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The American Journal of Managed Care December 2018
Feasibility of Expanded Emergency Department Screening for Behavioral Health Problems
Mamata Kene, MD, MPH; Christopher Miller Rosales, MS; Sabrina Wood, MS; Adina S. Rauchwerger, MPH; David R. Vinson, MD; and Stacy A. Sterling, DrPH, MSW
From the Editorial Board: Jonas de Souza, MD, MBA
Jonas de Souza, MD, MBA
Risk Adjusting Medicare Advantage Star Ratings for Socioeconomic Status
Margaret E. O’Kane, MHA, President, National Committee for Quality Assurance
Reducing Disparities Requires Multiple Strategies
Melony E. Sorbero, PhD, MS, MPH; Susan M. Paddock, PhD; and Cheryl L. Damberg, PhD
Cost Variation and Savings Opportunities in the Oncology Care Model
James Baumgardner, PhD; Ahva Shahabi, PhD; Christopher Zacker, RPh, PhD; and Darius Lakdawalla, PhD
Patient Attribution: Why the Method Matters
Rozalina G. McCoy, MD, MS; Kari S. Bunkers, MD; Priya Ramar, MPH; Sarah K. Meier, PhD; Lorelle L. Benetti, BA; Robert E. Nesse, MD; and James M. Naessens, ScD, MPH
Currently Reading
Patient Experience During a Large Primary Care Practice Transformation Initiative
Kaylyn E. Swankoski, MA; Deborah N. Peikes, PhD, MPA; Nikkilyn Morrison, MPPA; John J. Holland, BS; Nancy Duda, PhD; Nancy A. Clusen, MS; Timothy J. Day, MSPH; and Randall S. Brown, PhD
Primary Care Burnout and Populist Discontent
James O. Breen, MD
Adalimumab Persistence for Inflammatory Bowel Disease in Veteran and Insured Cohorts
Shail M. Govani, MD, MSc; Rachel Lipson, MSc; Mohamed Noureldin, MBBS, MSc; Wyndy Wiitala, PhD; Peter D.R. Higgins, MD, PhD, MSc; Sameer D. Saini, MD, MSc; Jacqueline A. Pugh, MD; Dawn I. Velligan, PhD; Ryan W. Stidham, MD, MSc; and Akbar K. Waljee, MD, MSc
The Value of Novel Immuno-Oncology Treatments
John A. Romley, PhD; Andrew Delgado, PharmD; Jinjoo Shim, MS; and Katharine Batt, MD
Medicare Advantage Control of Postacute Costs: Perspectives From Stakeholders
Emily A. Gadbois, PhD; Denise A. Tyler, PhD; Renee R. Shield, PhD; John P. McHugh, PhD; Ulrika Winblad, PhD; Amal Trivedi, MD; and Vincent Mor, PhD
Provider-Owned Insurers in the Individual Market
David H. Howard, PhD; Brad Herring, PhD; John Graves, PhD; and Erin Trish, PhD
Mixed Messages to Consumers From Medicare: Hospital Compare Grades Versus Value-Based Payment Penalty
Jennifer Meddings, MD, MSc; Shawna N. Smith, PhD; Timothy P. Hofer, MD, MSc; Mary A.M. Rogers, PhD, MS; Laura Petersen, MHSA; and Laurence F. McMahon Jr, MD, MPH

Patient Experience During a Large Primary Care Practice Transformation Initiative

Kaylyn E. Swankoski, MA; Deborah N. Peikes, PhD, MPA; Nikkilyn Morrison, MPPA; John J. Holland, BS; Nancy Duda, PhD; Nancy A. Clusen, MS; Timothy J. Day, MSPH; and Randall S. Brown, PhD
Four years of practice transformation toward comprehensive primary care had little effect on patient experience.

Objectives: To determine how the multipayer Comprehensive Primary Care (CPC) initiative that transformed primary care delivery affected patient experience of Medicare fee-for-service beneficiaries. The study examines whether patient experience changed during the 4-year initiative, whether ratings of CPC practices changed relative to ratings of comparison practices, and areas in which practices still have an opportunity to improve patient experience.

Study Design: Prospective study using 2 cross-sectional samples of more than 25,000 Medicare fee-for-service beneficiaries attributed to 490 CPC practices and more than 8000 beneficiaries attributed to 736 comparison practices.

