Physician-Level Continuity of Care and Patient Outcomes in All-Payer Claims Database.

INTRODUCTION: Being one of the few existing measures of primary care functions, physician-level continuity of care (Phy-CoC) is measured by the weighted average of patient continuity scores. Compared with the well-researched patient-level continuity, Phy-CoC is a new instrument with limited evidence from Medicare beneficiaries. This study aimed to expand the patient sample to include patients of all ages and all types of insurance and reassess the associations between full panel-based Phy-CoC scores and patient outcomes. METHODS: Cross-sectional analysis at patient-level using Virginia All-Payer Claims Database (VA-APCD). Phy-CoC scores were calculated by averaging patient's Bice-Boxerman Index scores and weighted by the total number of visits. Patient outcomes included total cost and preventable hospitalization. RESULTS: In a sample of 1.6 million Virginians, patients who lived in rural areas or had Medicare as primary insurance were more likely to be attributed to physicians with the highest Phy-CoC scores. Across all adult patient populations, we found that being attributed to physicians with higher Phy-CoC was associated with 7%-11.8% higher total costs, but was not associated with the odds of preventable hospitalization. Results from models with interactions revealed nuanced associations between Phy-CoC and total cost with patient's age and comorbidity, insurance payer, and the specialty of their physician. CONCLUSIONS: In this comprehensive examination of Phy-CoC using all populations from the VA-APCD, we found an overall positive association of higher full panel-based Phy-CoC with total cost, but a non-significant association with the risk of preventable hospitalization. Achieving higher full panel-based Phy-CoC may have unintended cost implications.

Trends of Geriatric Certification and Practice Patterns of Family Physicians: 1988-2019.

BACKGROUND AND OBJECTIVES: Demand for geriatric care is increasing due to aging population. Trends in maintaining certification in geriatrics are unreported. Our objective was to describe the historic trend of family physicians who certified in geriatric medicine (FPs-GM) since 1988 and to assess differences in practice patterns between FPs-GM and family physicians (FPs). METHODS: We performed a retrospective descriptive study using administrative data collected by the American Board of Family Medicine (ABFM). The study population was family physicians registering to continue their ABFM certification from 2017 to 2019. Medicare public use billing data was linked to ABFM administrative data on certification history. We used univariate analysis for descriptive analysis and logistic regression to identify contributors of recertification in geriatrics. RESULTS: We identified a total of 3,207 FPs-GM between 1988 and 2019. More than half maintained GM certification since 2009 (57%), with male gender, White race, and urban practice associated with maintaining GM certification; 61% of their patients were older adults. FPs-GM were more likely to be in an academic practice setting with nearly half (53%) also practicing in hospitals or nursing homes. In the adjusted regression model, younger FPs or FPs who treat more older patients were significantly more likely to be recertified in geriatrics whereas other demographics and practice characteristics were not significant. CONCLUSIONS: Most FPs who recently earned GM certification tended to retain certification since the required accredited fellowship started in 1995.

Physician- versus practice-level primary care continuity and association with outcomes in Medicare beneficiaries.

OBJECTIVE: To compare physician-level versus practice-level primary care continuity and their association with expenditure and acute care utilization among Medicare beneficiaries and evaluate whether continuity of outpatient primary care at either/both physician or/and practice level could be useful quality measures. DATA SOURCE: Medicare Fee-For-Service claims data for community dwelling beneficiaries without end-stage renal disease who were attributed to a national random sample of primary care practices billing Medicare (2011-2017). STUDY DESIGN: Retrospective secondary data analysis at per Medicare beneficiary per year level. We used multivariable linear regression with practice-level fixed effects to estimate continuity of care score at physician versus practice level and their associations with outcomes. DATA COLLECTION/EXTRACTION METHOD: We calculated clinician- and practice-level Bice-Boxerman continuity of care index scores, ranging from 0 to 1, using primary care outpatient claims. Medicare expenditures, hospital admissions, emergency department (ED) visits, and readmissions were obtained from the Medicare Beneficiary Summary File: Cost and Utilization Segment. Ambulatory care sensitive conditions (ACSC) were defined using diagnosis codes on inpatient claims. PRINCIPAL FINDINGS: We studied 2,359,400 beneficiaries who sought care from 13,926 physicians. Every 0.1 increase in physician continuity score was associated with a $151 reduction in expenditure per beneficiary per year (p < 0.01), and every 0.1 increase in practice continuity score was associated with $282 decrease (p < 0.01) per beneficiary per year. Both physician- and practice-level continuity were associated with lower Medicare expenditures among small, medium, and large practices. Both physician- and practice-level continuity were associated with lower probabilities of hospitalization, ED visit, admissions for ACSC, and readmission. CONCLUSIONS: Primary care continuity of care could serve as a potent value-based care quality metric. Physician-level continuity is a unique value center that cannot be supplanted by practice-level continuity.

