Evaluating Primary Care Renewal in                  Oregon’s Safety Net Clinics:               Preliminary Quantitative Fi...
CareOregon Non-profit Medicaid health plan HQ in Portland (1993) 155,000 low-income Oregon residents; 60% age 0-19     ...
Primary Care Renewal (PCR)       2007: Transform primary care using the patient-centered        medical home (PCMH) model...
PCR “Pioneer”                                  Organizations Virginia Garcia Memorial Health Center        Federally Qua...
Study Objectives       AHRQ-funded mixed-methods PCR assessment        (quantitative and qualitative components)       O...
Study Population CareOregon members 1/1/06–4/30/11      Assigned to PCMH: 6 “pioneer” (2 at OHSU) and 11 “spread” clinic...
Outcome Measures and   Primary Independent Variable       Utilization (per 1,000 members per year)              > 1 hosp...
Analytic Approach:   Segmented regression      Clinic-month analysis (not patient-based)      Models assess relative dif...
Sample Characteristics                                                       PCMH Clinics     Non-PCMH Clinics            ...
Results: Segmented RegressionUtilization and Cost                                                 PCMH                 Non...
Adult Inpatient Utilization:                                   PCMH/Non-PCMH Comparison                                   ...
ED Utilization:                                  PCMH/Non-PCMH Comparison                                                 ...
Primary Care Utilization:   PCMH/Non-PCMH Comparison                                                                      ...
PMPM Costs:   PCMH/Non-PCMH Comparison© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
Preliminary Conclusions                                                       Adult Population                      Inpati...
Limitations      Analyses based on claims data only      No pharmacy data available      No clinical data available    ...
Policy Implications and   Future Research      Findings somewhat consistent with previous studies      Effect of PCMH im...
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Evaluating Primary Care Renewal

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Evaluating Primary Care Renewal in Oregon’s Safety Net Clinics: Preliminary Quantitative Findings
Kaiser Center for

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  • Emphasize funding by AHRQ Agency funds research on improving care Mission: To improve the quality, safety, efficiency, and effectiveness of health care for all Americans . Funds research that … “Improves the quality of health care services”
  • Our understanding is that several previous presentations done in previous years about the history and implementation of Primary Care Renewal. Is this so? Thus, intent is to go over very briefly just to provide the context and background necessary to understand the study and its results. Safe, Effective, Efficient, Personalized, Timely, Equitable Improve the health of the defined population; • Enhance the patient care experience (including quality, access and reliability) • Reduce, or at least control, the per capita cost of care
  • In 2007,  five teams began a series of health care reforms supported and funded by grants through CareOregon. Today, they have not only revolutionized their daily office practices, they have integrated mental health services, planned for the care of populations rather that just one-to-one care, and created a learning organization. Our understanding is that several previous presentations done in previous years about the history and implementation of Primary Care Renewal. Is this so? Thus, intent is to go over very briefly just to provide the context and background necessary to understand the study and its results.
  • Emphasize only first 2 included in today’s qualitative, but all included in quantitative.
  • Outcomes of interest (hospital, ED, and primary care utilization, total costs) aggregated into 58 monthly intervals. Used interrupted time series regression models (segmented regression) to test if changes in outcomes occurring post-impl. differed for PHC and non-PHC clinics, controlling for pre-impl. intervention trends. Models: constant baseline slope term to control for secular trends pre-impl., terms estimating changes in level and slope of outcome rates, interaction terms to compare baseline trends and changes in level and slope between PCMH and non-PCMH clinics.
  • Evaluating Primary Care Renewal

