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The American Journal of Managed Care May 2015
Comparison of Provider and Plan-Based Targeting Strategies for Disease Management
Ann M. Annis, MPH, RN; Jodi Summers Holtrop, PhD, MCHES; Min Tao, PhD; Hsiu-Ching Chang, PhD; and Zhehui Luo, PhD
Making Measurement Meaningful
Christine K. Cassel, MD, President and CEO, National Quality Forum
Care Fragmentation, Quality, and Costs Among Chronically Ill Patients
Brigham R. Frandsen, PhD; Karen E. Joynt, MD, MPH; James B. Rebitzer, PhD; and Ashish K. Jha, MD, MPH
Results From a National Survey on Chronic Care Management by Health Plans
Soeren Mattke, MD, DSc; Aparna Higgins, MA; and Robert Brook, MD, ScD
Association Between the Patient-Centered Medical Home and Healthcare Utilization
Rainu Kaushal, MD, MPH; Alison Edwards, MStat; and Lisa M. Kern, MD, MPH
Transforming Oncology Care: Payment and Delivery Reform for Person-Centered Care
Kavita Patel, MD, MS; Andrea Thoumi, MSc; Jeffrey Nadel, BA; John O'Shea, MD, MPA; and Mark McClellan, MD, PhD
True "Meaningful Use": Technology Meets Both Patient and Provider Needs
Heather Black, PhD; Rodalyn Gonzalez, BA; Chantel Priolo, MPH; Marilyn M. Schapira, MD, MPH; Seema S. Sonnad, PhD; C. William Hanson III, MD; Curtis P. Langlotz, MD, PhD; John T. Howell, MD; and Andrea J. Apter, MD, MSc
Innovative Care Models for High-Cost Medicare Beneficiaries: Delivery System and Payment Reform to Accelerate Adoption
Karen Davis, PhD, APN; Christine Buttorff, PhD; Bruce Leff, MD; Quincy M. Samus, PhD; Sarah Szanton, PhD, APN; Jennifer L. Wolff, PhD; and Farhan Bandeali, MSPH
Annual Diabetic Eye Examinations in a Managed Care Medicaid Population
Elham Hatef, MD, MPH; Bruce G. Vanderver, MD, MPH; Peter Fagan, PhD; Michael Albert, MD; and Miriam Alexander, MD, MPH
Systematic Review of Benefit Designs With Differential Cost Sharing for Prescription Drugs
Oluwatobi Awele Ogbechie, MD, MBA; and John Hsu, MD, MBA, MSCE
Changing Trends in Type 2 Diabetes Mellitus Treatment Intensification, 2002-2010
Rozalina G. McCoy, MD; Yuanhui Zhang, PhD; Jeph Herrin, PhD; Brian T. Denton, PhD; Jennifer E. Mason, PhD; Victor M. Montori, MD; Steven A. Smith, MD; Nilay D. Shah, PhD
Medicaid-Insured and Uninsured Were More Likely to Have Diabetes Emergency/Urgent Admissions
Monica A. Fisher, PhD, DDS, MPH, MS; and Zhen-qiang Ma, MD, MPH, MS
Roles of Prices, Poverty, and Health in Medicare and Private Spending in Texas
Chapin White, PhD; Suthira Taychakhoonavudh, PhD; Rohan Parikh, MS; and Luisa Franzini, PhD
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Measuring Patient-Centered Medical Home Access and Continuity in Clinics With Part-Time Clinicians
Ann-Marie Rosland, MD, MS; Sarah L. Krein, PhD, RN; Hyungjin Myra Kim, ScD; Clinton L. Greenstone, MD; Adam Tremblay, MD; David Ratz, MS; Darcy Saffar, MPH; and Eve A. Kerr, MD, MPH

Measuring Patient-Centered Medical Home Access and Continuity in Clinics With Part-Time Clinicians

Ann-Marie Rosland, MD, MS; Sarah L. Krein, PhD, RN; Hyungjin Myra Kim, ScD; Clinton L. Greenstone, MD; Adam Tremblay, MD; David Ratz, MS; Darcy Saffar, MPH; and Eve A. Kerr, MD, MPH
Commonly used measures of performance for assessing patient access do not reflect PCMH-encouraged strategies to improve access that may be preferentially used by part-time physicians.
ABSTRACT
 
Objectives: Common patient-centered medical home (PCMH) performance measures value access to a single primary care provider (PCP), which may have unintended consequences for clinics that rely on part-time PCPs and team-based care.
 
Study Design and Methods: Retrospective analysis of 110,454 primary care visits from 2 Veterans Health Administration clinics from 2010 to 2012. Multi-level models examined associations between PCP availability in clinic, and performance on access and continuity measures. Patient experiences with access and continuity were compared using 2012 patient survey data (N = 2881).

Results: Patients of PCPs with fewer half-day clinic sessions per week were significantly less likely to get a requested same-day appointment with their usual PCP (predicted probability 17% for PCPs with 2 sessions/week, 20% for 5 sessions/week, and 26% for 10 sessions/week). Among requests that did not result in a same-day appointment with the usual PCP, there were no significant differences in same-day access to a different PCP, or access within 2 to 7 days with patients’ usual PCP. Overall, patients had >92% continuity with their usual PCP at the hospital-based site regardless of PCP sessions/week. Patients of full-time PCPs reported timely appointments for urgent needs more often than patients of part-time PCPs (82% vs 71%; P <.01), but reported similar experiences with routine access and continuity.
 
