The Patient- Centered Medical Home’s Impact on Cost & Quality:

An Annual Update of the Evidence,

2012-2013

January 2014

Authors:

Marci Nielsen, PhD, MPH

J. Nwando Olayiwola, MD, MPH Paul Grundy, MD, MPH

Kevin Grumbach, MD

Made possible with support from the Milbank Memorial Fund

ABOUT THE

PATIENT-CENTERED PRIMARY CARE COLLABORATIVE (PCPCC)

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ABOUT THE

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AUTHORS

Marci Nielsen, PhD, MPH

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J. Nwando Olayiwola, MD, MPH

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Paul Grundy, MD, MPH

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Kevin Grumbach, MD

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Contributing Author:

Lisa Dulsky Watkins, MD

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PAGE 2

ACKNOWLEDGMENTS

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Melinda Abrams, MS

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The Commonwealth Fund

Asaf Bitton, MD, MPH

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,QVWUXFWRU, 'HSDUWPHQW RI +HDOWK &DUH 3ROLF\, Harvard Medical School

Mark Gibson

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Oregon Health & Science University

Bruce Landon, MD, MBA, MSc

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Beth Israel Deaconess Medical Center

Len Nichols, PhD

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George Mason University

Kavita Patel, MD

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)HOORZ, (FRQRPLF 6WXGLHV, The Brookings Institution

Mary Takach, MPH, RN

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National Academy for State Health Policy

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PAGE 3

PCPCC STAFF

Marci Nielsen, PhD, MPH

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Amy Gibson, RN, MS

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Michelle Shaljian, MPA

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Tara Hacker, MSPH

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Staci GoldbergBelle, MPA

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Yuki Ueda

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Graphic design and layout: Top Shelf Design, Arlington, VA

PCPCC BOARD OF DIRECTORS

David K. Nace, MD, Chairman

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Paul Grundy, MD, MPH, President

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Douglas Henley, MD, Vice Chairman

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Andrew Webber, Treasurer

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Errol Alden, MD

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Susan Edgman-Levitan, PA-C

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Elizabeth J. Fowler, PhD, JD

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Jill Rubin Hummel, JD

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Beverley H. Johnson

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Hal C. Lawrence III, MD

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Harlan Levine, MD

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Marci Nielsen, PhD, MPH

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Steven E. Weinberger, MD, FACP

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Adrienne White-Faines, MPA

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Association

PAGE 4

TABLE OF CONTENTS

EXECUTIVE SUMMARY.........................................................................6

SECTION ONE

An Overview of the Patient-Centered Medical Home .............................8

'H÷QLWLRQ ........................................................................................................................................... 8

PCMH recognition programs.......................................................................................................... 9

SECTION TWO

Summary of Cost & Quality Results.......................................................10

Methods........................................................................................................................................... 10

Results ............................................................................................................................................. 10

Table 1. Peer-reviewed reports ...........................................................................................................11

Table 2. Industry-generated reports..................................................................................................15

Discussion ....................................................................................................................................... 16

Table 3. Number and percent of studies reporting medical home metrics ...........................16

The challenge of studying the PCMH ................................................................................................18

The right metrics.................................................................................................................................18

The right methods...............................................................................................................................18

SECTION THREE

The Future of Primary Care and the PCMH...............................................20

The PCMH’s Role in Delivery System Reform.......................................................................... 20

The foundation of high-performing Accountable Care Organizations ..................................20

A hub for medical neighborhood.........................................................................................................20

The payment reform imperative ..........................................................................................................21

All-payer or multi-payer payment reform ........................................................................................21

Employer and consumer engagement.................................................................................................22

Conclusion....................................................................................................................................... 23

APPENDIX A: PCMH Initiatives and Evidence since 2009....................25

APPENDIX B: The Year in Review: Case Study Highlights ....................31

REFERENCES ......................................................................................34

PAGE 5

EXECUTIVE SUMMARY

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1. PCMH studies continue to demonstrate impressive improvements across a broad range of categories including: cost, utilization, population health, prevention, access to care, and patient satisfaction, while a gap still exists in reporting impact on clinician satisfaction.

