Primary Care First - Is It a Step Back?

Impact of Referring High-Risk Patients to Intensive Outpatient Primary Care Services: A Propensity Score-Matched Analysis

BACKGROUND

Many healthcare systems have implemented intensive outpatient primary care programs with the hopes of reducing healthcare costs.

OBJECTIVE

The Veterans Health Administration (VHA) piloted primary care intensive management (PIM) for patients at high risk for hospitalization or death, or "high-risk." We evaluated whether a referral model would decrease high-risk patient costs.

DESIGN

Retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 to September 2018 to 415 high-risk patients matched on propensity score.

PARTICIPANTS

Veterans in the top 10th percentile of risk for 90-day hospitalization or death and recent hospitalization or emergency department (ED) visit.

INTERVENTION

PIM consisted of interdisciplinary teams that performed comprehensive assessments, intensive case management, and care coordination services.

MAIN OUTCOMES AND MEASURES

Change in VHA and non-VHA outpatient utilization, inpatient admissions, and costs 12 months pre- and post-index date.

KEY RESULTS

Of the 456 patients referred to PIM, 301 (66%) enrolled. High-risk patients referred to PIM had a marginal reduction in ED visits (- 0.7; [95% CI - 1.50 to 0.08]; p = 0.08) compared to propensity-matched high-risk patients; overall outpatient costs were similar. High-risk patients referred to PIM had similar number of medical/surgical hospitalizations (- 0.2; [95% CI, - 0.6 to 0.16]; p = 0.2), significant increases in length of stay (6.36; [CI, - 0.01 to 12.72]; p = 0.05), and higher inpatient costs ($22,628, [CI, $3587 to $41,669]; p = 0.02) than those not referred to PIM.

CONCLUSIONS AND RELEVANCE

VHA intensive outpatient primary care was associated with higher costs. Referral to intensive case management programs targets the most complex patients and may lead to increased utilization and costs, particularly in an integrated healthcare setting with robust patient-centered medical homes.

TRIAL REGISTRATION

PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project (PIM2). NCT04521816. https://clinicaltrials.gov/study/NCT04521816.

Routine and preventive health care use in the community among women sentenced to probation

BACKGROUND

Women involved in the criminal legal (CL) system in the United States have much higher levels of chronic and infectious illness than women in the general population. Over 80% of women in the CL system are on community supervision, which means they receive health care in community settings. While the use of Emergency Department care among CL involved populations has been examined fairly extensively, less is known about engagement in routine and preventive medical care among people on community supervision.

METHODS

We conducted a longitudinal study of health care utilization among women with Medicaid who were currently or previously sentenced to probation in Alameda County, CA (N = 328). At baseline, 6- and 12-months, we interviewed participants about every medical care visit in the six months prior, and about potential influences on  health care utilization based on the Behavioral Model for Vulnerable Populations (BMVP). Associations between BMVP factors and utilization of routine or preventive care were estimated using Poisson regression models with robust standard errors. Generalized estimating equations (GEE) were used account for repeated measures over time.

RESULTS

A diagnosis of one or more chronic illnesses was reported by 82% of participants. Two-thirds (62%) of women engaged in routine or preventive care in the six months prior to interview. A quarter of women engaging in routine or preventive care did not have a primary care provider (PCP). Having a PCP doubled the likelihood of using routine or preventive care (adjusted Relative Risk [adjRR] 2.27, p < 0.001). Subsistence difficulty (adjRR 0.74, p = 0.01) and unmet mental health care need (adjRR 0.83, p = 0.001) were associated with a lower likelihood of using routine or preventive care.

CONCLUSION

Findings underscore the importance of meeting the basic needs of women on community supervision and of connecting them with primary health care providers.

Capitated versus fee-for-service reimbursement and quality of care for chronic disease: a US cross-sectional analysis

BACKGROUND

Upcoming alternative payment models Primary Care First (PCF) and Kidney Care Choices (KCC) incorporate capitated payments for chronic disease management. Prior research on the effect of capitated payments on chronic disease management has shown mixed results. We assessed the patient, physician, and practice characteristics of practices with capitation as the majority of revenue, and evaluated the association of capitated reimbursement with quality of chronic disease care.

METHODS

We performed a cross-sectional analysis of visits in the United States' National Ambulatory Medical Care Survey (NAMCS) for patients with hypertension, diabetes, or chronic kidney disease (CKD). Our predictor was practice reimbursement type, classified as 1) majority capitation, 2) majority FFS, or 3) other reimbursement mix. Outcomes were quality indicators of hypertension control, diabetes control, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use, and statin use.

RESULTS

About 9% of visits were to practices with majority capitation revenue. Capitated practices, compared with FFS and other practices, had lower visit frequency (3.7 vs. 5.2 vs. 5.2, p = 0.006), were more likely to be located in the West Census Region (55% vs. 18% vs. 17%, p < 0.001), less likely to be solo practice (21% vs. 37% vs. 35%, p = 0.005), more likely to be owned by an insurance company, health plan or HMO (24% vs. 13% vs. 13%, p = 0.033), and more likely to have private insurance (43% vs. 25% vs. 19%, p = 0.004) and managed care payments (69% vs. 23% vs. 26%, p < 0.001) as the majority of revenue. The prevalence of controlled hypertension, controlled diabetes, ACEi/ARB use, and statin use was suboptimal across practice reimbursement types. Capitated reimbursement was not associated with differences in hypertension, diabetes, or CKD quality indicators, in multivariable models adjusting for patient, physician, and practice characteristics.

CONCLUSIONS

Practices with majority capitation revenue differed substantially from FFS and other practices in patient, physician, and practice characteristics, but were not associated with consistent quality differences. Our findings establish baseline estimates of chronic disease quality of care performance by practice reimbursement composition, informing chronic disease care delivery within upcoming payment models.