Assessment of structured data elements for social risk factors.

OBJECTIVES: Computable social risk factor phenotypes derived from routinely collected structured electronic health record (EHR) or health information exchange (HIE) data may represent a feasible and robust approach to measuring social factors. This study convened an expert panel to identify and assess the quality of individual EHR and HIE structured data elements that could be used as components in future computable social risk factor phenotypes. STUDY DESIGN: Technical expert panel. METHODS: A 2-round Delphi technique included 17 experts with an in-depth knowledge of available EHR and/or HIE data. The first-round identification sessions followed a nominal group approach to generate candidate data elements that may relate to socioeconomics, cultural context, social relationships, and community context. In the second-round survey, panelists rated each data element according to overall data quality and likelihood of systematic differences in quality across populations (ie, bias). RESULTS: Panelists identified a total of 89 structured data elements. About half of the data elements (n = 45) were related to socioeconomic characteristics. The panelists identified a diverse set of data elements. Elements used in reimbursement-related processes were generally rated as higher quality. Panelists noted that several data elements may be subject to implicit bias or reflect biased systems of care, which may limit their utility in measuring social factors. CONCLUSIONS: Routinely collected structured data within EHR and HIE systems may reflect patient social risk factors. Identifying and assessing available data elements serves as a foundational step toward developing future computable social factor phenotypes.

Practice strategies to improve primary care for chronic disease patients under a pay-for-value program.

BACKGROUND: Improving primary care for patients with chronic illness is critical to advancing healthcare quality and value. Yet, little is known about what strategies are successful in helping primary care practices deliver high-quality care for this population under value-based payment models. METHODS: Double-blind interviews in 14 primary care practices in the state of Michigan, stratified based on whether they did (n = 7) or did not (n = 7) demonstrate improvement in primary care outcomes for patients with at least one reported chronic disease between 2010 and 2013. All practices participate in a statewide pay-for-performance program run by a large commercial payer. Using an implementation science framework to identify leverage points for effecting organizational change, we sought to identify, describe and compare strategies among improving and non-improving practices across three domains: (1) organizational learning opportunities, (2) approaches to motivating staff, and (3) acquisition and use of resources. RESULTS: We identified 10 strategies; 6 were "differentiating" - that is, more prevalent among improving practices. These differentiating strategies included: (1) participation in learning collaboratives, (2) accessing payer tools to monitor quality performance, (3) framing pay-for-performance as a practice transformation opportunity, (4) reinvesting earned incentive money in equitable, practice-centric improvement, (5) employing a care manager, and (6) using available technical support from local hospitals and provider organizations to support performance improvement. Implementation of these strategies varied based on organizational context and relative strengths. CONCLUSIONS: Practices that succeeded in improving care for chronic disease patients pursued a mix of strategies that helped meet immediate care delivery needs while also creating new adaptive structures and processes to better respond to changing pressures and demands. These findings help inform payers and primary care practices seeking evidence-based strategies to foster a stronger delivery system for patients with significant healthcare needs.

Sustained participation in a pay-for-value program: impact on high-need patients.

OBJECTIVE: To assess whether multi-year engagement by primary care practices in a pay-for-value program was associated with improved care for high-need patients. STUDY DESIGN: Longitudinal cohort study of 17,443 patients with 2 or more conditions who were assigned to primary care providers (PCPs) within 1582 practices that did and did not continuously participate in Blue Cross Blue Shield of Michigan's pay-for-value program (the Physician Group Incentive Program [PGIP]) between 2010 and 2013. METHODS: We used generalized linear mixed models, with patient-level random effects, to assess the relationship between whether practices continuously participated in PGIP and those practices' cost, use, and quality outcomes (derived from claims data) over a 4-year period. For most outcomes, models estimated the odds of any cost and utilization, as well as the amount of cost and utilization contingent on having any. RESULTS: High-need patients whose PCPs continuously participated in PGIP had lower odds of 30- and 90-day readmissions (odds ratio [OR], 0.65 and 0.63, respectively; P <.01 for both) over time compared with patients with PCPs who did not continuously participate. They also appeared to have lower odds of any emergency department visits (OR, 0.88; P <.01) and receive higher overall quality (1.6% higher; P <.01), as well as medication management-specific quality (3.0% higher; P <.01). We observed no differences in overall medical-surgical cost. CONCLUSIONS: Continuous PCP participation in a pay-for-value program was associated with lower use and improved quality over time, but not lower costs, for high-need patients. National policy efforts to engage PCPs in pay-for-value reimbursement is therefore likely to achieve some intended outcomes but may not be sufficient to deliver care that is of substantially higher value.

