A lifeline for primary care

Configuration and Delivery of Primary Care in Rural and Urban Settings

BACKGROUND

There are concerns about the capacity of rural primary care due to potential workforce shortages and patients with disproportionately more clinical and socioeconomic risks. Little research examines the configuration and delivery of primary care along the spectrum of rurality.

OBJECTIVE

Compare structure, capabilities, and payment reform participation of isolated, small town, micropolitan, and metropolitan physician practices, and the characteristics and utilization of their Medicare beneficiaries.

DESIGN

Observational study of practices defined using IQVIA OneKey, 2017 Medicare claims, and, for a subset, the National Survey of Healthcare Organizations and Systems (response rate=47%).

PARTICIPANTS

A total of 27,716,967 beneficiaries with qualifying visits who were assigned to practices.

MAIN MEASURES

We characterized practices' structure, capabilities, and payment reform participation and measured beneficiary utilization by rurality.

KEY RESULTS

Rural practices were smaller, more primary care dominant, and system-owned, and had more beneficiaries per practice. Beneficiaries in rural practices were more likely to be from high-poverty areas and disabled. There were few differences in patterns of outpatient utilization and practices' care delivery capabilities. Isolated and micropolitan practices reported less engagement in quality-focused payment programs than metropolitan practices. Beneficiaries cared for in more rural settings received fewer recommended mammograms and had higher overall and condition-specific readmissions. Fewer beneficiaries with diabetes in rural practices had an eye exam. Most isolated rural beneficiaries traveled to more urban communities for care.

CONCLUSIONS

While most isolated Medicare beneficiaries traveled to more urban practices for outpatient care, those receiving care in rural practices had similar outpatient and inpatient utilization to urban counterparts except for readmissions and quality metrics that rely on services outside of primary care. Rural practices reported similar care capabilities to urban practices, suggesting that despite differences in workforce and demographics, rural patterns of primary care delivery are comparable to urban.

Trends in Outpatient Care for Medicare Beneficiaries and Implications for Primary Care, 2000 to 2019

BACKGROUND

Despite the central role of primary care in improving health system performance, there are little recent data on how use of primary care and specialists has evolved over time and its implications for the range of care coordination needed in primary care.

OBJECTIVE

To describe trends in outpatient care delivery and the implications for primary care provider (PCP) care coordination.

DESIGN

Descriptive, repeated, cross-sectional study using Medicare claims from 2000 to 2019, with direct standardization used to control for changes in beneficiary characteristics over time.

SETTING

Traditional fee-for-service Medicare.

PATIENTS

20% sample of Medicare beneficiaries.

MEASUREMENTS

Annual counts of outpatient visits and procedures, the number of distinct physicians seen, and the number of other physicians seen by a PCP's assigned Medicare patients.

RESULTS

The proportion of Medicare beneficiaries with any PCP visit annually only slightly increased from 61.2% in 2000 to 65.7% in 2019. The mean annual number of primary care office visits per beneficiary also changed little from 2000 to 2019 (2.99 to 3.00), although the mean number of PCPs seen increased from 0.89 to 1.21 (36.0% increase). In contrast, the mean annual number of visits to specialists increased 20% from 4.05 to 4.87, whereas the mean number of unique specialists seen increased 34.2% from 1.63 to 2.18. The proportion of beneficiaries seeing 5 or more physicians annually increased from 17.5% to 30.1%. In 2000, a PCP's Medicare patient panel saw a median of 52 other physicians (interquartile range, 23 to 87), increasing to 95 (interquartile range, 40 to 164) in 2019.

LIMITATION

Data were limited to Medicare beneficiaries and, because of the use of a 20% sample, may underestimate the number of other physicians seen across a PCP's entire panel.

CONCLUSION

Outpatient care for Medicare beneficiaries has shifted toward more specialist care received from more physicians without increased primary care contact. This represents a substantial expansion of the coordination burden faced by PCPs.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Flipping the Pain Care Model: A Sociopsychobiological Approach to High-Value Chronic Pain Care

OBJECTIVE

Much of the pain care in the United States is costly and associated with limited benefits and significant harms, representing a crisis of value. We explore the current factors that lead to low-value pain care within the United States and provide an alternate model for pain care, as well as an implementation example for this model that is expected to produce high-value pain care.

METHODS

From the perspective of aiming for high-value care (defined as care that maximizes clinical benefit while minimizing harm and cost), we describe the current evidence practice gap (EPG) for pain care in the United States, which has developed as current clinical care diverges from existing evidence. A discussion of the biomedical, biopsychosocial, and sociopsychobiological (SPB) models of pain care is used to elucidate the origins of the current EPG and the unconscious factors that perpetuate pain care systems despite poor results.

RESULTS

An interprofessional pain team within the Veterans Health Administration is described as an example of a pain care system that has been designed to deliver high-value pain care and close the EPG by implementing the SPB model.

CONCLUSIONS

Adopting and implementing a sociopsychobiological model may be an effective approach to address the current evidence practice gap and deliver high-value pain care in the United States. The Phoenix VA Health Care System's Chronic Pain Wellness Center may serve as a template for providing high-value, evidence-based pain care for patients with high-impact chronic pain who also have medical, mental health, and opioid use disorder comorbidities.

The Effect of Supervision Waivers on Practice: A Survey of Massachusetts Nurse Practitioners During the COVID-19 Pandemic

BACKGROUND

While optimal utilization of the nurse practitioner (NP) workforce is an increasingly popular proposal to alleviate the growing primary care shortage, federal, state, and organizational scope of practice policies inhibit NPs from practicing to the full extent of their license and training. In March of 2020, NP state-specific supervisory requirements were temporarily waived to meet the demands of the coronavirus disease 2019 (COVID-19) pandemic in Massachusetts.

OBJECTIVE

The objective of this study was to examine the impact of temporarily waived state practice restrictions on NP perception of care delivery during the initial surge of the COVID-19 pandemic in Massachusetts.

RESEARCH DESIGN

Mixed methods descriptive analysis of a web-based survey of Massachusetts NPs (N=391), conducted in May and June 2020.

RESULTS

The vast majority (75%) of NPs believed the temporary removal of practice restriction did not perceptibly improve clinical work. Psychiatric mental health NPs were significantly more likely than other NP specialties to believe the waiver improved clinical work (odds ratio=6.68, P=0.001). NPs that experienced an increase in working hours during the pandemic surge were also more likely to report a positive effect of the waiver (odds ratio=2.56, P=0.000).

CONCLUSIONS

Temporary removal of state-level practice barriers alone is not sufficient to achieve immediate full scope of practice for NPs. The successful implementation of modernized scope of practice laws may require a collective effort to revise organizational and payer policies accordingly.

