Reducing Acute Hospitalizations at High-Performing CPC+ Primary Care Practice Sites: Strategies, Activities, and Facilitators.

Purpose: Despite evidence suggesting that high-quality primary care can prevent unnecessary hospitalizations, many primary care practices face challenges in achieving this goal, and there is little guidance identifying effective strategies for reducing hospitalization rates. We aimed to understand how practices in the Comprehensive Primary Care Plus (CPC+) program substantially reduced their acute hospitalization rate (AHR) over 2 years.

Methods: We used Bayesian analyses to identify the CPC+ practice sites having the highest probability of achieving a substantial reduction in the adjusted Medicare AHR between 2016 and 2018 (referred to here as AHR high performers).

Local public hospitals: changing with the times.

Over the last 15 years, public hospitals have pursued multiple strategies to help maintain financial viability without abandoning their mission to care for low-income people, according to findings from the Center for Studying Health System Change's (HSC) site visits to 12 nationally representative metropolitan communities. Local public hospitals serve as core safety net providers in five of these communities--Boston, Cleveland, Indianapolis, Miami and Phoenix--weathering increased demand for care from growing numbers of uninsured and Medicaid patients and fluctuations in public funding over the past 15 years. Generally, these public hospitals have adopted six key strategies to respond to growing capacity and financial pressures: establishing independent governance structures; securing predictable local funding sources; shoring up Medicaid revenues; increasing attention to revenue collection; attracting privately insured patients; and expanding access to community-based primary care.

A long and winding road: federally qualified health centers, community variation and prospects under reform.

Community health centers have evolved from fringe providers to mainstays of many local health care systems. Those designated as federally qualified health centers (FQHCs), in particular, have largely established themselves as key providers of comprehensive, efficient, high-quality primary care services to low-income people, especially Medicaid and uninsured patients. The Center for Studying Health System Change's (HSC's) site visits to 12 nationally representative metropolitan communities since 1996 document substantial growth in FQHC capacity, based on growing numbers of Medicaid enrollees and uninsured people, increased federal support, and improved managerial acumen.

Safety-net providers in some US communities have increasingly embraced coordinated care models.

Safety-net organizations, which provide health services to uninsured and low-income people, increasingly are looking for ways to coordinate services among providers to improve access to and quality of care and to reduce costs. In this analysis, a part of the Community Tracking Study, we examined trends in safety-net coordination activities from 2000 to 2010 within twelve communities in the United States and found a notable increase in such activities. Six of the twelve communities had made formal efforts to link uninsured people to medical homes and coordinate care with specialists in 2010, compared to only two communities in 2000.

Improving health care access for low-income people: lessons from ascension health's community collaboratives.

Communities across the nation are struggling with how to improve access to health care for low-income people. We examined seven communities where Ascension Health collaborated with other safety-net providers and organizations to achieve better health care results for patients. Following a five-step model, each community established infrastructure to track the use of services, expand service capacity, coordinate care, and encourage the cost-effective use of providers.

Key findings from HSC's 2010 site visits: health care markets weather economic downturn, brace for health reform.

Lingering fallout--loss of jobs and employer coverage--from the great recession slowed demand for health care services but did little to slow aggressive competition by dominant hospital systems for well-insured patients, according to key findings from the Center for Studying Health System Change's (HSC) 2010 site visits to 12 nationally representative metropolitan communities. Hospitals with significant market clout continued to command high payment rate increases from private insurers, and tighter hospital-physician alignment heightened concerns about growing provider market power. High and rising premiums led to increasing employer adoption of consumer-driven health plans and continued increases in patient cost sharing, but the broader movement to educate and engage consumers in care decisions did not keep pace.

The economic recession: early impacts on health care safety net providers.

While the recession increased demands on the health care safety net as Americans lost jobs and health insurance, the impact on safety net providers has been mixed and less severe--at least initially--than expected in some cases, according to a new study of five metropolitan communities by the Center for Studying Health System Change (HSC). Even before the recession, many safety net providers reported treating more uninsured patients and facing tighter state and local funding. Federal expansion grants for community health centers during the past decade, however, have increased capacity at many health centers.

