98.1%) completed the interview. A total of 1993 women reported having sough health care in the past 6 months, and after excluding those who were ineligible and survey weighting, the total sample included 1946 women. Among these, 629 women (32.3%) reported bypassing their nearest facilities for primary care. Women who bypassed their nearest facilities, compared with women who did not, were more likely to visit a private facility (152 women [24.5%] vs 202 women [15.6%]) and borrow money to pay for their care (151 women [24.0%] vs 234 women [17.8%]). After adjusting for covariates, women who bypassed reported paying a mean of 107.2 (95% CI, 79.1-135.4) Ghanaian Cedis (US $18.50 [95% CI, $13.65-$23.36]) for their care, compared with a mean of 58.6 (95% CI, 28.1-89.2) Ghanaian Cedis (US $10.11 [95% CI, $4.85-15.35]) for women who did not bypass (P = .006). Women who bypassed cited clinician competence (136 women [34.3%]) and availability of supplies (93 women [23.4%]) as the most important factors in choosing a health facility. Conclusions and Relevance: The findings of this survey study suggest that bypassing the nearest health care facility was common among women in Ghana and that available services at lower levels of primary care are not meeting the needs of a large proportion of women. Among the benefits women perceived from bypassing were clinician competence and availability of supplies. These data provide insights to policy makers regarding potential gaps in service delivery and may help to guide primary health care improvement efforts.

The status of Ghanaian community health workers' supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey.

Introduction: Community-based services are a critical component of high-quality primary healthcare. Ghana formally launched the National Community Health Worker (CHW) program in 2014, to augment the pre-existing Community-based Health Planning and Services (CHPS). To date, however, there is scant data about the program's implementation. We describe the current supervision and service delivery status of CHWs throughout the country. Methods: Data were collected regarding CHW supervision and service delivery during the 2017 round of the Performance Monitoring and Accountability 2020 survey. Descriptive analyses were performed by facility type, supervisor type, service delivery type, and regional distribution. Results: Over 80% of CHWs had at least monthly supervision interactions, but there was variability in the frequency of interactions. Frequency of supervision interactions did not vary by facility or supervisor type. The types of services delivered by CHWs varied greatly by facility type and region. Community mobilization, health education, and outreach for loss-to-follow-up were delivered by over three quarters of CHWs, while mental health counseling and postnatal care are provided by fewer than one third of CHWs. The Western region and Greater Accra had especially low rates of CHW service provision. Non-communicable disease treatment, which is not included in the national guidelines, was reportedly provided by some CHWs in nine out of ten regions. Conclusions: Overall, this study demonstrates variability in supervision frequency and CHW activities. A high proportion of CHWs already meet the expected frequency of supervision. Meanwhile, there are substantial differences by region of CHW service provision, which requires further research, particularly on novel CHW services such as non-communicable disease treatment. While there are important limitations to these data, these findings can be instructive for Ghanaian policymakers and implementers to target improvement initiatives for community-based services.

Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017.

INTRODUCTION: The 2018 Astana Declaration reaffirmed global commitment to primary healthcare (PHC) as a core strategy to achieve universal health coverage. To meet this potential, PHC in low-income and middle-income countries (LMIC) needs to be strengthened, but research is lacking and fragmented. We conducted a scoping review of the recent literature to assess the state of research on PHC in LMIC and understand where future research is most needed. METHODS: Guided by the Primary Healthcare Performance Initiative (PHCPI) conceptual framework, we conducted searches of the peer-reviewed literature on PHC in LMIC published between 2010 (the publication year of the last major review of PHC in LMIC) and 2017. We also conducted country-specific searches to understand performance trajectories in 14 high-performing countries identified in the previous review. Evidence highlights and gaps for each topic area of the PHCPI framework were extracted and summarised. RESULTS: We retrieved 5219 articles, 207 of which met final inclusion criteria. Many PHC system inputs such as payment and workforce are well-studied. A number of emerging service delivery innovations have early evidence of success but lack evidence for how to scale more broadly. Community-based PHC systems with supportive governmental policies and financing structures (public and private) consistently promote better outcomes and equity. Among the 14 highlighted countries, most maintained or improved progress in the scope of services, quality, access and financial coverage of PHC during the review time period. CONCLUSION: Our findings revealed a heterogeneous focus of recent literature, with ample evidence for effective PHC policies, payment and other system inputs. More variability was seen in key areas of service delivery, underscoring a need for greater emphasis on implementation science and intervention testing. Future evaluations are needed on PHC system capacities and orientation toward social accountability, innovation, management and population health in order to achieve the promise of PHC.