The Patient-Centered Medical Home as a Community-based Strategy

Increasing attention has been devoted to the important role that primary care will play in improving population health. One innovation, the patient-centered medical home (PCMH), aims to unite a variety of professionals with patients in the prevention and treatment of illness. Although patient perspectives are critical to this model, this article questions whether the PCMH in practice is truly community-based. That is, do physicians, planners, and other health care professionals take seriously the value of integrating local knowledge into medical care? The argument presented is that community-based philosophy contains a foundational principle that the perspectives of health care practitioners and community members must be integrated. Although many proponents of the PCMH aim to offer patient-centered and sustainable health care, focusing on this philosophical shift will ensure that services are organized by communities in collaboration with health care professionals.

Breast Cancer Care in California and Ontario: Primary Care Protections Greatest Among the Most Socioeconomically Vulnerable Women Living in the Most Underserved Places

BACKGROUND

Better health care among Canada's socioeconomically vulnerable versus America's has not been fully explained. We examined the effects of poverty, health insurance and the supply of primary care physicians on breast cancer care.

METHODS

We analyzed breast cancer data in Ontario (n = 950) and California (n = 6300) between 1996 and 2000 and followed until 2014. We obtained socioeconomic data from censuses, oversampling the poor. We obtained data on the supply of physicians, primary care and specialists. The optimal care criterion was being diagnosed early with node negative disease and received breast conserving surgery followed by adjuvant radiation therapy.

RESULTS

Women in Ontario received more optimal care in communities well supplied by primary care physicians. They were particularly advantaged in the most disadvantaged places: high poverty neighborhoods (rate ratio = 1.65) and communities lacking specialist physicians (rate ratio = 1.33). Canadian advantages were explained by better health insurance coverage and greater primary care access.

CONCLUSIONS

Policy makers ought to ensure that the newly insured are adequately insured. The Medicaid program should be expanded, as intended, across all 50 states. Strengthening America's system of primary care will probably be the best way to ensure that the Affordable Care Act's full benefits are realized.

Recent Trends in Primary Care Interest and Career Choices Among Medical Students at an Academic Medical Institution

Phenomenon: As an impending shortage of primary care physicians is expected, understanding career trajectories of medical students will be useful in supporting interest in primary care fields and careers. The authors sought to characterize recent trends in primary care interest and career trajectories among medical students at an academic medical institution that did not have a family medicine department.

APPROACH

Match data for 2,477 graduates who matched into resident training programs between 1989 and 2014 were analyzed to determine the proportion entering primary care residency programs. An online search and confirmatory phone call methodology was used to determine primary care career trajectories for the 795 graduates who matched into primary care residency programs between 1989 to 2010. Subanalyses were performed to characterize primary care career entrance among graduates who matched into the three primary care residency programs: Family Medicine, Categorical and Primary Care Internal Medicine, and Categorical and Primary Care Pediatrics.

FINDINGS

Between 1989 and 2014, 911 (37%) of all matched graduates matched into primary care residency programs. Of the 795 graduates who matched into these programs between 1989 and 2010, less than half (245; 31%) entered primary care careers. Of the graduates who ultimately entered primary care careers, 82% matched into either internal medicine or pediatrics residency programs and 18% matched into family medicine programs. Although there have been fluctuations in primary care interest that seem to parallel health care trends over the 26-year period, the overall percentage of graduates entering primary care residency programs and careers has remained fairly stable. Between 2006 and 2010, entrance into both primary care residency programs and primary care careers steadily increased. Despite this, the overall percentage of matched graduates who entered primary care careers over the 22-year study period (12%) was less than the national average (16%-18%). Insights: In the 26-year period between 1989 and 2014, primary care career interest increased slightly among medical students at this academic medical institution, with fluctuations that seem to coincide with national health care trends. Year-to-year fluctuations appear to be driven by rising numbers of Categorical Pediatrics and Categorical Internal Medicine matchers pursuing careers in primary care. There may be a need for specialized curricula and strategies to promote and retain interest in primary care at academic medical institutions, especially at institutions without family medicine training programs.

Osteopathic medical students' understanding of the Patient Protection and Affordable Care Act: a first step toward a policy-informed curriculum

CONTEXT

Current osteopathic medical students will play an important role in implementing, modifying, and advocating for or against the Patient Protection and Affordable Care Act (ACA) of 2010. Accordingly, medical educators will need to address curricular gaps specific to the ACA and medical practice. Research that gauges osteopathic medical students' level of understanding of the ACA is needed to inform an evidence-based curriculum.

OBJECTIVE

To assess first- and second-year osteopathic medical students' beliefs about the ACA.

METHODS

In this descriptive cross-sectional survey-based study, first- and second-year students were recruited because their responses would be indicative of what, if any, information about the ACA was being covered in the preclinical curriculum. A 30-item survey was distributed in November 2013, after the health insurance exchanges launched on October 1, 2013.

RESULTS

A total of 239 first- and second-year osteopathic medical students completed the survey. One hundred ten students (46%) disagreed and 103 (43.1%) agreed that the ACA would provide health insurance coverage for all US citizens. The ACA was predicted to lead to lower wages and fewer jobs (73 students [30.5%]), as well as small business bankruptcy because of employees' health insurance costs (96 [40.2%]). Regarding Medicare recipients, 113 students (47.3%) did not know whether these individuals would be required to buy insurance through the health insurance exchanges. The majority of students knew that the ACA would require US citizens to pay a penalty if they did not have health insurance (198 [82.8%]) and understood that not everyone would be required to purchase health insurance through health insurance exchanges (137 [57.3%]). Although students took note of certain clinical benefits for patients offered by the ACA, they remained concerned about the ACA's impact on their professional prospects, particularly in the area of primary care.

CONCLUSION

These findings build on the existing literature that emphasize the need for incorporating into the osteopathic medical curriculum knowledge of the dynamics of health care policy and reform and for creating opportunities for students to follow health policy developments as they evolve in real time.

Changing medical relationships after the ACA: Transforming perspectives for population health

American health care has undergone significant organizational change in recent decades. But what is the state of core medical relationships in the wake of these changes? Throughout ACA-era health care reform, the doctor-patient relationship was targeted as a particularly important focus for improving communication and health outcomes. Recent developments however have shifted the focus from individual-level outcomes to the wellbeing of populations. This, we argue, requires a fundamental rethinking of health care reform as an opportunity to renegotiate relationships. For example, the move to population medicine requires that the very concept of a patient be resituated and the scope of relevant relationships expanded. Medical relationships in this era of health care are likely to include partnerships between various types of clinicians and the communities in which patients reside, as well as a host of new actors, from social workers and navigators to scribes and community health workers. To address the upstream determinants of population health, providers must be increasingly willing and trained to collaborate with community stakeholders to address both medical and non-medical issues. These community-based partnerships are critical to providing health care that is both relevant and appropriate for addressing problems, and sustainable. Approaching health care reform, and the focus on population health, as a fundamental reworking of relationships provides scholars with a sharper theoretical lens for understanding 21st century American health care.

Is Access to and Use of Patient Perceived Patient-Centered Medical Homes Associated With Reduced Nonurgent Emergency Department Use?

