From RAND, Arlington, VA (J.W.T., A. Kress, E.K.C., C.B., A. Kofner, A.M.), Pittsburgh (C.M.S.), Boston (M.W.F., R.M.), and Santa Monica, CA (P.J.M., B.A.W., M.K., A.R., L.H., K.L.K.); Tufts Medical Center (T.A.L.) and Brigham and Women's Hospital and Harvard Medical School (M.W.F.), Boston; David Geffen School of Medicine at UCLA, Los Angeles (K.L.K.); and the Centers for Medicare and Medicaid Services, Baltimore (K.G.).
N Engl J Med. 2017 Jul 20;377(3):246-256. doi: 10.1056/NEJMsa1616041. Epub 2017 Jun 21.
From 2011 through 2014, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration provided care management fees and technical assistance to a nationwide sample of 503 federally qualified health centers to help them achieve the highest (level 3) medical-home recognition by the National Committee for Quality Assurance, a designation that requires the implementation of processes to improve access, continuity, and coordination.
We examined the achievement of medical-home recognition and used Medicare claims and beneficiary surveys to measure utilization of services, quality of care, patients' experiences, and Medicare expenditures in demonstration sites versus comparison sites. Using difference-in-differences analyses, we compared changes in outcomes in the two groups of sites during a 3-year period.
Level 3 medical-home recognition was awarded to 70% of demonstration sites and to 11% of comparison sites. Although the number of visits to federally qualified health centers decreased in the two groups, smaller reductions among demonstration sites than among comparison sites led to a relative increase of 83 visits per 1000 beneficiaries per year at demonstration sites (P<0.001). Similar trends explained the higher performance of demonstration sites with respect to annual eye examinations and nephropathy tests (P<0.001 for both comparisons); there were no significant differences with respect to three other process measures. Demonstration sites had larger increases than comparison sites in emergency department visits (30.3 more per 1000 beneficiaries per year, P<0.001), inpatient admissions (5.7 more per 1000 beneficiaries per year, P=0.02), and Medicare Part B expenditures ($37 more per beneficiary per year, P=0.02). Demonstration-site participation was not associated with relative improvements in most measures of patients' experiences.
Demonstration sites had higher rates of medical-home recognition and smaller decreases in the number of patients' visits to federally qualified health centers than did comparison sites, findings that may reflect better access to primary care relative to comparison sites. Demonstration sites had larger increases in emergency department visits, inpatient admissions, and Medicare Part B expenditures. (Funded by the Centers for Medicare and Medicaid Services.).
从 2011 年至 2014 年，联邦合格医疗中心高级初级保健实践示范项目向全国范围内的 503 家联邦合格医疗中心提供了医疗管理费用和技术援助，以帮助它们达到全国质量保证委员会的最高（三级）医疗之家认可，这一指定要求实施改进获得途径、连续性和协调性的流程。
我们检查了医疗之家认可的实现情况，并使用医疗保险索赔和受益人的调查来衡量在示范点和对照点的服务利用、护理质量、患者体验和医疗保险支出。使用差异分析，我们比较了两组在三年期间的结果变化。
三级医疗之家的认可授予了 70%的示范点和 11%的对照点。尽管两组联邦合格医疗中心的就诊次数都有所减少，但示范点的就诊次数减少幅度较小，导致每年每 1000 名受益人就诊次数相对增加了 83 次（P<0.001）。类似的趋势解释了示范点在年度眼部检查和肾病测试方面表现更好（两种比较均 P<0.001）；在其他三个过程指标方面没有显著差异。与对照点相比，示范点的急诊就诊次数（每年每 1000 名受益人增加 30.3 次，P<0.001）、住院入院次数（每年每 1000 名受益人增加 5.7 次，P=0.02）和医疗保险 B 部分支出（每位受益人每年增加 37 美元，P=0.02）均有较大增加。示范点的参与与患者体验的大多数指标的相对改善无关。
与对照点相比，示范点的医疗之家认可率更高，患者到联邦合格医疗中心就诊的次数减少幅度更小，这可能反映了与对照点相比，获得初级保健的途径更好。示范点的急诊就诊次数、住院入院次数和医疗保险 B 部分支出增加幅度更大。（由医疗保险和医疗补助服务中心资助）。
