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

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

Burden Of Health-Related Social Needs Among Dual- And Non-Dual-Eligible Medicare Advantage Beneficiaries.

Little information exists to inform stakeholders' efforts to screen for, address, and risk-adjust for the health-related social needs (HRSNs) of Medicare Advantage (MA) enrollees, particularly those not dually Medicaid-Medicare eligible and those younger than age sixty-five. HRSNs can include food insecurity, housing instability, transportation issues, and other factors. We examined the prevalence of HRSNs in 2019 among 61,779 enrollees in a large, national MA plan. Although HRSNs were more common among dual-eligible beneficiaries, with 80 percent reporting at least one (average, 2.2 per beneficiary), 48 percent of non-dual-eligible beneficiaries reported one or more, indicating that dual eligibility alone would have inadequately captured HRSN risk. HRSN burden was unequally distributed across multiple beneficiary characteristics, notably with beneficiaries younger than age sixty-five more likely than those ages sixty-five and older to report having an HRSN. We also found that some HRSNs were more strongly associated with hospitalizations, emergency department visits, and physician visits than others. These findings suggest the importance of considering the HRSNs of dual- and non-dual-eligible beneficiaries, as well as those of beneficiaries of all ages, when exploring how to address HRSNs in the MA population.

Intensive care management for high-risk veterans in a patient-centered medical home - do some veterans benefit more than others?

BACKGROUND: Primary care intensive management programs utilize interdisciplinary care teams to comprehensively meet the complex care needs of patients at high risk for hospitalization. The mixed evidence on the effectiveness of these programs focuses on average treatment effects that may mask heterogeneous treatment effects (HTEs) among subgroups of patients. We test for HTEs by patients' demographic, economic, and social characteristics. METHODS: Retrospective analysis of a VA randomized quality improvement trial. 3995 primary care patients at high risk for hospitalization were randomized to primary care intensive management (n = 1761) or usual primary care (n = 1731). We estimated HTEs on ED and hospital utilization one year after randomization using model-based recursive partitioning and a pre-versus post-with control group framework. Splitting variables included administratively collected demographic characteristics, travel distance, copay exemption, risk score for future hospitalizations, history of hospital discharge against medical advice, homelessness, and multiple residence ZIP codes. RESULTS: There were no average or heterogeneous treatment effects of intensive management one year after enrollment. The recursive partitioning algorithm identified variation in effects by risk score, homelessness, and whether the patient had multiple residences in a year. Within each distinct subgroup, the effect of intensive management was not statistically significant. CONCLUSIONS: Primary care intensive management did not affect acute care use of high-risk patients on average or differentially for patients defined by various demographic, economic, and social characteristics. IMPLICATIONS: Reducing acute care use for high-risk patients is complex, and more work is required to identify patients positioned to benefit from intensive management programs.

Medicare beneficiaries with more comprehensive primary care physicians report better primary care.

OBJECTIVE: To examine whether primary care physician (PCP) comprehensiveness is associated with Medicare beneficiaries' overall rating of care from their PCP and staff. DATA SOURCES: We linked Medicare claims with survey data from Medicare beneficiaries attributed to Comprehensive Primary Care Plus (CPC+) physicians and practices. STUDY DESIGN: We performed regression analyses of the associations between two claims-based measures of PCP comprehensiveness in 2017 and beneficiaries' rating of care from their PCP and practice staff in 2018. DATA COLLECTION/EXTRACTION METHODS: The analytic sample included 6228 beneficiaries cared for by 3898 PCPs. Regressions controlled for beneficiary, physician, practice, and market characteristics. PRINCIPAL FINDINGS: Beneficiaries with more comprehensive PCPs rated care from their PCP and practice staff higher than did those with less comprehensive PCPs. For each comprehensiveness measure, beneficiaries whose PCP was in the 75th percentile were more likely than beneficiaries whose PCP was in the 25th percentile to rate their care highly (2 percentage point difference, p = 0.02). CONCLUSIONS: Medicare beneficiaries with more comprehensive PCPs rate overall care from their PCPs and staff higher than those with less comprehensive PCPs.

How Did Veterans' Reliance on Veterans Health Administration Outpatient Care Change After Expansion of the Veterans Community Care Program?

