Melinda K. Abrams

The Affordable Care Act at 5 Years

This report marks the fifth anniversary of the Affordable Care Act. The authors discuss the ACAs effects on health care access, quality, and cost resulting from the laws expansion of health insurance coverage and reforms of the U.S. health care delivery system.

How the Affordable Care Act Will Strengthen the Nation's Primary Care Foundation

As the country turns toward implementation of the Patient Protection and Affordable Care Act, realizing the potential of reform will require significant transformation of the American system of health care delivery. To that end, the new law seeks to strengthen the nation’s primary care foundation through enhanced reimbursement rates for providers and the use of innovative delivery models such as patient-centered medical homes. Evidence suggests that these strategies can return substantial benefits to both patients and providers by increasing access to primary care services, reducing administrative hassles and burdens, and facilitating coordination across the continuum of care. If successfully implemented, the Affordable Care Act has the potential to realign incentives within the health system and create opportunities for providers to be rewarded for delivering high value, patient-centered primary care. Such a transformation could lead to better outcomes for patients, increase job satisfaction among physicians and encourage more sustainable levels of health spending for the nation.

The Changes Involved in Patient-Centered Medical Home Transformation

In 2007, the major primary care professional societies collaboratively introduced a new model of primary care: the patient-centered medical home (PCMH). The published document outlines the basic attributes and expectations of a PCMH but not with the specificity needed to help interested clinicians and administrators make the necessary changes to their practice. To identify the specific changes required to become a medical home, the authors reviewed literature and sought the opinions of two multi-stakeholder groups. This article describes the eight consensus change concepts and 32 key changes that emerged from this process, and the evidence supporting their inclusion.

Structuring Payment to Medical Homes After the Affordable Care Act

ABSTRACTThe Patient-Centered Medical Home (PCMH) is a leading model of primary care reform, a critical element of which is payment reform for primary care services. With the passage of the Affordable Care Act, the Accountable Care Organization (ACO) has emerged as a model of delivery system reform, and while there is theoretical alignment between the PCMH and ACOs, the discussion of physician payment within each model has remained distinct. Here we compare payment for medical homes with that for accountable care organizations, consider opportunities for integration, and discuss implications for policy makers and payers considering ACO models. The PCMH and ACO are complementary approaches to reformed care delivery: the PCMH ultimately requires strong integration with specialists and hospitals as seen under ACOs, and ACOs likely will require a high functioning primary care system as embodied by the PCMH. Aligning payment incentives within the ACO will be critical to achieving this integration and enhancing the care coordination role of primary care in these settings.

Toward Increased Adoption of Complex Care Management

Increasing evidence supports using specially trained, primary care–integrated, complex care management teams to improve outcomes and reduce costs by addressing the needs of high-cost patients. Yet substantial barriers to more widespread adoption remain.

The safety net medical home initiative: transforming care for vulnerable populations.

Background:Despite findings that medical homes may reduce or eliminate health care disparities among underserved and minority populations, most previous medical home pilot and demonstration projects have focused on health care delivery systems serving commercially insured patients and Medicare beneficiaries. Objectives:To develop a replicable approach to support medical home transformation among diverse practices serving vulnerable and underserved populations. Design:Facilitated by a national program team, convening organizations in 5 states provided coaching and learning community support to safety net practices over a 4-year period. To guide transformation, we developed a framework of change concepts aligned with supporting tools including implementation guides, activity checklists, and measurement instruments. Subjects:Sixty-five health centers, homeless clinics, private practices, residency training centers, and other safety net practices in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania. Measures:We evaluated implementation of the change concepts using the Patient-Centered Medical Home-Assessment, and conducted a survey of participating practices to assess perceptions of the impact of the technical assistance. Results:All practices implemented key features of the medical home model, and nearly half (47.6%) implemented the 33 identified key changes to a substantial degree as evidenced by level A Patient-Centered Medical Home-Assessment scores. Two thirds of practices that achieved substantial implementation did so only after participating in the initiative for >2 years. By the end of the initiative, 83.1% of sites achieved external recognition as medical homes. Conclusions:Despite resource constraints and high-need populations, safety net clinics made considerable progress toward medical home implementation when provided robust, multimodal support over a 4-year period.

Tailoring Complex Care Management for High-Need, High-Cost Patients

Improving the care of high-need, high-cost (HNHC) patients is a compelling national challenge and should be a high priority for the next federal administration. Highneed, high-cost patients, who experience a variety of complex medical conditions, often compounded by limitations in their ability to care for themselves, are among the 5% of patients who account for 50% of health care spending. These patients are also more likely than other patients to experience problems with quality and safety in their care. Physicians, health care organizations, public officials, and other stakeholders involved in health care cannot achieve their quality or cost goals unless they manage this patient population better.

Assessing Progress toward Becoming a Patient-Centered Medical Home: An Assessment Tool for Practice Transformation

Objective. To describe the properties of the Patient-Centered Medical Home Assessment (PCMH-A) as a tool to stimulate and monitor progress among primary care practices interested in transforming to patient-centered medical homes (PCMHs). Study Setting. Sixty-five safety net practices from five states participating in a national demonstration program for PCMH transformation. Study Design. Longitudinal analyses of PCMH-A scores were performed. Scores were reviewed for agreement and sites were categorized over time into one of five categories by external facilitators. Comparisons to key activity completion rates and NCQA PCMH recognition status were completed. Data Collection/Extraction Methods. Multidisciplinary teams at each practice completed the 33-item self-assessment tool every 6 months between March 2010 and September 2012. Principal Findings. Mean overall PCMH-A scores increased (7.2, March 2010, to 9.1, September 2012; [p < .01]). Increases were statistically significant for each of the change concepts (p < .05). Facilitators agreed with scores 82% of the time. NCQA-recognized sites had higher PCMH-A scores than sites that were not yet recognized. Sites that completed more transformation activities and progressed over defined tiers reported higher PCMH-A scores. Scores improved most in areas where technical assistance was provided. Conclusions. The PCMH-A was sensitive to change over time and provided an accurate reflection of practice transformation.