Practice Expenses Associated with Comprehensive Primary Care Capabilities.

Through the Comprehensive Primary Care (CPC) and Comprehensive Primary Care Plus (CPC+) programs, the Centers for Medicare & Medicaid Services (CMS) has encouraged primary care practices to invest in "comprehensive primary care" capabilities. Empirical evidence suggests these capabilities are under-reimbursed or not reimbursed under prevailing fee-for-service payment models. To help CMS design alternative payment models (APMs) that reimburse the costs of these capabilities, the authors developed a method for estimating related practice expenses. Fifty practices, sampled for diversity across CPC+ participation status, geographic region, rural status, size, and parent-organization affiliation, completed the study. Researchers developed a mixed-methods strategy, beginning with interviews of practice leaders to identify their capabilities and the types of costs incurred. This was followed by researcher-assisted completion of a workbook tailored to each practice, which gathered related labor and nonlabor costs. In a final interview, practice leaders reviewed cost estimates and made any needed corrections before approval. A main goal was to address a persistent question faced by CMS: When practices reported widely divergent costs for a given capability, was that divergence due to practices having different prices for the same capability or from their having substantially different capabilities? The cost estimation method developed in this project collected detailed data on practice capabilities and their costs. However, the small sample did not allow quantitative estimation of the contributions of service level and pricing to the variation in overall costs. This cost estimation method, deployed on a larger scale, could generate robust data to inform new payment models aimed at incentivizing and sustaining comprehensive primary care.

Perspectives of Physicians in Small Rural Practices on the Medicare Quality Payment Program.

The Centers for Medicare & Medicaid Services (CMS) recently launched its Quality Payment Program (QPP), which considerably changes the way physicians are paid under Medicare. There has been significant concern about the ability of small rural practices to successfully participate in the program. To address these concerns, RAND researchers conducted interviews with physicians in small rural practices on the initial implementation of the QPP in order to understand the flexibility provisions for small rural practices and to inform future federal rulemaking for the QPP. The findings suggest that small rural practices are struggling to participate in the QPP. Interviewees reported frustration with a lack of clarity of program details, requirements that appeared to be determined late and were subject to change, and the amount of effort needed to participate. Interviewees suggested several changes to the QPP and Medicare policy to improve the ability of small rural practices to participate in the program. These changes included clarifying and specifying program requirements, reducing the frequency of program policy changes, delaying program implementation for small practices, avoiding penalizing small practices that serve vulnerable populations, developing less obtrusive methods for assessing the quality of care of small practices, providing additional information technology support for small rural practices, and enabling greater engagement of rural physicians by policymakers.

Estimating the Costs of Implementing Comprehensive Primary Care: A Narrative Review.

The performance of the any health-care system relies on a high-functioning primary care system. Increasing primary care practices' adoption of "comprehensive primary care" capabilities might yield meaningful improvements in the quality and efficiency of primary care. However, many comprehensive primary care capabilities, such as care management and coordination, are not compensated via traditional fee-for-service payment. To calculate new payments for these capabilities, policymakers would need estimates of the costs that practices incur when adopting, maintaining, and using the capabilities. We performed a narrative review of the existing literature on the costs of adopting and implementing comprehensive primary care capabilities. These studies have found that practices incur significant costs when adopting and implementing comprehensive primary care capabilities. However, the studies had significant limitations that prevent extensive use of their estimates for payment policy. Particularly, the strongest studies focused on a small numbers of practices in specific geographic areas and the concepts and methods used to assess costs varied greatly across the studies. Furthermore, none of the studies in our review attempted to estimate differences in costs across practices with patients at varying levels of complexity and illness burden which is important for risk-adjusting payments to practices. Therefore, due to the heterogeneous designs and limited generalizability of published studies highlight the need for additional research, especially if payers wish to link their financial support for comprehensive primary care capabilities to the costs of these capabilities for primary care practices.

It's Still The Prices, Stupid: Why The US Spends So Much On Health Care, And A Tribute To Uwe Reinhardt.