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• Decreases in the cost of care, VXFK DV SHU PHPEHU SHU PRQWK (3030) FRVWV, UHWXUQ RQ LQYHVWPHQW, DQG WRWDO FRVW RI FDUH (61% RI SHHU-UHYLHZHG DQG 57% RI LQGXVWU\-JHQHUDWHG VWXGLHV);

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• Improvements in population health indicators and increase in preventive services, such

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2. The PCMH continues to play a role in strengthening the larger health care system, specifically Accountable Care Organizations and the emerging medical neighborhood model.

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3. Significant payment reforms are incorporating the PCMH and its key attributes.

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6LJQL÷FDQW strides were also made this year in the private sector, as commercial health plans increasingly transitioned their PCMH pilots into

a standard business operation.

PAGE 7

SECTION ONE

AN OVERVIEW OF THE PATIENT-CENTERED MEDICAL HOME

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“That high quality

primary care is acknowledged as a key solution to

the US health conundrum makes intuitive sense. Most individuals

are closely connected

to the health system via their primary care practice, and their primary care provider

is viewed as an entryway to the complicated

world of health and health

care.”

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PAGE 8

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“A persistent challenge

is not only meeting the basics of PCMH recognition, rather, it is

the capability of practices and health

systems to self- sustain their

improvements.”

PAGE 9

SECTION TWO

SUMMARY OF COST & QUALITY RESULTS

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Methods

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Results

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patient or clinician satisfaction DV FROOHFWHG YLD SDWLHQW, VWDII DQG FOLQLFLDQ VXUYH\V.

PAGE 10

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Table 1. Peer Review-Reported Outcomes 2012-2013, by location and by category

Location/Initiative Cost & Utilization Population Health

& Preventive

Services

Access Patient or Clinician

Satisfaction

Alaska

Alaska Southcentral Foundation Nuka System of Care32

Published:2013

Data Review: 1996-2009

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(S<.001), DQG GURSSHG GXULQJ DQG DIWHU LPSOHPHQWDWLRQ (S<.001)

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• ,QFUHDVH LQ DFFHVV WR VDPH-GD\ DSSRLQWPHQWV, H[WHQGHG RI÷FH KRXUV, DQG QRQ-IDFH-WR-IDFH visits

Colorado

Colorado Multi-Payer

PCMH Pilot 33

Published: Sept. 2012

Data Review: 2009-2012

• 15% IHZHU (' YLVLWV

(Y. 4% IHZHU LQ FRQWURO JURXS)

• 18% IHZHU LQSDWLHQW DGPLVVLRQV (Y. 18% LQFUHDVH LQ FRQWURO JURXS)

• 1XPEHU RI VSHFLDOW\ YLVLWV UHPDLQHG øDW (Y.

10% LQFUHDVH LQ FRQWURO JURXS)

• )RU HYHU\ GROODU

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• ,PSURYHPHQWV DFURVV

DOO PHDVXUHV RI GLDEHWHV FDUH

High patient satisfaction:

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• 97% VDLG WKH\ ZRXOG UHFRPPHQG WR IDPLO\I IULHQGV

• 90% VDLG LW ZDV HDV\ WR VSHDN WR SK\VLFLDQ

Michigan

BlueCross BlueShield of Michigan Physician Group Incentive Program34

Published: July 2013

Data Review: 2009-2010

• 3UDFWLFHV ZLWK IXOO

3&0+ LPSOHPHQWDWLRQ KDG VDYLQJV RI $26.37

3030 (S .0529)

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PAGE 11

Table 1 continued

Location/Initiative Cost & Utilization Population Health

& Preventive

Services

Access Patient or Clinician

Satisfaction

National

Military Health System

PCMH Initiative 35

Published: Feb. 2013

Data Review: 2008-2009

For all patients:

• 4% IHZHU LQSDWLHQW DGPLVVLRQV; DQG 18% PRUH LQSDWLHQW GD\V

• 6.8% IHZHU (' YLVLWV (39% GHFUHDVH DW :DOWHU

5HHG 1DWÚO 0HGLFDO

&HQWHU)

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• 9% UHGXFWLRQ LQ 3034

WRWDO FRVWV

For those with chronic conditions:

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• 3% IHZHU VSHFLDOW\ HQFRXQWHUV

• 13% UHGXFWLRQ LQ SKDUPDF\ FRVWV

• 17% UHGXFWLRQ LQ DQFLOODU\ KHDOWK FRVWV

• 11% UHGXFWLRQ ($83) LQ WRWDO 3034 FRVWV

• ,PSURYHPHQWV DFURVV HLJKW SUHYHQWLYH VHUYLFHV PHDVXUHV UHODWHG WR FKURQLF GLVHDVH PDQDJHPHQW

For all patients:

• 21% KLJKHU SULPDU\ FDUH XVH WKDQ FRPSDULVRQ sites

• ,QFUHDVH LQ WHOHSKRQH FRQVXOWV IURP 16% WR

24%

• ,PSURYHPHQW LQ DELOLW\ WR VFKHGXOH DSSRLQWPHQWV

For those with chronic conditions:

• 26% LQFUHDVH LQ SULPDU\ FDUH YLVLWV

• 19% LPSURYHPHQW LQ

FDUH FRQWLQXLW\ DW :DOWHU

5HHG (Y. QRQ-3&0+V)

• 6WDWLVWLFDOO\ VLJQL÷FDQW LPSURYHPHQWV IRU

11 PHDVXUHV RI SDWLHQW VDWLVIDFWLRQ (Y. FRPSDULVRQ VLWHV)

• 8% KLJKHU VDWLVIDFWLRQ DW (GZDUGV $LU )RUFH

%DVH

National

Veterans Health Administration Patient Aligned Care Team

(PACT) 36

Published: July 2013

Data Review: 2010-2012

• ,QFUHDVH LQ LQ-SHUVRQ RU SKRQH HQFRXQWHUV IURP 85 WR 101 SHU

100 SDWLHQWV (S<.01 IRU WUHQG)

• 3DWLHQWV HYDOXDWHG ZLWKLQ 48 KRXUV RI LQSDWLHQW GLVFKDUJH LQFUHDVHG 6% WR 61% (S IRU WUHQG <.01)

• 'HFUHDVH LQ IDFH-WR-IDFH SULPDU\ FDUH YLVLWV (53

WR 43 SHU 100 SDWLHQWV SHU FDOHQGDU TXDUWHU;

S <.01)

• ,QFUHDVH LQ SKRQH HQFRXQWHUV (2.7 WR 28.8

SHU 100 SDWLHQWV SHU TXDUWHU; S<.01)

• ,QFUHDVHV LQ SHUVRQDO KHDOWK UHFRUG XVH (3% WR

13% RI SDWLHQWV HQUROOHG)

• ,QFUHDVHV LQ HOHFWURQLF PHVVDJLQJ WR SURYLGHUV (0.01% WR 2.3% RI SDWLHQWV SHU TXDUWHU)

• ,QFUHDVH LQ VDPH GD\ DSSRLQWPHQWV (S<.01)

• ,QFUHDVH LQ SDWLHQWV VHHQ ZLWKLQ 7 GD\V RI GHVLUHG DSSRLQWPHQW GDWH (85% WR 90%; S IRU WUHQG <.01)