This study examined whether access to and use of patient-centered medical home (PCMH) practices is associated with reduced nonurgent emergency department (ED) use, especially among the uninsured population. This retrospective study used 2010-2011 Medical Expenditure Panel Survey data. Difference-in-difference methods, multivariate logit model, marginal effect, and survey procedures were employed. A total of 1287 adults had any ED visit in 2011, which represented weighted 29 463 684 people in the population. Reductions in odds of nonurgent ED use between the full PCMH group and the “no regular provider” group was significantly larger for the uninsured group than publicly and privately insured groups (β = −1.70, P = .009, and β = −1.04, P = .040, respectively). Similar results were found between the partial PCMH group and the “no regular provider” group for the uninsured group compared to the public group (β = −1.67, P = .019). PCMH models demonstrate higher odds of reduced nonurgent ED use among uninsured individuals compared to public and private enrollees nationwide.

The Selling of Primary Care 2015

The role of undergraduate medical education in creating, perpetuating, and potentially solving the physician shortage in adult primary care has been debated for years, but often the discussions revolve around overly simplistic notions of supply and demand. The supply is curtailed, it is said, because the work is hard and the pay is low relative to other career options. Missing is a recognition that medical schools make choices in developing primary care learning environments that profoundly affect student perceptions of this career. Emerging developments in healthcare, including the transformation of academic health centers into integrated health systems that enter into risk-based contracts, may provide an opportunity to re-direct discussions about primary care. More schools may begin to recognize that they can control the quality of primary care teaching environments, and that doing so will help them achieve excellence in education and compete in the new marketplace. The selling of primary care to medical schools may be the first step in primary care selling itself to medical students.

Is Access to and Use of Primary Care Practices that Patients Perceive as Having Essential Qualities of a Patient-Centered Medical Home Associated With Positive Patient Experience? Empirical Evidence From a U.S. Nationally Representative Sample

OBJECTIVE

The patient-centered medical home (PCMH) has emerged as an innovative healthcare delivery model that holds the conceptual promise to improve healthcare quality and patient experience. This study examined how patient perceived PCMH is related to patient satisfaction and experience nationwide. This study advances academic discussion in that it is among the first to examine empirical evidence using a U.S. nationally representative sample.

METHODS

This retrospective cohort study used data from the 2010 to 2011 Medical Expenditure Panel Survey. This study focused on insured individuals aged 18 and older. We measured and identified cohorts for a "full PCMH," a "partial PCMH" (i.e., with a usual source of care but not a PCMH), and an "unknown PCMH," with the reference group being the "no regular provider" group and the partial PCMH group, respectively. Using logit models, we assessed patient experiences of the PCMH use controlling for covariates in 2010. Given the nature of the complex survey design, the weights and variance were adjusted using the survey procedures to yield nationally representative results.

RESULTS

The final study sample consisted of 7,743 individuals, representing 191 million individuals in the weighted population. After controlling for covariates in 2010, the full PCMH group was consistently observed to have higher odds of positive patient experience than individuals with no usual source of care: odds ratio (OR) = 1.89 (p = .003) for providers "listened carefully to you"; OR = 1.81 (p = .001) for providers "spent enough time with you"; OR = 1.85 (p = .007) for providers "showed respect for what you had to say"; and OR = 1.89 (p < .001) for the composite patient experience. Similarly, compared with the partial PCMH group, consistently higher odds of patient satisfaction among all patient experience measures were observed for the full medical home group: OR = 1.45 (p = .070, significant at α = 0.1 level) for providers "explained things so you understood"; OR = 1.69 (p = .002) for providers "listened carefully to you"; OR = 1.57 (p = .003) for providers "spent enough time with you"; OR = 1.48 (p = .039) for providers "showed respect for what you had to say"; and OR = 1.56 (p = .001) for the composite patient experience.

CONCLUSIONS

Overall, the PCMH model was associated with improved patient satisfaction nationwide. Findings from this study have shed light on strategies of innovative healthcare delivery models in improving patient experience, which in turn, may translate to patients' compliance to treatment regimen and improved health outcomes.

Initiatives to Enhance Primary Care Delivery: Two Examples from the Field

OBJECTIVES

Increasing demands on primary care providers have created a need for systems-level initiatives to improve primary care delivery. The purpose of this paper is to describe and present outcomes for two such initiatives: the Pennsylvania Academy of Family Physicians' Residency Program Collaborative (RPC) and the St. Johnsbury Vermont Community Health Team (CHT).

METHODS

Researchers conducted case studies of the initiatives using mixed methods, including: secondary analysis of program and electronic health record data, systematic document review and interviews.

RESULTS

RPC is a learning collaborative that teaches quality improvement and patient-centeredness to primary care providers, residents, clinical support staff, and administrative staff in residency programs. Results show that participation in a higher number of live learning sessions resulted in a significant increase in patient centered medical home recognition attainment and significant improvements in performance in diabetic process measures including eye exams (14.3%, p=0.004), eye referrals (13.82%, p=0.013), foot exams (15.73%, p=0.003), smoking cessation (15.83%, p=0.012), and self-management goals (25.45%, p=0.001). As a community-clinical linkages model, CHT involves primary care practices, community health workers (CHWs), and community partners. Results suggest that CHT members successfully work together to coordinate comprehensive care for the individuals they serve. Further, individuals exposed to CHWs experienced increased stability in access to health insurance (p=0.001) and prescription drugs (p=0.000), and the need for health education counseling (p=0.000).

CONCLUSION

Findings from this study indicate that these two system-level strategies have the promise to improve primary care delivery. Additional research can determine the extent to which these strategies can improve other health outcomes.

Comparing the implementation of team approaches for improving diabetes care in community health centers

BACKGROUND

Patient panel management and community-based care management may be viable strategies for community health centers to improve the quality of diabetes care for vulnerable patient populations. The objective of our study was to clarify implementation processes and experiences of integrating office-based medical assistant (MA) panel management and community health worker (CHW) community-based management into routine care for diabetic patients.

METHODS

Mixed methods study with interviews and surveys of clinicians and staff participating in a study comparing the effectiveness of MA and CHW health coaching for improving diabetes care. Participants included 24 key informants in five role categories and 249 clinicians and staff survey respondents from 14 participating practices. We conducted thematic analyses of key informant interview transcripts to clarify implementation processes and describe barriers to integrating the new roles into practice. We surveyed clinicians and staff to assess differences in practice culture among intervention and control groups. We triangulated findings to identify concordant and disparate results across data sources.

RESULTS

Implementation processes and experiences varied considerably among the practices implementing CHW and MA team-based approaches, resulting in differences in the organization of health coaching and self-management support activities. Importantly, CHW and MA responsibilities converged over time to focus on health coaching of diabetic patients. MA health coaches experienced difficulty in allocating dedicated time due to other MA responsibilities that often crowded out time for diabetic patient health coaching. Time constraints also limited the personal introduction of patients to health coaches by clinicians. Participants highlighted the importance of a supportive team climate and proactive leadership as important enablers for MAs and CHWs to implement their health coaching responsibilities and also promoted professional growth.

