Multipayer primary care transformation: impact for Medicaid managed care beneficiaries.

OBJECTIVES: To evaluate the effects of Michigan Primary Care Transformation (MiPCT), a statewide multipayer patient-centered medical home (PCMH) demonstration in 2012-2015, on cost, utilization, and quality among Medicaid managed care beneficiaries. STUDY DESIGN: Observational longitudinal study with comparison groups. METHODS: Difference-in-differences (DID) analyses compared changes in outcomes among beneficiaries whose primary care providers participated in MiPCT, non-MiPCT PCMH, and non-PCMH practices. Net cost savings were derived. RESULTS: The study included 173,179 MiPCT, 209,181 non-MiPCT PCMH, and 148,657 non-PCMH beneficiaries. Against 1 or both comparison groups relative to 2011, MiPCT adults had significant reductions in cost, emergency department (ED) visits, and hospitalization risk in 2015. Against both comparison groups, MiPCT high-risk adults showed significant cost reduction in 2014-2015, ED reduction in 2015, and reduced hospitalization risk in 2013-2015. For children, no significant relative change in cost occurred, but both ED and hospitalization risk were reduced in 2015. In 2013-2015, cumulative net cost savings were $15,569,526 (95% CI, $3,416,832-$27,722,219) (return on investment [ROI], $3.60) for adults and $23,998,180 (95% CI, $11,782,031-$36,214,347) (ROI, $10.69) for high-risk adults, and a cost increase of $16,517,948 (95% CI, $7,712,286-$25,323,609) (ROI, -$1.30) for children. Quality metrics were significantly higher in MiPCT in most years, although most DID estimates were not significant. CONCLUSIONS: Evidence of cost savings exists among MiPCT Medicaid managed care adults; it was driven by high-risk adults, who also had reduced hospitalization risk. For children, no cost reductions occurred, but hospital and ED utilization were reduced in 2015. MiPCT maintained equal or higher quality of care but did not show consistent improvement.

Patient Experience with the Patient-Centered Medical Home in Michigan's Statewide Multi-Payer Demonstration: A Cross-Sectional Study.

BACKGROUND: The literature on patient-centered medical homes (PCMHs) and patient experience is somewhat mixed. Government and private payers are promoting multi-payer PCMH initiatives to align requirements and resources and to enhance practice transformation outcomes. To this end, the multipayer Michigan Primary Care Transformation (MiPCT) demonstration project was carried out. OBJECTIVE: To examine whether the PCMH is associated with a better patient experience, and whether a mature, multi-payer PCMH demonstration is associated with even further improvement in the patient experience. DESIGN: This is a cross-sectional comparison of adults attributed to MiPCT PCMH, non-participating PCMH, and non-PCMH practices, statistically controlling for potential confounders, and conducted among both general and high-risk patient samples. PARTICIPANTS: Responses came from 3893 patients in the general population and 4605 in the high-risk population (response rates of 31.8% and 34.1%, respectively). MAIN MEASURES: The Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey, with PCMH supplemental questions, was administered in January and February 2015. KEY RESULTS: MiPCT general and high-risk patients reported a significantly better experience than non-PCMH patients in most domains. Adjusted mean differences were as follows: access (0.35**, 0.36***), communication (0.19*, 0.18*), and coordination (0.33**, 0.35***), respectively (on a 10-point scale, with significance indicated by: *= p<0.05, **= p<0.01, and ***= p<0.001). Adjusted mean differences in overall provider ratings were not significant. Global odds ratios were significant for the domains of self-management support (1.38**, 1.41***) and comprehensiveness (1.67***, 1.61***). Non-participating PCMH ratings fell between MiPCT and non-PCMH across all domains and populations, sometimes attaining statistical significance. CONCLUSIONS: PCMH practices have more positive patient experiences across domains characteristic of advanced primary care. A mature multi-payer model has the strongest, most consistent association with a better patient experience, pointing to the need to provide consistent expectations, resources, and time for practice transformation. Our results held for a general population and a high-risk population which has much more contact with the healthcare system.

An Exploration of Genetic Test Utilization, Genetic Counseling, and Consanguinity within the Inborn Errors of Metabolism Collaborative (IBEMC).