New Hampshire

New Hampshire Citizens

Health Initiative 37

Published: Sept. 2012

Data Review: 2010-2011

• :HOO3RLQW SDUWLFLSDQWV, FRVWV IRU 3&0+ HQUROOHHV LQFUHDVHG 5%, Y. 12% LQ WUDGLWLRQDO SUDFWLFHV

PAGE 12

Table 1 continued

Location/Initiative Cost & Utilization Population Health

& Preventive

Services

Access Patient or Clinician

Satisfaction

New Jersey

Horizon Blue Cross Blue Shield New Jersey Single Private Payer Pilot38

Published: June 2013

Data Review: 2010-2011

• +HDOWK FDUH XWLOL]DWLRQ and costs did not VLJQL÷FDQWO\ FKDQJH, KRZHYHU, WKLV ZDV

D VLQJOH \HDU VWXG\ DQDO\]LQJ HLJKW SUDFWLFHV

• ,QFUHDVH LQ EUHDVW FDQFHU VFUHHQLQJV LQFUHDVHG E\

2.2 SHUFHQWDJH SRLQWV RQ D EDVH RI 69.5% (S

<0.001)

• ,QFUHDVH LQ QHSKURSDWK\ VFUHHQLQJV E\ 6.6

SHUFHQWDJH SRLQWV RQ D EDVH RI 51.8% (S 0.05)

New York

EmblemHealth High Value Medical Home Initiative 39

* randomized trial

Published: June 2013

Data Review: 2008-2010

• 3.8% IHZHU (' YLVLWV SHU \HDU, VDYLQJ DSSUR[LPDWHO\ $1,900 LQ (' FRVWV SHU SK\VLFLDQ, SHU \HDU (S .002)

• 3K\VLFLDQV LPSURYHG HI÷FLHQF\ IRU DOO HSLVRGH W\SHV E\ 3.3% (S 0.07)

• ,PSURYHPHQWV LQ %3

FRQWURO (23% Y. 2%; S

0.02) DQG EUHDVW FDQFHU VFUHHQLQJV (3.5% Y.

0.4%; S 0.03

New York

WellPoint’s Single Health Plan Model New York PCMH 40

Published: Sept. 2012

Data Review: 2007-2010

Compared to control group:

• 11% IHZHU (' YLVLWV IRU

DGXOWV; 17% IRU FKLOGUHQ

• 14.5% ORZHU ULVN DGMXVWHG WRWDO 3030

FRVWV IRU DGXOWV; 8.6% ORZHU IRU FKLOGUHQ

• /RZHU UDWHV RI LQDSSURSULDWH DQWLELRWLF XVH (27.5% Y. 35.4%;

S .001)

• +LJKHU UDWHV RI +E$1F WHVWLQJ Y. FRQWURO JURXS (82.1% YHUVXV 77.7%; S!.001)

Pennsylvania

UPMC Health Plan

Medical Home Pilot 41

Published: Nov. 2012

Data Review: 2008-2010

• 5.1% IHZHU (' YLVLWV (S<.05)

• 6.1% LQFUHDVH LQ LQSDWLHQW DGPLVVLRQV (Y.

8.1% IRU QRQ-3&0+V; S<.05)

• 12.5% IHZHU UHDGPLVVLRQV (2008-

2009; S<.05); 18.3% IHZHU (2009-2010; S<.05)

• 160% UHWXUQ RQ LQYHVWPHQW IRU 3&0+V

• 3&0+ SUDFWLFHV FRQVLVWHQWO\ RXWSHUIRUPHG WKH UHVW

RI WKH QHWZRUN DFURVV DOO TXDOLW\ PHDVXUHV

Rhode Island

Rhode Island Chronic Care Sustainability Initiative 42

Published: Nov. 2013

Data Review: 2006 - 2010

• 11.6% IHZHU DPEXODWRU\ FDUH VHQVLWLYH (' YLVLWV (0.8 SHU 1000 PHPEHU;

S .002)

• )HZHU RYHUDOO (' YLVLWV, LQSDWLHQW DGPLVVLRQV, DQG DPEXODWRU\ FDUH VHQVLWLYH LQSDWLHQW DGPLVVLRQV (QRW VWDWLVWLFDOO\ VLJQL÷FDQW)