CONCLUSION

Implementation of team-based strategies to improve diabetes care for vulnerable populations was diverse, however all practices converged in their foci on health coaching roles of CHWs and MAs. Our study suggests that a flexible approach to implementing health coaching is more important than fidelity to rigid models that do not allow for variable allocation of responsibilities across team members. Clinicians play an instrumental role in supporting health coaches to grow into their new patient care responsibilities.

Engaging Patients at the Front Lines of Primary Care Redesign: Operational Lessons for an Effective Program

Article-at-a-Glance Background: The lack of patient engagement in quality improvement is concerning. As part of an enterprisewide initiative to redesign primary care at UW Health, interdisciplinary primary care teams received training in patient engagement.

METHODS

Organizational stakeholders held a structured discussion and used nominal group technique to identify the key components critical to fostering a culture of patient engagement and critical lessons learned. These findings were augmented and illustrated by review of transcripts of two focus groups held with clinic managers and 69 interviews with individual microsystem team members.

RESULTS

From late 2009 to 2014, 47 (81%) of 58 teams have engaged patients in various stages of practice improvement projects. Organizational components identified as critical to fostering a culture of patient engagement were alignment of the organization's vision that guided the redesign with national priorities, readily available external experts, involvement of all care team members in patient engagement, integration within an existing continuous improvement team development program, and an intervention deliberately matched to organizational readiness. Critical lessons learned were the need to embed patient engagement into current improvement activities, designate a neutral point person(s) or group to navigate organizational complexities, commit resources to support patient engagement activities, and plan for sustained team-patient interactions.

CONCLUSIONS

Current national health care policy and local market pressures are compelling partnering with patients in efforts to improve the value of the health care delivery system. The UW Health experience may be useful for organizations seeking to introduce or strengthen the patient role in designing delivery system improvements.

Do patient-centered medical homes reduce emergency department visits?

OBJECTIVE

To assess whether adoption of the patient-centered medical home (PCMH) reduces emergency department (ED) utilization among patients with and without chronic illness.

DATA SOURCES

Data from approximately 460,000 Independence Blue Cross patients enrolled in 280 primary care practices, all converting to PCMH status between 2008 and 2012.

RESEARCH DESIGN

We estimate the effect of a practice becoming PCMH-certified on ED visits and costs using a difference-in-differences approach which exploits variation in the timing of PCMH certification, employing either practice or patient fixed effects. We analyzed patients with and without chronic illness across six chronic illness categories.

PRINCIPAL FINDINGS

Among chronically ill patients, transition to PCMH status was associated with 5-8 percent reductions in ED utilization. This finding was robust to a number of specifications, including analyzing avoidable and weekend ED visits alone. The largest reductions in ED visits are concentrated among chronic patients with diabetes and hypertension.

CONCLUSIONS

Adoption of the PCMH model was associated with lower ED utilization for chronically ill patients, but not for those without chronic illness. The effectiveness of the PCMH model varies by chronic condition. Analysis of weekend and avoidable ED visits suggests that reductions in ED utilization stem from better management of chronic illness rather than expanding access to primary care clinics.

The relationships between access to and use of a patient-centered medical home and healthcare utilization and costs: A cohort study using Medical Expenditure Panel Survey data from 2007 to 2010

Objective

The patient-centered medical home has emerged as an innovative healthcare delivery model that holds the conceptual promise to improve healthcare quality while reducing costs. This study is among the first to examine how patient perceived patient-centered medical home is related to utilization and costs for emergency department and inpatient care nationwide in the U.S.

Methods

This retrospective cohort study used data from the 2007–2010 Medical Expenditure Panel Survey. This study focused upon insured individuals aged 18 and older. In each two-year cohort, we measured and identified a full patient-centered medical home group, a partial patient-centered medical home group (with a usual source of care but not a patient-centered medical home), and an unknown patient-centered medical home group. Using negative binomial regression and generalized linear models, we conducted the analysis while controlling for covariates at baseline. Given the nature of the complex survey design, we adjusted weights and variance.

Results

The study sample consisted of 15,595 individuals, representing a total of 368 million people in the U.S. In the trend of outcome changes from the baseline to the follow-up year, the full and partial patient-centered medical home groups demonstrated reduced efficiency for the 2007–2008 cohort, but increased efficiency for the 2009–2010 cohort, as compared to the no regular provider group.

Conclusions

Overall, the empirical evidence does not indicate whether patient-centered medical home models reduce healthcare utilization and costs, but it does suggest their potential as mechanisms for achieving healthcare system efficiency, when primary care practices have grown from early to middle stage of patient-centered medical home transformation. A longer observation window and holistic view on all stages of patient-centered medical home growth may be more informative on patient-centered medical home’s efficiency.

Teaching medical ethics to meet the realities of a changing health care system

The changing context of medical practice--bureaucratic, political, or economic--demands that doctors have the knowledge and skills to face these new realities. Such changes impose obstacles on doctors delivering ethical care to vulnerable patient populations. Modern medical ethics education requires a focus upon the knowledge and skills necessary to close the gap between the theory and practice of ethical care. Physicians and doctors-in-training must learn to be morally sensitive to ethical dilemmas on the wards, learn how to make professionally grounded decisions with their patients and other medical providers, and develop the leadership, dedication, and courage to fulfill ethical values in the face of disincentives and bureaucratic challenges. A new core focus of medical ethics education must turn to learning how to put ethics into practice by teaching physicians to realistically negotiate the new institutional maze of 21st-century medicine.

Acceptance of insurance by psychiatrists and the implications for access to mental health care

IMPORTANCE

There have been recent calls for increased access to mental health services, but access may be limited owing to psychiatrist refusal to accept insurance.

OBJECTIVE

To describe recent trends in acceptance of insurance by psychiatrists compared with physicians in other specialties.

DESIGN, SETTING, AND PARTICIPANTS

We used data from a national survey of office-based physicians in the United States to calculate rates of acceptance of private noncapitated insurance, Medicare, and Medicaid by psychiatrists vs physicians in other specialties and to compare characteristics of psychiatrists who accepted insurance and those who did not.

MAIN OUTCOMES AND MEASURES

Our main outcome variables were physician acceptance of new patients with private noncapitated insurance, Medicare, or Medicaid. Our main independent variables were physician specialty and year groupings (2005-2006, 2007-2008, and 2009-2010).

RESULTS

The percentage of psychiatrists who accepted private noncapitated insurance in 2009-2010 was significantly lower than the percentage of physicians in other specialties (55.3% [95% CI, 46.7%-63.8%] vs 88.7% [86.4%-90.7%]; P < .001) and had declined by 17.0% since 2005-2006. Similarly, the percentage of psychiatrists who accepted Medicare in 2009-2010 was significantly lower than that for other physicians (54.8% [95% CI, 46.6%-62.7%] vs 86.1% [84.4%-87.7%]; P < .001) and had declined by 19.5% since 2005-2006. Psychiatrists' Medicaid acceptance rates in 2009-2010 were also lower than those for other physicians (43.1% [95% CI, 34.9%-51.7%] vs 73.0% [70.3%-75.5%]; P < .001) but had not declined significantly from 2005-2006. Psychiatrists in the Midwest were more likely to accept private noncapitated insurance (85.1%) than those in the Northeast (48.5%), South (43.0%), or West (57.8%) (P = .02).

