Article Figures & Data
Tables
High-Value Cohort (n=12) Average-Value Cohort (n=4) No. (%) Independently owned 4 (33) 1 (25) No. (%) Multi-specialty group practices 6 (50) 1 (25) No. of physicians per practice, mean (SD) 7 (5) 17 (27) No. of primary care physicians with attributed patients, mean (SD) 5 (6) 7 (8) No. of attributed patients per primary care physician, mean (SD) 46 (405) 599 (507) Case mix index, mean (SD) 1.3 (0.5) 1.1 (0.2) Allowed cost clinical risk group-adjusted O/E spending ratio, mean (SD) 0.66 (0.11) 0.94 (0.01) Mean number of quality measures applicable to each practice 24 (6) 33 (10) Weighted quality composite index O/E ratio, mean (SD) 1.14 (0.04) 0.99 (0.00) No. (%) by census region Midwest 2 (17) 1 (25) Northeast 3 (25) 1 (25) South 3 (25) 1 (25) West 4 (33) 1 (25) O/E=Observed vs expected.
PPPM Spending, Mean (SD) $ High-Value Cohort Average-Value Cohort Total inpatient 42 (27) 63 (19) Inpatient maternity 3 (5) 1 (3) Inpatient medical 21 (15) 16 (14) Inpatient surgical 19 (18) 46 (6) Emergency department 20 (13) 21 (3) Outpatient hospital/ambulatory surgery center 48 (16) 73 (39) Office 41 (8) 39 (9) Diagnostics 44 (13) 49 (13) Laboratory 20 (6) 25 (5) Imaging 24 (9) 24 (10) Prescription medicationsa 78 (20) 111 (7) Other 20 (9) 35 (18) PPPM=per-patient-per-month.
↵a Prescription medications includes both prescription claims and office/outpatient-administered medications/injections/infusions.
- Table 3
Attributes More Frequently in High-Value Practices Relative to Average-Value Practicesa
Attribute Description Expanded access Practices offer same-day appointments and accommodate walk-ins, extend evening and weekend hours, and often take their own after-hours calls with access to their patients’ electronic medical records. Decision support for evidence-based medicinea The care team ensures that patients receive all evidence-based care and treatment, often by making guideline-based reminders available to clinicians in the electronic medical record. Some practice office managers regularly run reports to identify care gaps to alert the care team to take action—such as a list of patients overdue for colorectal cancer screening. Physicians consciously avoid ordering tests that would not change management. Risk-stratified care managementa Each patient receives support that is matched to his or her unique needs. High-risk patients are monitored and advised by a care manager, scheduled for longer office visits, receive frequent phone checks by office staff, or in some cases, clinician home visits. Shared decision-making and advanced care planning When diagnostic and treatment options substantially differ in their consequences and cost such as care near the end of life, clinicians walk patients through likely scenarios and tradeoffs. Complaints are gold Complaints from patients are perceived to be as valuable as compliments, if not more so. Practices take every opportunity to encourage patient feedback. Comprehensive primary care Clinicians practice within the full scope of their expertise, including services that primary care clinicians often refer out, such as skin biopsies, suturing, insulin initiation and stabilization, joint injections, and IUD placement. In some cases, such as treadmill testing, practices arrange training and supervision by specialists. Careful selection of specialistsa When services outside the scope of the primary care practice are necessary, primary care clinicians rely on a carefully selected list of specialists with whom they trust to follow evidence-based guidelines and remain in close contact as treatment plans develop. Coordinated carea Care teams monitor patients outside of primary care visits. They ensure patients complete referrals to specialists and schedule timely follow-up after unexpected hospitalizations. In some cases, they track medication adherence by communicating with pharmacies or counting refills. Upshifted staff roles Physicians are supported by a team of medical assistants, front desk staff, and in some cases, nurses and advanced practice clinicians who practice near the full potential of their education, skills, and licensure. As a result, physicians devote more time to the most complex patients. Standing orders and protocolsa Practices develop standing orders and protocols for uncomplicated acute illnesses and chronic disease management. Nonclinician team members use these standardized workflows to care for patients without requiring direct clinician intervention. Shared work spaces Care teams including clinicians and nonclinicians work together in a common work area, enabling face-to-face communication that facilitates problem-solving in real-time. Balanced compensationa Physician salary is linked to value instead of only volume. Compensation reflects performance on at least one of the following components: (1) quality of care, (2) patient experience, (3) resource utilization, and (4) contribution to practice-wide improvement activities. Low overhead space and equipment Practices rent modest offices and typically invest in laboratory, imaging, and other equipment only if it allows clinicians to provide care more efficiently than referring to outside services. Some practices partner with other practices to jointly operate imaging equipment at a lower cost per study. IUD=intrauterine device.
↵a Attributes with a statistically significant association with high-value practices compared with average-value practices.
Attribute High-Value Cohort Median (IQR) Average-Value Cohort Median (IQR) P (Mann-Whitney) Expanded access 4 (1) 3 (0.75) .065 Decision support for evidence-based medicine 4 (2) 3 (0.5) .020 Risk-stratified care management 4 (1.125) 2 (0.25) .012 Shared decision making and advanced care planning 4 (0.25) 3 (0.5) .056 Complaints are gold 3.5 (3) 2.5 (1) .709 Comprehensive care 4 (0.25) 3.5 (1.5) .590 Careful selection of specialists 4 (1.25) 3 (0.25) .013 Coordinated care 4 (2) 2 (0.25) .006 Upshifted staff roles 5 (1) 2.5 (1.5) .058 Standing orders and protocols 3.5 (1) 1.5 (1.25) .020 ↵a A 5 indicated fullest implementation of the attribute; 1 indicated no implementation of the attribute.
Attribute High-Value Cohort (n=12) Average-Value Cohort (n=4) P (Fisher’s Exact Score) Shared work spaces 42% 0 .245 Balanced compensation 92% 25% .027 Low overhead on space and equipment 100% 50% .05
Additional Files
The Article in Brief
Exploring Attributes of High-Value Primary Care
Arnold Milstein , and colleagues
Background To address criticisms that the US health system rewards service volume rather than value, Medicare and some private payers are defining and rewarding high value. However, little is known about what physicians can do to attain low per capita spending and favorable quality scores for Medicare and non-Medicare populations. This study set out to identify care delivery attributes associated with value as defined by payers.
What This Study Found Six attributes of primary care delivery are associated with high value: decision support for evidence-based medicine, risk-stratified care management, careful selection of specialists, coordination of care, standing orders and protocols, and balanced physician compensation. Researchers analyzed commercial health insurance claims data from 2009 to 2011 for more than 40 million PPO patients and 53,000 primary care practice sites and found that the six statistically significant attributes relate to three themes: the need for "care traffic control" to help patients with complex conditions navigate the fragmented US health care system (risk-stratified care management, careful selection of specialists, and coordination of care), the need for tools to ease the cognitive burden of physicians and staff (decision support for evidence-based medicine and standing orders and protocols), and the importance of reimbursement based on value rather than volume (balanced compensation).
Implications
- According to the authors, awareness of care delivery attributes associated with high value may help physicians respond successfully to incentives from Medicare and private payers intended to lower health care spending and improve quality of care.
Supplemental Appendixes
Supplemental Appendixes
Files in this Data Supplement:
- Supplemental data: Appendixes - PDF file