Facility management associated with improved primary health care outcomes in Ghana.

BACKGROUND: Strong primary health care (PHC) is essential for achieving universal health coverage, but in many low- and middle-income countries (LMICs) PHC services are of poor quality. Facility management is hypothesized to be critical for improving PHC performance, but evidence about management performance and its associations with PHC in LMICs remains limited. METHODS: We quantified management performance of PHC facilities in Ghana and assessed the experiences of women who sought care at sampled facilities. Using multi-level models, we examined associations of facility management with five process outcomes and eight experiential outcomes. FINDINGS: On a scale of 0 to 1, the average overall management score in Ghana was 0·76 (IQR = 0·68-0·85). Facility management was significantly associated with one process outcome and three experiential outcomes. Controlling for facility characteristics, facilities with management scores at the 90th percentile (management score = 0·90) had 22% more essential drugs compared to facilities with management scores at the 10th percentile (0·60) (p = 0·002). Positive statistically non-significant associations were also seen with three additional process outcomes-integration of family planning services (p = 0·054), family planning types provided (p = 0·067), and essential equipment availability (p = 0·104). Compared to women who sought care at facilities with management scores at the 10th percentile, women who sought care at facilities at the 90th percentile reported 8% higher ratings of trust in providers (p = 0·028), 15% higher ratings of ease of following provider's advice (p = 0·030), and 16% higher quality rating (p = 0·020). However, women who sought care in the 90th percentile facilities rated their waiting times as worse (22% lower, p = 0·039). INTERPRETATION: Higher management scores were associated with higher scores for some process and experiential outcomes. Large variations in management performance indicate the need to strengthen management practices to help realize the full potential of PHC in improving health outcomes.

Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015.

Importance: Recent US health care reforms incentivize improved population health outcomes and primary care functions. It remains unclear how much improving primary care physician supply can improve population health, independent of other health care and socioeconomic factors. Objectives: To identify primary care physician supply changes across US counties from 2005-2015 and associations between such changes and population mortality. Design, Setting, and Participants: This epidemiological study evaluated US population data and individual-level claims data linked to mortality from 2005 to 2015 against changes in primary care and specialist physician supply from 2005 to 2015. Data from 3142 US counties, 7144 primary care service areas, and 306 hospital referral regions were used to investigate the association of primary care physician supply with changes in life expectancy and cause-specific mortality after adjustment for health care, demographic, socioeconomic, and behavioral covariates. Analysis was performed from March to July 2018. Main Outcomes and Measures: Age-standardized life expectancy, cause-specific mortality, and restricted mean survival time. Results: Primary care physician supply increased from 196 014 physicians in 2005 to 204 419 in 2015. Owing to disproportionate losses of primary care physicians in some counties and population increases, the mean (SD) density of primary care physicians relative to population size decreased from 46.6 per 100 000 population (95% CI, 0.0-114.6 per 100 000 population) to 41.4 per 100 000 population (95% CI, 0.0-108.6 per 100 000 population), with greater losses in rural areas. In adjusted mixed-effects regressions, every 10 additional primary care physicians per 100 000 population was associated with a 51.5-day increase in life expectancy (95% CI, 29.5-73.5 days; 0.2% increase), whereas an increase in 10 specialist physicians per 100 000 population corresponded to a 19.2-day increase (95% CI, 7.0-31.3 days). A total of 10 additional primary care physicians per 100 000 population was associated with reduced cardiovascular, cancer, and respiratory mortality by 0.9% to 1.4%. Analyses at different geographic levels, using instrumental variable regressions, or at the individual level found similar benefits associated with primary care supply. Conclusions and Relevance: Greater primary care physician supply was associated with lower mortality, but per capita supply decreased between 2005 and 2015. Programs to explicitly direct more resources to primary care physician supply may be important for population health.

Health Care Spending Slowed After Rhode Island Applied Affordability Standards To Commercial Insurers.

States are introducing regulations to slow health care spending growth, but which of these successfully reduce spending growth remains unclear. We studied Rhode Island's 2010 affordability standards, which imposed price controls-particularly inflation caps and diagnosis-based payments-on contracts between commercial insurers and hospitals and clinics and required commercial insurers to increase their spending on primary care and care coordination services. Using a difference-in-differences design, we compared spending among 38,001 commercially insured adults in Rhode Island to that among 38,001 matched adults in other states in the period 2007-16. Relative to quarterly fee-for-service (FFS) spending among the control group, quarterly FFS spending among the Rhode Island group decreased by $76 per enrollee after implementation of the policy, or a decline of 8.1 percent from 2009 spending. Quarterly non-FFS primary care coordination spending increased by $21 per enrollee. Total spending growth decreased, driven by lower prices concordant with the adoption of price controls. Quality measures were unaffected or improved. The Rhode Island experience indicates that states may be able to slow total commercial health care spending growth through price controls while maintaining quality.

