Search

Background: In Canada, primary care reforms led to the implementation of various team-based care models to improve access and provide more comprehensive care for patients. Despite these advances, ongoing challenges remain. The aim of this scoping review is to explore current understanding of the functioning of these care models as well as the contexts in which they have emerged and their impact on the population, providers and healthcare costs. Methods: The Medline and CINAHL databases were consulted. To be included, team-based care models had to be co-located, involve a family physician, specify the other professionals included, and provide information about their organization, their relevance and their impact within a primary care context. Models based on inter-professional intervention programs were excluded. The organization and coordination of services, the emerging contexts and the impact on the population, providers and healthcare costs were analysed. Results: A total of 5952 studies were screened after removing duplicates; 15 articles were selected for final analysis. There was considerable variation in the information available as well as the terms used to describe the models. They are operationalized in various ways, generally consistent with the Patient's Medical Home vision. Except for nurses, the inclusion of other types of professionals is variable and tends to be associated with the specific nature of the services offered. The models primarily focus on individuals with mental health conditions and chronic diseases. They appear to generally satisfy the expectations of the overarching framework of a high-performing team-based primary care model at patient and provider levels. However, economic factors are seldom integrated in their evaluations. Conclusions: The studies rarely provide an overarching view that permits an understanding of the specific contexts, service organization, their impacts, and the broader context of implementation, making it difficult to establish universal guidelines for the operationalization of effective models. Negotiating the inherent complexity associated with implementing models requires a collaborative approach between various stakeholders, including patients, to tailor the models to the specific needs and characteristics of populations in given areas, and reflection about the professionals to be included in delivering these services. [ABSTRACT FROM AUTHOR]

Value‐based primary care has reduced health care costs, improved the quality of rendered care, and enhanced the patient experience. Value‐based care emphasizes prevention, outreach, follow‐up, patient engagement, and comprehensive, whole‐person health. Primary care Accountable Care Organizations have leveraged technology‐enabled workflows, practice transformation, and cutting‐edge data and analytics to achieve success. These efforts are increasingly aided by predictive modeling used in the context of patient identification and prioritization algorithms. Value‐based kidney care programs can glean salient takeaways from successful value‐based primary care methods and models. The kidney care community is experiencing unprecedented transformation as novel payer programs and financial models burgeon. The authors contend these efforts can be accelerated by the adoption of techniques honed in value‐based primary care. To optimize value‐based kidney care, though, nephrology thought leaders must transcend the archetype of value‐based primary care. To do so, the nephrology community must: (1) impel behavioral change among fee‐for‐service adherents; (2) harness emerging policy, guidelines, and quality measures; (3) adopt innovative tools, technologies, and therapies. In aggregating lessons from value‐based primary care—and leveraging novel methodologies and approaches—the kidney care community will be better equipped to achieve the quadruple aim for kidney care. [ABSTRACT FROM AUTHOR]

Background: There are persistent racial/ethnic disparities in the occurrence of severe maternal morbidity. Patient-centered medical home care has the potential to address disparities in maternal outcomes. Objectives: To examine (1) the association between receiving patient-centered medical home care and severe maternal morbidity outcomes and (2) the interaction of race/ethnicity on patient-centered medical home status and severe maternal morbidity. Design/Methods: Using 2007 to 2016 data from the Medical Expenditures Panel Survey, we conducted a cross-sectional study to estimate the association between receipt of care from a patient-centered medical home and the occurrence of severe maternal morbidity, and racial-specific (White, Black, Asian, Other) relative risks of severe maternal morbidity. Our study used race as a proxy measure for exposure racism. We identified mothers (⩾15 years) who gave birth during the study period. We identified patient-centered medical home qualities using 11 Medical Expenditures Panel Survey questions and severe maternal morbidities using medical claims, and calculated generalized estimating equation models to estimate odds ratios of severe maternal morbidity and 95% confidence intervals. Results: Among all mothers who gave birth (N = 2801; representing 5,362,782 US lives), only 25% received some exposure patient-centered medical home care. Two percent experienced severe maternal morbidity, and this did not differ statistically (p = 0.11) by patient-centered medical home status. However, our findings suggest a 85% decrease in the risk of severe maternal morbidity among mothers who were defined as always attending a patient-centered medical home (odds ratios: 0.15; 95% confidence interval:0.01–1.87; p = 0.14) and no difference in the risk of severe maternal morbidity among mothers who were defined as sometimes attending a patient-centered medical home (odds ratios: 1.00; 95% confidence interval:0.16–6.42; p = 1.00). There was no overall interaction effect in the model between race and patient-centered medical home groups (p = 0.82), or ethnicity and patient-centered medical home groups (p = 0.62) on the severe maternal morbidity outcome. Conclusion: While the rate of severe maternal morbidity was similar to US rates, few mothers received care from a patient-centered medical home which may be due to underreporting. Future research should further investigate the potential for patient-centered medical home-based care to reduce odds of severe maternal morbidity across racial/ethnic groups. [ABSTRACT FROM AUTHOR]

Introduction: This nationwide study builds on prior research, which suggests that Federally Qualified Health Centers (FQHCs) and other primary care providers are associated with increased access to opioid use disorder (OUD) treatment. We compare health care utilization, spending, and quality for Medicaid patients diagnosed with OUD who receive primary care at FQHCs and Medicaid patients who receive most primary care in other settings, such as physician offices (non-FQHCs). We hypothesized that the integrated care model of FQHCs would be associated with greater access to medication for opioid use disorder (MOUD) and/or behavioral health therapy and lower rates of potentially inappropriate co-prescribing. Methods: This cross-sectional study examined 2012 Medicaid Analytic eXtract files for patients diagnosed with OUD receiving most (>50%) primary care at FQHCs (N = 37,142) versus non-FQHCs (N = 196,712) in all 50 states and Washington DC. We used propensity score overlap weighting to adjust for measurable confounding between patients who received care at FQHCs versus non-FQHCs and increase generalizability of findings given variation in Medicaid programs and substance use policies across states. Results: FQHC patients displayed higher primary care utilization and fee-for-service spending, and similar or lower utilization and fee-for-service spending for other health service categories. Contrary to our hypotheses, non-FQHC patients were more likely to receive timely (≤90 days) MOUD (buprenorphine, methadone, naltrexone, or suboxone) (Relative Risk [RR] = 1.10, 95% CI: 1.07, 1.12) and more likely be retained in medication treatment (>180 days) (RR = 1.12, 95% CI: 1.09, 1.14). However, non-FQHC patients were less likely to receive behavioral health therapy (mental health or substance use therapy) (RR = 0.90, 95% CI: 0.88, 0.92) and less likely to remain in behavioral health treatment (RR = 0.92, 95% CI: 0.89, 0.94). Non-FQHC patients were more likely to fill potentially inappropriate prescriptions of benzodiazepines and opioids after OUD diagnosis (RR = 1.35, 95% CI: 1.30, 1.40). Conclusions: Observed patterns suggest that Medicaid patients diagnosed with OUD who obtained primary care at FQHCs received more integrated care compared to non-FQHC patients. Greater care integration may be associated with increased access to behavioral health therapy and quality of care (lower potentially inappropriate co-prescribing) but not necessarily greater access to MOUD. [ABSTRACT FROM AUTHOR]

