Cost Estimates for Operating a Primary Care Practice Facilitation Program

INTRODUCTION

Improving primary care practices in the United States is a widely agreed-upon strategy for improving access to and quality of health care without increasing costs.^1–6 Practice facilitation is a promising and practical method for supporting practice redesign in small primary care settings.^7–10 Often improvements targeted by practice facilitation programs result in improved quality of care and process outcomes. A recent systematic review found that practices receiving practice facilitation are 2.76 (95% CI, 2.18–3.43) times more likely to make changes necessary to implement evidence-based guidelines and concludes that it is a robust intervention for improving primary care.¹¹

Although practice facilitation is widely recognized as a promising method for achieving large-scale practice redesign, little is known about its cost. Developing cost estimates associated with administering a practice facilitation program in local or regional primary care settings is necessary to be able to plan for the supporting infrastructure.¹² The purpose of this article is to report the variable costs (those costs that occurred while carrying out all practice facilitation activities) of providing practice facilitation to small primary care practices from the perspective of an organization supporting the program.

METHODS

RESULTS

Selected practice characteristics (full-time equivalent staff, health information technology, patient volume, and payer mix) are displayed in Table 1. Practices attempted to implement a variety of improvement strategies. Sixteen practices targeted improvements in patient self-management support and activation, such as providing patients with logbooks to track outcomes and placing educational posters and reading materials in examination rooms. Approximately one-half of the practices initiated or increased the number of staff meetings to discuss clinical quality improvement activities, and 9 of 19 practices initiated short (3- to 5-minute) daily staff huddles to communicate daily workflow plans. Another 8 practices implemented delivery system design changes, such as group diabetes visits or point-of-care hemoglobin A_1c testing.

Median variable costs of selected facilitation activities can be found in Table 2. Supplemental Table 1 (available at http://annfammed.org/content/11/3/207/suppl/DC1) contains a detailed breakout of the median cost and the range of costs for selected key components of practice facilitation activities. The median total variable cost of all practice facilitation intervention activities from start-up through monitoring, including travel and food, was $9,670 per practice (range = $8,050 to $15,682). More than 46% of the costs was spent on start-up activities to initiate practice facilitation ($4,517, range = $4,178 to $5,589 per practice [see Supplemental Table 1]). Of this start-up cost, almost 65% was attributable to baseline practice evaluation activities, with the 2 largest cost components being the chart audit ($1,298) and preparing the baseline feedback report ($1,095).

The median total variable cost of all facilitation meeting activities (Table 2, part B) was $2,449 per clinic (range = $2,194 to $4,062). The total direct practice facilitation activity cost was split between cost of preparing and presenting baseline feedback reports to the clinics (40% of costs) and the cost of all practice facilitation meeting activities with clinics (60% of costs) during the remainder of the study period.

The median total cost of ongoing monitoring and follow-up reporting (Table 2, part C) was $448 (range = $319 to $615). Finally, median travel and food cost (Table 2, part D) was an additional $2,054, but varied by clinic based mainly on the actual distance to the clinic and the number of staff members participating in practice facilitation activities at each clinic.

Table 3 displays the median cost estimates for the simulations. Increasing the hourly wage of practice facilitators from $30 to $40 per hour increased the total median variable cost (with travel or food) from $9,670 to $11,797, a 22.0% increase. Cost estimates for raising the hourly wage to $50 per hour are also shown. Doubling the number of facilitation meetings from 6 to 12 only added $1,415 to median total variable costs of all practice facilitation activities. Increasing the number of visits to 24 increased estimated median total variable costs of all practice facilitation activities by $5,428, for a total of $15,098.

DISCUSSION

The median total cost of a 6-visit practice facilitation intervention focused on improving chronic illness care in small primary care practices is approximately $9,670 per practice per year. This finding is consistent with a prior estimate by Hogg and colleagues for a facilitation intervention to improve preventive services.¹² Approximately 47% of the total practice facilitation costs were attributable to practice assessment and start-up activities, with another 25% attributable to facilitation visits. Although some may question the necessity of the assessment and start-up costs, many, if not all, of these small independent practices had no performance data. For buy-in to occur, it was critical to provide practices with a picture of their current clinical performance and operations, which required auditing medical records, undertaking surveys, and conducting interviews with practice staff. During practice assessment, the facilitator was also able to establish a relationship of trust and respect with staff and clinicians, which was essential for effective facilitation.^14,15

If the practice facilitation program were undertaking in a larger health care system in which there were 60 primary care practices, for example, at $9,670 per practice per year, total variable costs over the first year would be approximately $580,000. Assuming an overhead cost rate of 40%, the total costs would be $812,000 in the first year of the program. This study found, however, that much of the cost of practice facilitation is devoted to start-up and practice assessment. As a result, the costs of ongoing facilitation activities in subsequent years are likely to be much lower.

Many improvements targeted by practice facilitation programs in primary care may result in a decrease in future hospitalizations. In fact, early findings from patient-centered medical home demonstrations show reductions in emergency department visits and avoidable admissions.^16–18 Medicare ProPAC reported in 2009 (during the study period) that acute care hospital cost per discharge on average ranged from $5,800 to $6,400.¹⁹ Using the lower of these estimates, the break even case for returning variable cost of practice facilitation activities from a delivery system perspective is a reduction in hospitalizations or readmissions by 2 per year per practice.

These cost estimates are for variable practice facilitation costs only and do not include the cost of facilitator training or the fixed costs of office rent, utilities, information technology, etc, which are likely to vary by geographic location. In addition, this study was limited to a single geographic area in one state, which may reduce the generalizability of the cost estimates. We attempted to address this limitation with a sensitivity analysis that varies facilitator’s salaries and travel time estimates. Finally, it is important to note that this study did not address the cost to the practice of implementing improvements designed to improve diabetes care and outcomes in response to facilitation. It is likely that these costs are not negligible, as staff and clinicians both invested time meeting with the facilitator and implementing changes between the facilitation visits, time supported by their salaries that did not contribute toward direct patient care.

In conclusion, depending on the intensity of the intervention, the median cost of practice facilitation is between $9,670 and $15,098 per practice per year, the cost of between 2 and 3 hospitalizations per year.