Building the basis for a population
health driven model for primary
care: An analysis of Maryland
primary care
Laura Mandel
Preceptors: Chad Perman & Russ Montgomery
DHMH – Office of Population Health
Improvement (OPHI)
Background on Healthcare System
Transformation
• Instead of focusing on treating
patients in hospitals, the system
is emphasizing keeping patients
healthy in the community
• Trying to move away from “feefor-service” – doctors paid based
on number of services provide
• Shifting towards other payment
models that reward value and
quality
Maryland’s All Payer Model
• Phase 1 - From 2014-2018, Maryland must:
• Shift hospital revenue to global payment models. Hospitals
have a soft cap on spending, or “global budget,” regardless of
volume
• meet quality targets;
• generate $330 million in Medicare saving;
• limit total hospital cost growth per capita;
• develop a proposal for Phase 2 – Total cost of Care Model
• BUT…. Primary care in Maryland continues to be
reimbursed on a fee-for-service basis
Primary Care transformation
• Patient-centered medical home
(PCMH) model
• primary care practice as the center
of whole person-centered care
• Improving access, prevention, and
care coordination.1
• Can lay groundwork for
improved patient outcomes and
decreased healthcare costs.6
Project Purpose
• How can the state best support primary care moving into
the second phase of the All Payer Model?
• What does primary care in Maryland look like now?
• Objectives:
• Description of primary care in Maryland
• Practice size (number of physicians)
• Practice ownership (hospital-owned vs. independent)
• Location
• Electronic health record (EHR) use
• Preliminary scan of PCMH programs or designations
• Opportunities for supporting primary care based on results
Data and Methods
Data Sources:
• Board of Physicians data (2015-2016)
• National Committee for Quality Assurance (NCQA)-recognized practices (March 2016)
• CareFirst PCMH-participating providers (February 2016)
• Maryland Multi-Payor Patient Centered Medical Home (MMPP)
Methods
• Linked non-standardized practice names across databases
• Geocoded using ArcGIS
• Literature review of PCMH structures and payments
Challenges
• Incomplete and messy data
• Linkages
• Access issues
Results
120%
100%
80%
60%
N = 185
N = 51
N = 770*
N = 870*
N = 2300*
40%
20%
0%
NCQA
recognition
MMPP
participation
* Preliminary estimates based on current analysis
CareFirst
ANY PCMH
PCMH
participation
Total
practices
Practice locations
PCMH locations
PCMH locations
Baltimore
Baltimore
Howard
Anne Arundel
Baltimore
Baltimore
Howard
Montgomery
Anne Arundel
Prince George's
Percent of NCQA practices by county
3.4%
3.5%
6.6%
14.3%
8.3%
2.6%
13.6%
8.5%
10.8%
0%
9.9%
6%
23.1%
14.1%
9.1%
7.3%
13.6%
8.3%
13.3%
8.3%
2.9%
22.7%
50%
50%
Percent of practices in county that are any
PCMH
41.4%
56.1%
63.9%
57.1%
20.8%
35.1%
60.6%
45.9%
35.8%
45.5%
63.6%
38.5%
69.2%
41.4%
45.5%
35.5%
45.5%
11.1%
23.3%
58.3%
55.9%
22.7%
60%
75%
75%
PCMH adoption by practice ownership
• Of NCQA-recognized practices, over half were hospital
owned.
• Of CareFirst participating practices, 75% were
independently owned
Implications
• Significant proportion of Maryland PCP practices have
begun efforts to transform care
• Small independent practices are an integral part of
Maryland’s primary care landscape.
• Tend to participate in CareFirst and not to be NCQArecognized
• small practices may experience significant barriers to PCMH
adoption through the formal NCQA process
• Advances to primary care are necessary, but must reflect
reasonable and realistic changes for small independent
practices.
Opportunities for Maryland
• Variety of approaches to support primary care practices
• accommodate practices at different levels of readiness
• physicians can choose which program fits their practice best
• Take advantage of national programs
• chronic care management code (CCM) in Medicare
• CMS Comprehensive Primary Care Plus (CPC+) model.
• For practices who are less ready to participate in a federal
program:
• Could build on the successful CareFirst model of virtual panels in
order to allow small practices to work together to achieve shared
savings, without requiring consolidation or hospital ownership. 8
Future analyses
• Descriptive and preliminary study
• Ensure inclusion of all PCPs through additional databases
• Incorporate other aspects of advanced delivery reform, such as
Accountable Care Organizations (ACOs) and team-based care
• Future analyses will include more robust analytic methods
• Test the association between other advanced primary care and
quality outcomes.
• Regression analyses will be performed to test whether PCMH
status and EHR use varies based on geography, practice size,
practice type and ownership.
Conclusions
• Primary care as integral component in the transition from
volume-based to value-based healthcare.
• Many primary care practices in Maryland participate in or
have adopted patient-centered medical home principles.
• The results of this preliminary analysis of advanced
primary care in Maryland suggest the state could support
multiple options for primary care practices, including for:
• Small independent practices: virtual panels with shared saving
incentives
• Practices already involved in PCMH: support participation in
national initiatives
Acknowledgements
• Chad Perman
• Dr. Russ Montgomery
• Dr. Howard Haft
• Maryland Healthcare Commission
• Maryland Board of Physicians