Part 1 of this essay argued that the root causes of primary care's problems lie in (1) the low percent of national health expenditures dedicated to primary care and (2) overly large patient panels that clinicians without a team are unable to manage, leading to widespread burnout and poor patient access. Part 2 explores policies and practice changes that could solve or mitigate these primary care problems.Initiatives attempting to improve primary care are discussed. Diffuse multi-component initiatives-patient-centered medical homes (PCMHs), accountable care organizations (ACOs), and Comprehensive Primary Care Plus (CPC+)-have had limited success in addressing primary care's core problems. More focused initiatives-care management, open access, and telehealth-offer more promise.To truly revitalize primary care, 2 fundamental changes are needed: (1) a substantially greater percent of health expenditures dedicated to primary care, and (2) the building of powerful teams that add capacity to care for large panels while reducing burnout.Part 2 of the essay reviews 3 approaches to increasing primary care spending: state-level legislation, eliminating Medicare's disparity between primary care and procedural specialty reimbursement, and efforts by health systems. The final section of Part 2 addresses the building of powerful core and interprofessional teams. [ABSTRACT FROM AUTHOR]

Objective: The Veterans Health Administration (VHA) conducted a randomized quality improvement evaluation to determine whether augmenting patient‐centered medical homes with Primary care Intensive Management (PIM) decreased utilization of acute care and health care costs among patients at high risk for hospitalization. PIM was cost‐neutral in the first year; we analyzed changes in utilization and costs in the second year. Data sources: VHA administrative data for five demonstration sites from August 2013 to March 2019. Data sources: Administrative data extracted from VHA's Corporate Data Warehouse. Study design: Veterans with a risk of 90‐day hospitalization in the top 10th percentile and recent hospitalization or emergency department (ED) visit were randomly assigned to usual primary care vs primary care augmented by PIM. PIM included interdisciplinary teams, comprehensive patient assessment, intensive case management, and care coordination services. We compared the change in mean VHA inpatient and outpatient utilization and costs (including PIM expenses) per patient for the 12‐month period before randomization and 13‐24 months after randomization for PIM vs usual care using difference‐in‐differences. Principal findings: Both PIM patients (n = 1902) and usual care patients (n = 1882) had a mean of 5.6 chronic conditions. PIM patients had a greater number of primary care visits compared to those in usual care (mean 4.6 visits/patient/year vs 3.7 visits/patient/year, p < 0.05), but ED visits (p = 0.45) and hospitalizations (p = 0.95) were not significantly different. We found a small relative increase in outpatient costs among PIM patients compared to those in usual care (mean difference + $928/patient/year, p = 0.053), but no significant differences in mean inpatient costs (+$245/patient/year, p = 0.97). Total mean health care costs were similar between the two groups during the second year (mean difference + $1479/patient/year, p = 0.73). Conclusions: Approaches that target patients solely based on the high risk of hospitalization are unlikely to reduce acute care use or total costs in VHA, which already offers patient‐centered medical homes. [ABSTRACT FROM AUTHOR]

Objective: A consolidated state‐of‐the‐art review of U.S. healthcare reform efforts that documents the evolution towards value‐based healthcare (VBH) is lacking in peer‐review literature. This field guide attempts to clarify working definitions and conceptual boundaries within the lexicon of U.S. healthcare reform efforts that predated and have common thematic perspectives within the evolving VBH reform paradigm. Data Sources: Pubmed/MEDLINE/Google search. Review Methods: Pubmed/MEDLINE/Google search was performed during August 1, 2020‐January14, 2021 for U.S. healthcare reform terms, legislative and government agency publications. Those citing relevant legislative, regulatory, philosophical and technological advancements integral to the development and function of VBH were catalogued according to the targeted stakeholders and evolving reform strategy or technology. Conclusions: Eight healthcare reform paradigms were identified as influential precursors to VBH: Patient‐Centered Care Model, Patient‐Centered Medical Home, Population Health, Personalized Medicine, P4 Medicine, Precision Medicine, Managed Care, and Accountable Care. Several of these models have similar nomenclature and, confusingly, many have multiple interpretations of the terms used to describe these models. However, consistent stakeholders identified within these paradigms are key to VBH; notably the patient, the physician and the payer (the "Big 3"). Demonstrable healthcare spending reductions have been best achieved when the Big 3 stakeholder interests are aligned within healthcare reform legislation. The definition of "Value" within each reform model was found to be based upon the perspective of the targeted stakeholder. Within VBH, the perspectives of the Big 3 stakeholders form a multidimensional meaning of "Value" that can be represented by the equation Value = Patient Experience Management3. [ABSTRACT FROM AUTHOR]

Patient-centered medical homes based at federally-qualified health centers (FQHCs) can benefit patients with complex health needs, such as severe mental illness (SMI). However, little is known about FQHC characteristics associated with changes in health care expenditures and utilization for individuals with SMI. Using North Carolina Medicaid claims and FQHC data from the Uniform Data System, multivariate regression identified FQHC characteristics associated with total expenditures, medication adherence and emergency department utilization among adults with SMI, controlling for time-invariant differences by health center. Few of the FQHC-level factors affected the outcomes—not even offering on-site behavioral health services. Although the FQHCs in the analysis sample exhibited considerable variation in the provision of specialty behavioral services and in staffing configurations, it may be the case that the examination of average effects across a heterogeneous group of adults with SMI mask benefits of FQHCs to certain subgroups. These findings support the conclusion that there is no "one-size-fits-all" model that works best for this diverse patient population. Study results are relevant for practices embarking on expanded medical home services for people with SMI. [ABSTRACT FROM AUTHOR]