CONCLUSIONS AND RELEVANCE

Acceptance rates for all types of insurance were significantly lower for psychiatrists than for physicians in other specialties. These low rates of acceptance may pose a barrier to access to mental health services.

The impact of global budgets on pharmaceutical spending and utilization: early experience from the alternative quality contract

In 2009, Blue Cross Blue Shield of Massachusetts implemented a global budget-based payment system, the Alternative Quality Contract (AQC), in which provider groups assumed accountability for spending. We investigate the impact of global budgets on the utilization of prescription drugs and related expenditures. Our analyses indicate no statistically significant evidence that the AQC reduced the use of drugs. Although the impact may change over time, early evidence suggests that it is premature to conclude that global budget systems may reduce access to medications.

Small physician practices in new york needed sustained help to realize gains in quality from use of electronic health records

The 2009 American Recovery and Reinvestment Act spurred adoption of electronic health records (EHRs) in the United States, through such measures as financial incentives to providers through Medicare and Medicaid and regional extension centers, which provide ongoing technical assistance to practices. Yet the relationship between EHR adoption and quality of care remains poorly understood. We evaluated the early effects on quality of the Primary Care Information Project, which provides subsidized EHRs and technical assistance to primary care practices in underserved neighborhoods in New York City, using the regional extension center model. We found that just general participation in, or exposure to, the project was not enough to improve quality of care. It took sustained exposure on the part of these practices and technical assistance to them before they demonstrated improvement on measures of care most likely to be affected by the use of electronic health records, such as cancer screenings and care for patients with diabetes. Participating in the Primary Care Information Project for nine or more months was associated with significantly improved quality, but only for this limited group of quality measures and only for physicians receiving extensive technical assistance.

The learners' perceptions survey-primary care: assessing resident perceptions of internal medicine continuity clinics and patient-centered care

BACKGROUND

In 2010, the Department of Veterans Affairs (VA) implemented a national patient-centered care initiative that organized primary care into interdisciplinary teams of health care professionals to provide patient-centered, continuous, and coordinated care.

OBJECTIVE

We assessed the discriminate validity of the Learners' Perceptions Survey-Primary Care (LPS-PC), a tool designed to measure residents' perceptions about their primary and patient-centered care experiences.

METHODS

Between October 2010 and June 2011, the LPS-PC was administered to Loma Linda University Medical Center internal medicine residents assigned to continuity clinics at the VA Loma Linda Healthcare System (VALLHCS), a university setting, or the county hospital. Adjusted differences in satisfaction ratings across settings and over domains (patient- and family-centered care, faculty and preceptors, learning, clinical, work and physical environments, and personal experience) were computed using a generalized linear model.

RESULTS

Our response rate was 86% (77 of 90). Residents were more satisfied with patient- and family-centered care at the VALLHCS than at either the university or county (P < .001). However, faculty and preceptors (odds ratio [OR]  =  1.53), physical (OR  =  1.29), and learning (OR  =  1.28) environments had more impact on overall resident satisfaction than patient- and family-centered care (OR  =  1.08).

CONCLUSIONS

The LPS-PC demonstrated discriminate validity to assess residents' perceptions of their patient-centered clinical training experience across outpatient primary care settings at an internal medicine residency program. The largest difference in scores was the patient- and family-centered care domain, in which residents rated the VALLHCS much higher than the university or county sites.

The military veteran to physician assistant pathway: building the primary care workforce

The physician assistant (PA) profession emerged to utilize the skills of returning Vietnam-era military medics and corpsmen to fortify deficits in the health care workforce. Today, the nation again faces projected health care workforce shortages and a significant armed forces drawdown. The authors describe national efforts to address both issues by facilitating veterans' entrance into civilian PA careers and leveraging their skills.More than 50,000 service personnel with military health care training were discharged between 2006 and 2010. These veterans' health care experience and maturity make them ideal candidates for civilian training as primary care providers. They trained and practiced in teams and functioned under minimal supervision to care for a broad range of patients. Military health care personnel are experienced in emergency medicine, urgent care, primary care, public health, and disaster medicine. However, the PA profession scarcely taps this valuable resource. Fewer than 4% of veterans with health care experience may ever apply for civilian PA training.The Health Resources and Services Administration (HRSA) implements two strategies to help prepare and graduate veterans from PA education programs. First, Primary Care Training and Enhancement (PCTE) grants help develop the primary care workforce. In 2012, HRSA introduced reserved review points for PCTE: Physician Assistant Training in Primary Care applicants with veteran-targeted activities, increasing their likelihood of receiving funding. Second, HRSA leads civilian and military stakeholder workgroups that are identifying recruitment and retention activities and curricula adaptations that maximize veterans' potential as PAs. Both strategies are described, and early outcomes are presented.

Electronic communication improves access, but barriers to its widespread adoption remain

Because electronic communication is quick, convenient, and inexpensive for most patients, care that is truly patient centered should promote the use of such communication between patients and providers, even using it as a substitute for office visits when clinically appropriate. Despite the potential benefits of electronic communication, fewer than 7 percent of providers used it in 2008. To learn from the experiences of providers that have widely incorporated electronic communication into patient care, we interviewed leaders of twenty-one medical groups that use it extensively with patients. We also interviewed staff in six of those groups. Electronic communication was widely perceived to be a safe, effective, and efficient means of communication that improves patient satisfaction and saves patients time but that increases the volume of physician work unless office visits are reduced. Practice redesign and new payment methods are likely necessary for electronic communication to be more widely used in patient care.

Teleconsultation improves primary care clinicians' confidence about caring for HIV

BACKGROUND

Telemedicine can facilitate communication between primary care clinicians and specialists. Generalists who use telemedicine for consultation (teleconsultation) may be able to practice more independently and reduce the number of formal referrals to specialists. In the United States, a federally funded human immunodeficiency virus (HIV) teleconsultation service (HIV Warmline) offers clinicians live telephone access to HIV specialists; however, its impact on clinicians' self-perceived clinical competence and referral rates has not been studied.

OBJECTIVE

To determine if primary care clinicians who used the HIV Warmline felt more capable of managing HIV in their own practices.

DESIGN

Online survey.

PARTICIPANTS

Primary care physicians and mid-level practitioners who used the HIV Warmline for teleconsultation between 1/2008 and 3/2010.

MAIN MEASURES

Participants compared the HIV Warmline to other methods of obtaining HIV clinical support, and then rated its impact on their confidence in their HIV skills and their referral patterns.

