Department of Medicine, University of California, San Francisco.
Center for Clinical Informatics and Improvement Research, University of California, San Francisco.
JAMA Health Forum. 2022 Feb 25;3(2):e220005. doi: 10.1001/jamahealthforum.2022.0005. eCollection 2022 Feb.
Policy makers envision synergistic benefits from primary care reform programs that advance infrastructure and processes in the context of a supportive payment environment. However, these programs have been operationalized and implemented separately, raising the question of whether synergies are achieved.
To evaluate associations between primary care engagement in voluntary delivery system and/or payment reform programs and health services outcomes.
This was an observational longitudinal analysis of US ambulatory primary care organizations (PCOs) with attributed Medicare fee-for-service beneficiaries (1.6-1.9 million unique beneficiaries annually) using data for 2009, 2010, and 2015 to 2017; PCOs included multispecialty practices that delivered primary care. Data analyses were performed from January 2020 to December 2021.
Annual PCO participation in or recognition by (1) the Centers for Medicare & Medicaid's meaningful use (MU) program, (2) the National Committee for Quality Assurance's Patient-Centered Medical Home (PCMH) program, and/or (3) the Medicare Shared Savings Program (MSSP), an Accountable Care Organizations program.
Independent and joint associations between an additional year of participation by a PCO in each of the 3 reform programs, and 3 types of outcomes: (1) hospital utilization (all-cause admissions, ambulatory care sensitive admissions, all-cause readmissions, all-cause emergency department visits); (2) evidence-based diabetes guideline adherence (≥1 annual glycated hemoglobin test, low-density lipoprotein cholesterol test, nephropathy screening, and eye examination); and (3) Medicare spending (total, acute inpatient, and skilled nursing facility).
The study sample comprised 47 880 unique PCOs (size ≤10 beneficiaries, 50%; ≤1-2 clinicians, 65%) and approximately 5.61 million unique Medicare beneficiaries (mean [SD] age, 71.4 [12.7] years; 3 207 568 [57.14%] women; 4 474 541 [79.71%] non-Hispanic White individuals) across the study years (2009, 2010, 2015-2017). Of the hospital utilization measures, only ambulatory care sensitive admission was associated with improved performance, showing a statistically significant marginal effect size for joint participation in MU and MSSP (-0.0002; 95% CI, -0.0005 to 0.0000) and MSSP alone (-0.0003; 95% CI, -0.0005 to -0.0001). For diabetes adherence, joint participation in PCMH and MU was associated with 0.06 more measures met (95% CI, 0.03 to 0.10) while participation in all 3 programs was associated with 0.05 more measures met (95% CI, 0.02 to 0.09). Stand-alone PCMH and stand-alone MU participation were also associated with improved performance. Joint participation in MU and MSSP was associated with $33.89 lower spending (95% CI, -$65.79 to -$1.99) as was stand-alone MSSP participation (-$37.04; 95% CI, -$65.73 to -$8.35).
This longitudinal observational study found that participation by PCOs in single or multiple reform programs was associated with better performance for only a subset of health services outcomes. More consistent and larger synergies may be realized with improved alignment of program requirements and goals.
重要性：政策制定者设想从推进基础设施和支持性支付环境下的流程的初级保健改革计划中获得协同效益。然而，这些计划已经被分别实施和执行，这就提出了一个问题，即是否实现了协同效应。
目的：评估初级保健参与自愿交付系统和/或支付改革计划与卫生服务结果之间的关联。
设计、设置和参与者：这是一项针对美国门诊初级保健组织（PCO）的观察性纵向分析，这些组织与 Medicare 按服务收费制的受益人相关联（每年有 160 万至 190 万独特的受益人），使用了 2009 年、2010 年和 2015 年至 2017 年的数据；PCO 包括提供初级保健的多专业实践。数据分析于 2020 年 1 月至 2021 年 12 月进行。
暴露因素：每年 PCO 参与或获得（1）医疗保险和医疗补助服务中心的有意义使用（MU）计划、（2）国家质量保证委员会的以患者为中心的医疗之家（PCMH）计划和/或（3）医疗保险共享储蓄计划（MSSP），一种责任医疗组织计划的认可。
主要结果和措施：PCO 每年在每个 3 个改革计划中的参与时间增加一年，与 3 种结果之间存在独立和联合关联：（1）医院利用率（所有原因入院、门诊护理敏感入院、所有原因再入院、所有原因急诊就诊）；（2）循证糖尿病指南的依从性（≥1 次年度糖化血红蛋白检测、低密度脂蛋白胆固醇检测、肾病筛查和眼部检查）；（3）医疗保险支出（总支出、急性住院和熟练护理设施）。
结果：研究样本包括 47880 个独特的 PCO（规模≤10 个受益人，50%；≤1-2 名临床医生，65%）和约 561 万独特的 Medicare 受益人（平均[标准差]年龄，71.4[12.7]岁；3207568[57.14%]女性；4474541[79.71%]非西班牙裔白人个体），涵盖了研究年份（2009 年、2010 年、2015 年至 2017 年）。在医院利用措施中，只有门诊护理敏感入院与改善表现相关，联合参与 MU 和 MSSP（-0.0002；95%CI，-0.0005 至 0.0000）和 MSSP 单独参与（-0.0003；95%CI，-0.0005 至 -0.0001）显示出统计学上显著的边际效应大小。对于糖尿病的依从性，PCMH 和 MU 的联合参与与符合标准的措施增加了 0.06 项（95%CI，0.03 至 0.10），而所有 3 项计划的参与与符合标准的措施增加了 0.05 项（95%CI，0.02 至 0.09）。单独的 PCMH 和 MU 参与也与改善表现相关。MU 和 MSSP 的联合参与与降低 33.89 美元的支出相关（95%CI，-65.79 美元至 -1.99 美元），而单独参与 MSSP 也与降低 37.04 美元的支出相关（95%CI，-65.73 美元至 -8.35 美元）。
结论和相关性：这项纵向观察性研究发现，PCO 参与单一或多项改革计划仅与部分卫生服务结果的表现相关。通过改进计划要求和目标的一致性和更大协同效应，可以实现更一致和更大的协同效应。