A 2003 article titled "It's the Prices, Stupid," and coauthored by the three of us and the recently deceased Uwe Reinhardt found that the sizable differences in health spending between the US and other countries were explained mainly by health care prices. As a tribute to him, we used Organization for Economic Cooperation and Development (OECD) Health Statistics to update these analyses and review critiques of the original article. The conclusion that prices are the primary reason why the US spends more on health care than any other country remains valid, despite health policy reforms and health systems restructuring that have occurred in the US and other industrialized countries since the 2003 article's publication. On key measures of health care resources per capita (hospital beds, physicians, and nurses), the US still provides significantly fewer resources compared to the OECD median country. Since the US is not consuming greater resources than other countries, the most logical factor is the higher prices paid in the US. Because the differential between what the public and private sectors pay for medical services has grown significantly in the past fifteen years, US policy makers should focus on prices in the private sector.

Comparing Quality of Care in Veterans Affairs and Non-Veterans Affairs Settings.

BACKGROUND: Congress, veterans' groups, and the press have expressed concerns that access to care and quality of care in Department of Veterans Affairs (VA) settings are inferior to access and quality in non-VA settings. OBJECTIVE: To assess quality of outpatient and inpatient care in VA at the national level and facility level and to compare performance between VA and non-VA settings using recent performance measure data. MAIN MEASURES: We assessed Patient Safety Indicators (PSIs), 30-day risk-standardized mortality and readmission measures, and ORYX measures for inpatient safety and effectiveness; Healthcare Effectiveness Data and Information Set (HEDIS®) measures for outpatient effectiveness; and Consumer Assessment of Healthcare Providers and Systems Hospital Survey (HCAHPS) and Survey of Healthcare Experiences of Patients (SHEP) survey measures for inpatient patient-centeredness. For inpatient care, we used propensity score matching to identify a subset of non-VA hospitals that were comparable to VA hospitals. KEY RESULTS: VA hospitals performed on average the same as or significantly better than non-VA hospitals on all six measures of inpatient safety, all three inpatient mortality measures, and 12 inpatient effectiveness measures, but significantly worse than non-VA hospitals on three readmission measures and two effectiveness measures. The performance of VA facilities was significantly better than commercial HMOs and Medicaid HMOs for all 16 outpatient effectiveness measures and for Medicare HMOs, it was significantly better for 14 measures and did not differ for two measures. High variation across VA facilities in the performance of some quality measures was observed, although variation was even greater among non-VA facilities. CONCLUSIONS: The VA system performed similarly or better than the non-VA system on most of the nationally recognized measures of inpatient and outpatient care quality, but high variation across VA facilities indicates a need for targeted quality improvement.

What are the appropriate methodological standards for international comparisons of health data?

International comparisons of health systems are frequently used to inform national health policy debates. These comparisons can be used to gauge areas of strength and weakness in a health system, and to find potential solutions from abroad that can be applied locally. But such comparisons are methodologically fraught and, if not carefully performed and used, can be misleading.In a recent IJHPR article, Baruch Levi has raised concerns about the use of international comparisons of self-reported health data in health policy debates in Israel. Self-reported health is one of the most robust and frequently used measures of health, and the OECD uses a commonly accepted measure specification, which has five response categories. Israel's survey question, unlike the OECD measure specification, includes only four response categories. While this may be a valid method when applied over time as a scale within Israel, it creates problems for international comparison.To improve comparability, Israel's Central Bureau of Statistics could revise the survey question. However, revising the question would introduce a "break" in the data series that interrupts comparisons within Israel over time. Israeli policymakers therefore face a decision about priorities: is it more important to them to be able to track health status within Israel over time, or to be able to make meaningful comparisons to other countries? If the priority were international comparisons and the Israel survey was revised, a small study could be conducted among a sample of Israeli respondents to enable crosswalking of self-reported health responses from the four-point scale to the five-point scale. If the Central Bureau of Statistics does not revise its survey, the OECD should examine whether a stronger caveat is possible for its comparisons.