KEY RESULTS

Respondents (N = 191, 59% response rate) found the HIV Warmline to be quicker (65%), more applicable (70%), and more trustworthy (57%) than other sources of HIV information. After using the HIV Warmline, 90% had improved confidence about caring for HIV, 67% stated it changed the way they managed HIV, and 74% were able to avoid referring patients to specialists. All valued the availability of live, free consultation.

CONCLUSIONS

Primary care clinicians who called the HIV Warmline reported increased confidence in their HIV care and less need to refer patients to specialists. Teleconsultation may be a powerful tool to help consolidate HIV care in the primary care setting, and could be adapted for use with a variety of other medical conditions. The direct impact of teleconsultation on actual referral rates, quality of care and clinical outcomes needs to be studied.

Medical homes versus individual practice in primary care: impact on health care expenditures

BACKGROUND

The medical home (MH) model has prompted increasing attention given its potential to improve quality of care while reducing health expenditures.

OBJECTIVES

We compare overall and specific health care expenditures in Belgium, from the third-party payer perspective (compulsory social insurance), between patients treated at individual practices (IP) and at MHs. We compare the sociodemographic profile of MH and IP users.

RESEARCH DESIGN

This is a retrospective study using public insurance claims data. Generalized linear models estimate the impact on health expenditures of being treated at a MH versus IP, controlling for individual, and area-based sociodemographic characteristics. The choice of primary care setting is modeled using logistic regressions.

SUBJECTS

A random sample of 43,678 persons followed during the year 2004.

MEASURES

Third-party payer expenditures for primary care, secondary care consultations, pharmaceuticals, laboratory tests, acute and long-term inpatient care.

RESULTS

Overall third-party payer expenditures do not differ significantly between MH and IP users (€+27). Third-party payer primary care expenditures are higher for MH than for IP users (€+129), but this difference is offset by lower expenditures for secondary care consultations (€-11), drugs (€-40), laboratory tests (€-5) and acute and long-term inpatient care (€-53). MHs attract younger and more underprivileged populations.

CONCLUSIONS

MHs induce a shift in expenditures from secondary care, drugs, and laboratory tests to primary care, while treating a less economically favored population. Combined with positive results regarding quality, MH structures are a promising way to tackle the challenges of primary care.

Open access in the patient-centered medical home: lessons from the Veterans Health Administration

BACKGROUND

The Veterans Health Administration (VHA) has undertaken a 5-year initiative to transform to a patient-centered medical home model. An early focus of implementation was on creating open access, defined as continuity and capacity in primary care.

OBJECTIVE

We describe the impact of readiness for implementation on efforts of pilot teams to make changes to improve access and identify successful strategies used by early adopters to overcome barriers to change.

DESIGN

A qualitative, formative evaluation of the first 18 months of implementation in one Veterans Integrated Service Network (VISN) spread across six states.

PARTICIPANTS

Members of local implementation teams including administrators, primary care providers, and staff from primary care clinics located at 10 medical centers and 45 outpatient clinics.

APPROACH

We conducted site visits during the first 6 months of implementation, observations at Learning Collaboratives, semi-structured interviews, and review of internal organizational documents. All data collection took place between April 2010 and December 2011.

KEY RESULTS

Early adopters employed various strategies to enhance access, with a focus on decreasing demand for face-to-face care, increasing supply of different types of primary care encounters, and improving clinic efficiencies. Our interviews with key contacts revealed three important areas where readiness for implementation (or lack thereof) had an impact on interventions to improve access: leadership engagement, staffing resources, and access to information and knowledge.

CONCLUSIONS

Key factors related to readiness for implementation had an impact on which interventions pilot teams could put into place, as well as the viability and sustainability of access gains. Wide variations in interventions to improve access occurring across sites situated within one organization have important implications for efforts to measure the impact of enhanced access on patient outcomes, costs, and other systems-level indicators of the Medical Home.

Survey of 5 European countries suggests that more elements of patient-centered medical homes could improve primary care

The patient-centered medical home is a US model for comprehensive care. This model features a personal physician or registered nurse who is augmented by a proactive team and information technology. Such a model could prove useful for advanced European systems as they strive to improve primary care, particularly for chronically ill patients. We surveyed 6,428 chronically ill patients and 152 primary care providers in five European countries to assess aspects of the patient-centered medical home. Although most patients reported that they had a personal physician and no problems in contacting the practice after hours, for example, other aspects of the patient-centered medical home, such as provision of written self-management support to patients, were not as widespread. We conclude that despite strong organizational structures, European primary care systems need additional efforts to recognize chronically ill patients as partners in care and can embrace patient-centered medical homes to improve care for European patients.

Readiness of primary care practices for medical home certification

OBJECTIVES

To assess the prevalence of medical home infrastructure among primary care practices for children and identify practice characteristics associated with medical home infrastructure.

METHODS

Cross-sectional analysis of restricted data files from 2007 and 2008 of the National Ambulatory Medical Care Survey. We mapped survey items to the 2011 National Committee on Quality Assurance's Patient-Centered Medical home standards. Points were awarded for each "passed" element based on National Committee for Quality Assurance scoring, and we then calculated the percentage of the total possible points met for each practice. We used multivariate linear regression to assess associations between practice characteristics and the percentage of medical home infrastructure points attained.

RESULTS

On average, pediatric practices attained 38% (95% confidence interval 34%-41%) of medical home infrastructure points, and family/general practices attained 36% (95% confidence interval 33%-38%). Practices scored higher on medical home elements related to direct patient care (eg, providing comprehensive health assessments) and lower in areas highly dependent on health information technology (eg, computerized prescriptions, test ordering, laboratory result viewing, or quality of care measurement and reporting). In multivariate analyses, smaller practice size was significantly associated with lower infrastructure scores. Practice ownership, urban versus rural location, and proportion of visits covered by public insurers were not consistently associated with a practice's infrastructure score.

CONCLUSIONS

Medical home programs need effective approaches to support practice transformation in the small practices that provide the vast majority of the primary care for children in the United States.

Lifetime earnings for physicians across specialties

BACKGROUND

Earlier studies estimated annual income differences across specialties, but lifetime income may be more relevant given physicians' long-term commitments to specialties.

METHODS

Annual income and work hours data were collected from 6381 physicians in the nationally representative 2004-2005 Community Tracking Study. Data regarding years of residency were collected from AMA FREIDA. Present value models were constructed assuming 3% discount rates. Estimates were adjusted for demographic and market covariates. Sensitivity analyses included 4 alternative models involving work hours, retirement, exogenous variables, and 1% discount rate. Estimates were generated for 4 broad specialty categories (Primary Care, Surgery, Internal Medicine and Pediatric Subspecialties, and Other), and for 41 specific specialties.

RESULTS

The estimates of lifetime earnings for the broad categories of Surgery, Internal Medicine and Pediatric Subspecialties, and Other specialties were $1,587,722, $1,099,655, and $761,402 more than for Primary Care. For the 41 specific specialties, the top 3 (with family medicine as reference) were neurological surgery ($2,880,601), medical oncology ($2,772,665), and radiation oncology ($2,659,657). The estimates from models with varying rates of retirement and including only exogenous variables were similar to those in the preferred model. The 1% discount model generated estimates that were roughly 150% larger than the 3% model.