Background: The Institute of Medicine reported that more than 1.5 million preventable adverse drug events occur annually in the United States. Comprehensive Medication Management (CMM) is the medication review process to improve clinical outcomes, enhance patient adherence, reduce drug therapy problems and reduce health care costs. University of Texas (UT) Physicians implemented a CMM program in several community-based clinics. We evaluated the effectiveness of CMM to reduce drug therapy problems and achieve medical cost savings.Methods: This was a retrospective, observational study of CMM participants from October 2015 to September 2016. Program participants included patients aged 18 years or older who had taken more than 4 prescribed medications and were diagnosed with at least one of the following chronic diseases: hypertension, congestive heart failure, chronic obstructive pulmonary disease, asthma or diabetes. Under the CMM program, a clinical pharmacist reviewed patients' electronic health records and created action plans to resolve identified drug problems. As part of the evaluation of the clinical process, two independent physicians conducted peer review on the recommendations issued by the pharmacist in order to establish inter-rater reliability of drug therapy problems and potential consequent medical services. The drug therapy problems were identified and classified into four categories: indication, effectiveness, safety and/or compliance. The average cost of avoided medical services was obtained based on cost extrapolations from the literature, combined with hospital discharge data. Potential medical services avoided were linked to the average cost of those services to calculate the total cost savings of the program from the payers' perspective.Results: By reviewing electronic health records of 3280 patients, the pharmacist identified 301 drug therapy problems and resolved 49.8% of these problems with collaboration from the patient's primary care physician or care team. The most commonly identified drug problems were related to potentially adverse drug reactions or inappropriate drug dosage. The CMM program resulted in potential cost savings of $1,143,015.Conclusions: The CMM program resolved medication therapy problems among program participants and achieved significant health care cost savings. [ABSTRACT FROM AUTHOR]

Background: Preventive home visits are suited for patients with reduced mobility, such as older people. Healthcare needs for older patients are expected to increase due to the extended life expectancy estimated in coming years. The implementation of low-cost, patient-centered methodologies may buffer this rise in health care costs without affecting the quality of service. In order to find the best home care model with less investment, this paper describes a study protocol comparing two models of home care for older people.Methods: We describe a quasi-experimental study that compares the outcome of two different home care models already implemented in two primary care centers in Badalona (Barcelona, Spain). The traditional model (control model) is integrated in the sense that is continuous, the same primary care center team looks after its assigned patients both at the center and in preventive home visits. The new functional home care model (study model), consisting of a highly trained team, is specifically designed to meet patient needs and give total attention to preventive home interventions. The study will start and end on the expected dates, June 2018 to October 2020, and include all patients over 65 years old already enrolled in the home care programs of the primary care centers selected. The primary endpoint assessed will be the difference in hospitalization days between patients included in both home care programs. Other variables regarding health status, quality of care and resource utilization will also be compared between the two models.Discussion: The study in progress will assess whether a functional and highly trained home care team will meet the ever-aging population needs in terms of cost and health outcomes better than a traditional, integrated one. Lessons learned from this pilot study will provide guidelines for a future model of home care based on the IHI Triple Aim: better care, better health, and lower costs.Trial Registration: Registered in ClinicalTrials.gov (Identifier: NCT03461315; March 12, 2018). [ABSTRACT FROM AUTHOR]

Purpose: Practice transformation in primary care is a movement toward data-driven redesign of care, patient-centered care delivery, and practitioner activation. A critical requirement for achieving practice transformation is availability of tools to engage practices.Methods: A total of 48 practices with 109 practice sites participate in the Garden Practice Transformation Network in Maryland (GPTN-Maryland) to work together toward practice transformation and readiness for the Quality Payment Program implemented by the Centers for Medicare & Medicaid Services. Practice-specific data are collected in GPTN-Maryland by practices themselves and by practice transformation coaches, and are provided by the Centers for Medicare & Medicaid Services. These data are overwhelming to practices when presented piecemeal or together, a barrier to practices taking action to ensure progress on the transformation spectrum. The GPTN-Maryland team therefore created a practice transformation analytics dashboard as a tool to present data that are actionable in care redesign.Results: When practices reviewed their data provided by the Centers for Medicare & Medicaid Services using the dashboard, they were often seeing, for the first time, cost data on their patients, trends in their key performance indicator data, and their practice transformation phase. Overall, 72% of practices found the dashboard engaging, and 48% found the data as presented to be actionable.Conclusions: The practice transformation analytics dashboard encourages practices to advance in practice transformation and improvement of patient care delivery. This tool engaged practices in discussions about data, care redesign, and costs of care, and about how to develop sustainable change within their practices. Research is needed to study the impact of the dashboard on costs and quality of care delivery. [ABSTRACT FROM AUTHOR]

Purpose: Primary care transformation is widely seen as essential to improving patient outcomes and health care costs. The medical home model can achieve these ends, but dissemination and scale-up of practice transformation is challenging. We sought to understand how to move past successful pilot efforts by early adopters to widespread adoption by applying cognitive task analysis using the diffusion of innovations framework.Methods: We undertook a qualitative cross-sectional comparison of 3 early adopter practices and 15 early majority practices in Alberta, Canada. Practices completed a total of 42 cognitive task analysis interviews. We conducted a framework-guided qualitative analysis, with allowance for emergent themes, using the macrocognition framework on which cognitive task analysis is based. Independent codings of interview transcripts for key macrocognitive functions were reviewed in group analysis meetings to describe macrocognitive functions and team mental models, and identify emergent themes. Two external focus groups provided support for these findings.Results: Three prominent findings emerged. The first was a spectrum of mental models from "doctor with helpers," through degrees of delegation, to fully team based care. The second was differences in how teams distributed macrocognitive functions among members, with early adopters distributing these functions more widely across the team than early majority practices. Finally, we saw emergence of several themes also common in the diffusion of innovations literature, such as the importance of trying new practices in small, reversible steps.Conclusions: Our findings provide guidance to practice teams, health systems, and policymakers seeking to move beyond early adopters, to improve team functioning and advance the medical home transformation at scale. [ABSTRACT FROM AUTHOR]

Background: Continuity of care could reduce health care consumption by patients and reduce the number of referrals to specialist care, but it is unknown if there is a difference in referral rates to specific medical specialties.Aim: We aimed to determine the relationship between continuity of care and both the referral rate (referrals per patient per year) and the medical specialties for which this relationship was strongest.Design and Setting: A retrospective cohort study of 19333 patients in primary care in the north of the Netherlands.Method: Patients with at least two contacts with a general practitioner (GP) over a 2-year period (2013-2014) were included. The number of contacts with their own or other GPs were calculated, and referral rates were determined. Continuity of care was included as a dichotomous variable (absent or present).Results: The odds of being referred were higher for older patients, females and patients with more practitioner contacts. However, the presence of continuity of care was associated with the highest odds of referral. The referral rate was significantly highest for patients with continuity of care when referred to paediatrics, as well as for patients without continuity of care who were referred to gastroenterology, ophthalmology and psychiatry.Conclusion: Increased continuity of care decreases referral to specialist care, most notably for referrals to paediatrics. Despite continued pressures on continuity of care, policy makers should invest in this cornerstone of primary care to temper health care expenditures. [ABSTRACT FROM AUTHOR]