A mixed-methods evaluation of an Integrated Medication Management program and implications for implementation.

BACKGROUND: Improving medication adherence is a common and challenging issue. Taking medications as prescribed becomes particularly difficult for individuals with multiple chronic conditions. Poor adherence can lead to exacerbated health issues and prolonged disease severity. Medication Therapy Management is increasingly being used to help clinics improve medication adherence and reduce adverse events, but factors that enable implementation of such programs are not well identified. OBJECTIVE: To describe the factors associated with implementation of an innovative pharmacy program and to measure the impact of the intervention. METHODS: This mixed-methods cohort study in a federal qualified health center with its own pharmacy examined the implementation and the impact of a broad program including MTM. The intervention included appointments with pharmacists, communication between pharmacists and physicians, and, for some, monthly pre-packaged medications. Semi-structured interviews with patients and staff were recorded, transcribed, and analyzed for themes relating to implementation, satisfaction, and challenges. Quantitative methods using data collected by the pharmacists at each visit were used to compare the first visit to those at later visits and provided measures of impact on diabetes control, statin use, and medication-related problems (MRPs). RESULTS: Qualitative interviews identified enabling factors that contributed to successful implementation of this program, including: program factors such as data access, communication with patients, and dedicated staff; organizational factors such as culture of integration, leadership support, and staffing; and lastly, environmental factors such as the availability of 340B funding. Quantitative analyses were limited by poor retention and lack of a similarly-documented comparison group. Health outcomes were not found to be significantly better, though there was a significant decrease in some kinds of MRPs. This program was well received by patients and staff and demonstrated some clinical impact. CONCLUSION: The program's implementation was enabled by design as well as organizational and external factors. Financial and leadership support allowed for flexibility and creativity, which contributed to successful implementation. Alternative delivery models beyond fee-for-service payments may make this kind of program more feasible.

Association Between Patient-Centered Medical Home Capabilities and Outcomes for Medicare Beneficiaries Seeking Care from Federally Qualified Health Centers.

BACKGROUND: Patient-centered medical home (PCMH) models of primary care have the potential to expand access, improve population health, and lower costs. Federally qualified health centers (FQHCs) were early adopters of PCMH models. OBJECTIVE: We measured PCMH capabilities in a diverse nationwide sample of FQHCs and assessed the relationship between PCMH capabilities and Medicare beneficiary outcomes. DESIGN: Cross-sectional, propensity score-weighted, multivariable regression analysis. PARTICIPANTS: A convenience sample of 804 FQHC sites that applied to a nationwide FQHC PCMH initiative and 231,163 Medicare fee-for-service beneficiaries who received a plurality of their primary care services from these sites. MAIN MEASURES: PCMH capabilities were self-reported using the National Committee for Quality Assurance's (NCQA's) 2011 application for PCMH recognition. Measures of utilization, continuity of care, quality, and Medicare expenditures were derived from Medicare claims covering a 1-year period ending October 2011. KEY RESULTS: Nearly 88% of sites were classified as having PCMH capabilities equivalent to NCQA Level 1, 2, or 3 PCMH recognition. These more advanced sites were associated with 228 additional FQHC visits per 1000 Medicare beneficiaries (95% CI: 176, 278), compared with less advanced sites; 0.02 points higher practice-level continuity of care (95% CI: 0.01, 0.03); and a greater likelihood of administering two of four recommended diabetes tests. However, more advanced sites were also associated with 181 additional visits to specialists per 1000 beneficiaries (95% CI: 124, 232) and 64 additional visits to emergency departments (95% CI: 35, 89)-but with no differences in inpatient utilization. More advanced sites had higher Part B expenditures ($111 per beneficiary [95% CI: $61, $158]) and total Medicare expenditures of $353 [95% CI: $65, $614]). CONCLUSIONS: Implementation of PCMH models in FQHCs may be associated with improved primary care for Medicare beneficiaries. Expanded access to care, in combination with slower development of key PCMH capabilities, may explain higher Medicare expenditures and other types of utilization.

