Neal Wallace, Ph.D. Shauna Petchel, MPH Portland State University Oregon’s Patient Centered Primary Care Home Model after Three Years: Use and Expenditures Neal Wallace, Ph.D. Shauna Petchel, MPH Portland State University Research Support from the Oregon Health Authority (PI: Sherril Gelmon, DrPH)

Background The Oregon Legislature established the Patient-Centered Primary Care Home (PCPCH) Program in 2009 to create access to patient-centered, high quality care and reduce costs by supporting practice transformation. The PCPCH model is Oregon’s characterization of a “medical home,” and is defined by six core attributes each with a number of corresponding standards and measures. The attributes include: Access to Care; Accountability; Comprehensive Whole-Person Care; Continuity; Coordination and Integration; and Person and Family Centered Care. The Program is responsible for defining the model, administering the application process to recognize practices that have achieved the model, and providing technical assistance to clinics. As of December 2015, over 600 practices across the state had been formally recognized by the OHA as a PCPCH.

Research Objective To assess the impact of Oregon’s Patient Centered Primary Care Home (PCPCH) program on use and expenditures: For all PCPCH designated clinics through the first three years of the program Across all covered services and key service types For the program overall and by PCPCH duration of designation.

Study Design Generalized difference-in-difference design to accommodate staggered PCPCH implementation: Compare patients empirically attributed to PCPCH or non-PCPCH primary care providers in each study year Minimum one year pre-PCPCH data and maximum three years post PCPCH designation Applied to a two part model to assess probability of use, expenditures per user and per person

Study Data Four years of Oregon All Payer All Claims (APAC) claims, eligibility and provider data: October 2010 through September 2014 (first PCPCH designations October 1, 2011) APAC contains all claims for commercial, self- insured, Medicaid, and Medicare Advantage Does not include Medicare FFS, VA claims Excludes substance use and some sensitive condition (e.g. AIDS/HIV) related service claims

Study Population - Individuals 1,192,435 individuals were initially identified who during a study year had: Consistent residence in Oregon Consistent, full year insurance coverage At least one primary care visit to an Oregon provider These individuals were empirically attributed to a provider billing unit during each study year based on plurality of visits or last visit (tie) The final study population consists of 1,128,234 individuals solely (100%) attributed to either PCPCH or non-PCPCH primary care provider billing units (606,881 PCPCH and 599,990 non-PCPCH)

Study Population - Providers 510 PCPCH practices continuously designated within the study period (on or after October 2011) PCPCH related claims were initially identified using practice and/or organizational National Provider Identifiers (NPIs). NPI-based claims were grouped using a “provider crosswalk key”: Practice billing units reflecting common/linking billing information (e.g. name, address, secondary NPI, etc). Links practitioners billing under individual NPI but otherwise identifying as part of larger practice group Practices may have multiple “billing units”

Study Population - Observations The unit of analysis for the study was a provider billing unit quarter. Individual use, expenditure and demographic characteristics were aggregated to provider billing unit by quarter 100,084 observations (7,380 PCPCH/92,704non-PCPCH) representing 510 PCPCH and 8,435 non-PCPCH billing units

Outcome Measures Main outcome measures are percentage of subjects using service in a quarter, expenditures per service user, and expenditures per subject The outcome measures are applied to all covered services and eight specific service types: Primary care office visits and procedures Specialty office visits and procedures Outpatient mental health care Non-therapeutic radiation Lab Pharmacy Emergency Department Inpatient

Subject Characteristics Subject characteristics aggregated to the practice billing unit quarter as percentages include: Gender Age group (9) Specific insurance type (16) Physical and behavioral condition markers (10) including diabetes, COPD/asthma, chronic heart failure, chronic kidney disease, coronary heart disease, cerebrovascular disease, obesity, schizophrenia, affective disorders, and other behavioral health conditions

Analytic Methods Two-way fixed effects (practice billing unit and quarter) weighted (individuals) OLS regression Inclusion of all subject characteristics measures Samples are not matched but >99% support found across PCPCH and non-PCPCH observations PCPCH effects identified by a binary variable(s): For all PCPCH related quarterly observations on or after PCPCH designation date, or PCPCH designated quarters by year of designation (1-3) Standard errors adjusted for clustering on practice billing unit

Results: Subject Characteristics   non-PCPCH PCPCH Observations 3,717,920 3,977,248 Insurance Type Private 71.0% 41.3% Gender Medicare 10.9% 5.0% Female 44.3% 46.7% Medicaid 18.1% 53.7% Male 55.7% 53.3% Chronic Disease None 59.4% 56.3% Age Group Diabetes 8.2% 6.2% 0-1 2.0% 5.5% COPD/Asthma 10.8% 13.6% 2-5 6.8% 15.4% Chronic Heart Failure 0.6% 0.4% 6-11 15.6% Chronic Kidney Disease 0.5% 12-17 8.4% 13.4% Cerebrovascular Disease 1.5% 1.0% 18-25 7.5% 7.0% Coronary Heart Disease 0.8% 26-40 23.1% 16.5% Obesity 1.3% 2.5% 41-64 31.8% 20.2% Schizophrenia 0.2% 65-80 11.2% 5.8% Affective Disorder 3.3% 3.9% 81+ 1.1% 0.7% Other Behavioral Health 12.6% 14.2%

