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

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. 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. 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. 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. 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. 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. 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. 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. 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. Results: Segmented Regression
Utilization 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. 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. ED Utilization:
PCMH/Non-PCMH Comparison
Adult ED
1400
1200
Rate (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. 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. PMPM Costs:
PCMH/Non-PCMH Comparison
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH

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. 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. 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