Michigan's fee-for-value physician incentive program reduces spending and improves quality in primary care.

As policy makers and others seek to reduce health care cost growth while improving health care quality, one approach gaining momentum is fee-for-value reimbursement. This payment strategy maintains the traditional fee-for-service arrangement but includes quality and spending incentives. We examined Blue Cross Blue Shield of Michigan's Physician Group Incentive Program, which uses a fee-for-value approach focused on primary care physicians. We analyzed the program's impact on quality and spending from 2008 to 2011 for over three million beneficiaries in over 11,000 physician practices. Participation in the incentive program was associated with approximately 1.1 percent lower total spending for adults (5.1 percent lower for children) and the same or improved performance on eleven of fourteen quality measures over time. Our findings contribute to the growing body of evidence about the potential effectiveness of models that align payment with cost and quality performance, and they demonstrate that it is possible to transform reimbursement within a fee-for-service framework to encourage and incentivize physicians to provide high-quality care, while also reducing costs.

Improving EHR Capabilities to Facilitate Stage 3 Meaningful Use Care Coordination Criteria.

Primary care practices have been limited in their ability to leverage electronic health records (EHRs) and health information exchange (HIE) to improve care coordination, but will soon be incentivized to do so under proposed Stage 3 meaningful use criteria. We use mixed methods to understand how primary care practices manage, share and reconcile electronic patient information across care settings, and identify innovations in EHR design to support enhanced care coordination. Opportunities identified by practices focused on availability and usability of features that facilitate (1) generation of customized summary of care records, (2) team-based care approaches, and (3) management of the increased volume of electronic information generated and exchanged during care transitions. More broadly, vendors and policymakers need to continue to work together to improve interoperability as the key to effective care coordination. If these EHR innovations were widespread, the value of meeting the proposed Stage 3 care coordination criteria would be substantially enhanced.

Benchmarking health IT among OECD countries: better data for better policy.

OBJECTIVE: To develop benchmark measures of health information and communication technology (ICT) use to facilitate cross-country comparisons and learning. MATERIALS AND METHODS: The effort is led by the Organisation for Economic Co-operation and Development (OECD). Approaches to definition and measurement within four ICT domains were compared across seven OECD countries in order to identify functionalities in each domain. These informed a set of functionality-based benchmark measures, which were refined in collaboration with representatives from more than 20 OECD and non-OECD countries. We report on progress to date and remaining work to enable countries to begin to collect benchmark data. RESULTS: The four benchmarking domains include provider-centric electronic record, patient-centric electronic record, health information exchange, and tele-health. There was broad agreement on functionalities in the provider-centric electronic record domain (eg, entry of core patient data, decision support), and less agreement in the other three domains in which country representatives worked to select benchmark functionalities. DISCUSSION: Many countries are working to implement ICTs to improve healthcare system performance. Although many countries are looking to others as potential models, the lack of consistent terminology and approach has made cross-national comparisons and learning difficult. CONCLUSIONS: As countries develop and implement strategies to increase the use of ICTs to promote health goals, there is a historic opportunity to enable cross-country learning. To facilitate this learning and reduce the chances that individual countries flounder, a common understanding of health ICT adoption and use is needed. The OECD-led benchmarking process is a crucial step towards achieving this.