Conclusions: Part-time PCP performance appeared worse when using measures focused on same-day access to patients’ usual PCP. However, clinic-level same-day access, same-week access to the usual PCP, and overall continuity were similar for patients of part-time and full-time PCPs. Measures of in-person access to a usual PCP do not capture alternate access approaches encouraged by PCMH, and often used by part-time providers, such as team-based or non–face-to-face care.
 
  Am J Manag Care. 2015;21(5):e320-e328
Take-Away Points
  • At 2 sites, established patients of part-time primary care providers (PCPs) had less same-day access with their usual PCP than patients of full-time PCPs.
  • However, rates of clinic-level same-day access, same-week access to the usual PCP, and the overall rate of continuity were similar for patients of part-time and full-time PCPs.
  • Currently feasible patient-centered medical home access measures that may be more appropriate for clinics with part-time physicians include:  a) rates of urgent access at the clinic or PCP-team level; b) measures that include nurse or non–face-to-face visits as acceptable urgent access; and c) measures of patient satisfaction with, or clinical appropriateness of, access achieved.
As US healthcare systems transition to patient-centered medical home (PCMH) and accountable care organization (ACO) models of care, improving patients’ access to and continuity with their primary care providers (PCPs) has positioned itself at the forefront of reform.1,2 Implementation of these initiatives requires measurement of access and continuity performance. There are several developed performance measures, based on administrative data or patient self-report, for access to a primary care (PC) clinic or a usual care provider.3-6 Health systems with electronic scheduling often choose administrative measures, as they are more comprehensive, collected continuously and easily, and less subject to bias.7 Because strategies to improve PC access are driven by these performance measures, administrative measures must be chosen carefully. They must be comprehensive and precise enough to capture differences in access that are important to clinical outcomes and patient experience, but should not be so restrictive that they unnecessarily single out clinics and providers for performance differences that are not relevant to patients or their care.

Carefully choosing PCMH access measures is particularly important as health systems also adapt to primary care workforce realities. One such reality is the increasing numbers of PCPs who care for patients for only part of each week. Many of these providers work full-time, but spend part of their week in other vital roles, such as working in other clinical areas (eg, inpatient wards), teaching trainees, conducting research, or performing administrative tasks that are increasingly important to running population management–focused PC clinics. Additionally, increasing numbers of PCPs are limiting their total hours to a part-time schedule. Nationally, 44% of female and 22% of male PCPs reported working part-time in 2011.8 Part-time physicians tend to have higher job satisfaction and less burnout than full-time physicians, with similar clinical productivity and process-related performance.9-13 Including PCPs with part-time availability in PC clinics is indispensable to meeting the growing demand for PCPs in an age of expanded medical insurance coverage and rapidly expanding models of care in which PCPs are central, such as the PCMH and ACOs. The PCMH model, with its emphasis on team-based care and non–face-to-face care access, supports the strategies that part-time PCPs often use to provide access and coordinated care to their patients. However, PCMH performance measures may not always capture or reward these modes of improving access and continuity.

The Veterans Health Administration (VHA) uses comprehensive and detailed administrative measures of primary care access to drive PCMH implementation, while also employing many part-time PCPs. VHA PC clinics nationwide are in the midst of a 5-year plan to implement a comprehensive PCMH program called Patient Aligned Care Teams (PACT).14 PACT places emphasis on improving access, particularly same-day access, to a patient’s usual PCP, to whom patients are “assigned” after their first PC visit. PACT also emphasizes increased team-based and non–face-to-face care. However, in efforts to inform clinics’ performance improvement, PACT currently reports administrative access measures for in-person provider visits only, at the individual PCP and clinic levels. The VHA uses these access and continuity measures as 2 of the 4 parts of the main score used to evaluate and reward clinic performance in implementing PACT. Furthermore, many VHA facilities are using these measures at the individual PCP level as one of the determinants of PCP performance pay.

In this study, we examined the impact of part-time PCP availability on performance in current and alternate VHA measures of urgent access. Primarily, we sought to examine whether differences in performance between part-time and full-time PCPs were attenuated when moving from measures focusing on access to a patient’s usual PCP, to access to any clinic PCP, and from measures focusing on access to the usual PCP on the same day versus within 7 days. As secondary analyses, we examined differences in overall administrative measures of continuity, and patient survey–reported experiences of access and continuity, between patients assigned to part-time versus full-time PCPs.