This essay questions the wisdom of adherence to an indulgent approach to vertical integration in health care. It first critiques the bases for antitrust law's traditional tolerance of vertical integration and describes contemporary economic learning that supports more robust antitrust enforcement. It goes on to dispute arguments urging extra caution in dealing with the health care sector and concludes with several justifications for close scrutiny of vertical health sector mergers. [ABSTRACT FROM AUTHOR]

Primary care is widely viewed as being in crisis despite its purported central role in addressing population issues related to healthcare cost, quality, access, and equity. Despite this pivotal role, the nature of the clinical practice today has largely emerged by default. We review the evolution of clinical practice in primary care from its genesis in small practices with paper charts and telephonic patient communication to managed care, pay-for-performance, and today's era of the electronic medical record, value-based payment, and consumerism. We suggest a necessary "reset" of expectations that focuses on today's practice structure and the historic face-to-face patient care expectations. Only by doing so can we successfully meet the demands of patients, society, and practicing internists. [ABSTRACT FROM AUTHOR]

Context: Over the years, a patient population that has received increased attention is high-cost, highneed (HCHN) patients. Research has shown that about 5% of patients account for nearly half of all U.S. health care spending, and that many of those costs could be preventable or modifiable. As a result, many health systems are now focusing on identifying and addressing the needs of these patients. A number of health systems have developed "intensive primary care" programs or "ambulatory intensive care units" to provide more targeted and comprehensive care to HCHN patients. However, a key piece that is missing in the evaluation of these programs that may provide insights into the effectiveness and sustainability is patient experience and perspectives. Objective: To qualitatively examine the perspectives and experience of HCHN patients enrolled in a complex care program as part of one health system's primary care transformation. Study Design: Semi-structured qualitative interviews carried out April-July 2021. Setting: A suburban primary care clinic in the Twin Cities, Minnesota. Population studied: Eighteen patients that were part of the Complex Care program. Outcome measures: Patient experience within the program. Results: There were 11 major themes that emerged which described patients' experience in the Complex Care program which were categorized into four domains. Patients discussed (1) how the program was introduced to them and their initial impressions, (2) their thoughts on the care team, including having a designated Complex Care team, the trust and relationship that they have with the team, how the team provides easy and prompt access to care, and how the team provides care continuity and coordination, (3) the Complex Care visits, including their thoughts on pre-visit planning, having more time in the visits, having team visits, and virtual visits, and (4) outcomes of the program, such as feeling that they are getting more comprehensive care and have improved health and a better patient experience. Conclusions: The Quadruple Aim, which encompasses improving clinical outcomes, decreasing health care costs, while improving patient and care team experience, is widely accepted as a compass to optimize health system performance. The results of this work illustrate how Complex Care programs can positively impact the patient experience of HCHN patients. [ABSTRACT FROM AUTHOR]

The article focuses on the value-based payments to primary care physicians frequently employ measures that are not aligned or do not recognize the higher-level integrating, personalizing, and prioritizing functions of primary care and the needs of patients, communities, or health care systems. It mentions that clinical quality measurements should drive improved patient-centered care. It also mentions that continuity of Care is defined as seeing the same primary care clinician over time.

The article discusses three areas where activity in the local market could surface and change the environment in which U.S. oncologists provide care. The areas include the state payment reform, employer initiatives in payment reform and competitors for infusion drugs. The initiatives have been expected to change the competitive positioning of healthcare providers. Some business-based groups have reviewed the costs of oncology care and have considered potential alliances with providers.

Objective: Individuals with behavioral health conditions may benefit from enhanced care management provided by a patient-centered medical home (PCMH). In late 2011 and early 2012 Medicare began participating in PCMH initiatives in eight states through the Multi-Payer Advanced Primary Care Practice (MAPCP) demonstration. This study examined how the initiatives addressed the needs of patients with behavioral health conditions and the impacts of the demonstration on expenditures and utilization for this population.Methods: Semistructured interviews provided insight into states' approaches to improving care, and multivariate difference-in-difference regressions of Medicare and Medicaid claims data were used to model changes in utilization and expenditures, comparing Medicare and Medicaid beneficiaries with behavioral health conditions in MAPCP demonstration practices with similar beneficiaries in non-PCMH primary care practices. Utilization included inpatient admissions and emergency department visits for all causes and for behavioral health conditions and outpatient visits for behavioral health conditions. Expenditure outcomes included expenditures for all services and those with a principal diagnosis of a behavioral health condition.Results: Practices reported screening more patients for behavioral health conditions, linking patients to community-based behavioral health resources, and hiring behavioral health specialists to provide care. Several states embarked on unique initiatives to improve access to behavioral health services. However, few significant associations were found between participation in the MAPCP demonstration and utilization and expenditures for behavioral health services.Conclusions: Even though PCMHs made concerted efforts to improve access to care for their patients with behavioral health conditions, few substantial changes in patterns of care were noted. [ABSTRACT FROM AUTHOR]

Background: Care coordination is a critical component of managing high-risk patients, who tend to have complex and multiple medical and psychosocial problems and are typically at high risk for increased hospitalization and incur high health care expenditures. Primary care models such as the patient-centered medical homes (PCMHs) are designed to improve care coordination and reduce care fragmentation. However, little is known about how the burden of care coordination for high-risk patients influences PCMH team members' stress.Objective: To evaluate the relationship between provider stress and care coordination time in high-risk patient care and whether availability of help is associated with reduced stress.Study Design: Multivariable regression analysis of a cross-sectional survey of PCMH primary care providers (PCPs) and nurses.Participants: A total of 164 PCPs and 272 nurses in primary care practices at five geographically diverse Veteran Health Administration (VA) medical center health systems.Main Measures: The main outcome variable was provider stress due to high-risk patient care. Independent variables were the reported proportion of high-risk patients in PCP/nurse patient panels, time spent coordinating care for these patients, and provider satisfaction with help received in caring for them.Key Results: The response rate was 44%. Spending more than 8 h per week coordinating care was significantly associated with a 0.21-point increase in reported provider stress compared to spending 8 h or less per week (95% CI: 0.04-0.39; p = 0.015). The magnitude of the association between stress and care coordination time was diminished when provider satisfaction with help received was included in the model.Conclusions: Perceived provider stress from care of high-risk patients may arise from challenges related to coordinating their care. Our findings suggest that the perception of receiving help for high-risk patient care may be valuable in reducing provider stress. [ABSTRACT FROM AUTHOR]

