Analysis of the Comprehensive Primary Care Initiative shows mixed results

1. Analysis of the Comprehensive Primary Care Initiative (CPCI) at the two-year midpoint revealed no significant reductions in Medicare expenditures per beneficiary.

2. Analysis did show significant improvement in management of high-risk patients and access to care.

Evidence Rating Level: 2 (Good)           

Study Rundown: In October 2012, the Centers for Medicare & Medicaid Services (CMS) launched the CPCI, which followed the accountable care organization model as a new population health management tool in primary care to improve quality and reduce costs. Participating primary care practices were required to make CMS-specified changes in care delivery. This study analyzed the results of the program at its two-year midpoint. The results of the primary outcome measures – annualized expenditures in Medicare Parts A and B with and without care-management fees – revealed no significant reductions in initiative practices. However, analysis of the secondary outcomes – variables regarding utilization and quality – revealed significant improvement in management of high-risk patients and access to care in the initiative practices.

The two-year time frame of this analysis may not be sufficient to determine the true effect of the CPCI. It is notable that patient attribution as it complicates quality and cost health care initiatives was not addressed by the authors. Lastly, prescription drugs were also not included in the analysis, which may significantly alter the results.

Click to read the study, published today, in NEJM

Relevant Reading: Primary care and accountable care – two essential elements of delivery-system reform

In-Depth [retrospective cohort]: This retrospective, non-blinded data analysis used propensity score matching to analyze 497 participating practices in comparison to non-participating practices with similar demographic and market factors. The sample size included 432 080 Medicare beneficiaries attributed to initiative practices and 890 110 beneficiaries attributed to comparison practices. The analysis was based on a differences-in-differences framework. Secondary outcomes were measured on the basis of a 12-point scale using multiple data points, with higher numbers indicating better approaches to care delivery. High-risk patients were defined using the hierarchical condition category.

The primary outcome showed no significant differences in expenditures, with or without the inclusion of care-management fees. Average expenditures in the initiative practices increased $7 more with fees (95%CI -$5 to $19; difference 1.3%; p = 0.07) and $11 less without fees (95%CI -$23 to $1; difference 0.9%; p = 0.27). Risk-stratified care management improved from 4.6 to 9.7. High-risk patients with diabetes had an approximately 3% greater chance of receiving all four recommended tests in initiative practices than comparison (p = 0.001 in year 1 and p = 0.01 in year 2). Additionally, access to care improved from 7.0 to 9.6 and the number of new visits to primary care physicians was 3% less for initiative practices than comparison (p < 0.001).

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