BALTIMORE – Even primary care practices that were well along the continuum of delivering more sophisticated care were lagging when it comes to better-coordinating care, according to findings from a baseline study of the 497 practices participating in the Centers for Medicare and Medicaid Services Comprehensive Primary Care Initiative (CPCI).
The CMS selected 502 practices – that were already making ample use of electronic health records and, in many cases, acting as patient-centered medical homes – to participate in the initiative. Several practices dropped out. The remaining 497 began receiving financial incentives to cut the cost of care and improve quality in the fall of 2012. The practices received a $20/member per month of care management fee for 2 years from CMS and other payers, covering Medicare patients. The fee drops to $15/member per month for the second 2 years of the program. After that, physician practices have the opportunity to share savings with the CMS and the other payers.
To be eligible for the CPCI, practices had to serve at least 120 Medicare patients and be heavy users of electronic health records (EHRs).
Rachel Shapiro, a researcher with Mathematica Policy Research, presented results from a survey of all 497 of the practices. They were queried at baseline, before they began receiving any financial incentives or other assistance from the CMS. The agency hired Mathematica and Group Health Research Institute to conduct on-going surveys to gauge how well the practices are doing in meeting the CPCI objectives over the next 5 years.
Those objectives include:
• Intensive care management for patients with multiple medical conditions, including creating care plans for each individual patient.
• Ensuring access to care 24 hours a day, 7 days a week.
• Delivering preventive care on an appropriate and timely basis.
• Engaging patients and caregivers in their care.
• Coordinating care “across the medical neighborhood.”
The first survey was e-mailed to the practices from October to December 2012; all 497 responded, said Ms. Shapiro. Most of the practices had between one and four clinicians, including physicians, nurse practitioners, and physician assistants. Only 12% are multispecialty practices, but 46% are owned by a larger entity. Of the participating practices, 41% had been certified as a patient-centered medical home and 79% had reached stage 1 of meaningful use under the CMS’ criteria for EHRs.
They assessed their performance before CPCI began, on six measures: access and continuity; planned chronic and preventive care; patient and caregiver engagement; care coordination across the medical neighborhood; continuous quality improvement; and, risk-stratified care management. The practices assigned themselves scores of 1 to 12, with a higher score indicating better implementation of the goals. Practices averaged a score of 8 for the measures of access and care planning. At bottom, the practices scored a 4, on average, for risk-stratified care management.
There was definitely room for improvement across the board, said Ms. Shapiro. She noted that innovative ways to engage and communicate with patients – such as e-mail, texting, group visits, and phone visits – were not available at 54% of the practices. Of the reporting practices, 24% made limited use of such methods.
Integration of practice guidelines into care was reported by 60% practices, but only 16% routinely use care plans. The same percentage does not have access to registry or full panel data from the practice to help identify issues across a number of patients rather than just reacting to an individual patient, Ms. Shapiro said. Only a third of practices said they had a care manager.
Patient and caregiver engagement is also lacking. Only 16% of practices routinely collect patient and caregiver feedback.
All the practices make referrals to specialists, but often, they are not transmitting full information to that clinician.
Of the reporting practices, 77% do not conduct quality improvement activities, citing a lack of resources and staff.
Ms. Shapiro and her colleagues looked at whether being a medical home or a meaningful user made any difference in terms of scoring. They also looked at the effect of practice size. Designated medical homes reported better functioning, but practice size did not make a difference. Meaningful users of EHRs had better scores, but only in continuous quality improvement and risk stratification.
The study shows that even practices that were somewhat sophisticated before the start of the initiative still have a ways to go in terms of delivering better-coordinated care, said Ms. Shapiro. She noted that these practices will likely progress, though, as they will be given technical assistance tailored to their unique needs and also quarterly reports to track performance and improvements in patient care.