The Medicare Access And CHIP Reauthorization Act: Effects On Medicare Payment Policy And Spending.

In 2015, Congress repealed the Sustainable Growth Rate formula for Medicare physician payment, eliminating mandatory payment cuts when spending exceeded what was budgeted. In its place, Congress enacted the Medicare Access and CHIP Reauthorization Act (MACRA), which established a two-track performance-based payment system that encourages physicians to participate in alternative payment models. MACRA could have huge effects on health care delivery, but the nature of those effects is highly uncertain. Using the RAND Corporation's Health Care Payment and Delivery Simulation Model, we estimated the effects of MACRA on Medicare spending and utilization and examined how effects would differ under various scenarios. We estimate that MACRA will decrease Medicare spending on physician services by -$35 to -$106 billion (-2.3 percent to -7.1 percent) and change spending on hospital services by $32 to -$250 billion (0.7 percent to -5.1 percent) in 2015-30. The spending effects are critically dependent on the strength of incentives in the alternative payment models, particularly the incentives for physicians to reduce hospital spending and physician responses to MACRA payment rates.

Episode-Based Approaches to Measuring Health Care Quality.

Most currently available quality measures reflect point-in-time provider tasks, providing a limited and fragmented assessment of care. The concept of episodes of care could be used to develop quality measurement approaches that reflect longer periods of care. With input from clinical experts, we constructed episode-of-care frameworks for six illustrative conditions and identified potential gaps and measure development priority areas. Episode-based measures could assess changes in health outcomes ("delta measures"), the amount of time during an episode in which a patient has suboptimal health status ("integral measures"), quality contingent upon events occurring previously ("contingent measures"), and composites of measures throughout the episode. This article identifies a number of challenges that will need to be addressed to advance operationalization of episode-based quality measurement.

Comparing VA and Non-VA Quality of Care: A Systematic Review.

BACKGROUND: The Veterans Affairs (VA) health care system aims to provide high-quality medical care to veterans in the USA, but the quality of VA care has recently drawn the concern of Congress. The objective of this study was to systematically review published evidence examining the quality of care provided at VA health care facilities compared to quality of care in other facilities and systems. METHODS: Building on the search strategy and results of a prior systematic review, we searched MEDLINE (from January 1, 2005, to January 1, 2015) to identify relevant articles on the quality of care at VA facilities compared to non-VA facilities. Articles from the prior systematic review published from 2005 and onward were also included and re-abstracted. Studies were classified, analyzed, and summarized by the Institute of Medicine's quality dimensions. RESULTS: Sixty-nine articles were identified (including 31 articles from the prior systematic review and 38 new articles) that address one or more Institute of Medicine quality dimensions: safety (34 articles), effectiveness (24 articles), efficiency (9 articles), patient-centeredness (5 articles), equity (4 articles), and timeliness (1 article). Studies of safety and effectiveness indicated generally better or equal performance, with some exceptions. Too few articles related to timeliness, equity, efficiency, and patient-centeredness were found from which to reliably draw conclusions about VA care related to these dimensions. DISCUSSION: The VA often (but not always) performs better than or similarly to other systems of care with regard to the safety and effectiveness of care. Additional studies of quality of care in the VA are needed on all aspects of quality, but particularly with regard to timeliness, equity, efficiency, and patient-centeredness.

The Relative Importance of Post-Acute Care and Readmissions for Post-Discharge Spending.