Patient-centered medical home models are fundamental to the advanced alternative payment models defined in the Medicare Access and Children's Health Insurance Plan Reauthorization Act (MACRA). The patient-centered medical home is a model of healthcare delivery supported by alternative payment mechanisms and designed to promote coordinated medical care that is simultaneously patient-centric and population-oriented. This transformative care model requires shifting reimbursement to include a per-patient payment intended to cover services not previously reimbursed such as disease management over time. Payment is linked to quality measures, including proportion of care delivered according to predefined pathways and demonstrated impact on outcomes. Some medical homes also include opportunities for shared savings by reducing overall costs of care. Recent proposals have suggested expanding the medical home model to specialized populations with complex needs because primary care teams may not have the facilities or the requisite expertise for their unique needs. An example of a successful care model that may provide valuable lessons for those creating specialty medical home models already exists in many hematopoietic cell transplantation (HCT) centers that deliver multidisciplinary, coordinated, and highly specialized care. The integration of care delivery in HCT centers has been driven by the specialty care their patients require and by the payment methodology preferred by the commercial payers, which has included bundling of both inpatient and outpatient care in the peritransplant interval. Commercial payers identify qualified HCT centers based on accreditation status and comparative performance, enabled in part by center-level comparative performance data available within a national outcomes database mandated by the Stem Cell Therapeutic and Research Act of 2005. Standardization across centers has been facilitated via voluntary accreditation implemented by Foundation for the Accreditation of Cell Therapy. Payers have built on these community-established programs and use public outcomes and program accreditation as standards necessary for inclusion in specialty care networks and contracts. Although HCT centers have not been described as medical homes, most HCT providers have already developed the structures that address critical requirements of MACRA for medical homes. [ABSTRACT FROM AUTHOR]

Background: Patient-centered medical home (PCMH) models of primary care have the potential to expand access, improve population health, and lower costs. Federally qualified health centers (FQHCs) were early adopters of PCMH models.Objective: We measured PCMH capabilities in a diverse nationwide sample of FQHCs and assessed the relationship between PCMH capabilities and Medicare beneficiary outcomes.Design: Cross-sectional, propensity score-weighted, multivariable regression analysis.Participants: A convenience sample of 804 FQHC sites that applied to a nationwide FQHC PCMH initiative and 231,163 Medicare fee-for-service beneficiaries who received a plurality of their primary care services from these sites.Main Measures: PCMH capabilities were self-reported using the National Committee for Quality Assurance's (NCQA's) 2011 application for PCMH recognition. Measures of utilization, continuity of care, quality, and Medicare expenditures were derived from Medicare claims covering a 1-year period ending October 2011.Key Results: Nearly 88% of sites were classified as having PCMH capabilities equivalent to NCQA Level 1, 2, or 3 PCMH recognition. These more advanced sites were associated with 228 additional FQHC visits per 1000 Medicare beneficiaries (95% CI: 176, 278), compared with less advanced sites; 0.02 points higher practice-level continuity of care (95% CI: 0.01, 0.03); and a greater likelihood of administering two of four recommended diabetes tests. However, more advanced sites were also associated with 181 additional visits to specialists per 1000 beneficiaries (95% CI: 124, 232) and 64 additional visits to emergency departments (95% CI: 35, 89)-but with no differences in inpatient utilization. More advanced sites had higher Part B expenditures ($111 per beneficiary [95% CI: $61, $158]) and total Medicare expenditures of $353 [95% CI: $65, $614]).Conclusions: Implementation of PCMH models in FQHCs may be associated with improved primary care for Medicare beneficiaries. Expanded access to care, in combination with slower development of key PCMH capabilities, may explain higher Medicare expenditures and other types of utilization. [ABSTRACT FROM AUTHOR]

Background: From 2011 through 2014, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration provided care management fees and technical assistance to a nationwide sample of 503 federally qualified health centers to help them achieve the highest (level 3) medical-home recognition by the National Committee for Quality Assurance, a designation that requires the implementation of processes to improve access, continuity, and coordination.Methods: We examined the achievement of medical-home recognition and used Medicare claims and beneficiary surveys to measure utilization of services, quality of care, patients' experiences, and Medicare expenditures in demonstration sites versus comparison sites. Using difference-in-differences analyses, we compared changes in outcomes in the two groups of sites during a 3-year period.Results: Level 3 medical-home recognition was awarded to 70% of demonstration sites and to 11% of comparison sites. Although the number of visits to federally qualified health centers decreased in the two groups, smaller reductions among demonstration sites than among comparison sites led to a relative increase of 83 visits per 1000 beneficiaries per year at demonstration sites (P<0.001). Similar trends explained the higher performance of demonstration sites with respect to annual eye examinations and nephropathy tests (P<0.001 for both comparisons); there were no significant differences with respect to three other process measures. Demonstration sites had larger increases than comparison sites in emergency department visits (30.3 more per 1000 beneficiaries per year, P<0.001), inpatient admissions (5.7 more per 1000 beneficiaries per year, P=0.02), and Medicare Part B expenditures ($37 more per beneficiary per year, P=0.02). Demonstration-site participation was not associated with relative improvements in most measures of patients' experiences.Conclusions: Demonstration sites had higher rates of medical-home recognition and smaller decreases in the number of patients' visits to federally qualified health centers than did comparison sites, findings that may reflect better access to primary care relative to comparison sites. Demonstration sites had larger increases in emergency department visits, inpatient admissions, and Medicare Part B expenditures. (Funded by the Centers for Medicare and Medicaid Services.). [ABSTRACT FROM AUTHOR]

An introduction is presented in which the authors discuss various reports within the journal on topics including a patient-centered medical home (PCMH) medical care model for people living with HIV (PLWH), medical care for homeless HIV patients, and physical health-related quality of life.