Adverse Events and Resource Use Before and After Treat-to-Target in Rheumatoid Arthritis: A Post Hoc Analysis of a Randomized Controlled Trial.

OBJECTIVE: Treat-to-target (TTT) is an accepted paradigm for care of patients with rheumatoid arthritis (RA). Because TTT can be associated with more medication switches, concerns arise regarding whether implementing TTT may increase adverse events and/or resource use. The aim of this study was to examine adverse events and resource use during the preintervention and intervention periods of the TTT intervention trial. METHODS: We used data from 6 practices enrolled in an 18-month cluster-randomized controlled trial to compare adverse events and resource use before (months 1-9) and during (months 10-18) a TTT intervention. The outcomes of interest, adverse events and resource use, were based on medical record review of all rheumatology visits for RA patients before and during the intervention. RESULTS: We examined records for 321 patients before the intervention and 315 during the intervention. An adverse event was recorded in 10.2% of visits before the intervention and 8.8% of visits during the intervention (P = 0.41). Biologic disease-modifying antirheumatic drugs were taken by 53.6% of patients before the intervention and 49.8% of patients during the intervention (P = 0.73). Rheumatology visits were more frequent before the intervention (mean ± SD 4.0 ± 1.4) than during the intervention (mean ± SD 3.6 ± 1.2; P = 0.02). More visits were accompanied by monitoring laboratory tests before the intervention (90.0%) compared with during the intervention (52.7%; P < 0.001). A greater percentage of visits before the intervention included diagnostic imaging (15.4%) versus during the intervention (8.9%; P < 0.001). CONCLUSION: We observed similar rates of adverse events before and during the implementation of TTT for RA. Rheumatology visits, use of laboratory monitoring, and diagnostic imaging did not increase during the TTT intervention.

Gatekeeping and patterns of outpatient care post healthcare reform.

OBJECTIVES: As US healthcare spending increases, insurers are focusing attention on decreasing potentially avoidable specialist care. Little recent research has assessed whether the design of modern health maintenance organization (HMO) insurance is associated with lower utilization of outpatient specialty care versus less restrictive preferred provider organization (PPO) plans. STUDY DESIGN: Observational study of Massachusetts residents aged 21 to 64 years with any HMO or PPO insurance coverage from 2010 to 2013. METHODS: We examined rates and patterns of primary care visits, new specialist visits, and specialist spending among HMO versus PPO enrollees. We estimated multivariable regression models for each outcome, adjusting for patient and insurance characteristics. RESULTS: From 2010 to 2013, 546,397 and 295,427 individuals had continuous HMO or PPO coverage, respectively. HMO patients had fewer annual new specialist visits per member versus PPO patients (unadjusted, 0.37 vs 0.43), a difference after adjustment of 0.05 annual visits, or a 12% relative decrease among HMO members (P <.001). These visits were more likely to be with a specialist in the same health system as the patient's primary care physician (44.9% vs 40.7%; adjusted difference, 2.8 percentage points; P <.001). Mean annual spending on new specialist visits and subsequent follow-up per member was lower in HMO versus PPO patients (unadjusted, $104.10 vs $128.10), translating to 12% lower annual spending (adjusted difference, -$16.26; P <.001). CONCLUSIONS: Having HMO insurance was associated with lower rates of new specialist visits and lower spending on specialist visits, and these visits were less likely to occur across multiple health systems. The impact of this change on overall spending and clinical outcomes remains unknown.

Finance and Time Use Implications of Team Documentation for Primary Care: A Microsimulation.

PURPOSE: To estimate the conditions under which team documentation-having a staff member enter history, place orders, and guide patients-would be financially viable at primary care practices, accounting for implementation costs. METHODS: We applied a validated microsimulation model of practice costs, revenues, and time use to data from 643 US primary care practices. We estimated critical threshold values for time saved from routine visits that would need to be redirected to new visits to avoid net revenue losses under: (1) a clerical documentation assistant (CDA) strategy where a scribe assists with recordkeeping; and (2) an advanced team-based care (ATBC) strategy where medical assistants perform history, documentation, counseling, and order entry. RESULTS: Using a fee-for-service model, we estimated that physicians would need to save 3.5 (95% CI, 3.3-3.7) minutes/encounter under a CDA strategy and 7.4 (95% CI, 4.3-10.5) minutes/encounter under an ATBC strategy to prevent net revenue losses. The redirected time would be expected to add 317 visit slots per year under CDA strategy, and 720 under ATBC strategy. Using a capitated payment model, physicians would need to empanel at least 127 (95% CI, 70-187) more patients under CDA and 227 (95% CI, 153-267) under ATBC to prevent revenue losses. Additional patient visits expected would be 279 (95% CI, 140-449) additional visit slots per year under CDA and 499 (95% CI, 454-641) under ATBC. CONCLUSIONS: Financial viability of team documentation under fee-for-service payment may require more physician time to be reallocated to patient encounters than under a capitated payment model.