The Impact of HIT on Cost and Quality in Patient-Centered Medical Home Practices.

While health IT is thought to play a critical role in supporting new models of care delivery, we know little about the extent to which HIT improves cost and quality outcomes. We studied a large patient-centered medical home (PCMH) program to assess which types of HIT led to improvements in composite performance outcomes: PMPM cost, chronic disease management, medication management, and preventive care. At baseline, registries were associated with lower PMPM spending (-$19.37; p<0.05). Over time, practices that newly adopted EHRs had smaller gains in chronic disease management adherence relative to non-adopters (diff-in-diff: -1.55%; p<0.05). We failed to find a relationship between other types of HIT - ePrescribing and PHRs/Portals - and our composite outcomes. The lack of consistent relationship between HIT adoption and improved performance suggest that these tools may not yet support the clinical activities and approaches to patient engagement that enable PCMHs to deliver higher-quality, lower-cost care.

Engaging primary care physicians in quality improvement: lessons from a payer-provider partnership.

A health insurer in Michigan, through its Physician Group Incentive Program, engaged providers across the state in a collection of financially incentivized initiatives to transform primary care and improve quality. We investigated physicians' and other program stakeholders' perceptions of the program through semistructured interviews with more than 80 individuals. We found that activities across five areas contributed to successful provider engagement: (1) developing a vision of improving primary care, (2) deliberately fostering practice-practice partnerships, (3) using existing infrastructure, (4) leveraging resources and market share, and (5) managing program trade-offs. Our research highlights effective strategies for engaging primary care physicians in program design and implementation processes and creating learning communities to support quality improvement and practice change.

The policy context of patient centered medical homes: perspectives of primary care providers.

BACKGROUND: Interest in the patient centered medical home (PCMH) model has increased significantly in recent years. Despite this attention, information is limited regarding the influence of policy context on implementation of the PCMH model. Using comparative, qualitative data, we identify several key policy impediments to PCMH implementation, and propose practical guidelines for addressing these issues. RESEARCH DESIGN: Qualitative, semi-structured in-person interviews with representatives of physician organizations and primary care practices pursuing PCMH. PARTICIPANTS: Practitioners and staff at 16 physician practices in Michigan, as well as key leaders of physician organizations. KEY RESULTS: We identified five primary policy issues cited by physicians and physician organization leaders as most impactful on their efforts to adopt PCMH: misalignment of current reimbursement schemes, administrative burden, conflicting criteria for PCMH designation, workforce policy issues, and uncertainty of health care reform. These policies were largely seen as barriers to their ability to implement PCMH. CONCLUSIONS: Providers' motivation to embrace PCMH, and their level of confidence regarding the results of such change, are greatly influenced by their perception of the external environment and the control they believe they have over this environment. Having policies in place that shape the path to PCMH in a manner that makes it as easy as possible for providers to accomplish the desired changes could well make the difference in whether successful transformation is achieved.

Implementing the IT infrastructure for health reform: adoption of health IT among patient-centered medical home practices.

While health IT is thought to be critical to the success of new models of care delivery, we know little about the extent to which those pursuing these models are relying on HIT. We studied a large patient-centered medical home (PCMH) demonstration project, a new model of care delivery that has received substantial policy attention, in order to assess which types of HIT were most widely used, and how adoption rates changed over time as PCMH practices matured. We found that clinically-focused HIT tools were both widely adopted, and increasingly adopted, in PCMH practices compared to non-PCMH practices. In contrast, HIT that supports patient-engagement, patient portals and personal health records, was neither in widespread use nor more likely to be adopted over time by PCMH practices compared to other practices. This suggests that these tools may not yet support the types of patient engagement and interactions that PCMH practices seek.

Physician practice responses to financial incentive programs: exploring the concept of implementation mechanisms.

