The Comprehensive Primary Care Plus Model and Health Care Spending, Service Use, and Quality

Factors Associated with Health Care Costs in Older Adults with Type 2 Diabetes: Insights for Value-Based Payment Models

Diabetes accounts for 1 in 4 health care dollars spent. Succeeding in value-based payment models depends on identifying those at risk for high costs and providing them with appropriate treatment. The objective was to determine factors associated with type 2 diabetes mellitus costs. In this cohort study, this study used longitudinal data from a national insurer between 2016 and 2020. The authors included individuals aged 65 and older with type 2 diabetes mellitus with at least 12 months of continuous enrollment in Medicare Advantage. Exclusions included those who died during the study period or had incomplete data. Factors included study year, demographics (age, sex, race/ethnicity, language, dual eligibility, rurality), and diabetes complications (Diabetes Complications Severity Index). The outcomes of interest were medical and prescription costs. The study included 49,843 individuals. Diabetes complications (coefficient = $3582.11, P < 0.001), year (coefficient = $1003.22, P < 0.001, 2020 vs. 2016), sex (coefficient = $238.35, P < 0.001, female vs. male), dual eligibility (coefficient = $618.61, P < 0.001, yes vs. no), and rurality (coefficient = $1242.38, P < 0.001, yes vs. no) were associated with higher medical costs. Age (coefficient = $-2851.67, P < 0.001), race/ethnicity (coefficient = $-1458.03, P < 0.001, Black vs. White; coefficient = $-1679.81, P < 0.001, Hispanic vs. White), and language (coefficient = $-2523.29, P < 0.001, Spanish vs. English) were associated with lower medical costs. Individuals who had complications, were female, were dually eligible, and lived in rural communities had higher medical costs. Black, Hispanic, and Spanish-speaking individuals had lower medical costs, mirroring well-known disparities. Policy makers and health care organizations can use these data to more efficiently deliver care to some while ensuring adequate access for others.

Transporting difference-in-differences estimates to assess health equity impacts of payment and delivery models

OBJECTIVE

To demonstrate the use of transportability methods to extend findings from payment model evaluations to groups of historically underserved beneficiaries.

STUDY SETTING AND DESIGN

We used a simulation study to transport the effects of the Comprehensive Primary Care Plus (CPC+) model to a target population of Black fee-for-service (FFS) Medicare beneficiaries living outside the original 18 CPC+ regions. Our main outcome variable was total Medicare spending per beneficiary per year (pbpy).

DATA SOURCES AND ANALYTIC SAMPLE

We simulated practice-level spending in 18 CPC+ regions and 32 non-CPC+ regions (1200 practices per region). We calibrated the simulation parameters to values from the literature and then varied four key parameters to create 16 realistic simulation scenarios. These scenarios varied the representativeness of practices in CPC+ regions that joined CPC+ (i.e., the sample) relative to the target population by changing the distribution of Black beneficiaries across practices and the distribution of practices across regions. Practices were characterized by their experience with the Medicare Shared Savings Program (SSP) and system/hospital ownership because these are known to modify the effect of CPC+ on spending.

PRINCIPAL FINDINGS

Across the 16 simulation scenarios, transporting the treatment effect of CPC+ to Black FFS beneficiaries in non-CPC+ regions yielded median treatment effects that ranged from $15.5 pbpy smaller to $10 pbpy larger than in the sample. These differences are roughly the same magnitude as the estimated overall effect of $13 pbpy.

CONCLUSIONS

The Center for Medicare and Medicaid Innovation has pledged to put equity at the center of its demonstration models. However, offering models in limited geographic areas with voluntary provider participation may result in unrepresentative samples. Naively generalizing CPC+ effects from geographically limited, voluntary samples to all Black FFS beneficiaries could be misleading. Under some circumstances, transportability methods can be used to estimate effects in this target population.

Comprehensiveness in Primary Care: A Scoping Review

Policy Points Efforts to address a perceived decline of comprehensiveness in primary care are hampered by the absence of a clear and common understanding of what comprehensiveness means. This scoping review mapped two domains of comprehensiveness (breadth of care and approach to care) as well as a set of factors that enable comprehensive practice. The resulting conceptual map supports greater clarity for future use of the term comprehensiveness, facilitating more precisely targeted research, practice, and policy efforts to improve primary care systems.

CONTEXT

Associated with system efficiency and patient-perceived quality, comprehensiveness is widely recognized as foundational to high-quality primary care. However, there is concern that comprehensiveness is declining and that primary care physicians are providing a narrower range of services. Efforts to address this perceived decline are hampered by the many different and sometimes vague definitions of comprehensiveness in current use. This scoping review explored how comprehensiveness in primary care is conceptualized and defined in order to map its attributes in support of being able to more clearly and precisely define this key concept in research, practice, and policy.

METHODS

We conducted a scoping review, following the methods of Arksey and O'Malley and Levac and colleagues. The search included terms for two key concepts: primary care and comprehensiveness. Developed in Ovid Medical Literature Analysis and Retrieval System Online (MEDLINE), the search was adapted for Cumulated Index in Nursing and Allied Health Literature (CINAHL) and Embase, as well as for gray literature. After a multistep review, included sources underwent detailed data extraction.

