The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative's effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions. The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures. As CMS and other payers increasingly use alternative payment models that reward quality and value, CPC provides important lessons about supporting practices in transforming care.
Midway through this 4-year intervention, practices participating in the initiative have reported progress in transforming the delivery of primary care. However, at this point these practices have not yet shown savings in expenditures for Medicare Parts A and B after accounting for care-management fees, nor have they shown an appreciable improvement in the quality of care or patient experience. (Funded by the Department of Health and Human Services, Centers for Medicare and Medicaid Services; ClinicalTrials.gov number, NCT02320591.).
Objective To develop claims‐based measures of comprehensiveness of primary care physicians (PCPs) and summarize their associations with health care utilization and cost. Data Sources and Study Setting A total of 5359 PCPs caring for over 1 million Medicare fee‐for‐service beneficiaries from 1404 practices. Study Design We developed Medicare claims‐based measures of physician comprehensiveness (involvement in patient conditions and new problem management) and used a previously developed range of services measure. We analyzed the association of PCPs’ comprehensiveness in 2013 with their beneficiaries’ emergency department, hospitalizations rates, and ambulatory care‐sensitive condition (ACSC) admissions (each per 1000 beneficiaries per year), and Medicare expenditures (per beneficiary per month) in 2014, adjusting for beneficiary, physician, practice, and market characteristics, and clustering. Principal Findings Each measure varied across PCPs and had low correlation with the other measures—as intended, they capture different aspects of comprehensiveness. For patients whose PCPs’ comprehensiveness score was at the 75th vs 25th percentile (more vs less comprehensive), patients had lower service use (P < 0.05) in one or more measures: involvement with patient conditions: total Medicare expenditures, −$17.4 (−2.2 percent); hospitalizations, −5.5 (−1.9 percent); emergency department (ED) visits, −16.3 (−2.4 percent); new problem management: total Medicare expenditures, −$13.3 (−1.7 percent); hospitalizations, −7.0 (−2.4 percent); ED visits, −19.7 (−2.9 percent); range of services: ED visits, −17.1 (−2.5 percent). There were no significant associations between the comprehensiveness measures and ACSC admission rates. Conclusions These measures demonstrate strong content and predictive validity and reliability. Medicare beneficiaries of PCPs providing more comprehensive care had lower hospitalization rates, ED visits, and total Medicare expenditures.
Prior literature suggests that Daylight Saving Time (DST) can both increase the risk of automobile crashes in the short run and decrease the risk of automobile crashes in the long run. We use 28 years (1976-2003) of automobile crash data from the United States, and exploit a natural experiment arising from a 1986 federal law that changed the time when states switched to DST to identify the short run and long run effects of DST on automobile crashes. Our findings suggest that (1) DST has no significant detrimental effect on automobile crashes in the short run; (2) DST significantly reduces automobile crashes in the long run with a 8-11% fall in crashes involving pedestrians, and a 6-10% fall in crashes for vehicular occupants in the weeks after the spring shift to DST.
We bring together 40 randomized and non-randomized evaluations of education programs to compare cost-effectiveness, seeking to facilitate prioritization of different candidate interventions by policymakers. We examine cost-effectiveness across three outcomes (enrollment, attendance, and test scores) and find distinct "best interventions" for each outcome. For increasing enrollment, urban fellowships, school consolidation, and extra teachers have proven most cost effective. For school attendance, school-based deworming stands out as most cost effective. And for improving test scores, several interventions seem similarly cost effective, including providing blackboards, workbooks, training teachers, and others. We discuss some of the challenges inherent to comparing interventions. _______________________________________________________________________ Acknowledgments:We are grateful for financial support from the RAND Corporation. We especially thank Lynn Karoly for helpful comments on the paper and Rachel Glennerster for helpful conversations, as well as the authors of many of the cited papers for additional cost information not available in the published versions of their papers. All errors are our own.
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