Evaluating Primary Care Renewal

© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH

Evaluating Primary Care Renewal in Oregon’s Safety Net Clinics:

Preliminary Quantitative Findings

Richard Meenan, PhD, MPH, MBA David Mosen, PhD, MPH

Sabrina Luke, MS Nancy Perrin, PhD

Work supported by AHRQ 1R18HS019146-01


CareOregon Non-profit Medicaid health plan HQ in Portland (1993) 155,000 low-income Oregon residents; 60% age 0-19

76% live near Portland

Network of 1,530 primary care clinicians community health centers, academic health centers, large health systems, small and

large group practices

Contracts with 6,550 specialists, 43 hospitals, 34 public health departments


Primary Care Renewal (PCR) 2007: Transform primary care using the patient-centered

medical home (PCMH) model IHI Triple Aim: improve population health, lower cost, enhance

patient experience “Care payer” to “care integrator” Inspired by mentors at Southcentral Foundation in Alaska Internally funded financial incentive offered to clinics Plan to spread PCR to other clinics and organizations


PCR “Pioneer” Organizations

Virginia Garcia Memorial Health Center Federally Qualified Health Center (FQHC), Migrant

Oregon Health & Science University (OHSU) FQHC “Look-Alike”, Family Practice Residency, Urban, Ethnically Diverse

Multnomah County Health Department FQHC, Refugee, Ethnically Diverse

Legacy Health System Urban, Internal Medicine Residency

Central City Concern FQHC, Homeless, Chemical Dependencies


Study Objectives AHRQ-funded mixed-methods PCR assessment

(quantitative and qualitative components) Our focus: Assess effect of PCR initiative on metrics

Utilization measures Hospital stays Emergency department (ED) visits Primary care visits

Cost measure Per member per month (PMPM) medical costs


Study Population CareOregon members 1/1/06–4/30/11

Assigned to PCMH: 6 “pioneer” (2 at OHSU) and 11 “spread” clinics Assigned to non-PCMH: remaining CareOregon clinics

Segmented regression design Observation period

Pre-implementation: 1/1/06-6/30/07 (18 months) Post-implementation: 1/1/08-4/30/11 (40 months) 6-month break (7/1/07-12/31/07) for PCR implementation roll-out


Outcome Measures and Primary Independent Variable Utilization (per 1,000 members per year)

> 1 hospital admission > 1 ED visit > 1 primary care visit

Costs: Total per member per month (PMPM) paid by CareOregon

Primary independent variable Implementation status: post- vs. pre-


Analytic Approach: Segmented regression Clinic-month analysis (not patient-based) Models assess relative difference in slope change

from pre- to post-implementation between PCMH and non-PCMH clinics for each outcome measure


Sample CharacteristicsPCMH Clinics Non-PCMH Clinics

Overall Population (Unique Members) 22,406 (27.1%) 60,271 (72.9%)

Demographics by Eligibility Group*Adult

Age (Mean +/- SD)Female (%)Non-white (%)Non-English language (%)

39.6 +/- 13.069.138.116.2

37.3 +/- 12.470.828.58.8

Expanded Diagnosis Cluster (EDC) Characteristics*

EDC (Mean +/- SD)% 0% 1-2% 3+

1.6 +/- 2.653.423.323.4

0.89 +/- 2.071.915.412.7

*All differences: p < .0001.


Results: Segmented RegressionUtilization and Cost

Utilization/Cost Metric

PCMHSlope Change Post2 vs. Pre-Period1

Parameter SE

Non-PCMHSlope Change Post2 vs. Pre-Period1

Parameter SE

Interaction Term

Parameter SE

Any Hospital Utilization -5.30*** 0.96 -1.25 0.96 -4.06*** 1.37

Any ED Utilization +2.04 2.61 +1.39 2.38 +0.65 3.53

Any Primary Care Utilization

-33.30** 7.61 -18.29* 6.11 -15.01 9.76

Total Cost (PMPM)3 -10.39*** 2.00 -6.60** 1.35 -3.79* 2.41

1Pre-period includes 18 monthly time points: 1/1/2006 - 6/30/2007

2Post-period includes 40 monthly time points: 1/1/2008 - 4/30/2011

3 Cost parameters based on NON-log transformed data; p-values from log-transformed data.

*** p < .001, ** p < .05, * p < .10


Adult Inpatient Utilization:PCMH/Non-PCMH Comparison

Adult Inpatient

0

50

100

150

200

250

300

350

Time (Month/Year)

Ra

te (

pe

r 1

00

0 a

du

lts

pe

r y

ea

r)

Non-PCMH

PCMH

Non-PCMH crude rates

PCMH crude rates

Implementation Period


ED Utilization:PCMH/Non-PCMH Comparison

Adult ED

0

200

400

600

800

1000

1200

1400

Time (Month/Year)

Rate

(per 1000 a

dults p

er year)

Estimated Non-PCMH

Estimated PCMH

Non-PCMH observed rates

PCMH observed ratesImplementation Period


Primary Care Utilization: PCMH/Non-PCMH Comparison

Adult Primary Care

0

500

1000

1500

2000

2500

3000

3500

4000

Time (Month/Year)

Rate

(per 1000 a

dults p

er year)

Estimated Non-PCMH

Estimated PCMH

Non-PCMH observed rates

PCMH observed ratesImplementation Period


PMPM Costs: PCMH/Non-PCMH Comparison


Preliminary ConclusionsAdult Population

Inpatient utilization

Declined at faster rate in PCMH clinics relative to non-PCMH clinics

EDutilization

No differences

Primary careutilization

No differences

PMPM costs No differences


Limitations Analyses based on claims data only No pharmacy data available No clinical data available

For example, changes in HbA1c may be relatively more sensitive to PCMH implementation

PCR rolled out in stages, not hard implementation date More observations may be needed to assess longer-term

effects


Policy Implications and Future Research Findings somewhat consistent with previous studies

Effect of PCMH implementation on process of care and clinical measures sensitive to change Provider payment incentives HbA1c, mental health screening, mental health functional status, etc. Access measures (e.g. same day appointment access, abandoned call rate) Continuity of care measures Satisfaction/patient experience metrics

How do challenges (and opportunities) of PCMH implementation differ between integrated health systems (e.g., GHC, Kaiser) and open “IPA-like” networks (e.g., CareOregon)?

Health & Medicine

Evaluating Primary Care Renewal