CONCLUSIONS

There was considerable variation in the lifetime earnings across physician specialties. After accounting for varying residency years and discounting future earnings, primary care specialties earned roughly $1-3 million less than other specialties. Earnings' differences across specialties may undermine health reform efforts to control costs and ensure adequate numbers of primary care physicians.

Analysis & commentary. How to forge a high-tech marriage between primary care and population health

There has been much discussion in the policy arena about increasing the supply of primary care physicians or creating incentives to encourage physicians to practice in "medical homes" and focus on population health. However, innovations that deliver primary and population health care directly to consumers are the seeds of a solution that promise far greater benefit. These innovations include in-store clinics, in-home and on- and in-body monitoring devices with wireless communication linkages, and emerging diagnostic tools that promise greater precision in recognizing preclinical disease states. They can help the United States and other nations address the significant challenges ahead: major demographic shifts, increased global competition, the growing burden of chronic illness, and the costs of training and employing sufficient numbers of primary care physicians to meet future demands.

Primary care: a critical review of the evidence on quality and costs of health care

Despite contentious debate over the new national health care reform law, there is an emerging consensus that strengthening primary care will improve health outcomes and restrain the growth of health care spending. Policy discussions imply three general definitions of primary care: a specialty of medical providers, a set of functions served by a usual source of care, and an orientation of health systems. We review the empirical evidence linking each definition of primary care to health care quality, outcomes, and costs. The available evidence most directly supports initiatives to increase providers' ability to serve primary care functions and to reorient health systems to emphasize delivery of primary care.

Primary care: current problems and proposed solutions

In 2005, approximately 400,000 people provided primary medical care in the United States. About 300,000 were physicians, and another 100,000 were nurse practitioners and physician assistants. Yet primary care faces a growing crisis, in part because increasing numbers of U.S. medical graduates are avoiding careers in adult primary care. Sixty-five million Americans live in what are officially deemed primary care shortage areas, and adults throughout the United States face difficulty obtaining prompt access to primary care. A variety of strategies are being tried to improve primary care access, even without a large increase in the primary care workforce.

Value-based reengineering: twenty-first century chronic care models

The need for improved models of chronic care is great and will become critical over the next years as the Medicare-aged population doubles. Many promising models have been developed by outstanding groups across the country. This article reviews key strategies used by successful models in chronic disease management and discusses in detail how Geisinger has evolved and organized its cohesive delivery model.

German GPs' willingness to expand roles of physician assistants: a regional survey of perceptions and informal practices influencing uptake of health reforms in primary health care

BACKGROUND

Many countries with shortages in health personnel are introducing task shifting in primary health care. GPs' attitudes and practices strongly affect task shifting and the expansion of the roles of physician assistants (PAs).

OBJECTIVE

To assess, in a German state with shortages of health personnel, the overall willingness of GPs to delegate home visit tasks to PAs and to elicit their perceptions of barriers to and benefits of such delegation and the current practice of informal delegation.

METHODS

Postal self-administered anonymous survey of all practicing GPs in the rural state of Mecklenburg-Vorpommern. Main outcomes were GPs' willingness to delegate in home visit tasks to a properly trained PA, perceived barriers to and benefits of home visit delegation and current practice of informal delegation. Using multinomial logistic regression, associations were identified among outcome variables, and characteristics of the GPs and of their practices.

RESULTS

Response rate was 47%. Responders (500) were comparable to all GPs in the state (1096); 48% of practitioners are willing to delegate home visits tasks to PAs. The main barrier to delegation was the related costs of PAs' training (34%), and the main benefit that it 'saves the GP's time' (67%). The 46% of practitioners who are informally delegating home visit tasks were significantly more likely be younger [odds ratio (OR) and 95% confidence interval (CI)] [OR = 0.96 (0.93-0.99)] and female [OR = 1.70 (1.12-2.58)].

CONCLUSION

The increasing proportion of women in family medicine might favor task shifting in General Practice.

Developing a community-based graduate medical education consortium for residency sponsorship: one community's experience

Faced with a funding crisis that threatened a single-sponsor family medicine residency program critical to a county-wide health system, health care organizations located in the California community described in this article formed a nonprofit, corporate graduate medical education (GME) consortium to sponsor a new residency program. Institutional GME sponsors are typically single hospitals or academic medical centers associated with medical schools. However, as the authors describe, community-based residency sponsorship through a GME consortium can allow multiple stakeholders to assume a model of shared ownership that reflects alignment of pooled community resources with the distributive benefits associated with residencies. Although this community's stakeholders encountered expected governance complexities as they worked to reconcile competing interests, they successfully collaborated to develop the Valley Consortium for Medical Education by addressing a variety of fiscal, workforce benefit, and community coordination challenges. The authors describe the key phases of development and discuss the challenges that must be overcome to establish an institutional sponsor with multiple stakeholders. The financial pressure that traditional institutional sponsors are experiencing with the inexorable decline in GME funding may prompt them to explore partnerships in which they can share expenses for the mutual benefit of physician workforce development. The authors believe that the community-based GME consortium is a viable model to consider.

The 'Alternative Quality Contract,' based on a global budget, lowered medical spending and improved quality

Seven provider organizations in Massachusetts entered the Blue Cross Blue Shield Alternative Quality Contract in 2009, followed by four more organizations in 2010. This contract, based on a global budget and pay-for-performance for achieving certain quality benchmarks, places providers at risk for excessive spending and rewards them for quality, similar to the new Pioneer Accountable Care Organizations in Medicare. We analyzed changes in spending and quality associated with the Alternative Quality Contract and found that the rate of increase in spending slowed compared to control groups, more so in the second year than in the first. Overall, participation in the contract over two years led to savings of 2.8 percent (1.9 percent in year 1 and 3.3 percent in year 2) compared to spending in nonparticipating groups. Savings were accounted for by lower prices achieved through shifting procedures, imaging, and tests to facilities with lower fees, as well as reduced utilization among some groups. Quality of care also improved compared to control organizations, with chronic care management, adult preventive care, and pediatric care within the contracting groups improving more in year 2 than in year 1. These results suggest that global budgets with pay-for-performance can begin to slow underlying growth in medical spending while improving quality of care.

Patient perceptions in New Mexico about doctors of chiropractic functioning as primary care providers with limited prescriptive authority

OBJECTIVES

The purpose of this study was to determine chiropractic patients' perceptions of chiropractors serving as primary care providers and having a limited prescriptive authority.

METHODS

Four doctors of chiropractic in Albuquerque and Santa Fe, NM, participated in surveying their patients during the summer of 2008. The chiropractors distributed the questionnaires consecutively to chiropractic patients. Patients answered questions regarding their perceptions of their chiropractors, use of chiropractic care, and medications for pain. The participating chiropractors collected the completed patient questionnaires and mailed them to the primary investigator.