Methods: We analyzed patient experience 8 to 12 months and 45 to 48 months after CPC began, measured using 5 domains of the Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey with Patient-Centered Medical Home items, version 2.0. A regression-adjusted analysis compared differences in the proportion of beneficiaries giving the best responses (and, as a sensitivity test, mean responses) to survey questions over time and between CPC and comparison practices.

Results: Patient ratings of care over time were generally comparable for CPC and comparison practices. CPC had favorable effects on measures of follow-up care after hospitalizations and emergency department visits.

Conclusions: Practice transformation did not alter patient experience. The lack of favorable findings raises questions about how future efforts in primary care can succeed in improving patient experience.

Am J Manag Care. 2018;24(12):607-613
Takeaway Points

The 4-year Comprehensive Primary Care (CPC) initiative aimed to transform primary care delivery. 
  • Patient ratings of care over the 4 years were generally comparable for Medicare fee-for-service beneficiaries in CPC and comparison practices. 
  • The only differences were the higher proportions of beneficiaries in CPC practices who reported receiving follow-up care from their primary care practice after either a hospitalization or an emergency department visit (by 11 and 8 percentage points, respectively); such follow-up is a focus of CPC. 
  • Results suggest that transforming care during the 4-year CPC initiative did not alter patient experience.
As CMS and other payers test the patient-centered medical home (PCMH) and similar models, and as they increasingly pay for care through alternative payment models that reward quality and value,1,2 it is important to measure how these efforts affect patient experience of care.

In 2012, CMS launched the Comprehensive Primary Care (CPC) initiative, a unique collaboration with 39 other payers to improve primary care delivery. The 4-year initiative helped practices implement 5 functions in their delivery of care—(1) access and continuity, (2) planned chronic and preventive care, (3) risk-stratified care management, (4) patient and caregiver engagement, and (5) coordination of care across the medical neighborhood. CMS selected 502 practices in 7 US regions to participate. To help practices improve care delivery, CPC provided enhanced payment, a robust learning system, and data feedback.3-5

CPC was expected to improve costs, quality, and patient experience of care. Patient-centeredness was a core tenet underlying CPC, and several features of this initiative aimed to improve patient experience of care. Practices were expected to improve access to care, engage patients to guide quality improvement, integrate culturally competent self-management support and shared decision making into usual care, and coordinate care across the patient’s providers. Also, CMS and some of the other participating payers considered patient experience when determining practice eligibility for shared savings payments.

Prior literature examining the effects of primary care transformation on patient experience, including a study examining the first 2 years of CPC, found few, generally small, statistically significant effects during the first 1 to 2 years of transformation.6-9 This paper examines the full 4 years of CPC to understand whether the lack of effects on patient experience for CPC and other primary care transformation models was due, in part, to short follow-up periods that did not allow adequate time for practice transformation to affect patient experience as intended. We examine how patient ratings from more than 25,000 Medicare fee-for-service (FFS) beneficiaries attributed to 490 CPC practices compare with those from more than 8000 beneficiaries in 736 comparison practices (selected using propensity score matching), in 2013 (8-12 months after CPC began) and in 2016 (5 months before CPC ended).



For each CPC region, we used propensity score matching to select comparison practices from a pool of potential comparisons containing practices (1) in the same regions as CPC practices that had applied to CPC but were not selected and (2) in nearby areas with similar demographic and market factors that had enough practices for matching ( number NCT02320591).

We selected up to 5 comparison practices per CPC practice using “full matching” to form matched sets that contained 1 CPC and multiple comparison practices or 1 comparison and multiple CPC practices. The evaluation included the 497 CPC practices participating at the end of the first quarter of CPC and their 908 comparison practices. The comparison group had similar patient, practice, and market characteristics to the CPC practices before CPC began.5

Sample and Response Rates

We administered an annual survey to a cross-sectional sample of Medicare FFS beneficiaries attributed to all open CPC practices (regardless of whether they still participated) and comparison practices. Using claims data, Medicare beneficiaries were attributed to practices where they had the largest share of selected evaluation and management visits to primary care clinicians over the prior 2 years. We invited about 60,000 of the roughly 300,000 Medicare FFS beneficiaries attributed to CPC practices, and 20,000 of the approximately 600,000 beneficiaries attributed to comparison practices, to respond to each survey round (Table 1). We expected responses from 40 beneficiaries per CPC practice and 14 beneficiaries per matched set of comparison practices. We selected larger CPC samples to support CPC practice–level estimates used in practice-level feedback and CMS’ shared savings calculations.

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