PURPOSE: To develop a framework for studying financial incentive program implementation mechanisms, the means by which physician practices and physicians translate incentive program goals into their specific office setting. Understanding how new financial incentives fit with the structure of physician practices and individual providers' work may shed some insight on the variable effects of physician incentives documented in numerous reviews and meta-analyses. DESIGN/METHODOLOGY/APPROACH: Reviewing select articles on pay-for-performance evaluations to identify and characterize the presence of implementation mechanisms for designing, communicating, implementing, and maintaining financial incentive programs as well as recognizing participants' success and effects on patient care. FINDINGS: Although uncommonly included in evaluations, evidence from 26 articles reveals financial incentive program sponsors and participants utilized a variety of strategies to facilitate communication about program goals and intentions, to provide feedback about participants' progress, and to assist-practices in providing recommended services. Despite diversity in programs' geographic locations, clinical targets, scope, and market context, sponsors and participants deployed common strategies. While these methods largely pertained to communication between program sponsors and participants and the provision of information about performance through reports and registries, they also included other activities such as efforts to engage patients and ways to change staff roles. LIMITATIONS: This review covers a limited body of research to develop a conceptual framework for future research; it did not exhaustively search for new articles and cannot definitively link particular implementation mechanisms to outcomes. PRACTICAL IMPLICATIONS: Our results underscore the effects implementation mechanisms may have on how practices incorporate new programs into existing systems of care which implicates both the potential rewards from small changes as well as the resources which may be required to obtain buy-in and support. ORIGINALITY/VALUE: We identify gaps in previous research regarding actual changes occurring in physician practices in response to physician incentive programs. We offer suggestions for future evaluation by proposing a framework for understanding implementation. Our model will assist future scholars in translating site-specific experiences with incentive programs into more broadly relevant guidance for practices by facilitating comparisons across seemingly disparate programs.

Journey toward a patient-centered medical home: readiness for change in primary care practices.

CONTEXT: Information is limited regarding the readiness of primary care practices to make the transformational changes necessary to implement the patient-centered medical home (PCMH) model. Using comparative, qualitative data, we provide practical guidelines for assessing and increasing readiness for PCMH implementation. METHODS: We used a comparative case study design to assess primary care practices' readiness for PCMH implementation in sixteen practices from twelve different physician organizations in Michigan. Two major components of organizational readiness, motivation and capability, were assessed. We interviewed eight practice teams with higher PCMH scores and eight with lower PCMH scores, along with the leaders of the physician organizations of these practices, yielding sixty-six semistructured interviews. FINDINGS: The respondents from the higher and lower PCMH scoring practices reported different motivations and capabilities for pursuing PCMH. Their motivations pertained to the perceived value of PCMH, financial incentives, understanding of specific PCMH requirements, and overall commitment to change. Capabilities that were discussed included the time demands of implementation, the difficulty of changing patients' behavior, and the challenges of adopting health information technology. Enhancing the implementation of PCMH within practices included taking an incremental approach, using data, building a team and defining roles of its members, and meeting regularly to discuss the implementation. The respondents valued external organizational support, regardless of its source. CONCLUSIONS: The respondents from the higher and lower PCMH scoring practices commented on similar aspects of readiness-motivation and capability-but offered very different views of them. Our findings suggest the importance of understanding practice perceptions of the motivations for PCMH and the capability to undertake change. While this study identified some initial approaches that physician organizations and practices have used to prepare for practice redesign, we need much more information about their effectiveness.

Physician practices, e-prescribing and accessing information to improve prescribing decisions.