The Inborn Errors of Metabolism Collaborative (IBEMC) includes clinicians from 29 institutions collecting data to enhance understanding of metabolic conditions diagnosable by newborn screening. Data collected includes hospitalizations, test results, services, and long-term outcomes. Through evaluation of this data, we sought to determine how frequently genetic counseling had been provided, how often genetic testing was performed, and also determine the consanguinity rate in this population. A data query was performed with the following elements abstracted/analyzed: current age, metabolic condition, whether genetic counseling was provided (and by whom), whether genetic testing was performed, and consanguinity. Genetic counseling was provided to families 95.8% of the time and in 68.6% of cases by a genetic counselor. Genetic testing was performed on 68.0% of subjects, with usage highest for fatty-acid-oxidation disorders (85.1%). The rate of consanguinity was 2.38%. Within this large national collaborative there is a high frequency of genetic counseling, though in one-third of cases a genetic counselor has not been involved. Additionally, while metabolic conditions have historically been diagnosed biochemically, there is currently high utilization of molecular testing suggesting DNA testing is being incorporated into diagnostic assessments - especially for fatty-acid-oxidation disorders where the underlying genotype helps predict clinical presentation.

Comparison of Methods of Initial Ascertainment in 58 Cases of Propionic Acidemia Enrolled in the Inborn Errors of Metabolism Information System Reveals Significant Differences in Time to Evaluation and Symptoms at Presentation.

OBJECTIVES: To compare time to evaluation and symptoms at diagnosis of propionic acidemia (PA) by method of ascertainment, and to explore correlations between genotype and biochemical variables. STUDY DESIGN: Clinical symptoms, genotype, and biochemical findings were analyzed retrospectively in 58 individuals with PA enrolled in the Inborn Errors of Metabolism Information System (IBEM-IS) based on the type of initial ascertainment: abnormal newborn screening (NBS), clinical presentation (symptomatic), or family history. RESULTS: The average age at initial evaluation and treatment was significantly younger in patients ascertained via abnormal NBS compared with those referred for clinical symptoms. Furthermore, the majority of individuals ascertained because of abnormal NBS were asymptomatic at diagnosis, compared with a minority of clinical presentations. A notable difference in the frequency of metabolic acidosis at initial presentation was observed between those with abnormal NBS (12.5%; 2 of 16) and those with an abnormal clinical presentation (79%; 19 of 24). The frequency of hyperammonemia was similar in the 2 groups. CONCLUSION: Our data support the continued value of NBS to identify individuals with PA, who are diagnosed and treated earlier than for other modes of ascertainment. There were no statistically significant correlations between genotype and NBS for C3 acylcarnitines. Although expanded use of NBS has allowed for early diagnosis and treatment, long-term outcomes of individuals with PA, especially with respect to mode of ascertainment, remain unclear and would benefit from a longitudinal study.

221 newborn-screened neonates with medium-chain acyl-coenzyme A dehydrogenase deficiency: Findings from the Inborn Errors of Metabolism Collaborative.

INTRODUCTION: There is limited understanding of relationships between genotype, phenotype and other conditions contributing to health in neonates with medium-chain acyl-coenzyme A dehydrogenase deficiency (MCADD) identified through newborn screening. METHODS: Retrospective analysis of comprehensive data from a cohort of 221 newborn-screened subjects identified as affected with MCADD in the Inborn Errors of Metabolism - Information System (IBEM-IS), a long term follow-up database of the Inborn Errors of Metabolism Collaborative, was performed. RESULTS: The average age at notification of first newborn screen results to primary care or metabolic providers was 7.45days. The average octanoylcarnitine (C8) value on first newborn screen was 11.2µmol/L (median 8.6, range 0.36-43.91). A higher C8 level correlated with an earlier first subspecialty visit. Subjects with low birth weight had significantly lower C8 values. Significantly higher C8 values were found in symptomatic newborns, in newborns with abnormal lab testing in addition to newborn screening and/or diagnostic tests, and in subjects homozygous for the c.985A>G ACADM gene mutation or compound heterozygous for the c.985A>G mutation and deletions or other known highly deleterious mutations. Subjects with neonatal symptoms, or neonatal abnormal labs, or neonatal triggers were more likely to have at least one copy of the severe c.985A>G ACADM gene mutation. C8 and genotype category were significant predictors of the likelihood of having neonatal symptoms. Neonates with select triggers were more likely to have symptoms and laboratory abnormalities. CONCLUSIONS: This collaborative study is the first in the United States to describe health associations of a large cohort of newborn-screened neonates identified as affected with MCADD. The IBEM-IS has utility as a platform to better understand the characteristics of individuals with newborn-screened conditions and their follow-up interactions with the health system.