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.

Is managed care closing substance abuse treatment units?

Despite high levels of unmet need for outpatient substance abuse treatment, a significant percentage of outpatient units have closed over the past several years. This study drew on 1999-2000 and 2005 national surveys to determine if managed care was associated with outpatient substance abuse treatment units' likelihood of surviving. Each substance abuse unit director was asked about the presence of any managed care contracts, percentage revenues from managed care, percentage of clients for whom prior authorization was required, and percentage of clients for whom concurrent review was required. A multiple logistic regression revealed that none of these factors was associated with substance abuse treatment unit survival. At this point, neither the presence nor the structure of managed care appears to affect the survival of outpatient substance abuse treatment units. Given the need for these facilities, however, and their vulnerability to closure, continued attention to managed care's potential influence is warranted.