Suburban poverty and the health care safety net.

Although suburban poverty has increased in the past decade, the availability of health care services for low-income and uninsured people in the suburbs has not kept pace. According to a new study by the Center for Studying Health System Change (HSC) of five communities--Boston, Cleveland, Indianapolis, Miami and Seattle--low-income people living in suburban areas face significant challenges accessing care because of inadequate transportation, language barriers and lack of awareness of health care options. Low-income people often rely on suburban hospital emergency departments (EDs) and urban safety net hospitals and health centers.

Access to prescription drugs for Medicare beneficiaries.

Despite the introduction of a Medicare outpatient prescription drug benefit in January 2006, roughly the same proportion of elderly Medicare beneficiaries in 2003 and 2007--about 8 percent--skipped filling at least one prescription drug because of cost concerns, according to a new national study by the Center for Studying Health System Change (HSC). However, over the same period, more working-age adults went without a prescribed drug because of cost, suggesting the new Medicare drug benefit may have prevented a similar deterioration in access for the elderly. But, the proportion of seniors dually eligible for Medicare and Medicaid who went without a prescribed medicine almost doubled between 2003 and 2007--from 10.

More nonelderly Americans face problems affording prescription drugs.

More children and working-age Americans are going without prescription drugs because of cost concerns, according to a new national study by the Center for Studying Health System Change (HSC). In 2007, one in seven Americans under age 65 reported not filling a prescription in the previous year because they couldn't afford the medication, up from one in 10 in 2003. Rising prescription drug costs and less generous drug coverage likely contributed to the growth in nonelderly Americans--from 10.

Massachusetts health reform: high costs and expanding expectations may weaken employer support.

Passage of health reform legislation in Massachusetts required significant bipartisan compromise and buy in among key stakeholders, including employers. However, findings from a recent follow-up study by the Center for Studying Health System Change (HSC) suggest two important developments may threaten employer support as the reform plays out. First, improved access to the non-group--or individual--insurance market, the availability of state-subsidized coverage, and the costs of increased employee take up of employer-sponsored coverage and rising premiums potentially weaken employers' motivation and ability to provide coverage.

Community efforts to expand dental services for low-income people.

Poor oral health among low-income people is gaining attention as a significant health care problem. Key barriers to dental services include low rates of dental insurance coverage, limited dental benefits available through public insurance programs, and a lack of dentists willing to serve low-income patients, according to findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. Communities are attempting to provide more dental services to low-income residents.

Developing health system surge capacity: community efforts in jeopardy.

Since Sept. 11, 2001, communities have responded to the federal call to enhance health care surge capacity--the space, supplies, staffing and management structure to care for many injured or ill people during a terrorist attack, natural disaster or infectious disease pandemic. Communities with varied experience handling emergencies are building broad surge capacity, including transportation, communication, hospital care and handling mass fatalities, according to a new study by the Center for Studying Health System Change (HSC).

Falling behind: Americans' access to medical care deteriorates, 2003-2007.

The number and proportion of Americans reporting going without or delaying needed medical care increased sharply between 2003 and 2007, according to findings from the Center for Studying Health System Change's (HSC) nationally representative 2007 Health Tracking Household Survey. One in five Americans--59 million people--reported not getting or delaying needed medical care in 2007, up from one in seven--36 million people--in 2003. While access deteriorated for both insured and uninsured people, insured people experienced a larger relative increase in access problems compared with uninsured people.

The role of nurses in hospital quality improvement.

As the nation's hospitals face increasing demands to participate in a wide range of quality improvement activities, the role and influence of nurses in these efforts is also increasing, according to a new study by the Center for Studying Health System Change (HSC). Hospital organizational cultures set the stage for quality improvement and nurses' roles in those activities. Hospitals with supportive leadership, a philosophy of quality as everyone's responsibility, individual accountability, physician and nurse champions, and effective feedback reportedly offer greater promise for successful staff engagement in improvement activities.