Background: The Chronic Care Initiative (CCI) was a large state-wide patient-centered medical home (PCMH) initiative in Pennsylvania in place from 2008-2011.Objective: Determine whether the CCI impacted the utilization and costs for Medicaid patients with chronic medical conditions and comorbid psychiatric or substance use disorders.Design: Analysis of Medicaid claims using difference-in-difference regression analyses to compare changes in utilization and costs for patients treated at CCI practices to propensity score-matched patients treated at comparison non-CCI practices.Setting: Ninety-six CCI practices in Pennsylvania and 60 non-CCI practices during the same time period.Participants: A total of 11,105 comorbid Medicaid patients treated in CCI practices and an equal number of propensity-matched comparison patients treated in non-CCI practices.Measurements: Changes in total per-patient costs from 1 year prior to 1 year following an index episode period. Secondary outcomes included utilization and costs for emergency department (ED), inpatient, and outpatient services.Results: The CCI group experienced an average adjusted total cost savings of $4145.28 per patient per year (P = 0.023) for the CCI relative to the non-CCI group. This was largely driven by a $3521.15 savings (P = 0.046) in inpatient medical costs, in addition to relative savings in outpatient psychiatric ($21.54, P < 0.001) and substance abuse service costs ($16.42, P = 0.013), compared to the non-CCI group. The CCI group, related to the non-CCI group, had decreases in expected mean counts of ED visits (for those who had any) and psychiatric hospitalizations of 15.6 (95 % CI: -21, -9) and 40.7 (95 % CI: -57, -18) percentage points respectively.Limitations: We do not measure quality of care and cannot make conclusions about the overall cost-effectiveness or long-term effects of the CCI.Conclusions: The CCI was associated with substantial cost savings, attributable primarily to reduced inpatient costs, among a high-risk group of Medicaid patients, who may disproportionally benefit from care management in patient-centered medical homes. [ABSTRACT FROM AUTHOR]

Background: Enhanced primary care models have diffused slowly and shown uneven results. Because their structural features are costly and challenging for small practices to implement, they offer modest rewards for improved performance, and improvement takes time.Objective: To test whether a patient-centered medical home (PCMH) model that significantly rewarded cost savings and accommodated small primary care practices was associated with lower spending, fewer hospital admissions, and fewer emergency room visits.Design: We compared medical care expenditures and utilization among adults who participated in the PCMH program to adults who did not participate. We computed difference-in-difference estimates using two-part multivariate generalized linear models for expenditures and negative binomial models for utilization. Control variables included patient demographics, county, chronic condition indicators, and illness severity.Participants: A total of 1,433,297 adults aged 18-64 years, residing in Maryland, Virginia, and the District of Columbia, and insured by CareFirst for at least 3 consecutive months between 2010 and 2013.Intervention: CareFirst implemented enhanced fee-for-service payments to the practices, offered a large retrospective bonus if annual cost and quality targets were exceeded, and provided information and care coordination support.Measures: Outcomes were quarterly claims expenditures per member for all covered services, inpatient care, emergency care, and prescription drugs, and quarterly inpatient admissions and emergency room visits.Results: By the third intervention year, annual adjusted total claims payments were $109 per participating member (95 % CI: -$192, -$27), or 2.8 % lower than before the program and compared to those who did not participate. Forty-two percent of the overall decline in spending was explained by lower inpatient care, emergency care, and prescription drug spending. Much of the reduction in inpatient and emergency spending was explained by lower utilization of services.Conclusions: A PCMH model that does not require practices to make infrastructure investments and that rewards cost savings can reduce spending and utilization. [ABSTRACT FROM AUTHOR]

This study investigates whether patient-reported characteristics of the medical home are associated with improved quality and equity of preventive care, advice on health habits, and emergency department use. We used adjusted risk ratios to examine the association between medical home characteristics and care measures based on the 2010 Medical Expenditure Panel Survey. Medical home characteristics are associated with 6 of the 11 outcome measures, including flu shots, smoking advice, exercise advice, nutrition advice, all advice, and emergency department visits. Educational and income groups benefit relatively equally from medical home characteristics. However, compared with insurance and access to a provider, medical home characteristics have little influence on overall disparities in care. In sum, our findings support that medical home characteristics can improve quality and reduce emergency visits but we find no evidence that medical home characteristics alleviate disparities in care. [ABSTRACT FROM AUTHOR]

Background: Medical home initiatives encourage primary care practices to invest in new structural capabilities such as patient registries and information technology, but little is known about the costs of these investments.Objectives: To estimate costs of transformation incurred by primary care practices participating in a medical home pilot.Design: We interviewed practice leaders in order to identify changes practices had undertaken due to medical home transformation. Based on the principles of activity-based costing, we estimated the costs of additional personnel and other investments associated with these changes.Setting: The Pennsylvania Chronic Care Initiative (PACCI), a statewide multi-payer medical home pilot.Participants: Twelve practices that participated in the PACCI.Measurements: One-time and ongoing yearly costs attributed to medical home transformation.Results: Practices incurred median one-time transformation-associated costs of $30,991 per practice (range, $7694 to $117,810), equivalent to $9814 per clinician ($1497 to $57,476) and $8 per patient ($1 to $30). Median ongoing yearly costs associated with transformation were $147,573 per practice (range, $83,829 to $346,603), equivalent to $64,768 per clinician ($18,585 to $93,856) and $30 per patient ($8 to $136). Care management activities accounted for over 60% of practices' transformation-associated costs. Per-clinician and per-patient transformation costs were greater for small and independent practices than for large and system-affiliated practices.Limitations: Error in interviewee recall could affect estimates. Transformation costs in other medical home interventions may be different.Conclusions: The costs of medical home transformation vary widely, creating potential financial challenges for primary care practices-especially those that are small and independent. Tailored subsidies from payers may help practices make these investments.Primary Funding Source: Agency for Healthcare Research and Quality. [ABSTRACT FROM AUTHOR]

The impact of a patient-centered medical home (PCMH) in reducing total cost of care remains a subject of debate, particularly among the non-elderly adult population. This study examines a 6-year experience of a large integrated regional health care delivery system in the US implementing PCMH among its commercially insured population. A regional health plan's claims data from 2008 through 2013 among its commercially insured members were obtained and analyzed. Over the 6-year period, the PCMH implementation beyond the first 6 months of exposure was associated with a lower total cost of care of ~9% (P,0.05). The largest reduction was observed in outpatient costs (12%; P,0.05). This study suggests that PCMH implementation among the non-elderly adult population can potentially lead to cost savings. Future studies are necessary to identify the drivers of the cost savings and examine if similar results can be replicated elsewhere by other health care delivery systems. [ABSTRACT FROM AUTHOR]