Hoping to reduce medication errors and contain health care costs, policy makers are promoting electronic prescribing through Medicare and Medicaid financial incentives. Many e-prescribing systems provide electronic access to important information--for example, medications prescribed by physicians in other practices, patient formularies and generic alternatives--when physicians are deciding what medications to prescribe. However, physician practices with e-prescribing face challenges using these features effectively, according to a new qualitative study by the Center for Studying Health System Change (HSC) funded by the Agency for Healthcare Research and Quality (AHRQ). While most of the 24 practices studied reported that physicians had access to patient formulary information, only slightly more than half reported physician access to patient medication histories, and many physicians did not routinely review these sources of information when making prescribing decisions. Study respondents highlighted two barriers to use: (1) tools to view and import the data into patient records were cumbersome to use in some systems; and (2) the data were not always perceived as useful enough to warrant the additional time to access and review them, particularly during time-pressed patient visits. To support generic prescribing, practices typically set their system defaults to permit pharmacist substitution of generics; many practices also used other tools to more proactively identify and select generic alternatives at the point of prescribing. Overall, physicians who more strongly perceived the need for third-party data, those in practices with greater access to complete and accurate data, and those with easier-to-use e-prescribing systems were more likely to use these features consistently.

Workplace clinics: a sign of growing employer interest in wellness.

Interest in workplace clinics has intensified in recent years, with employers moving well beyond traditional niches of occupational health and minor acute care to offering clinics that provide a full range of wellness and primary care services. Employers view workplace clinics as a tool to contain medical costs, boost productivity and enhance companies' reputations as employers of choice. The potential for clinics to transform primary care delivery through the trusted clinician model holds promise, according to experts interviewed for a new qualitative research study from the Center for Studying Health System Change (HSC). Achieving that model is dependent on gaining employee trust in the clinic, as well as the ability to recruit and retain clinicians with the right qualities--a particular challenge in communities with provider shortages. Even when clinic operations are outsourced to vendors, initial employer involvement--including the identification of the appropriate scope and scale of clinic services--and sustained employer attention over time are critical to clinic success. Measuring the impact of clinics is difficult, and credible evidence on return on investment (ROI) varies widely, with very high ROI claims made by some vendors lacking credibility. While well-designed, well-implemented workplace clinics are likely to achieve positive returns over the long term, expecting clinics to be a game changer in bending the overall health care cost curve may be unrealistic.

The economic recession: early impacts on health care safety net providers.

While the recession increased demands on the health care safety net as Americans lost jobs and health insurance, the impact on safety net providers has been mixed and less severe--at least initially--than expected in some cases, according to a new study of five metropolitan communities by the Center for Studying Health System Change (HSC). Even before the recession, many safety net providers reported treating more uninsured patients and facing tighter state and local funding. Federal expansion grants for community health centers during the past decade, however, have increased capacity at many health centers. And, programs to help direct people to primary care providers may have helped stem the expected surge in emergency department use by the uninsured during the downturn. Federal stimulus funding--the 2009 American Recovery and Reinvestment Act--has assisted hospitals and health centers in weathering the economic storm, helping to offset reductions in state, local and private funding. And, the economic downturn has generated some potential benefits, including lower rents and broader employee applicant pools. While safety net providers have adopted strategies to stay financially viable, many believe they have not yet felt the full impact of the deepest recession since the Great Depression.

Individual insurance: health insurers try to tap potential market growth.

Individual insurance is the only source of health coverage for people without access to employer-sponsored insurance or public insurance. Individual insurance traditionally has been sought by older, sicker individuals who perceive the need for insurance more than younger, healthier people. The attraction of a sicker population to the individual market creates adverse selection, leading insurers to employ medical underwriting--which most states allow--to either avoid those with the greatest health needs or set premiums more reflective of their expected medical use. Recently, however, several factors have prompted insurers to recognize the growth potential of the individual market: a declining proportion of people with employer-sponsored insurance, a sizeable population of younger, healthier people forgoing insurance, and the likelihood that many people receiving subsidies to buy insurance under proposed health insurance reforms would buy individual coverage. Insurers are pursuing several strategies to expand their presence in the individual insurance market, including entering less-regulated markets, developing lower-cost, less-comprehensive products targeting younger, healthy consumers, and attracting consumers through the Internet and other new distribution channels, according to a new study by the Center for Studying Health System Change (HSC). Insurers' strategies in the individual insurance market are unlikely to meet the needs of less-than-healthy people seeking affordable, comprehensive coverage. Congressional health reform proposals, which envision a larger role for the individual market under a sharply different regulatory framework, would likely supersede insurers' current individual market strategies.