RESULTS

The chiropractic providers collected 275 chiropractic patient questionnaires. The number of patient questionnaires collected by each of the 4 participating chiropractors ranged from 35 to 100. The patients primarily sought care for the management and treatment of pain (98.5%), and 57.5% considered that their chiropractors were "primary care providers." Eighty-five percent preferred that their chiropractor be qualified to prescribe medications and provide hands-on treatment, whereas 97.5% perceived their chiropractors to be chiropractic physicians.

CONCLUSIONS

This small group of chiropractic patients from 4 offices in New Mexico perceived that their doctors of chiropractic were physicians and primary care providers, and 85% preferred that their chiropractor treat patients with limited prescriptive authority when appropriately trained.

Primary care utilization and colorectal cancer outcomes among Medicare beneficiaries

BACKGROUND

Primary medical care may improve colorectal cancer (CRC) outcomes through increased use of CRC screening tests and earlier diagnosis. We examined the association between primary care utilization and CRC screening, stage at diagnosis, CRC mortality, and all-cause mortality.

METHODS

We conducted a retrospective cohort study of patients, aged 67 to 85 years, diagnosed as having CRC between 1994 and 2005 in the Surveillance, Epidemiology, and End Results-Medicare-linked database. Association of the number of visits to primary care physicians (PCPs) in the 3- to 27-month period before the CRC diagnosis and CRC screening, early-stage diagnosis, CRC mortality, and all-cause mortality were examined using multivariable logistic regression and Cox proportional hazards models.

RESULTS

The odds of CRC screening and early-stage diagnosis increased with increasing number of PCP visits (P < .001 for trend). Compared with persons having 0 or 1 PCP visit, patients with 5 to 10 visits had increased odds of ever receiving CRC screening at least 3 months before diagnosis (adjusted odds ratio, 2.60; 95% CI, 2.48-2.72) and early-stage diagnosis (1.35; 1.29-1.42). Persons with 5 to 10 visits had 16% lower CRC mortality (adjusted hazard ratio [AHR], 0.84; 95% CI, 0.80-0.88) and 6% lower all-cause mortality (0.94; 0.91-0.97) compared with persons with 0 or 1 visit.

CONCLUSIONS

Medicare beneficiaries with CRC have better outcomes if they have greater utilization of primary care before diagnosis. Revitalization of primary care in the United States may help strengthen the national efforts to reduce the burden of CRC.

Preparing primary care for the future - perspectives from the Netherlands, England, and USA

BACKGROUND

All modern healthcare systems need to respond to the common challenges posed by an aging population combined with a growing number of patients with (complex) chronic conditions and rising patient expectations. Countries with 'stronger' primary care systems (e.g. the Netherlands and England) seem to be better prepared to address these challenges than countries with 'weaker' primary care (e.g. USA). The role of primary care in a health care system is strongly related to its organisation and funding, thus determining the starting point and the possibilities for change.

METHOD

We selected the Netherlands, England, and USA as examples for the diversity of approaches to organise and finance health care. We analysed the main problems for primary care and reviewed strategies and practice models used to meet the challenges described above.

RESULTS

The Netherlands aim to strengthen prevention for chronic diseases, while England strives to improve the management of patients with multimorbidity, prevent hospital admissions to contain costs, and to satisfy the increased demand of patients for access to primary care. Both countries seek to reorganise care around the patient and place their needs at the centre. The USA has to provide sufficient workforce, organisation, and funding for primary care to ensure better access, prevention, and provision of chronic care for its population. Strategies to improve (trans-sectoral) cooperation and care coordination, a main issue in all three countries, include the implementation of standards of care and bundled payments for chronic diseases in the Netherlands, GP commissioning, federated and group practice models in England, and the introduction of the Patient-Centred Medical Home and accountable care organisations in the USA.

CONCLUSION

Organisation and financing of health care differ widely in the three countries. However, the necessity to improve coordination and integration of chronic disease care remains a common and core challenge.

Physician practices and readiness for medical home reforms: policy, pitfalls, and possibilities

OBJECTIVE

To determine the proportion of physician practices in the United States that currently meets medical home criteria.

DATA SOURCE/STUDY SETTING

2007 and 2008 National Ambulatory Medical Care Survey.

STUDY DESIGN

We mapped survey items to the National Committee on Quality Assurance's (NCQA's) medical home standards. After awarding points for each "passed" element, we calculated a practice's infrastructure score, dividing its cumulative total by the number of available points. We identified practices that would be recognized as a medical home (Level 1 [25-49 percent], Level 2 [50-74 percent], or Level 3 [infrastructure score ≥75 percent]) and examined characteristics associated with NCQA recognition.

RESULTS

Forty-six percent (95 percent confidence interval [CI], 42.5-50.2) of all practices lack sufficient medical home infrastructure. While 72.3 percent (95 percent CI, 64.0-80.7 percent) of multi-specialty groups would achieve recognition, only 49.8 percent (95 percent CI, 45.2-54.5 percent) of solo/partnership practices meet NCQA standards. Although better prepared than specialists, 40 percent of primary care practices would not qualify as a medical home under present criteria.

CONCLUSION

Almost half of all practices fail to meet NCQA standards for medical home recognition.

Health care spending and quality in year 1 of the alternative quality contract

BACKGROUND

In 2009, Blue Cross Blue Shield of Massachusetts (BCBS) implemented a global payment system called the Alternative Quality Contract (AQC). Provider groups in the AQC system assume accountability for spending, similar to accountable care organizations that bear financial risk. Moreover, groups are eligible to receive bonuses for quality.

METHODS

Seven provider organizations began 5-year contracts as part of the AQC system in 2009. We analyzed 2006-2009 claims for 380,142 enrollees whose primary care physicians (PCPs) were in the AQC system (intervention group) and for 1,351,446 enrollees whose PCPs were not in the system (control group). We used a propensity-weighted difference-in-differences approach, adjusting for age, sex, health status, and secular trends to isolate the treatment effect of the AQC in comparisons of spending and quality between the intervention group and the control group.

RESULTS

Average spending increased for enrollees in both the intervention and control groups in 2009, but the increase was smaller for enrollees in the intervention group--$15.51 (1.9%) less per quarter (P=0.007). Savings derived largely from shifts in outpatient care toward facilities with lower fees; from lower expenditures for procedures, imaging, and testing; and from a reduction in spending for enrollees with the highest expected spending. The AQC system was associated with an improvement in performance on measures of the quality of the management of chronic conditions in adults (P<0.001) and of pediatric care (P=0.001), but not of adult preventive care. All AQC groups met 2009 budget targets and earned surpluses. Total BCBS payments to AQC groups, including bonuses for quality, are likely to have exceeded the estimated savings in year 1.

CONCLUSIONS

The AQC system was associated with a modest slowing of spending growth and improved quality of care in 2009. Savings were achieved through changes in referral patterns rather than through changes in utilization. The long-term effect of the AQC system on spending growth depends on future budget targets and providers' ability to further improve efficiencies in practice. (Funded by the Commonwealth Fund and others.).