OBJECTIVE: To understand what patterns of health care use are associated with higher post-hospitalization spending. DATA SOURCES: Medicare hospital, skilled nursing, inpatient rehabilitation, and home health agency claims, and Medicare enrollment data from 2007 and 2008. STUDY DESIGN: For 10 common inpatient conditions, we calculated variation across hospitals in price-standardized and case mix-adjusted Medicare spending in the 30 days following hospital discharge. We estimated the fraction of spending differences between low- and high-spending hospitals attributable to readmissions versus post-acute care, and within post-acute care between inpatient rehabilitation facility (IRF) versus skilled nursing facility (SNF) use. For each service, we distinguished between differences in probability of use and spending conditional on use. DATA EXTRACTION METHODS: We identified index hospital claims and examined hospital and post-acute care occurring within a 30-day period following hospital discharge. For each Medicare Severity Diagnosis-Related Group (MS-DRG) at each hospital, we calculated average price-standardized Medicare payments for readmissions, SNFs, IRFs, and post-acute care overall (also including home health agencies and long-term care hospitals). PRINCIPAL FINDINGS: There was extensive variation across hospitals in Medicare spending in the 30 days following hospital discharge. For example, the interquartile range across hospitals ranged from $1,245 for chronic obstructive pulmonary disease to over $4,000 for myocardial infarction MS-DRGs. The proportion of differences attributable to readmissions versus post-acute care differed across conditions. For myocardial infarction, 74 to 93 percent of the variation was due to readmissions. For hip and femur procedures and joint replacement, 72 to 92 percent of the variation was due to differences in post-acute care spending. There was also variation in the relative importance of the type of post-acute spending. For hip and femur procedures, joint replacement, and stroke, whether patients received IRF was the key driver of variation in post-acute care spending In contrast, for pneumonia and heart failure, whether patients received SNF care was the key driver of variation in post-acute spending. CONCLUSIONS: Through initiatives such as bundled payment, hospitals are financially responsible for spending in the post-hospitalization period. The key driver of variation in post-hospitalization spending varied greatly across conditions. For some conditions, the key driver was having a readmission, for others it was whether patients receive any post-acute care, and for others the key driver was the type of post-acute care. These findings may help hospitals implement strategies to reduce post-discharge spending.

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the Department of Veterans Affairs (VA) current and projected health care capabilities and resources. An examination of data from a variety of sources, along with a survey of VA medical facility leaders, revealed the breadth and depth of VA resources and capabilities: fiscal resources, workforce and human resources, physical infrastructure, interorganizational relationships, and information resources. The assessment identified barriers to the effective use of these resources and capabilities. Analysis of data on access to VA care and the quality of that care showed that almost all veterans live within 40 miles of a VA health facility, but fewer have access to VA specialty care. Veterans usually receive care within 14 days of their desired appointment date, but wait times vary considerably across VA facilities. VA has long played a national leadership role in measuring the quality of health care. The assessment showed that VA health care quality was as good or better on most measures compared with other health systems, but quality performance lagged at some VA facilities. VA will require more resources and capabilities to meet a projected increase in veterans' demand for VA care over the next five years. Options for increasing capacity include accelerated hiring, full nurse practice authority, and expanded use of telehealth.

Measuring Care Continuity: A Comparison of Claims-based Methods.

BACKGROUND: Assessing care continuity is important in evaluating the impact of health care reform and changes to health care delivery. Multiple measures of care continuity have been developed for use with claims data. OBJECTIVE: This study examined whether alternative continuity measures provide distinct assessments of coordination within predefined episodes of care. RESEARCH DESIGN AND SUBJECTS: This was a retrospective cohort study using 2008-2009 claims files for a national 5% sample of beneficiaries with congestive heart failure, chronic obstructive pulmonary disease, and diabetes mellitus. MEASURES: Correlations among 4 measures of care continuity-the Bice-Boxerman Continuity of Care Index, Herfindahl Index, usual provider of care, and Sequential Continuity of Care Index-were derived at the provider- and practice-levels. RESULTS: Across the 3 conditions, results on 4 claims-based care coordination measures were highly correlated at the provider-level (Pearson correlation coefficient r=0.87-0.98) and practice-level (r=0.75-0.98). Correlation of the results was also high for the same measures between the provider- and practice-levels (r=0.65-0.92). CONCLUSIONS: Claims-based care continuity measures are all highly correlated with one another within episodes of care.