    1. 1. 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© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    2. 2. 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© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    3. 3. 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© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    4. 4. 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© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    5. 5. 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© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    6. 6. 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© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    7. 7. 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-© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    8. 8. 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© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    9. 9. Sample Characteristics PCMH Clinics Non-PCMH Clinics Overall Population (Unique Members) 22,406 (27.1%) 60,271 (72.9%) Demographics by Eligibility Group* Adult Age (Mean +/- SD) 39.6 +/- 13.0 37.3 +/- 12.4 Female (%) 69.1 70.8 Non-white (%) 38.1 28.5 Non-English language (%) 16.2 8.8 Expanded Diagnosis Cluster (EDC) Characteristics* EDC (Mean +/- SD) 1.6 +/- 2.6 0.89 +/- 2.0 %0 53.4 71.9 % 1-2 23.3 15.4 % 3+ 23.4 12.7 *All differences: p < .0001.© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    10. 10. Results: Segmented RegressionUtilization and Cost PCMH Non-PCMH Interaction Term Slope Change Post2 Slope Change Utilization/Cost Metric vs. Pre-Period1 Post2 vs. Pre- Period1 Parameter SE Parameter SE 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 -33.30** 7.61 -18.29* 6.11 -15.01 9.76 Utilization Total Cost (PMPM)3 -10.39*** 2.00 -6.60** 1.35 -3.79* 2.41 1 Pre-period includes 18 monthly time points: 1/1/2006 - 6/30/2007 2 Post-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© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    11. 11. Adult Inpatient Utilization: PCMH/Non-PCMH Comparison Adult Inpatient 350 300 Rate (per 1000 adults per year) 250 200 150 100 50 Implementation Period 0 Non-PCMH -06 r-06 -06 l-06 -06 -06 -07 r-07 -07 l-07 -07 -07 -08 r-08 -08 l-08 -08 -08 -09 r-09 -09 l-09 -09 -09 -10 r-10 -10 l-10 -10 -10 -11 r-1PCMH 1 Jan Ma ay Ju Sep Nov Jan Ma ay Ju Sep Nov Jan Ma ay Ju Sep Nov Jan Ma ay Ju Sep Nov Jan Ma ay Ju Sep Nov Jan Ma M M M M M Non-PCMH crude rate Time (Month/Year) PCMH crude rates© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    12. 12. ED Utilization: PCMH/Non-PCMH Comparison Adult ED 1400 1200Rate (per 1000 adults per year) 1000 800 600 400 Estimated Non-PCMH Estimated PCMH Non-PCMH observed rates 200 Implementation Period PCMH observed rates 0 6 6 6 6 6 6 7 7 7 7 7 7 8 8 8 8 8 8 9 9 9 9 9 9 0 0 0 0 0 0 1 1 -0 r-0 -0 l-0 -0 -0 -0 r-0 -0 l-0 -0 -0 -0 r-0 -0 l-0 -0 -0 -0 r-0 -0 l-0 -0 -0 -1 r-1 -1 l-1 -1 -1 -1 r-1 J an Ma May Ju Sep Nov Jan Ma May Ju Sep Nov Jan Ma May Ju Sep Nov Jan Ma May Ju Sep Nov Jan Ma May Ju Sep Nov Jan Ma Time (Month/Year)© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    13. 13. Primary Care Utilization: PCMH/Non-PCMH Comparison Adult Primary Care 4000 3500 Rate (per 1000 adults per year) 3000 2500 2000 1500 1000 Estimated Non-PCMH Estimated PCMH 500 Non-PCMH observed rates Implementation Period PCMH observed rates 0 06 06 06 06 06 06 07 07 07 07 07 07 08 08 08 08 08 08 09 09 09 09 09 09 10 10 10 10 10 10 11 11 n- r- y- ul- p- v- n- r- y- ul- p- v- n- r- y- ul- p- v- n- r- y- ul- p- v- n- r- y- ul- p- v- n- r- Ja Ma Ma J Se No Ja Ma Ma J Se No Ja Ma Ma J Se No Ja Ma Ma J Se No Ja Ma Ma J Se No Ja Ma Time (Month/Year)© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    14. 14. PMPM Costs: PCMH/Non-PCMH Comparison© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    15. 15. Preliminary Conclusions Adult Population Inpatient Declined at faster rate in utilization PCMH clinics relative to non-PCMH clinics ED No differences utilization Primary care No differences utilization PMPM costs No differences© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    16. 16. 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© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
    17. 17. 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)?© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH

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