Family Practices in Transforming Clinical Practice Initiative Showed No Changes in Medicare Costs or Utilization.

BACKGROUND: The Centers for Medicare and Medicaid Services proposed that the Transforming Clinical Practice Initiative (TCPI) would improve health outcomes for patients, reduce utilization of institutional services, and generate significant savings for payers by the end of September 2019. OBJECTIVE: The objective of this study was to investigate whether participation in TCPI's Practice Transformation Networks (PTNs) was associated with improved cost and utilization outcomes for Medicare patients of family medicine-based practices in the first 2 years, that is, 2016-2017, of the Initiative. STUDY DESIGN: A quasi-experimental design with a longitudinal cohort of family medicine-based practices and a propensity-matched comparison sample. SUBJECTS: A total of 761 PTN practices and 3451 non-PTN practices. MEASURES: To measure practice-level patient outcomes, we attributed patients to practice based on the plurality of office visits. We obtained Medicare claims from 2011 to 2017 to assess PTN participation effects for Medicare Part A and B costs, hospital admission, and emergency department visit rates using a Difference-in-Differences design, adjusting for baseline characteristics. RESULTS: The differences in Medicare Part A and B costs (-1.71%, P=0.25), annual rates of hospitalization (-0.59%, P=0.12) and emergency department visit (-0.29%, P=0.46) were not significantly lower among PTN practices (N=761) than among propensity score-matched non-PTN practices (N=3541). CONCLUSIONS: TCPI's transforming efforts, such as the outcomes examined in the study, might need a longer time frame to manifest and require evaluation after the full 4-year participation period. The indistinguishable effect of PTN participation may also be attributed to the fact that non-PTN practices might have participated in other initiatives that changed their care and curbed health care utilization and costs consequently.

Can one or two simple questions predict poor medication adherence?

RATIONALE, AIMS, AND OBJECTIVES: Poor adherence to evidence-based medications is a major problem in conventional clinical practise. Better prognostic tools are needed to identify those with the highest likelihood of being non-adherent. The objective of this study is to determine if a 2-item patient activation status (PAS) measure identifies Medicare beneficiaries at risk of poor adherence to drugs typically recommended in treating type 2 diabetes. METHODS: PAS and medication adherence were assessed for respondents to the 2009 Medicare Current Beneficiary Survey and then compared using bivariate and multivariate tests. Participants' PAS was classified as "active," "high effort," "complacent," or "passive" based on how confident they were in identifying needed medical care and whether they brought medication lists to their doctors' visits. Adherence with oral antidiabetic drugs, angiotensin-converting enzyme-inhibitors/angiotensin receptor blockers, and statins was assessed using proportion of days covered (PDC). RESULTS: A total of 940 Medicare beneficiaries with diabetes enrolled in Part D plans in 2009. The overall effect of PAS on medication adherence was small (3% lower PDC for complacent/passive vs active/high effort beneficiaries, P < 0.10). However, interactions of complacent/passive PAS with other characteristics associated with poor adherence identified certain subgroups as especially prone to problematic adherence: age < 65 (PDC -11%, P < 0.05), non-Hispanic black (PDC -13%, P < 0.05), and morbidly obese (-9%, P < 0.10). CONCLUSION: A single question relating to taking medication lists to doctor visits may help identify patient subgroups prone to poor adherence in conventional practise, but larger samples are necessary to validate and extend these findings.

Prevalence and Factors Associated with Family Physicians Providing E-Visits.