The patient-centered medical home (PCMH) model provides a compelling vision for primary care transformation, but studies of its impact have used insufficiently patient-centered metrics with inconsistent results. We propose a framework for defining patient-centered value and a new model for value-based primary care transformation: the primary care value model (PCVM). We advocate for use of patient-centered value when measuring the impact of primary care transformation, recognition, and performance-based payment; for financial support and research and development to better define primary care value-creating activities and their implementation; and for use of the model to support primary care organizations in transformation. [ABSTRACT FROM AUTHOR]

Background: The benefits of the patient-centered medical home (PCMH) over and above that of a usual source of medical care have yet to be determined, particularly for adults with mental health disorders.Objective: To examine qualities of a usual provider that align with PCMH goals of access, comprehensiveness, and patient-centered care, and to determine whether PCMH qualities in a usual provider are associated with the use of mental health services (MHS).Design: Using national data from the Medical Expenditure Panel Survey, we conducted a lagged cross-sectional study of MHS use subsequent to participant reports of psychological distress and usual provider and practice characteristics.Participants: A total of 2,358 adults, aged 18-64 years, met the criteria for serious psychological distress and reported on their usual provider and practice characteristics.Main Measures: We defined "usual provider" as a primary care provider/practice, and "PCMH provider" as a usual provider that delivered accessible, comprehensive, patient-centered care as determined by patient self-reporting. The dependent variable, MHS, included self-reported mental health visits to a primary care provider or mental health specialist, counseling, and psychiatric medication treatment over a period of 1 year.Results: Participants with a usual provider were significantly more likely than those with no usual provider to have experienced a primary care mental health visit (marginal effect [ME] = 8.5, 95 % CI = 3.2-13.8) and to have received psychiatric medication (ME = 15.5, 95 % CI = 9.4-21.5). Participants with a PCMH were additionally more likely than those with no usual provider to visit a mental health specialist (ME = 7.6, 95 % CI = 0.7-14.4) and receive mental health counseling (ME = 8.5, 95 % CI = 1.5-15.6). Among those who reported having had any type of mental health visit, participants with a PCMH were more likely to have received mental health counseling than those with only a usual provider (ME = 10.0, 95 % CI = 1.0-19.0).Conclusions: Access to a usual provider is associated with increased receipt of needed MHS. Patients who have a usual provider with PCMH qualities are more likely to receive mental health counseling. [ABSTRACT FROM AUTHOR]

The article offers information on primary care in the U.S. and discusses whether a payment reform is needed to transform it. Topics discussed include the efforts to transform outpatient generalist practices into patient-centered medical homes (PCMH); the Multi-Payer Advanced Primary Care Practice (MAPCP) model; and the testing of payment models by the Center for Medicare and Medicaid services (CMS).

Comparative effectiveness research (CER) is an important branch of pharmacoeconomics that systematically studies and evaluates the cost-effectiveness of medical interventions. CER plays instrumental roles in guiding government public health policy programs and insurance. Countries throughout the world use different methods of CER to help make medical decisions based on providing optimal therapy at a reduced cost. Expenses to the healthcare system continue to rise, and CER is one-way in which expenses could be curbed in the future by applying cost-effectiveness evidence to clinical decisions. China, India, South Korea, and the United Kingdom are of essential focus because these country's economies and health care expenses continue to expand. The structures and use of CER are diverse throughout these countries, and each is of prime importance. By conducting this thorough comparison of CER in different nations, strategies and organizational setups from different countries can be applied to help guide public health and medical decision-making in order to continue to expand the establishment and role of CER programs. The patient-centered medical home has been created to help reduce costs in the primary care sector and to help improve the effectiveness of therapy. Barriers to CER are also important as many stakeholders need to be able to work together to provide the best CER evidence. The advancement of CER in multiple countries throughout the world provides a possible way of reducing costs to the healthcare system in an age of expanding expenses. [ABSTRACT FROM AUTHOR]

Objective To compare health care utilization and payments between NCQA-recognized patient-centered medical home ( PCMH) practices and practices without such recognition. Data Sources Medicare Part A and B claims files from July 1, 2007 to June 30, 2010, 2009 Census, 2007 Health Resources and Services Administration and CMS Utilization file, Medicare's Enrollment Data Base, and the 2005 American Medical Association Physician Workforce file. Study Design This study used a longitudinal, nonexperimental design. Three annual observations (July 1, 2008-June 30, 2010) were available for each practice. We compared selected outcomes between practices with and those without NCQA PCMH recognition. Data Collection Methods Individual Medicare fee-for-service ( FFS) beneficiaries and their claims and utilization data were assigned to PCMH or comparison practices based on where they received the plurality of evaluation and management services between July 1, 2007 and June 30, 2008. Principal Findings Relative to the comparison group, total Medicare payments, acute care payments, and the number of emergency room visits declined after practices received NCQA PCMH recognition. The decline was larger for practices with sicker than average patients, primary care practices, and solo practices. Conclusions This study provides additional evidence about the potential of the PCMH model for reducing health care utilization and the cost of care. [ABSTRACT FROM AUTHOR]

IMPORTANCE Patient-centered medical homes have not been shown to reduce adverse outcomes or costs in adults or children with chronic illness. OBJECTIVE To assess whether an enhanced medical home providing comprehensive care prevents serious illness (death, intensive care unit [ICU] admission, or hospital stay >7 days) and/or reduces costs among children with chronic illness. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial o f high-risk children with chronic illness (≥3 emergency department visits, ≥2 hospitalizations, or ≥1 pediatric ICU admissions during previous year, and >50% estimated risk for hospitalization) treated at a high-risk clinic at the University of Texas, Houston, and randomized to comprehensive care (n = 105) or usual care (n = 96). Enrollment was between March 2011 and February 2013 (when predefined stopping rules for benefit were met) and outcome evaluations continued through August 31, 2013. INTERVENTIONS Comprehensive care included treatment from primary care clinicians and specialists in the same clinic with multiple features to promote prompt effective care. Usual care was provided locally in private offices or faculty-supervised clinics without modification. MAIN OUTCOMES AND MEASURES Primary outcome; children with a serious illness (death, ICU admission, or hospital stay >7 days), costs (health system perspective). Secondary outcomes: individual serious illnesses, medical services, Medicaid payments, and medical school revenues and costs. RESULTS In an intent-to-treat analysis, comprehensive care decreased both the rate of children with a serious illness (10 per 100 child-years vs 22 for usual care; rate ratio [RR], 0.45 [95% Cl, 0.28-0.73]), and total hospital and clinic costs ($16 523 vs $26 781 per child-year, respectively; cost ratio, 0.58 [95% Cl, 0.38-0.88]). In analyses of net monetary benefit, the probability that comprehensive care was cost neutral or cost saving was 97%. Comprehensive care reduced (per 100 child-years) serious illnesses (16 vs 44 for usual care; RR, 0.33 [95% Cl, 0.17-0.66]), emergency department visits (90 vs 190; RR, 0.48 [95% Cl, 0.34-0.67]), hospitalizations (69 vs 131; RR, 0.51 [95% Cl, 0.33-0.77]), pediatric ICU admissions (9 vs 26; RR, 0.35 [95% Cl, 0.18-0.70]), and number of days in a hospital (276 vs 635; RR, 0.36 [95% Cl, 0.19-0.67]). Medicaid payments were reduced by $6243 (95% Cl, $1302-$11 678) per child-year. Medical school losses (costs minus revenues) increased by $6018 (95% Cl, $5506-$6629) per child-year. CONCLUSIONS AND RELEVANCE Among high-risk children with chronic illness, an enhanced medical home that provided comprehensive care to promote prompt effective care vs usual care reduced serious illnesses and costs. These findings from a single site of selected patients with a limited number of clinicians require study in larger, broader populations before conclusions about generalizability to other settings can be reached. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02128776 [ABSTRACT FROM AUTHOR]

