The Changing Landscape Of Primary Care: Effects Of The ACA And Other Efforts Over The Past Decade.

Providing high-quality primary care is key to improving health care in the United States. The Affordable Care Act sharpened the emerging focus on primary care as a critical lever to use in improving health care delivery, lowering costs, and improving the quality of care. We describe primary care delivery system reform models that were developed and tested over the past decade by the Center for Medicare and Medicaid Innovation-which was created by the Affordable Care Act-and reflect on key lessons and remaining challenges.

Aggregating Claims Data Across Payers: Approaches, Challenges, and Lessons Learned From the Comprehensive Primary Care Initiative.

The Comprehensive Primary Care (CPC) initiative fueled the emergence of new organizational alliances and financial commitments among payers and primary care practices to use data for performance improvement. In most regions of the country, practices received separate confidential feedback reports of claims-based measures from multiple payers, which varied in content and provided an incomplete picture of a practice's patient panel. Over CPC's last few years, participating payers in several regions resisted the tendency to guard data as a proprietary asset, instead working collaboratively to produce aggregated performance feedback for practices.

The Effects of a Primary Care Transformation Initiative on Primary Care Physician Burnout and Workplace Experience.

Background: Physician burnout is associated with deleterious effects for physicians and their patients and might be exacerbated by practice transformation.

Objective: Assess the effect of the Comprehensive Primary Care (CPC) initiative on primary care physician experience.

Design: Prospective cohort study conducted with about 500 CPC and 900 matched comparison practices.

The Comprehensive Primary Care Initiative: Effects On Spending, Quality, Patients, And Physicians.

The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative's effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions.

Strengthening Multipayer Collaboration: Lessons From the Comprehensive Primary Care Initiative.

Unlabelled: Policy Points: Collaboration across payers to align financial incentives, quality measurement, and data feedback to support practice transformation is critical, but challenging due to competitive market dynamics and competing institutional priorities. The Centers for Medicare & Medicaid Services or other entities convening multipayer initiatives can build trust with other participants by clearly outlining each participant's role and the parameters of collaboration at the outset of the initiative. Multipayer collaboration can be improved if participating payers employ neutral, proactive meeting facilitators; develop formal decision-making processes; seek input on decisions from practice representatives; and champion the initiative within their organizations.

Uses and Limitations of Claims-based Performance Feedback Reports: Lessons From the Comprehensive Primary Care Initiative.

Background: Performance feedback is central to data-driven models of quality improvement, but the use of claims-based data for feedback has received little attention.

Purpose: To examine the challenges, uses, and limitations of quarterly Medicare claims-based performance feedback reports generated for practices participating in the Comprehensive Primary Care (CPC) initiative from 2012 to 2015.

Methods: Mixed methods study of nearly 500 CPC practices in seven regions, combining pilot testing; systematic monitoring; surveys; in-depth interviews; user feedback; and input from data feedback team.

Using the Consolidated Framework for Implementation Research (CFIR) to produce actionable findings: a rapid-cycle evaluation approach to improving implementation.

Background: Much research does not address the practical needs of stakeholders responsible for introducing health care delivery interventions into organizations working to achieve better outcomes. In this article, we present an approach to using the Consolidated Framework for Implementation Research (CFIR) to guide systematic research that supports rapid-cycle evaluation of the implementation of health care delivery interventions and produces actionable evaluation findings intended to improve implementation in a timely manner.

Methods: To present our approach, we describe a formative cross-case qualitative investigation of 21 primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a multi-payer supported primary care practice transformation intervention led by the Centers for Medicare and Medicaid Services.

Two-Year Costs and Quality in the Comprehensive Primary Care Initiative.

Background: The 4-year, multipayer Comprehensive Primary Care Initiative was started in October 2012 to determine whether several forms of support would produce changes in care delivery that would improve the quality and reduce the costs of care at 497 primary care practices in seven regions across the United States. Support included the provision of care-management fees, the opportunity to earn shared savings, and the provision of data feedback and learning support.

Methods: We tracked changes in the delivery of care by practices participating in the initiative and used difference-in-differences regressions to compare changes over the first 2 years of the initiative in Medicare expenditures, health care utilization, claims-based measures of quality, and patient experience for Medicare fee-for-service beneficiaries attributed to initiative practices and a group of matched comparison practices.

Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care managers.