PURPOSE: The use of telemedicine has grown in recent years. As a subset of telemedicine, e-visits typically involve the evaluation and management of a patient by a physician or other clinician through a Web-based or electronic communication system. The national prevalence of e-visits by primary care physicians is unclear as is what factors influence adoption. The purpose of this study was to examine the prevalence of family physicians providing e-visits and associated factors. METHODS: A national, cross-sectional practice demographic questionnaire for 7580 practicing family physicians was utilized. Bivariate statistics were calculated and logistic regression was conducted examining both physician level and practice level factors associated with offering e-visits. RESULTS: The overall prevalence of offering e-visits was 9.3% (n = 702). Compared with private practice physicians, other physicians were more likely to offer e-visits if their primary practice was an academic health center/faculty practice (odds ratio [OR], 1.73; 95% CI, 1.03 to 2.91), managed care/health maintenance organization (HMO) practice (OR, 9.79; 95% CI, 7.05 to 13.58), hospital-/health system-owned medical practice (not including managed care or HMO) (OR, 2.50; 95% CI, 1.83 to 3.41), workplace clinic (OR, 2.28; 95% CI, 1.43 to 3.63), or federal (military, Veterans Administration [VA]/Department of Defense) (OR, 4.49; 95% CI, 2.93 to 6.89). Physicians with no official ownership stake (OR, 0.44; 95% CI, 0.28 to 0.68) or other ownership arrangement (OR, 0.29; 95% CI, 0.12 to 0.71) had lower odds of offering e-visits compared with sole owners. CONCLUSION: Fewer than 10% of family physicians provided e-visits. Physicians in HMO and VA settings (ie, capitated vs noncapitated models) were more likely to provide e-visits, which suggests that reimbursement may be a major barrier.

Physician Opinions about American Board of Family Medicine Self-Assessment Modules (2006-2016).

INTRODUCTION: Maintenance of Certification (MOC) was implemented to help physicians remain current with evolving medical standards, but has been criticized for being irrelevant to practice. We assessed family physicians' (FPs') opinions about the content of American Board of Family Medicine (ABFM) self-assessment modules (SAMs). METHODS: We used ABFM administrative data from feedback surveys completed after each of the 16 SAMs from 2006 to 2016. FPs rated agreement with 2 statements-1) "Content is appropriate for my practice," and 2) "Content was presented at an appropriate level"-on a scale of 1 (strongly disagree) to 6 (strongly agree). We calculated mean ratings of each statement by year and stratified by Knowledge Assessment (KA) and Clinical Simulation (CS) portions of the SAM. We plotted mean ratings by FPs' age at their first SAM completion and the total number of SAMs completed. RESULTS: SAMs were completed (n = 633,198) from 2006 to 2016 with 448,408 (71%) feedback surveys completed. The annual mean ratings of both statements varied little (less than 0.5) and were above 4.5 for all SAMs. CS ratings were consistently lower than KA ratings. FPs of all ages at first SAM provided similar ratings and agreement with content appropriateness increased with repeated exposure to SAMs. CONCLUSION: Over 11 years, the content of ABFM SAMs was regarded by FPs as appropriate for practice and presented at an appropriate level. Continued monitoring of feedback is necessary to keep the content of MOC programs relevant for physicians' practice.

Practice Rurality of Family Physicians Enrolled in a Practice Transformation Network.

The Transforming Clinical Practice Initiative prioritized the delivery of free practice transformation assistance by Practice Transformation Networks (PTNs) to small and rural practices that may otherwise lack the resources needed to succeed in Medicare's value-based payment (VBP) programs. We assessed the enrollment of rural practices in PTNs using 2016 TCPI enrollment data and American Board of Family Medicine recertification examination registration data from 2013 to 2016. PTNs enrolled a higher proportion of rural family medicine practices than are represented across the general workforce (P < .0001). We await more comprehensive data releases to fully understand enrollment to this important initiative.

Fellowship or Further Training for Family Medicine Residents?

BACKGROUND AND OBJECTIVES: The breadth of family medicine (FM) generates debate about the length of residency training. One argument used by proponents for lengthening training is that residents feel unprepared for practice. The objectives of our study were to (1) identify the proportion of FM residency graduates intending to pursue fellowship training and those who would have done an additional year of core residency training had it been available, and (2) determine whether an association exists between these two variables. METHODS: We used data collected by the American Board of Family Medicine (ABFM) as part of resident certification examination application in 2014 and 2015. Data included fellowship intention, and interest in pursuing another year of residency training if it were available. We used descriptive and bivariate statistics. RESULTS: The questionnaire was completed by 6,235 residents, of which 17.0% (n=1,063) intended to enroll in a fellowship. Overall 54.2% of residents were "not at all likely" to extend residency training, with 19.9% "extremely/moderately likely". Forty-six percent of those intending a fellowship were "not at all likely" to extend training and only 29% of those "extremely/moderately likely" to extend residency training intended to enroll in a fellowship. CONCLUSIONS: We found a disconnect between fellowship intention and desire for another year of residency training. Desire for fellowship may be more about obtaining specific skills and expertise or additional certifications, and less about being prepared for general practice in family medicine.

Quantifying the Cost of Disability Transitions in Medicare.