METHODS

Context

In the PACT design, primary care is delivered by teamlets,15 each consisting of 1 full-time equivalent PCP, 1 registered nurse (RN), and 1 medical assistant assigned to 1 panel of patients. In practice, since many PCPs do not have daily clinic hours, 1 teamlet may be shared among 2 or 3 part-time PCPs. The main strategies used by PACT to improve in-person access for established primary care patients have been: 1) limiting the PCP-assigned patient panel size to a number proportional to the PCP’s clinic time (specifically, the examined sites assigned 120 patients per half day of weekly clinic time); 2) “open access” scheduling,16 in which patients call to schedule routine appointments at the time their appointment is due; 3) greatly increasing the number of primary care staff (PCPs, nurses, clinical pharmacists); and 4) increasing the percentage of encounters conducted via phone or secure electronic message.14 PACT implementation started in 2010, and the data examined here are from 2010 to 2012, so the data represent an initial phase of PACT implementation.

Data

We analyzed data from 2 sites within 1 VHA Healthcare System, which were selected from among sites for which we were able to access regional data. We purposively sampled the 2 sites based on: 1) representation of 1 hospital-based and 1 community-based site, 2) presence of adequate representation of and variation in a full range of PCP clinical hours per week, 3) ability to obtain local knowledge to confirm whether we had correctly characterized PCPs as full-time versus part-time, and 4) ability to identify contextual factors that might influence site-specific performance. We obtained all PC in-person encounters completed with a PCP from July 2010 to December 2012, for patients assigned to a PCP. Encounters for patients assigned to a resident PCP were excluded (5.5% of eligible encounters) because there is variability within and across VHA facilities in how resident encounters are coded, and in whether resident PCPs are assigned a panel of patients or see one another’s patients.

For each encounter, available data included the date the patient called to schedule the appointment, the patient’s desired appointment date, the date the appointment was completed, and the provider that was actually seen. Data did not include the patient’s preferred physician for that appointment; also, data were not available for all calls related to urgent issues, only for appointment requests that resulted in an in-person, completed PCP encounter. We excluded encounters for patients assigned to PCPs during months the PCP had ≤10 patients assigned or ≤10 appointments completed.

We obtained patient survey data from the Consumer Assessment of Healthcare Providers and Systems (CAHPS)–PCMH, an instrument used in many healthcare systems, including the VHA, to assess patient experiences with PCMH.17 The survey was mailed in October 2012 to 5476 patients who had completed 2 or more PC appointments in the past year at the 2 sites.

Measures

Definition of part-time PCP status. At the examined sites, PCPs are assigned 120 patients for each half-day session they cover in PC clinic each week. Therefore, we used PCP panel size each month divided by 120 as a proxy for the PCP’s number of weekly clinic sessions scheduled that month. A cutoff of 480 or fewer patients (corresponding to 4 half-day sessions/week) distinguished “part-time” from “full-time” PCPs in dichotomous analyses. This cutoff was chosen based on the distribution of panel sizes among PCPs (see eAppendix Data A, available at www.ajmc.com), and because PCPs with 5 or more half-day sessions per week likely had clinic hours during most, if not all, week days.

Urgent access. Among patient requests for same-day PC appointments (the desired date for the appointment equals the date the patient called for the appointment), we created 3 conditional measures:

•   Measure 1, Same-Day Usual PCP: Percent of all same-day requests that were completed by an encounter the same day (day 0) or the next day (day 1) with the patient’s usual (assigned) PCP.

•   Measure 2, Same-Day Other PCP: Among requests not resulting in a same-day or next-day encounter with the patient’s usual PCP, the percent of requests resulting in an encounter the same day or the next day with a non-assigned PCP.

•   Measure 3, 2 to 7 Days Usual PCP: Among requests not resulting in a same-day or next-day encounter, the percent of requests resulting in an encounter within 2 to 7 days with the patient’s assigned PCP.

Measure 1 parallels the VHA’s current performance measure for urgent access. In the year of the study, the VHA’s goal for percent of same-day appointment requests accommodated with a same-day appointment with the patient’s usual PCP was 45% or more. Measures 2 and 3 are measures devised for the purposes of this study.

Continuity. Overall continuity was calculated as the percent of all completed in-person PC encounters in which the provider was the patient’s assigned PCP.

Patient experiences. We used 3 CAHPS-PCMH questions to assess patient experiences with access (see eAppendix Data B for survey items). Patients’ experiences with urgent and routine access were collapsed into “always” or “usually” getting appointments in a PC clinic as soon as they needed to, versus “sometimes” or “never.” Responses to days “usually” waited for urgent appointments were collapsed into 3 groups: same-day/1 day, 2-7 days, and >7 days. We assessed patient experience with continuity using 2 questions: whether the PCP “usually” or “always” seemed to have knowledge of the patient’s medical history or prior specialist care, versus “sometimes” or “never.” These items are used by the VHA to assess patients’ overall satisfaction with care, but are not currently used by PACT to evaluate clinic or PCP performance in access or continuity.

Covariates. The patient’s gender and age on the encounter date were obtained from VHA records. Patients were identified as having certain chronic conditions (eg, diabetes, heart failure) based on International Classification of Diseases, Ninth Revision, Clinical Modification codes in encounters or hospitalizations during the year prior to the encounter. These diagnoses were not based solely on data from the performance measure encounters and do not necessarily reflect the reason for appointment requests. Patients were identified as chronic opioid users if they had at least 3 opioid pain medication fills (30 days each) in the year prior to the encounter.

 
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