Role of Nurse Practitioners in Caring for Patients With Complex Health Needs.

OBJECTIVE: The objective of this study was to estimate trends in the percentage of Medicare beneficiaries cared for by nurse practitioners from 2012 to 2017, to characterize beneficiaries cared for by nurse practitioners in 2017, and to examine how the percentage of beneficiaries cared for by nurse practitioners varies by practice characteristics. DESIGN: An observational study of 2012-2017 Medicare fee-for-service beneficiaries' ambulatory visits. We computed the percentage of beneficiaries with 1 or more ambulatory visits from nurse practitioners and the percentage of beneficiaries receiving the plurality of their ambulatory visits from a nurse practitioner versus a physician (ie, predominant provider). We compared beneficiary demographics, clinical characteristics, and utilization by the predominant provider. We then characterized the predominant provider by practice characteristics. KEY RESULTS: In 2017, 28.9% of beneficiaries received any care from a nurse practitioner and 8.0% utilized nurse practitioners as their predominant provider-an increase from 4.4% in 2012. Among beneficiaries cared for by nurse practitioners in 2017, 25.9% had 3 or more chronic conditions compared with 20.8% of those cared for by physicians. Beneficiaries cared for in practices owned by health systems were more likely to have a nurse practitioner as their predominant provider compared with those attending practices that were independently owned (9.3% vs. 7.0%). CONCLUSIONS: Nurse practitioners are caring for Medicare beneficiaries with complex needs at rates that match or exceed their physician colleagues. The growing role of nurse practitioners, especially in health care systems, warrants attention as organizations embark on payment and delivery reform.

Changes in spending and quality after ACO contract participation for dually eligible beneficiaries with mental illness.

BACKGROUND: Fragmented care and misaligned payment across Medicare and Medicaid lower care quality for dually eligible beneficiaries with mental illness. Accountable care organizations aim to improve the quality and value of care. METHODS: Using Medicare fee-for-service Part A and B claims data from 2009 to 2017 and a difference-in-differences design, we compared the spending and utilization of dually eligible beneficiaries with mental illness that were and were not attributed to Medicare ACO providers before and after ACO contract entry. RESULTS: Dually eligible beneficiaries with mental illness (N = 5,157,533, 70% depression, 22% bipolar, 27% schizophrenia and other psychotic disorders) had average annual Medicare spending of $17,899. ACO contract participation was generally not associated with spending or utilization changes. However, ACO contract participation was associated with higher rates of follow-up visits after mental health hospitalization: 1.17 and 1.30 percentage points within 7 and 30 days of discharge, respectively (p < 0.001). ACO-attributed beneficiaries with schizophrenia, bipolar, or other psychotic disorders received more ambulatory visits (393.9 per 1000 person-years, p = 0.002), while ACO-attributed beneficiaries with depression experienced fewer emergency department visits (-29.5 per 1000 person-years, p = 0.003) after ACO participation. CONCLUSIONS: Dually eligible beneficiaries served by Medicare ACOs did not have lower spending, hospitalizations, or readmissions compared with other beneficiaries. However, ACO participation was associated with timely follow-up after mental health hospitalization, as well as more ambulatory care and fewer ED visits for certain diagnostic groups. IMPLICATIONS: ACOs that include dually eligible beneficiaries with mental illness should tailor their designs to address the distinct needs of this population.

ACO Contracts With Downside Financial Risk Growing, But Still In The Minority.

Success of the accountable care organization (ACO) model may require stronger financial incentives, such as including downside risk in contracts. Using the National Survey of ACOs, we explored ACO structure and contracts in 2012-18. Though the number of ACO contracts and the proportion of ACOs with multiple contracts have grown, the proportion bearing downside risk has increased only modestly.

Comparison of Populations Served in Hospital Service Areas With and Without Comprehensive Primary Care Plus Medical Homes.

Importance: Little is known about the types of primary care practices that have chosen to participate in the Comprehensive Primary Care Plus (CPC+) program or about how participation could affect disparities. Objective: To describe practices that joined the CPC+ model and compare hospital service areas with and without CPC+ practices. Design, Setting, and Participants: This comparative cross-sectional study identified 2647 CPC+ practices in round 1 (from January 1, 2017; round 1 is ongoing through 2021). Using IMS Health Care Organization Services data, ownership and characteristics of health systems and practices were extracted. Practices participating in the CPC+ program were compared with practices with similar proportions of primary care physicians (>85%) within the 14 regions designated as eligible to participate by the Centers for Medicare & Medicaid Services. Within eligible regions, hospital service areas with (n = 434) and without (n = 322) 1 or more CPC+ practice were compared. Characteristics compared included area-level population demographics (from the US Census Bureau), health system characteristics (from the IMS Health Care Organization Services), and use of health services by Medicare fee-for-service enrollees (Dartmouth Atlas). Main Outcomes and Measures: Area-level characteristics of all eligible CPC+ regions, areas without a CPC+ practice, and areas with 1 or more CPC+ practices. Results: Of 756 eligible service areas, 322 had no CPC+ practices and 434 had at least 1 CPC+ practice. Of 2647 CPC+ practices, 579 (21.9%) had 1 physician and 1791 (67.7%) had 2 to 10 physicians. In areas without CPC+ practices, the population had a lower median income ($43 197 [interquartile range, $42 170-$44 224] vs $57 206 [interquartile range, $55 470-$58 941]), higher mean share of households living in poverty (17.8% [95% CI, 17.2%-18.4%] vs 14.4% [95% CI, 13.9%-15.0%]), higher mean educational attainment of high school or less (52.7% [95% CI, 51.7%-53.6%] vs 43.1% [95% CI, 42.1%-44.2%]), higher mean proportion of disabled residents (17.7% [95% CI, 17.3%-18.2%] vs 14.2% [13.8%-14.6%]), higher mean participation in Medicare (21.9% [95% CI, 21.3%-22.4%] vs 18.8% [95% CI, 18.3%-19.1%]) and Medicaid (22.2% [95% CI, 21.5%-22.9%]) vs 18.5% [95% CI, 17.8%-19.2%]), and higher mean proportion of uninsured residents (12.4% [95% CI, 11.9%-12.9%] vs 10.3% [95% CI, 9.9%-10.7%]) (P < .001 for all) compared with areas that had a CPC+ practice. Conclusions and Relevance: According to this study, although a diverse set of practices joined the CPC+ program, practices in areas characterized by patient populations with greater advantage were more likely to join, which may affect access to advanced primary care medical home models such as CPC+, by vulnerable populations.