BACKGROUND: The Veterans Community Care Program (VCCP) aims to address access constraints in the Veterans Health Administration (VA) by reimbursing care from non-VA community providers. Little existing research explores how veterans' choice of VA versus VCCP providers has evolved as a significant VCCP expansion in 2014 as part of the Veterans Access, Choice, and Accountability Act. OBJECTIVES: We examined changes in reliance on VA for primary care (PC), mental health (MH), and specialty care (SC) among VCCP-eligible veterans. RESEARCH DESIGN: We linked VA administrative data with VCCP claims to retrospectively examine utilization during calendar years 2016-2018. SUBJECTS: 1.78 million veterans enrolled in VA before 2013 and VCCP-eligible in 2016 due to limited VA capacity or travel hardship. MEASURES: We measured reliance as the proportion of total annual outpatient (VA+VCCP) visits occurring in VA for PC, MH, and SC. RESULTS: Of the 26.1 million total outpatient visits identified, 45.6% were for MH, 29.9% for PC, and 24.4% for SC. Over the 3 years, 83.2% of veterans used any VA services, 23.8% used any VCCP services, and 20.0% were dual VA-VCCP users. Modest but statistically significant declines in reliance were observed from 2016-2018 for PC (94.5%-92.2%), and MH (97.8%-96.9%), and a more significant decline was observed for SC (88.5%-79.8%). CONCLUSIONS: Veterans who have the option of selecting between VA or VCCP providers continued using VA for most of their outpatient care in the initial years after the 2014 VCCP expansion.

Effects of Medicaid expansion on self-reported use of dental services in socioeconomically vulnerable subgroups.

OBJECTIVE: Research suggests Medicaid expansion led to modest increases in the use of dental services among low-income adults, especially in states with more generous Medicaid dental benefits. We expand upon this research by examining whether the effect of Medicaid expansion differed across important socioeconomic subgroups. METHODS: Using Behavioral Risk Factor Surveillance System data from 2012 to 2016, we employed a difference-in-differences framework to estimate the effect of Medicaid expansion on annual use of dental services overall and by whether states offered more-than-emergency Medicaid dental benefits. We used generalized linear mixed-effects model trees to estimate effects across socioeconomic subgroups (e.g., age, education, race, income). RESULTS: The effect of Medicaid expansion varied by state's generosity of Medicaid dental coverage and combinations of socioeconomic subgroups. Overall, there was no significant association between Medicaid expansion and probability of using dental services (-0.1 pp percentage points [pp], p = 0.914). Medicaid expansion was associated with a modest increase in the probability of using dental services in states with more-than-emergency Medicaid dental benefits (2.3 pp, p < 0.001) and with a modest decrease in states with no or emergency-only benefits (-4.3 pp, p < 0.001). Among adults aged 21-35 without a high school diploma, Medicaid expansion was associated with an 8.1 pp (p = 0.003) increase in dental use probability, but there were no associated effects of Medicaid expansion for other subgroups. CONCLUSIONS: While Medicaid expansion alone is not sufficient to ensure adults receive recommended dental care, some vulnerable subgroups appear to have benefited. Efforts to mitigate barriers to dental care may be needed to increase uptake of dental services by low-income adults.

Primary Care Practice Transformation Introduces Different Staff Roles.

PURPOSE: Practices in the 4-year Comprehensive Primary Care (CPC) initiative changed staffing patterns during 2012-2016 to improve care delivery. We sought to characterize these changes and to compare practice patterns with those in similar non-CPC practices in 2016. METHODS: We conducted an online survey among selected US primary care practices. We statistically tested 2012-2016 changes in practice-reported staff composition among 461 CPC practices using 2-tailed t tests. Using logistic regression analysis, we compared differences in staff types between the CPC practices and 358 comparison practices that participated in the survey in 2016. RESULTS: In 2012, most CPC practices reported having physicians (100%), administrative staff (99%), and medical assistants (90%). By 2016, 84% reported having care managers/care coordinators (up from 24% in 2012), and 29% reported having behavioral health professionals, clinical psychologists, or social workers (up from 19% in 2014). There were also smaller increases (of less than 10 percentage points) in the share of practices having pharmacists, nutritionists, registered nurses, quality improvement specialists, and health educators. Larger and system-affiliated practices were more likely to report having care managers/care coordinators and behavioral health professionals. In 2016, relative to comparison practices, CPC practices were more likely to report having various staff types-notably, care managers/care coordinators (84% of CPC vs 36% of comparison practices), behavioral health professionals (29% vs 12%), and pharmacists (18% vs 4%). CONCLUSIONS: During the CPC initiative, CPC practices added different staff types to a fairly traditional staffing model of physicians with medical assistants. They most commonly added care managers/care coordinators and behavioral health staff to support the CPC model and, at the end of CPC, were more likely to have these staff members than comparison practices.

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.

Patient experience during a large primary care practice transformation initiative.