JOURNAL CLUB: Radiologists' Perceptions of Computerized Decision Support: A Focus Group Study From the Medicare Imaging Demonstration Project.

OBJECTIVE: The purpose of this study was to discern radiologists' perceptions regarding the implementation of a decision support system intervention as part of the Medicare Imaging Demonstration project and the effect of decision support on radiologists' interactions with ordering clinicians, their radiology work flow, and appropriateness of advanced imaging. SUBJECTS AND METHODS: A focus group study was conducted with a diverse sample of radiologists involved in interpreting advanced imaging studies at Medicare Imaging Demonstration project sites. A semistructured moderator guide was used, and all focus group discussions were recorded and transcribed verbatim. Qualitative data analysis software was used to code thematic content and identify representative segments of text. Participating radiologists also completed an accompanying survey designed to supplement focus group discussions. RESULTS: Twenty-six radiologists participated in four focus group discussions. The following major themes related to the radiologists' perceptions after decision support implementation were identified: no substantial change in radiologists' interactions with referring clinicians; no substantial change in radiologist work flow, including protocol-writing time; and no perceived increase in imaging appropriateness. Radiologists provided suggestions for improvements in the decision support system, including increasing the usability of clinical data captured, and expressed a desire to have greater involvement in future development and implementation efforts. CONCLUSION: Overall, radiologists from health care systems involved in the Medicare Imaging Demonstration did not perceive that decision support had a substantial effect, either positive or negative, on their professional roles and responsibilities. Radiologists expressed a desire to improve efficiencies and quality of care by having greater involvement in future efforts.

How will provider-focused payment reform impact geographic variation in Medicare spending?

OBJECTIVES: The Institute of Medicine has recently argued against a value index as a mechanism to address geographic variation in spending and instead promoted payment reform targeted at individual providers. It is unknown whether such provider-focused payment reform reduces geographic variation in spending. STUDY DESIGN: We estimated the potential impact of 3 Medicare provider-focused payment policies-pay-for-performance, bundled payment, and accountable care organizations-on geographic variation in Medicare spending across Hospital Referral Regions (HRRs). We compared geographic variation in spending, measured using the coefficient of variation (CV) across HRRs, between the baseline case and a simulation of each of the 3 policies. METHODS: Policy simulation based on 2008 national Medicare data combined with other publicly available data. RESULTS: Compared with the baseline (CV, 0.171), neither pay-for-performance nor accountable care organizations would change geographic variation in spending (CV, 0.171), while bundled payment would modestly reduce geographic variation (CV, 0.165). CONCLUSIONS: In our models, the bundled payment for inpatient and post acute care services in Medicare would modestly reduce geographic variation in spending, but neither accountable care organizations nor pay-for-performance appear to have an impact.

Evaluating the feasibility and utility of translating Choosing Wisely recommendations into e-Measures.

BACKGROUND: Efforts to reduce health care spending have focused on reducing use of low-value services, but relatively few performance measures address overuse of care. In 2012, the American Board of Internal Medicine Foundation's "Choosing Wisely" (CW) campaign identified 45 low-value services that clinicians and patients should avoid. Translating these overuse concepts into performance measures could assist in discouraging the use of these services. We assessed the feasibility and utility of converting these recommendations into e-Measures based on data from electronic health records [EHR]). MATERIALS AND METHODS: We used four criteria to evaluate 45 CW recommendations for e-Measure development: (1) feasibility of extracting needed data from EHR systems meeting Meaningful Use Stage 2 standards; (2) whether the recommendation's terminology was sufficiently specific for translation into an e-Measure; (3) scientific evidence supporting the recommendation; and (4) impact on reducing resource use. RESULTS: Only six of the 45 CW recommendations were deemed feasible for e-Measure development. Thirty-two recommendations require data elements unlikely to be found in current EHR systems; eight of 45 recommendations do not use sufficiently specific terminology. CONCLUSIONS: Improved capture of clinical information in EHRs and greater specificity of clinical terminology are required to advance these overuse concepts into standardized e-measures.