From Mathematica Policy Research, Chicago (S.B.D.), Princeton, NJ (A.G., D.N.P., F.B.Y., K.S., R.B.), and Washington DC (E.F.T., A.S.O.); and the Centers for Medicare and Medicaid Services, Baltimore (T.J.D., P.H.C., R.R., M.J.P., L.S.).
N Engl J Med. 2016 Jun 16;374(24):2345-56. doi: 10.1056/NEJMsa1414953. Epub 2016 Apr 13.
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.
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.
During the first 2 years, initiative practices received a median of $115,000 per clinician in care-management fees. The practices reported improvements in approaches to the delivery of primary care in areas such as management of the care of high-risk patients and enhanced access to care. Changes in average monthly Medicare expenditures per beneficiary did not differ significantly between initiative and comparison practices when care-management fees were not taken into account (-$11; 95% confidence interval [CI], -$23 to $1; P=0.07; negative values indicate less growth in spending at initiative practices) or when these fees were taken into account ($7; 95% CI, -$5 to $19; P=0.27). The only significant differences in other measures were a 3% reduction in primary care visits for initiative practices relative to comparison practices (P<0.001) and changes in two of the six domains of patient experience--discussion of decisions regarding medication with patients and the provision of support for patients taking care of their own health--both of which showed a small improvement in initiative practices relative to comparison practices (P=0.006 and P<0.001, respectively).
Midway through this 4-year intervention, practices participating in the initiative have reported progress in transforming the delivery of primary care. However, at this point these practices have not yet shown savings in expenditures for Medicare Parts A and B after accounting for care-management fees, nor have they shown an appreciable improvement in the quality of care or patient experience. (Funded by the Department of Health and Human Services, Centers for Medicare and Medicaid Services; ClinicalTrials.gov number, NCT02320591.).
2012 年 10 月启动了为期 4 年的多付款人综合初级保健倡议，以确定几种形式的支持是否会改变护理提供方式，从而改善美国 7 个地区的 497 个初级保健实践的护理质量并降低护理成本。支持包括提供护理管理费用、有机会获得共享储蓄，以及提供数据反馈和学习支持。
我们跟踪了参与该计划的实践在护理提供方面的变化，并使用差异差异回归比较了该倡议在 Medicare 支出、医疗保健利用、基于索赔的质量衡量标准和 Medicare 按服务收费受益人的患者体验方面的前 2 年的变化，这些变化归因于倡议实践和一组匹配的比较实践。
在最初的 2 年中，每位临床医生的倡议实践平均获得了 11.5 万美元的护理管理费用。这些实践报告了在提供初级保健方面的改进，例如管理高危患者的护理和增强获得护理的机会。当不考虑护理管理费用时（-11 美元；95%置信区间[CI]，-23 至 1 美元；P=0.07；负值表示在倡议实践中支出增长减少）或考虑这些费用时（7 美元；95%CI，-5 至 19 美元；P=0.27），倡议实践与比较实践之间的每位受益人的平均每月 Medicare 支出变化没有显着差异。其他措施中唯一显着的差异是，与比较实践相比，初级保健访问量减少了 3%（P<0.001），以及六个患者体验领域中的两个领域发生了变化-与患者讨论关于药物的决策以及为照顾自己健康的患者提供支持-这两个领域都显示出与比较实践相比，倡议实践有了较小的改善（P=0.006 和 P<0.001）。
在这个为期 4 年的干预措施进行到一半时，参与该计划的实践报告说在转变初级保健服务的提供方面取得了进展。然而，在这一点上，考虑到护理管理费用后，这些实践尚未在 Medicare 部分 A 和 B 的支出方面显示出节省，也没有显示出护理质量或患者体验的明显改善。（由美国卫生与公众服务部，医疗保险和医疗补助服务中心资助；ClinicalTrials.gov 编号，NCT02320591。）