OBJECTIVES: To determine how the multipayer Comprehensive Primary Care (CPC) initiative that transformed primary care delivery affected patient experience of Medicare fee-for-service beneficiaries. The study examines whether patient experience changed during the 4-year initiative, whether ratings of CPC practices changed relative to ratings of comparison practices, and areas in which practices still have an opportunity to improve patient experience. STUDY DESIGN: Prospective study using 2 cross-sectional samples of more than 25,000 Medicare fee-for-service beneficiaries attributed to 490 CPC practices and more than 8000 beneficiaries attributed to 736 comparison practices. METHODS: We analyzed patient experience 8 to 12 months and 45 to 48 months after CPC began, measured using 5 domains of the Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey with Patient-Centered Medical Home items, version 2.0. A regression-adjusted analysis compared differences in the proportion of beneficiaries giving the best responses (and, as a sensitivity test, mean responses) to survey questions over time and between CPC and comparison practices. RESULTS: Patient ratings of care over time were generally comparable for CPC and comparison practices. CPC had favorable effects on measures of follow-up care after hospitalizations and emergency department visits. CONCLUSIONS: Practice transformation did not alter patient experience. The lack of favorable findings raises questions about how future efforts in primary care can succeed in improving patient experience.

The Comprehensive Primary Care Initiative: Effects On Spending, Quality, Patients, And Physicians.

The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative's effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions. The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures. As CMS and other payers increasingly use alternative payment models that reward quality and value, CPC provides important lessons about supporting practices in transforming care.

Uses and Limitations of Claims-based Performance Feedback Reports: Lessons From the Comprehensive Primary Care Initiative.

BACKGROUND: Performance feedback is central to data-driven models of quality improvement, but the use of claims-based data for feedback has received little attention. PURPOSE: To examine the challenges, uses, and limitations of quarterly Medicare claims-based performance feedback reports generated for practices participating in the Comprehensive Primary Care (CPC) initiative from 2012 to 2015. METHODS: Mixed methods study of nearly 500 CPC practices in seven regions, combining pilot testing; systematic monitoring; surveys; in-depth interviews; user feedback; and input from data feedback team. RESULTS: Designing reports required addressing issues about timing, data completeness and reliability, variations in patient risk across practices, and use of benchmarks and metrics understandable to users. Practices' ability to use reports constructively depended on their experience, analytic resources, expectations, and perceptions about the role of primary care in improving reported outcomes. CONCLUSIONS: Generating claims-based feedback reports that support practices' quality improvement efforts requires a significant investment of analytic expertise, time, resources, continuous improvement, and technical assistance. IMPLICATIONS: Claims-based performance feedback can provide insight into patterns of patients' care across provider settings and opportunities for improvement, but practices need data from other sources to manage patients in real time or assess the short-term effects of specific changes in care delivery.

Patient experience midway through a large primary care practice transformation initiative.

OBJECTIVES: To determine how the multipayer Comprehensive Primary Care (CPC) initiative that transforms primary care delivery affects the patient experience of Medicare fee-for-service beneficiaries. The study examines how experience changed between the first and second years of CPC, how ratings of CPC practices have changed relative to ratings of comparison practices, and areas in which practices still have opportunities to improve patient experience. STUDY DESIGN: Prospective study using 2 serial cross-sectional samples of more than 25,000 Medicare fee-for-service beneficiaries attributed to 496 CPC practices and nearly 9000 beneficiaries attributed to 792 comparison practices. METHODS: We analyzed patient experience 8 to 12 months and 21 to 24 months after CPC began, measured using 6 domains of the Consumer Assessment of Healthcare Providers and Systems Clinician and Group 12-Month Survey with Patient-Centered Medical Home supplemental items. We compared changes over time in patients giving the best responses between CPC and comparison practices using a regression-adjusted difference-in-differences analysis. RESULTS: Patient ratings of care over time were generally comparable for CPC and comparison practices, with slightly more favorable differences-generally of small magnitude-for CPC practices than expected by chance. There were small, statistically significant, favorable effects for 2 of 6 composite measures measured using both the proportion giving the best responses and mean responses: getting timely appointments, care, and information; providers support patients in taking care of their own health; and providers discuss medication decisions. There was an additional small favorable effect on the proportion of patients giving the best response in getting timely appointments, care, and information; there was no effect on the mean. CONCLUSIONS: During the first 2 years of CPC, CPC practices showed slightly better year-to-year patient experience ratings for selected items, indicating that transformation did not negatively affect patient experience and improved some aspects slightly. Patient ratings for the 2 groups were generally comparable, and both faced substantial room for improvement.

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

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