An essay is presented on the implications of the U.S. Affordable Care Act (ACA) and medical-industrial complex (MIC) concept. Topics discussed include the impact of the improvement of primary care on the healths of the population, the use of electronic medical records (EMR) in the better integration of healthcare, and the benefits of the Patient-Centered Medical Home (PCMH) in addressing healthcare problems including integration, costs, and access.

An editorial is presented on the Patient-Centered Medical Home (PCMH) model with a focus on Medicare beneficiaries to identify which of its myriad requirements are most valuable. Topics include the use of registries to identify and remind patients due for preventive services, and using patient registries for pre-visit planning, clinician reminders, patient outreach, and population health monitoring.

Background: Digital health has the potential to revolutionize health care by improving accessibility, patient experience, outcomes, productivity, safety, and cost efficiency. In England, the NHS (National Health Service) Long Term Plan promised the right to access digital-first primary care by March 31, 2024. However, there are few global, fully digital-first providers and limited research into their effects on cost from a health system perspective.Objective: The aim of this study was to evaluate the impact of highly accessible, digital-first primary care on acute hospital spending.Methods: A retrospective, observational analysis compared acute hospital spending on patients registered to a 24/7, digital-first model of NHS primary care with that on patients registered to all other practices in North West London Collaboration of Clinical Commissioning Groups. Acute hospital spending data per practice were obtained under a freedom of information request. Three versions of NHS techniques designed to fairly allocate funding according to need were used to standardize or "weight" the practice populations; hence, there are 3 results for each year. The weighting adjusted the populations for characteristics that impact health care spending, such as age, sex, and deprivation. The total spending was divided by the number of standardized or weighted patients to give the spending per weighted patient, which was used to compare the 2 groups in the NHS financial years (FY) 2018-2019 (FY18/19) and 2019-2020 (FY19/20). FY18/19 costs were adjusted for inflation, so they were comparable with the values of FY19/20.Results: The NHS spending on acute hospital care for 2.43 million and 2.54 million people (FY18/19 and FY19/20) across 358 practices and 49 primary care networks was £1.6 billion and £1.65 billion (a currency exchange rate of £1=US $1.38 is applicable), respectively. The spending on acute care per weighted patient for Babylon GP at Hand members was 12%, 31%, and 54% (£93, P=.047; £223, P<.001; and £389, P<.001) lower than the regional average in FY18/19 for the 3 weighting methodologies used. In FY19/20, it was 15%, 35%, and 51% (£114, P=.006; £246, P<.001; and £362, P<.001) lower. This amounted to lower costs for the Babylon GP at Hand population of £1.37, £4.40 million, and £11.6 million, respectively, in FY18/19; and £3.26 million, £9.54 million, and £18.8 million, respectively, in FY19/20.Conclusions: Patients with access to 24/7, digital-first primary care incurred significantly lower acute hospital costs. [ABSTRACT FROM AUTHOR]

Background: The Patient-Centered Medical Home (PCMH) model is a coordinated-care model that has served as a means to improve several chronic disease outcomes and reduce management costs. However, access to PCMH has not been explored among adults suffering from chronic conditions in the United States. Therefore, the aim of this study was to describe the changes in receiving PCMH among adults suffering from chronic conditions that occurred from 2010 through 2015 and to identify predisposing, enabling, and need factors associated with receiving a PCMH.Methods: A cross-sectional analysis was conducted for adults with chronic conditions, using data from the 2010-2015 Medical Expenditure Panel Surveys (MEPS). Most common chronic conditions in the United States were identified by using the most recent data published by the Agency for Healthcare Research and Quality (AHRQ). The definition established by the AHRQ was used as the basis to determine whether respondents had access to PCMH. Multivariate logistic regression analyses were conducted to detect the association between the different variables and access to PCMH care.Results: A total of 20,403 patients with chronic conditions were identified, representing 213.7 million U.S. lives. Approximately 19.7% of the patients were categorized as the PCMH group at baseline who met all the PCMH criteria defined in this paper. Overall, the percentage of adults with chronic conditions who received a PCMH decreased from 22.3% in 2010 to 17.8% in 2015. The multivariate analyses revealed that several subgroups, including individuals aged 66 and older, separated, insured by public insurance or uninsured, from low-income families, residing in the South or the West, and with poor health, were less likely to have access to PCMH.Conclusion: Our findings showed strong insufficiencies in access to a PCMH between 2010 and 2015, potentially driven by many factors. Thus, more resources and efforts need to be devoted to reducing the barriers to PCMH care which may improve the overall health of Americans with chronic conditions. [ABSTRACT FROM AUTHOR]

The opening session of the 2014 annual meeting of the American Society of Anesthesiologists addressed game-changing “disruptive innovations” that challenge the health care status quo. This article discusses the concept of a perioperative surgical home, a patient-centered, team-based approach for providing coordinated and accessible health care focused on quality and reduced costs. [ABSTRACT FROM PUBLISHER]

The author discusses the payment system for patient-centered medical homes (PCMH). Topics discussed include the fee-for-service (FFS) reimbursement system for the primary care practice in the U.S., expectations for primary care practices to reorient toward providing enhanced services, reimbursement system under the payer-sponsored PCMH schemes and the optimal payment system for primary care.