Small Independent Primary Care Practices Serving Socially Vulnerable Urban Populations.

PURPOSE: This mixed methods study sought to describe the extent to which family physicians in urban communities serve socially vulnerable patients and to better understand their practices, their challenges, and the structural supports that could facilitate their patient care. METHODS: We conducted a quantitative analysis of questionnaire data from 100% of US physicians recertifying for family medicine from 2017 to 2020. We conducted qualitative analysis of in-depth interviews with 22 physician owners of urban, small, independent practices who reported that the majority of their patients were socially vulnerable. RESULTS: In 2020, in urban areas across the United States, 19.3% of family physicians served in independent practices with 1 to 5 clinicians, down from 22.6% in 2017. Nearly one-half of these physicians reported that >10% of their patients were socially vulnerable. Interviews with 22 physicians who reported that the majority of their patients were socially vulnerable revealed 5 themes: (1) substantial time spent addressing access issues and social determinants of health, (2) minimal support from health care entities, such as independent practice associations and health plans, and insufficient connection to community-based organizations, (3) myriad financial challenges, (4) serious concerns about the future, and (5) deep personal commitment to serving socially vulnerable patients in independent practice. CONCLUSIONS: Small independent practices serving vulnerable patients in urban communities are surviving because deeply committed physicians are making personal sacrifices. Health equity-focused policies could decrease the burden on these physicians and bolster independent practices so that socially vulnerable patients continue to have options when seeking primary care.

Reducing Acute Hospitalizations at High-Performing CPC+ Primary Care Practice Sites: Strategies, Activities, and Facilitators.

PURPOSE: Despite evidence suggesting that high-quality primary care can prevent unnecessary hospitalizations, many primary care practices face challenges in achieving this goal, and there is little guidance identifying effective strategies for reducing hospitalization rates. We aimed to understand how practices in the Comprehensive Primary Care Plus (CPC+) program substantially reduced their acute hospitalization rate (AHR) over 2 years. METHODS: We used Bayesian analyses to identify the CPC+ practice sites having the highest probability of achieving a substantial reduction in the adjusted Medicare AHR between 2016 and 2018 (referred to here as AHR high performers). We then conducted telephone interviews with 64 respondents at 14 AHR high-performer sites and undertook within- and cross-case comparative analysis. RESULTS: The 14 AHR high performers experienced a 6% average decrease (range, 4% to 11%) in their Medicare AHR over the 2-year period. They credited various care delivery activities aligned with 3 strategies for reducing AHR: (1) improving and promoting prompt access to primary care, (2) identifying patients at high risk for hospitalization and addressing their needs with enhanced care management, and (3) expanding the breadth and depth of services offered at the practice site. They also identified facilitators of these strategies: enhanced payments through CPC+, prior primary care practice transformation experience, use of data to identify high-value activities for patient subgroups, teamwork, and organizational support for innovation. CONCLUSIONS: The AHR high performers observed that strengthening the local primary care infrastructure through practice-driven, targeted changes in access, care management, and comprehensiveness of care can meaningfully reduce acute hospitalizations. Other primary care practices taking on the challenging work of reducing hospitalizations can learn from CPC+ practices and may consider similar strategies, selecting activities that fit their context, personnel, patient population, and available resources.

Patients' perspectives of care management: a qualitative study.

OBJECTIVES: Risk-stratified care management is a cornerstone of patient-centered medical home models, but studies on patients' perspectives of care management are scarce. We explored patients' experiences with care management, what they found useful, and what needs improvement. STUDY DESIGN: Semi-structured qualitative telephone interviews. METHODS: We interviewed 43 high-risk patients or their caregivers who were receiving care management from 11 practices in CMS' Comprehensive Primary Care initiative, provided by nurse care managers (9 practices) or the physician (2 [solo] practices). RESULTS: Patients' perceptions of care management were mixed. Patients who had regular contact with, and a desire to work with, their care manager valued the care management services provided. These patients valued care managers who listened to them and explained their conditions and options in lay terms, helped them navigate the healthcare system and community resources, and followed up after hospitalizations. However, one-fifth of the patients in practices that used nurse care managers could not identify their care manager although we: 1) sampled patients who had recent contact with their care manager and 2) defined the care manager's roles and provided examples of typical care management activities. Patients' interactions with care managers from health plans and hospitals contributed to confusion. CONCLUSIONS: Practices can improve patient buy-in for care management through in-person introductions to care managers by their physicians, offering care management to patients who need and are interested in it, broader agreement about terminology and the role of care managers and care plans, and better coordination with care management from insurers and hospitals.

CHIP and Medicaid: Evolving to Meet the Needs of Children.

OBJECTIVE: To examine the evolution of Children's Health Insurance Program (CHIP) and Medicaid programs after passage of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), focusing on policies affecting eligibility, enrollment, renewal, benefits, access to care, cost sharing, and preparation for health care reform. METHODS: Case studies were conducted in 10 states during 2012-which included key informant interviews and consumer focus groups-and a national survey of state CHIP program administrators was conducted in early 2013. RESULTS: Despite the recession that persisted during much of the study period, many states expanded children's coverage by raising upper income eligibility limits or by covering new groups made eligible by CHIPRA. Simplifying rules and procedures for enrollment and renewal continued to be a major priority for CHIP and Medicaid, and CHIPRA played a direct role in spurring innovation. CHIPRA's outreach grants played an important role in supporting and supplementing state outreach efforts. Important legacies of CHIPRA are the law's mandatory requirements for comprehensive dental benefits coverage and mental health parity for all types of CHIP programs. Although most states already offered generous coverage of these benefits, the mandate may have protected them from cuts during the economic downturn. Federal Maintenance of Effort rules were a crucial protection for CHIP, especially during the recession when state budget shortfalls could have led to program cuts. CONCLUSIONS: Passage of the Affordable Care Act has raised questions surrounding the future role of CHIP in a reformed health care system. A growing number of stakeholders have recommended a 2-year extension of federal CHIP funding to allow complex transition issues to be resolved.

The HCBS taxonomy: a new language for classifying home- and community-based services.

INTRODUCTION: As states make home- and community-based services (HCBS) more accessible, researchers have become more interested in understanding service use and spending. Because state Medicaid programs differ in the types of services they offer and in how they report these services, analyzing HCBS at the national level is challenging. OBJECTIVE: Describe the HCBS taxonomy and present findings on HCBS waiver expenditures and users. DATA: This brief analyzed fee-for-service claims from 28 approved states in 2010 Medicaid Analytic eXtract (MAX) files. We summed all expenditures and counted the unique number of users across each HCBS taxonomy service and category. METHODS: The taxonomy was developed jointly by Truven Health (at that time Thomson Reuters) and Mathematica Policy Research, with stakeholder input, and reviewed using procedure codes. Today, the taxonomy is organized by 18 categories and over 60 specific services. FINDINGS: For calendar year 2010, 28 states spent almost $23.6 billion on HCBS, with 80 percent of expenditures categorized as round-the-clock, home-based, and day services. Other services, such as case management, or equipment, modifications, and technology were widely used, but are not particularly costly and do not account for a large proportion of expenditures in every state. CONCLUSIONS: By providing a common language, the taxonomy presents detailed information on services and makes it easier to assess and identify state-level variation for HCBS.