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The American Journal of Managed Care September 2019
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Zachary Burningham, PhD; Wei Chen, PhD; Brian C. Sauer, PhD; Regina Richter Lagha, PhD; Jared Hansen, MStat; Tina Huynh, MPH, MHA; Shardool Patel, PharmD; Jianwei Leng, MStat; Ahmad Halwani, MD; and B. Josea Kramer, PhD
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Multi-Payer Advanced Primary Care Practice Demonstration on Quality of Care
Musetta Leung, PhD; Christopher Beadles, MD, PhD; Melissa Romaire, PhD; and Monika Gulledge, MPH; for the MAPCP Evaluation Team
Managed Care for Long-Stay Nursing Home Residents: An Evaluation of Institutional Special Needs Plans
Brian E. McGarry, PT, PhD; and David C. Grabowski, PhD
Changes in Ambulatory Utilization After Switching From Medicaid Fee-for-Service to Managed Care
Lisa M. Kern, MD, MPH; Mangala Rajan, MBA; Harold Alan Pincus, MD; Lawrence P. Casalino, MD, PhD; and Susan S. Stuard, MBA
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Laura Skopec, MS; Joshua Aarons, BA; and Stephen Zuckerman, PhD
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Cassandra Leighton, MPH; Evan Cole, PhD; A. Everette James, JD, MBA; and Julia Driessen, PhD
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Evelyn T. Chang, MD, MSHS; Rebecca Piegari, MS; Edwin S. Wong, PhD; Ann-Marie Rosland, MD, MS; Stephan D. Fihn, MD, MPH; Sandeep Vijan, MD; and Jean Yoon, PhD, MHS
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Kevin N. Griffith, MPA; Donglin Li, MPH; Michael L. Davies, MD; Steven D. Pizer, PhD; and Julia C. Prentice, PhD

Multi-Payer Advanced Primary Care Practice Demonstration on Quality of Care

Musetta Leung, PhD; Christopher Beadles, MD, PhD; Melissa Romaire, PhD; and Monika Gulledge, MPH; for the MAPCP Evaluation Team
An evaluation of the Multi-Payer Advanced Primary Care Practice Demonstration found mixed results in terms of quality of care provided to Medicare and Medicaid beneficiaries.
ABSTRACT

Objectives: We evaluated whether primary care practices in the Medicare Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration improved the quality of care and patient outcomes for beneficiaries.

Study Design: For our quantitative analyses, we employed a pre-post study design with a comparison group using enrollment data, Medicare fee-for-service claims data, and Medicaid managed care and fee-for-service claims data, covering the period 2 to 4 years before Medicare joined the state patient-centered medical home initiatives through December 2014. We used difference-in-differences (DID) regression analysis to compare quality and outcomes in the period before and after the demonstration began.

Methods: We examined the extent to which MAPCP and comparison group beneficiaries received up to 11 process and preventive care measures, as well as 4 measures of potentially avoidable hospitalizations to assess patient outcomes.

Results: Analyses of Medicare and Medicaid data did not consistently reflect the positive impacts intended by the demonstration. Our descriptive and DID analysis found an inconsistent pattern among the process-of-care results, and there were some significant unfavorable associations between participation in MAPCP and avoidable hospitalizations.

Conclusions: Our analyses showed few statistically significant, favorable impacts on quality metrics among Medicare or Medicaid beneficiaries receiving care from MAPCP practices.

Am J Manag Care. 2019;25(9):444-449
Takeaway Points
  • Impacts of the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration on quality of care were mixed across 8 participant states.
  • Our analyses showed few statistically significant, favorable impacts of the demonstration on the quality of care received by Medicare or Medicaid beneficiaries.
  • Our null or sometimes unfavorable quality-of-care findings may mean that our comparison group practices were also improving their care processes and quality of care in general.
  • Lessons and limitations learned from the MAPCP Demonstration can help set expectations for policy makers and payers around which quality measures may be most actionable for providers and most relevant for payers in monitoring provider progress in a new demonstration.
The patient-centered medical home (PCMH) is an approach to delivering patient-centered, community-based primary care.1 The PCMH model engages all elements of healthcare (the community, health system, self-management support, delivery system design, decision support, and clinical information systems) to facilitate greater patient involvement in healthcare decisions and to deliver better-coordinated, timely, and effective care.2-5 This primary care delivery model aims to reduce unnecessary utilization and expenditures while ensuring better access and improved quality of care, with some evidence of success.6,7

Many states and payers endorse the PCMH model, including CMS through its sponsorship of the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration. Under the MAPCP Demonstration, CMS joined 8 state-led, multipayer initiatives in Maine, Michigan, Minnesota, New York, North Carolina, Pennsylvania, Rhode Island, and Vermont in late 2011 and early 2012 to support primary care practices in their transformation to advanced primary care practices with a PCMH model at their core.8 Participating payers—Medicare, the state Medicaid agency, and commercial payers—offered participating practices a per-member per-month payment to support key transformation activities, including extending office hours, staffing care teams, coordinating care, and enhancing electronic health record capabilities. Medicare’s support not only provided additional Medicare payments to each state’s participating practices, but practices also received technical assistance and data reports. Additional details on each state’s PCMH initiative are included in Table 1.

Because the demonstration sought to improve the quality and coordination of healthcare services among participants,9 we evaluated whether these primary care practices improved the quality and safety of healthcare.8 Specifically, we assessed whether quality of care and patient outcomes for Medicare and Medicaid beneficiaries changed during the demonstration period relative to those of a comparison group using administrative claims data.

STUDY DATA AND METHODS

Study Design and Data Sources

For our quantitative analyses, we employed a pre-post study design with a comparison group. Files used included Medicare and Medicaid enrollment data, Medicare fee-for-service claims data, and Medicaid managed care and fee-for-service claims data, covering the period 2 to 4 years before Medicare joined the state initiatives through December 2014.

MAPCP and Comparison Group Identification

MAPCP practices were primary care practices selected by the states to participate in the state PCMH initiatives. Comparison group practices were nonparticipating primary care practices that did not have PCMH recognition by the National Committee for Quality Assurance. Medicare or Medicaid beneficiaries were attributed to the MAPCP or comparison practice with which they had the plurality of their primary care visits, with some caveats (eAppendix A [eAppendices available at ajmc.com]). To ensure that the comparison group closely resembled the MAPCP sample on a set of observable characteristics, comparison group data were entropy-balanced weighted based on beneficiary, practice, and geographic characteristics.10 These included sociodemographic factors (eg, age, race, dual Medicare-Medicaid enrollment, risk scores) and other factors (eg, practice type and size, percentage of primary care providers, county-level household income, population density). Reweighting resulted in the intervention and comparison groups looking more similar on all observable characteristics.


 
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