Coordination of care by primary care practices: strategies, lessons and implications.

Despite calls from numerous organizations and payers to improve coordination of care, there are few published accounts of how care is coordinated in real-world primary care practices. This study by the Center for Studying Health System Change (HSC) documents strategies that a range of physician practices use to coordinate care for their patients. While there was no single recipe for coordination given the variety of patient, physician, practice and market factors, some cross-cutting lessons were identified, such as the value of a commitment to interpersonal continuity of care as a foundation for coordination. Respondents also identified the importance of system support for the standardization of office processes to foster care coordination. While larger practices may have more resources to invest, many of the innovations described could be scaled to smaller practices. Some coordination strategies resulted in improved efficiency over time for practices, but by and large, physician practices currently pursue these efforts at their own expense. In addition to sharing information on effective strategies among practices, the findings also provide policy makers with a snapshot of the current care coordination landscape and implications for initiatives to improve coordination. Efforts to provide technical support to practices to improve coordination, for example, through medical-home initiatives, need to consider the baseline more typical practices may be starting from and tailor their support to practices ranging widely in size, resources and presence of standardized care processes. If aligned with payment incentives, some of these strategies have the potential to increase quality and satisfaction among patients and providers by helping to move the health care delivery system toward better coordinated care.

Financial and health burdens of chronic conditions grow.

Almost 72 million working-age Americans--18-64 years old--live with chronic conditions, such as diabetes, asthma or depression. In 2007, almost three in 10, or more than 20 million people with chronic conditions, lived in families with problems paying medical bills--a significant increase from 21 percent in 2003, according to a new national study by the Center for Studying Health System Change (HSC). While problems paying medical bills are especially acute and still rising for uninsured people with chronic conditions (62%), medical-bill problems also are significant and growing among people with private insurance and higher incomes. For the more than 20 million chronically ill adults with medical bill problems in 2007, one in four went without needed medical care, half put off care and more than half went without a prescription medication because of cost concerns.

Checking up on retail-based health clinics: is the boom ending?

Retail store-based health clinics, which provide basic preventive services and diagnose and treat simple health ailments, have proliferated rapidly in recent years. Younger families and people that have difficulty accessing health care services--including the uninsured and minorities--are among the groups most likely to use these clinics. Still, in 2007, only 1.2 percent of U.S. families reported they had visited a retail clinic during the past 12 months, and only 2.3 percent of families reported ever having visited one, according to the Health Tracking Household Survey conducted by the Center for Studying Health System Change. The boom in retail clinics, moreover, appears to be slowing. Continued fall-off in the growth of retail clinics would likely disproportionately affect underserved Americans who lack affordable alternatives for primary care.

Striking jump in consumers seeking health care information.

In 2007, 56 percent of American adults--more than 122 million people--sought information about a personal health concern, up from 38 percent in 2001, according to a new national study by the Center for Studying Health System Change (HSC). Use of all information sources rose substantially, with the Internet leading the way: Internet information seeking doubled to 32 percent during the six-year period. Consumers across all categories of age, education, income, race/ethnicity and health status increased their information seeking significantly, but education level remained the key factor in explaining how likely people are to seek health information. Although elderly Americans--65 and older--sharply increased their information seeking, they still trail younger Americans by a substantial margin, especially in using Internet information sources. Consumers who actively researched health concerns widely reported positive impacts: More than half said the information changed their overall approach to maintaining their health, and four in five said that the information helped them to better understand how to treat an illness or condition.