Risk Stratification Methods and Provision of Care Management Services in Comprehensive Primary Care Initiative Practices.

PURPOSE: Risk-stratified care management is essential to improving population health in primary care settings, but evidence is limited on the type of risk stratification method and its association with care management services. METHODS: We describe risk stratification patterns and association with care management services for primary care practices in the Comprehensive Primary Care (CPC) initiative. We undertook a qualitative approach to categorize risk stratification methods being used by CPC practices and tested whether these stratification methods were associated with delivery of care management services. RESULTS: CPC practices reported using 4 primary methods to stratify risk for their patient populations: a practice-developed algorithm (n = 215), the American Academy of Family Physicians' clinical algorithm (n = 155), payer claims and electronic health records (n = 62), and clinical intuition (n = 52). CPC practices using practice-developed algorithm identified the most number of high-risk patients per primary care physician (282 patients, P = .006). CPC practices using clinical intuition had the most high-risk patients in care management and a greater proportion of high-risk patients receiving care management per primary care physician (91 patients and 48%, P =.036 and P =.128, respectively). CONCLUSIONS: CPC practices used 4 primary methods to identify high-risk patients. Although practices that developed their own algorithm identified the greatest number of high-risk patients, practices that used clinical intuition connected the greatest proportion of patients to care management services.

Behavioral Health Integration into Primary Care: a Microsimulation of Financial Implications for Practices.

BACKGROUND: New payments from Medicare encourage behavioral health services to be integrated into primary care practice activities. OBJECTIVE: To evaluate the financial impact for primary care practices of integrating behavioral health services. DESIGN: Microsimulation model. PARTICIPANTS: We simulated patients and providers at federally qualified health centers (FQHCs), non-FQHCs in urban and rural high-poverty areas, and practices outside of high-poverty areas surveyed by the National Association of Community Health Centers, National Ambulatory Medical Care Survey, National Health and Nutrition Examination Survey, and National Health Interview Survey. INTERVENTIONS: A collaborative care model (CoCM), involving telephone-based follow-up from a behaviorist care manager, or a primary care behaviorist model (PCBM), involving an in-clinic behaviorist. MAIN MEASURES: Net revenue change per full-time physician. KEY RESULTS: When behavioral health integration services were offered only to Medicare patients, net revenue was higher under CoCM (averaging $25,026 per MD in year 1 and $28,548/year in subsequent years) than PCBM (-$7052 in year 1 and -$3706/year in subsequent years). When behavioral health integration services were offered to all patients and were reimbursed by Medicare and private payers, only practices adopting the CoCM approach consistently gained net revenues. The outcomes of the model were sensitive to rates of patient referral acceptance, presentation, and therapy completion, but the CoCM approach remained consistently financially viable whereas PCBM would not be in the long-run across practice types. CONCLUSIONS: New Medicare payments may offer financial viability for primary care practices to integrate behavioral health services, but this viability depends on the approach toward care integration.

High Levels Of Capitation Payments Needed To Shift Primary Care Toward Proactive Team And Nonvisit Care.

Capitated payments in the form of fixed monthly payments to cover all of the costs associated with delivering primary care could encourage primary care practices to transform the way they deliver care. Using a microsimulation model incorporating data from 969 US practices, we sought to understand whether shifting to team- and non-visit-based care is financially sustainable for practices under traditional fee-for-service, capitated payment, or a mix of the two. Practice revenues and costs were computed for fee-for-service payments and a range of capitated payments, before and after the substitution of team- and non-visit-based services for low-complexity in-person physician visits. The substitution produced financial losses for simulated practices under fee-for-service payment of $42,398 per full-time-equivalent physician per year; however, substitution produced financial gains under capitated payment in 95 percent of cases, if more than 63 percent of annual payments were capitated. Shifting to capitated payment might create an incentive for practices to increase their delivery of team- and non-visit-based primary care, if capitated payment levels were sufficiently high.