Results: Expenditures per Person Years of PCPCH Designation Service Type Overall   Year 1 Year 2 Year 3 Total -$40.73 * -$33.85 -$48.85 -$84.58 -4.2% -3.5% -5.0% -8.6% Primary Care $3.33 $2.93 $3.70 $6.48 3.1% 2.7% 3.4% 6.0% Speciality Care -$1.60 -$0.35 -$3.90 -$5.01 -3.6% -0.8% -8.7% -11.1% Mental Health -$3.11 -$2.52 -$3.63 -$7.79 -13.3% -10.6% -15.3% -32.7% Radiology -$0.01 -$0.10 -$0.31 $2.78 0.0% -0.3% 7.5% Lab $0.21 -$1.10 -$2.82 -1.0% 0.7% -9.2% Pharmacy $9.49 $7.87 $10.91 $22.51 5.1% 4.3% 5.9% 12.2% Emergency Department -$2.04 -$0.99 -$3.49 -$7.48 -5.3% -2.5% -9.0% -19.2% Inpatient -$29.21 -$26.07 -$32.96 -$48.99 -15.9% -14.1% -17.8% -26.4% * = p < .05

Results: Expenditures per User Years of PCPCH Designation Service Type Overall   Year 1 Year 2 Year 3 Total -$61.44 * -$52.52 -$70.67 -$128.02 -4.8% -4.1% -5.5% -10.0% Primary Care -$3.37 -$2.62 -$4.85 -$5.38 -1.6% -1.2% -2.3% -2.5% Speciality Care -$3.14 -$3.24 -$2.50 -$5.78 -1.5% -2.8% Mental Health $58.41 $35.28 $121.12 $128.15 7.2% 4.4% 15.2% 16.0% Radiology -$7.89 -$7.15 -$10.20 -$4.40 -3.2% -2.9% -1.8% Lab -$3.16 -$2.70 -$3.91 -$5.73 -2.4% -3.5% -5.1% Pharmacy $13.26 $10.58 $16.74 $30.25 3.7% 3.0% 4.8% 8.6% Emergency Department -$75.83 -$59.75 -$114.22 -$159.18 -8.6% -6.7% -12.9% -17.9% Inpatient -$757 -$485 -$1,718 -$3,322 -4.7% -3.0% -10.7% -20.6% * = p < .05

Results: Percent Service Use Years of PCPCH Designation Service Type Overall   Year 1 Year 2 Year 3 Total 0.72% * 0.65% 0.73% 1.56% 0.97% 0.88% 0.98% 2.10% Primary Care 2.19% 1.70% 2.95% 4.24% 4.27% 3.35% 5.80% 8.33% Speciality Care -0.60% 0.25% -2.21% -2.58% -2.90% 1.16% -10.46% -12.20% Mental Health -0.42% -0.22% -0.74% -1.15% -13.69% -6.99% -23.27% -36.22% Radiology 0.12% 0.16% -0.03% 0.51% 0.87% 1.10% -0.18% 3.63% Lab 0.79% 0.74% 0.78% 1.48% 3.21% 3.02% 3.16% 6.01% Pharmacy 0.50% 1.11% 2.80% 1.61% 1.02% 2.28% 5.73% Emergency Department 0.27% 0.26% 0.30% 4.96% 4.77% 5.44% 4.90% Inpatient -0.02% -0.01% 0.05% -1.87% -2.88% -0.63% 4.10% * = p < .05

Results: Summary Total expenditures were reduced by 4% overall with progressive reductions to 8% for PCPCHs in the third year of designation: Progressive decreases in overall expenditure per user coupled with progressive increases in overall service use Increases in primary care expenditure and use Reductions in specialty care expenditures and use No or inconsistent change in lab and radiology Increases in expenditure and use of pharmacy Decreases in expenditures for ED and inpatient: All due to decreases in expenditures per user – use up (ED) or unchanged (IP)

Study Limitations PCPCH program effects may be Oregon specific (e.g. culture of “transformation”) PCPCH practices have different characteristics than non-PCPCH and may reflect unique capabilities/motivations of practices that chose to participate APAC data missing some key services (e.g. substance abuse) and insurance groups (e.g. Medicare FFS) Observational, natural experiment design may fail to capture “unobservables” that influence outcomes Current design does not adjust for potential differences in reimbursement rates across insurance types over time Anticipatory behavior by PCPCHs (changes prior to designation) detected

Conclusions Oregon’s Patient Centered Primary Care Home Program appears to be incurring expected (or hoped for) system transformative effects – reducing expenditures in a “treatment positive” manner Findings are consistent with other large state level implementation efforts – e.g. Colorado and Michigan Apparent progressive effects among PCPCHs over time from designation may be important to understand from a policy, programmatic and evaluation standpoint: Policy makers may actually have to wait for large(r) results Progressive effects could be practice maturation (consistent with Oregon’s multi-level designation approach) and/or “dose response” as patients get more exposure to program. Some effects may not be apparent in short-term or “average” effect evaluations

Thank You Questions? nwallace@pdx.edu Mark O. Hatfield School of Government OHSU/PSU Joint School of Public Health Portland State University