Efforts to redesign primary care require multiple supports. Two potential members of the primary care team-practice facilitator and care manager-can play important but distinct roles in redesigning and improving care delivery. Facilitators, also known as quality improvement coaches, assist practices with coordinating their quality improvement activities and help build capacity for those activities-reflecting a systems-level approach to improving quality, safety, and implementation of evidence-based practices.

Using qualitative and quantitative methods to evaluate small-scale disease management pilot programs.

Interest in disease management programs continues to grow as managed care plans, the federal and state governments, and other organizations consider such efforts as a means to improve health care quality and reduce costs. These efforts vary in size, scope, and target population. While large-scale programs provide the means to measure impacts, evaluation of smaller interventions remains valuable as they often represent the early planning stages of larger initiatives.

Understanding a collaborative effort to reduce racial and ethnic disparities in health care: contributions from social network analysis.

Quality improvement collaboratives have become a common strategy for improving health care. This paper uses social network analysis to study the relationships among organizations participating in a large scale public-private collaboration among major health plans to reduce racial and ethnic disparities in health care in the United States. Pre-existing ties, the collaborative process, participants' perceived contributions, and the overall organizational standing of participants were examined.

Moving research into practice: lessons from the US Agency for Healthcare Research and Quality's IDSRN program.

Background: The U.S. Agency for Healthcare Research and Quality's (AHRQ) Integrated Delivery Systems Research Network (IDSRN) program was established to foster public-private collaboration between health services researchers and health care delivery systems.

Do determinants of medicare supplemental coverage choice vary by income.

Using data from the Community Tracking Study Household Survey (1998-99), we estimate the relationship between Medigap premiums and senior Medicare beneficiaries' supplemental coverage decisions. All seniors are more likely to be enrolled in an HMO in markets with higher Medigap prices. Lower income seniors are particularly sensitive to Medigap premiums and are more likely to have no supplemental coverage when faced with higher Medigap premiums.

The community safety net and prescription drug access for low-income, uninsured people.

While the new Medicare drug benefit has helped alleviate concerns about prescription drug access for elderly and disabled Americans, many low-income, uninsured people under age 65 continue to rely on community safety nets to get needed medications. As the number of uninsured Americans increases, safety net providers are stretching limited resources to meet growing prescription drug needs, according to findings from the Center for Studying Health System Change's (HSC) 2005 site visits to 12 nationally representative communities. Despite redoubled efforts--centered on obtaining discounted drugs and donated medications--to make affordable drugs available to needy patients, safety net providers and community advocates report that many low-income, uninsured people continue to face major barriers to obtaining prescription drugs.

The struggle to provide community-based care to low-income people with serious mental illnesses.

This paper describes gaps in services for low-income people with serious mental illnesses as reported by mental health professionals and other observers in twelve U.S. communities.

Who enrolls in community-based programs for the uninsured, and why do they stay?

Faced with growing numbers of uninsured people, many communities are developing local programs to provide coverage or improve access. Some might predict that only those with health problems would participate; however, little is known about who enrolls. This paper examines participation and retention in three different community programs aimed at low-income uninsured adults.

Community approaches to providing care for the uninsured.

Faced with rising uninsurance rates and little response at the state or federal levels in recent years, communities have developed various strategies to provide care for uninsured people. This paper profiles local strategies in the Community Tracking Study sites, focusing on efforts that go beyond traditional safety-net access. Our findings suggest that more-recent community efforts--which tend to be privately sponsored--are relatively modest in scope compared with more-mature programs that enjoy public financing.

Translating research to action: improving physician access in public insurance.

Policymakers continue to struggle with how to assure adequate access to physician services in public programs like Medicaid, State Children's Health Insurance Program, or other public coverage programs. In this article, we synthesize available research on this topic and provide a framework that policymakers may find useful in identifying and measuring barriers to care access, determining where and why problems exist, and identifying how to intervene. Using our experience constructing the framework, we also consider what observations can be drawn from this experience for those interested in the challenge of moving the insights from research to practice.

Donated care programs: a stopgap measure or a long-run alternative to health insurance?

In the absence of broad federal health care reform, interest has grown in local solutions to the problem of providing health care to the uninsured. Community-based donated medical care models have emerged as one alternative. We examine the early experience of a donated care program in southern Maine called CarePartners.

Medigap premiums and Medicare HMO enrollment.

Objective: Markets for Medicare HMOs (health maintenance organizations) and supplemental Medicare coverage are often treated separately in existing literature. Yet because managed care plans and Medigap plans both cover services not covered by basic Medicare, these markets are clearly interrelated. We examine the extent to which Medigap premiums affect the likelihood of the elderly joining managed care plans.