OBJECTIVE: To investigate the impact of disability transitions on annual Medicare Part A and B cost. METHOD: We analyzed 6,385 community-dwelling beneficiaries who were continuously enrolled in fee-for-service Medicare Part A and B from 2008 to 2009. We estimated adjusted effects of disability transitions on Medicare cost using a generalized linear model. RESULTS: Transitions to more severe disability states were associated with significantly higher average annual Medicare cost ranging from US$2,639 to US$5,405. Lower spending levels were observed for beneficiaries with improvements in functioning. Beneficiaries who transitioned from severe to moderate activities of daily living (ADLs) disability cost significantly less (-US$6,045) than those who remained severely disabled. DISCUSSION: Interventions aimed at preventing disability progression and efforts to restore functional capacity are promising strategies for containing costs and generating savings for Medicare. Future research is needed to assess the longer term impact of disability in association with the progression of chronic conditions.

Eligibility For And Enrollment In Medicare Part D Medication Therapy Management Programs Varies By Plan Sponsor.

Medicare Part D prescription drug plans must offer medication therapy management to beneficiaries with multiple chronic conditions and high drug expenditures. However, plan sponsors have considerable latitude in setting eligibility criteria. Newly available data indicate that enrollment rates in medication therapy management among stand-alone prescription drug plans and Medicare Advantage drug plans averaged only 10 percent in 2012. The enrollment variation across plan sponsors-from less than 0.2 percent to more than 57.0 percent-was associated with the restrictiveness of their eligibility criteria. For example, enrollment was 16.4 percent in plans requiring two chronic conditions versus 9.2 percent in plans requiring three, and 12.7 percent in plans requiring the use of any Part D drug versus 4.4 percent in plans requiring the use of drugs in specific classes. This variation represents inequities in access to medication therapy management across plans and results in missed opportunities for interventions that might improve therapeutic outcomes and reduce spending. The new Part D Enhanced Medication Therapy Management model of the Centers for Medicare and Medicaid Services has the potential to significantly increase the impact of medication therapy management by aligning financial incentives with improvements in medication use and encouraging innovation.

Geographic Variation in Antidiabetic Agent Adherence and Glycemic Control Among Patients with Type 2 Diabetes.

BACKGROUND: Medication nonadherence is an imperative public health concern. Among patients with type 2 diabetes mellitus (T2DM), poor adherence to antidiabetic agents is strongly associated with suboptimal glycemic control. Poor adherence and hyperglycemia greatly increase diabetes-related morbidity and mortality. At a national level, diabetes drug adherence using average proportion of days covered (PDC) is estimated to range between 36% and 81%, with an estimated range for diabetes control between 38% and 47%. At a state level no such studies exist. OBJECTIVE: To estimate the level of medication adherence to antidiabetic agents and of diabetes control, and their association among patients with T2DM receiving medication treatment at the state and the Metropolitan Statistical Area (MSA) levels among the populations covered by commercial insurance, Medicare, or Medicaid. METHODS: The study population included adults with T2DM aged ≥18 years who were identified using ICD-9-CM code 250.xx, who received diabetes medication, and who were covered by private insurance, Medicare, or Medicaid in each state, the District of Columbia, and the top 50 MSAs. Medication adherence was measured by average PDC and the percentage of population that had a PDC ≥ 80%. Diabetes control was identified using ICD-9-CM diagnosis codes. Patients who were not diagnosed with uncontrolled diabetes (250.x2 and 250.x3) were identified as being under control. The administrative claims databases used for this study included the 2012 medical and pharmacy claims from a large U.S. health plan, the complete 2011 Medicare Standard Analytical File linked with Part D claims, and the 2008 Mini-Medicaid Analytic eXtract (Mini-Max). Medication adherence and diabetes control were adjusted for age and sex to allow comparison across insurance coverage, states, and MSAs. RESULTS: For an insured patient population with T2DM that received diabetic drug treatment, average PDC was 79%. However, 35% of patients did not achieve an adherence of at least 80% of PDC. In addition, at least 40% of patients did not have their diabetes under control. Across insurance types, we found that patients insured with Medicare had relatively high average PDC and adherence levels (83% and 71%) in comparison with the commercially insured population (77% and 60%) and Medicaid patients (75% and 57%). In contrast, commercially insured patients had relatively better diabetes control (69%) than those insured with Medicare and Medicaid (54% and 53%, respectively). At a state level, we found that commercially insured and Medicare populations have relatively smaller geographic variation in drug adherence than the Medicaid population. CONCLUSIONS: This study identified gaps in T2DM drug adherence and pinpointed geographic areas that lag in terms of diabetes drug adherence or diabetes control and would benefit from implementing strategies to increase drug adherence.

