Exploring Attributes of High-Value Primary Care

Abstract

PURPOSE Medicare's merit-based incentive payment system and narrowing of physician networks by health insurers will stoke clinicians' and policy makers' interest in care delivery attributes associated with value as defined by payers. METHODSTo help define these attributes, we analyzed 2009 to 2011 commercial health insurance claims data for more than 40 million preferred provider organization patients attributed to over 53,000 primary care practice sites. We identified sites ranking favorably on both quality and low total annual per capita health care spending ("high-value") and sites ranking near the median ("average-value"). Sites were selected for qualitative assessment from 64 highvalue sites and 102 average-value sites with more than 1 primary care physician who delivered adult primary care and provided services to enough enrollees to permit meaningful spending and quality ranking. Purposeful sampling ensured regional diversity. Physicians experienced in primary care assessment and blinded to site rankings visited 12 high-value sites and 4 average-value sites to identify tangible attributes of care delivery that could plausibly explain a high ranking on value.RESULTS Thirteen attributes of care delivery distinguished sites in the highvalue cohort. Six attributes attained statistical significance: decision support for evidence-based medicine, risk-stratified care management, careful selection of specialists, coordination of care, standing orders and protocols, and balanced physician compensation.CONCLUSIONS Awareness of care delivery attributes that distinguish their high-value peers may help physicians respond successfully to incentives from Medicare and private payers to lower annual health care spending and improve quality of care.

Team Formation and Performance: Evidence from Healthcare Referral Networks

“…There is some evidence in support of this. In a detailed qualitative study, M. Simon, et al (2017) compared the attributes of six "high value" primary care practice sites with four "average" sites. High value sites were those whose average patient outcomes placed them in the top quintile of both the cost and quality metrics derived from a large sample of commercial health insurance plan enrollees.…”

Assessing Quality Improvement Capacity in Primary Care Practices

“…To identify and define core concepts or "domains" that contribute to QI capacity two members of the study team (KC, LM) along with two outside experts with considerable prior experience in patient centered medical home transformation efforts was convened. They first reviewed key articles in the literature related to the definitions and characteristics of QI capacity, 5,44 principles of transformation to a patient-centered medical home, [45][46][47][48][49] and elements of the chronic care model. 50,51 .…”

Sticking points: common‐agency problems and contracting in the US healthcare system

“…5 Many of the problems of poor care coordination result either from mishandled referrals to specialists (Mehrotra, Forrest, and Lin, 2011) or from fragmented care delivery (see Cebul et al, 2008;and Rebitzer and Votruba, 2011, for a discussion of the problem of care fragmentation and Frandsen et al, 2015;Hussey et al, 2014;Agha, Frandsen, and Rebitzer, 2017;and Romano, Segal, and Pollack, 2015, for estimates of its costs). 6 Mishandled referrals and fragmented care delivery are exacerbated by relatively weak investments in technology and process improvements that strengthen integration across providers and organizations (Milstein and Gilbertson, 2009;Simon et al, 2017). 7 Medical care in the United States has been historically delivered by practitioners operating out of their own offices or as attendings in hospitals (Starr, 1984;Robinson, 1999), and although it still commonly is (Burns, Goldsmith, and Sen, 2013;Baker, Bundorf, and Royalty, 2014), a rapidly growing percentage of physicians are operating in large groups organized by nonphysician owners (see Burns and Pauly, 2018, for a review of physician models of practice organization).…”

“…Mishandled referrals and fragmented care delivery are exacerbated by relatively weak investments in technology and process improvements that strengthen integration across providers and organizations (Milstein and Gilbertson, ; Simon et al., ).…”