Safety net hospital emergency departments: creating safety valves for non-urgent care.

Hospital emergency departments (EDs) are caring for more patients, including those with non-urgent needs that could be treated in alternative, more cost-effective settings, such as a clinic or physician's office. According to findings from the Center for Studying Health System Change's 2007 site visits to 12 nationally representative metropolitan communities, many emergency departments at safety net hospitals--the public and not-for-profit hospitals that serve large proportions of low-income, uninsured and Medicaid patients--are attempting to meet patients' non-urgent needs more efficiently. Safety net EDs are working to redirect non-urgent patients to their hospitals' outpatient clinics or to community health centers and clinics, with varied results.

Relief, restoration and reform: economic upturn yields modest and uneven health returns.

The sensitivity of state budgets to economic cycles contributes to fluctuations in health coverage, eligibility, benefits and provider payment levels in public programs, as well as support for safety net hospitals and community health centers (CHCs). The aftershocks of the 2001 recession on state budgets were felt well into 2004. More recently, the economic recovery allowed many states to restore cuts and, in some cases, expand health services for low-income people, according to findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities.

Community health centers tackle rising demands and expectations.

As key providers of preventive and primary care for underserved people, including the uninsured, community health centers (CHCs) are the backbone of the U.S. health care safety net.

Hospital emergency on-call coverage: is there a doctor in the house?

The nation's community hospitals face increasing problems obtaining emergency on-call coverage from specialist physicians, according to findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. The diminished willingness of specialist physicians to provide on-call coverage is occurring as hospital emergency departments confront an ever-increasing demand for services. Factors influencing physician reluctance to provide on-call coverage include decreased dependence on hospital admitting privileges as more services shift to non-hospital settings; payment for emergency care, especially for uninsured patients; and medical liability concerns.

Massachusetts health reform: employers, lower-wage workers and universal coverage.

As Massachusetts' landmark effort to reach nearly universal health coverage unfolds, the state is now focusing on employers to take steps to increase coverage. All employers--except firms with fewer than 11 workers--face new requirements under the 2006 law, including establishing Section 125, or cafeteria, plans to allow workers to purchase insurance with pre-tax dollars and paying a $295 annual fee if they do not make a "fair and reasonable" contribution to the cost of workers' coverage. Through interviews with Massachusetts health care leaders (see Data Source), the Center for Studying Health System Change (HSC) examined how the law is likely to affect employer decisions to offer health insurance to workers and employee decisions to purchase coverage.

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.

Public employees' health benefits survive major threats, so far.

Previous studies of public employees' health benefits indicate that they have been spared many of the changes evident in the private sector. But the recession and plunging state revenues in the early 2000s presented growing challenges to trying to preserve these benefits. Findings from the Round Five site visits of the Community Tracking Study (2005) reveal that benefits have still witnessed surprisingly few major modifications.

Initial findings from HSC's 2005 site visits: stage set for growing health care cost and access problems.

Many developments in local health care markets appear to be setting the stage for additional health care cost increases and access-to-care problems, according to initial findings from the Center for Studying Health System Change's (HSC) 2005 site visits to 12 nationally representative communities. Hospitals and physicians are competing more broadly and intensely for profitable specialty services, making costly investments to expand capacity and offer the latest medical technologies, especially in more affluent areas with well-insured populations. Employers and health plans have launched few initiatives to control rising costs beyond increasing patient cost sharing.

Health care access for low-income people: significant safety net gaps remain.

Despite signs that low-income and uninsured people's access to primary health care services has improved, serious gaps in care exist, especially for specialty physician, mental health and dental care, according to the Center for Studying Health System Change's (HSC) 2002-03 site visits to 12 nationally representative communities. Key factors contributing to these gaps in the safety net include declining private physician and dentist involvement, changes in funding and facilities, and more people in need. Community leaders have developed a variety of innovative strategies to add specialty, mental health and dental services but could benefit from more support from state and federal policy makers.