FINDINGS

A total of 360 sources were extracted; 57% were empirical studies and 65% were published between 2010 and 2022. Across these sources, we identified nine attributes of comprehensiveness in primary care. We mapped these attributes into two conceptual domains: breadth of care (services, settings, health needs and conditions, patients served, and availability) and approach to care (one-stop shop, whole-person care, referrals and coordination, and longitudinal care). Additionally, we identified three enablers of comprehensiveness, namely structures and resources, teams, and competency.

CONCLUSIONS

The conceptual map of comprehensiveness in primary care offers a valuable tool that supports clarity for future use of the term comprehensiveness. The domains and attributes we identified can be used to develop definitions and measures that are appropriate to research, practice, and policy contexts, enabling more precise efforts to improve primary care systems.

Association between Comprehensive Primary Care Plus and opioid prescribing and prescription fills among Medicare beneficiaries

INTRODUCTION

To examine if Medicare beneficiaries attributed to Comprehensive Primary Care Plus (CPC+) practices had a greater decrease in the potential overuse of prescription opioids relative to beneficiaries attributed to other primary care practices. Primary care practices that participated in CPC+ received enhanced Medicare payment to support five functions: access and continuity of care, care management, comprehensiveness and coordination, patient and caregiver engagement, and planned care and population health. CPC+ practices participated within two tracks starting in 2017; Track 2 practices received larger payments to support more enhanced care delivery than Track 1 practices.

METHODS

Employing difference-in-differences, we used Medicare claims and Part D data to examine changes in potential opioid overuse between 2016 (baseline) and 2021 (the fifth program year). Our measure of potential opioid overuse measure relies on specifications for an existing quality measure of the same name that is defined as filling opioid prescriptions at a daily dosage of 90 morphine milligram equivalents or more among beneficiaries who use opioids for at least 90 days of supply per year. A total of 40,219 Medicare fee-for-service beneficiaries used opioids long term and were attributed to 2888 CPC+ practices; 129,178 beneficiaries used opioids long term and were attributed to 6921 comparison practices.

RESULTS

Across the combined treatment and comparison groups, potential opioid overuse decreased from 19 % in 2016 to 12 % in 2021. Relative to the comparison group, beneficiaries attributed to Track 1 CPC+ practices experienced an 0.8 percentage point greater decrease in potential opioid overuse (95 % CI = -1.4, -0.2) in the third program year compared to baseline. These findings persisted in the fourth and fifth years and were similar in magnitude to those in the third year. Track 2 results were similar to Track 1 results. The findings were likely driven by changes in CPC+ clinicians' prescribing behaviors: clinicians in CPC+ practices reduced the average dosage and the number of days' supply of prescription opioids more than clinicians in comparison practices.

CONCLUSIONS

A large-scale primary care delivery transformation initiative was associated with reduced potential opioid overuse among Medicare beneficiaries.

Changes in US Primary Care Access and Capabilities During the COVID-19 Pandemic

Importance

Many of the capabilities needed to deliver accessible, high-quality primary care have been defined, but little is known about how their implementation has changed in US practices over the course of the COVID-19 pandemic or about the factors associated with greater capabilities.

Objective

To describe US primary care practices' accessibility and capabilities and examine recent changes.

Design, Setting, and Participants

This was a retrospective cohort study across 2 surveys, in 2017 to 2018 and 2022 to 2023, among a national sample of primary care practice leaders in the US. Data were analyzed from January 2023 to September 2024.

Exposures

Degree of integrated practice ownership and accountable care organization (ACO) participation.

Main Outcomes and Measures

Differences by practice ownership and ACO participation, and changes over time in access to care and care delivery capabilities. These were measured by composite scores of responses standardized to a scale of 0 to 100.

Results

This analysis included 710 practices, of which 234 were independently owned, 105 were physician group owned, and 321 were hospital/health system owned in 2017 to 2018, and 68 practices reported no ACO participation, 107 joined between surveys, and 486 otherwise participated in ACOs. Access to care (measured as extended weekday or weekend hours) was reported to decline from the first survey in 2017 to 2018 to the second in 2022 to 2023. Hospital/health system practices and ACO participants had higher rates of extended weekday hours than their comparators in 2022 to 2023. Average capability scores increased from 51 to 54 (increase of 4 points [95% CI, 1-6 points]). There was wide variation in scores within all ownership and ACO participant or nonparticipant groups. Capability scores were higher on average for more integrated practices (for physician groups compared to independent practices, 12 points [95% CI, 5-19 points] in 2017-2018 and 12 points [95% CI, 7-16 points] in 2022-2023) and for ACO participants compared to nonparticipants (13-point difference [6 to 20] in 2017-2018 and 12-point difference [6 to 18] in 2022-2023).

Conclusions and Relevance

In this cohort study, over the time period including the COVID-19 pandemic, primary care practices reported a decline in access to care, while average practice capabilities improved. Integrated practice ownership and ACO participation were both associated with better access and capability scores, suggesting that value-based payment and integrated care delivery support the development of higher-quality primary care. Variations across practices point to large opportunities for improvement overall and underscore the importance of incentives and structures as levers to improve primary care delivery.

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.