Does good medication adherence really save payers money?

BACKGROUND: Despite a growing consensus that better adherence with evidence-based medications can save payers money, assertions of cost offsets may be incomplete if they fail to consider additional drug costs and/or are biased by healthy adherer behaviors unobserved in typical medical claims-based analyses. OBJECTIVES: The objective of this study was to determine whether controlling for healthy adherer bias (HAB) materially affected estimated medical cost offsets and additional drug spending associated with higher adherence. SUBJECTS: A total of 1273 Medicare beneficiaries with diabetes enrolled in Part D plans between 2006 and 2009. RESEARCH DESIGN: Using survey and claims data from the Medicare Current Beneficiary Survey, we measured medical and drug costs associated with good and poor adherence (proportion of days covered ≥ 80% and <80%, respectively) to oral antidiabetic drugs, ACE inhibitors/ARBs, and statins over 2 years. To test for HAB, we estimated pairs of regression models, one set containing variables typically controlled for in conventional claims analysis and a second set with survey-based variables selected to capture HAB effects. RESULTS: We found consistent evidence that controlling for HAB reduces estimated savings in medical costs from better adherence, and likewise, reduces estimates of additional adherence-related drug spending. For ACE inhibitors/ARBs we estimate that controlling for HAB reduced adherence-related medical cost offsets from $6389 to $4920 per person (P<0.05). Estimates of additional adherence-related drug costs were 26% and 14% lower in HAB-controlled models (P < 0.05). CONCLUSIONS: These results buttress the economic case for action by health care payers to improve medication adherence among insured persons with chronic disease. However, given the limitations of our research design, further research on larger samples with other disease states is clearly warranted.

How Medicare Part D benefit phases affect adherence with evidence-based medications following acute myocardial infarction.

OBJECTIVE: Assess impact of Medicare Part D benefit phases on adherence with evidence-based medications after hospitalization for an acute myocardial infarction. DATA SOURCE: Random 5 percent sample of Medicare beneficiaries. STUDY DESIGN: Difference-in-difference analysis of drug adherence by AMI patients stratified by low-income subsidy (LIS) status and benefit phase. DATA COLLECTION/EXTRACTION METHODS: Subjects were identified with an AMI diagnosis in Medicare Part A files between April 2006 and December 2007 and followed until December 2008 or death (N = 8,900). Adherence was measured as percent of days covered (PDC) per month with four drug classes used in AMI treatment: angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta-blockers, statins, and clopidogrel. Monthly exposure to Part D benefit phases was calculated from flags on each Part D claim. PRINCIPAL FINDINGS: For non-LIS enrollees, transitioning from the initial coverage phase into the Part D coverage gap was associated with statistically significant reductions in mean PDC for all four drug classes: statins (-7.8 percent), clopidogrel (-7.0 percent), beta-blockers (-5.9 percent), and ACE inhibitor/ARBs (-5.1 percent). There were no significant changes in adherence associated with transitioning from the gap to the catastrophic coverage phase. CONCLUSIONS: As the Part D doughnut hole is gradually filled in by 2020, Medicare Part D enrollees with critical diseases such as AMI who rely heavily on brand name drugs are likely to exhibit modest increases in adherence. Those reliant on generic drugs are less likely to be affected.

Regions with higher Medicare Part D spending show better drug adherence, but not lower medicare costs for two diseases.

A quarter-century of research on geographic variation in Medicare costs has failed to find any positive association between high spending and better health outcomes. We conducted this study using a 5 percent random sample of Medicare beneficiaries with diabetes or heart failure in 2006 and 2007 to see whether there was any correlation between geographic variation in Part D spending and good medication-taking behavior-and, if so, whether that correlation resulted in reduced Medicare Parts A and B spending on diabetes and heart failure treatments. We found that beneficiaries residing in areas characterized by higher adjusted drug spending had significantly more "therapy days"-days with recommended medications on hand-than did beneficiaries in lower-spending areas. However, we did not find that this factor translated into short-term savings in Medicare treatment costs for these two diseases. This result might not be surprising, since returns from medication adherence can take years to manifest. At the same time, discovering which regional factors are responsible for differences in drug spending and medication practices should be a high priority. If the observed differences are related to poor physician communication or lack of good care coordination, then appropriately designed policy tools-including accountable care organizations, medical homes, and provider quality reporting initiatives-might help address them.