• ,PSURYHPHQWV ZHUH QRWHG IRU 3&0+V DFURVV GLDEHWHV FDUH PHDVXUHV FRPSDUHG ZLWK FRQWURO SUDFWLFHV (DOWKRXJK QRW VWDWLVWLFDOO\ VLJQL÷FDQW)

PAGE 13

Table 1 continued

Location/Initiative Cost & Utilization Population Health

& Preventive

Services

Access Patient or Clinician

Satisfaction

Utah

University of Utah Care by Design Program43

Published: Nov/Dec 2013

Data Review: 2008-2011

For the composite scores based on team based care, 2 measures of productivity and cost were statistically VLJQL÷FDQW (S<.OS)

• 6WDII FRVW, FOLQLFLDQ )7( (×0.94)

• 9LVLWVIFOLQLFLDQ )7( (×0.70)

Improvement in patient satisfaction

(S<.OS):

• ([SODQDWLRQ RI FDUH (0.67)

• &OLQLFLDQ LQVWUXFWLRQV (0.72)

• /LNHO\ WR UHFRPPHQG (0.76)

• 2YHUDOO VDWLVIDFWLRQ (0.67)

Improvement in clinician

VDWLVIDFWLRQ (S<.OS):

• 7LPH VSHQW ZRUNLQJ (0.68)

• 5HODWLRQVKLS ZLWK SDWLHQW (0.72)

Washington

Group Health Cooperative PCMH Program 44

* spread of prototype model to 26 clinics in Washington and Idaho

Published: May/June 2013

Data Review: 2008-2011

• 'HFOLQHV LQ (' YLVLWV LQ HDUO\ DQG ODWH VWDELOL]DWLRQ RI WKH SURJUDP (13.7% DQG

18.5%; S<.001)

• 5.1% DQG 6.7% GHFOLQHV LQ SULPDU\ FDUH RI÷FH YLVLWV LQ HDUO\ DQG ODWHU

\HDUV; FRUUHVSRQGLQJ LQFUHDVHV LQ VHFXUH PHVVDJHV (123%) DQG WHOHSKRQH HQFRXQWHUV (20%); (S<.001)

PAGE 14

Table 2. Industry-Reported Outcomes 2012-2013, by location and by category

Initiative Cost & Utilization Population Health

& Prevention

Alabama

Access Patient and

Clinician

Satisfaction

BlueCross BlueShield Alabama Medical Home Program 45

Published: Aug. 2012

Data Review: 2009 - 2011

• )HZHU (' YLVLWV

• )HZHU KRVSLWDO GD\V

• (VWLPDWHG FRVW VDYLQJV RI $1.9 PLOOLRQ

Compared to network avg., PCMHs had:

• 13.6% KLJKHU UDWH

RI FRORUHFWDO FDQFHU VFUHHQLQJV

• 11.8% KLJKHU UDWH RI EUHDVW FDQFHU VFUHHQLQJV

• 13.8% KLJKHU UDWH RI DSSURSULDWH WHVWLQJ RI FKLOGUHQ ZISKDU\QJLWLV

• 2YHUDOO LPSURYHPHQW LQ SDWLHQW VDWLVIDFWLRQ

Connecticut

Connecticut Health

Enhancement Program 46

Published: Jan. 2013

Data Review: 2011-2012

• 22.8% IHZHU PRQWKO\

ED visits

• 20.8% IHZHU VSHFLDOW\ FDUH YLVLWV

• 75% LQFUHDVH LQ SULPDU\ FDUH YLVLWV

• 70% GHFUHDVH LQ PHGLFDO WUHQG JURZWK UDWH

• 0RGHVW LPSURYHPHQWV LQ DGKHUHQFH WR KHDUW GLVHDVH, EORRG SUHVVXUH, FKROHVWHURO DQG GLDEHWHV PHGLFDWLRQ

Maryland

CareFirst BlueCross

BlueShield 47

Published: June 2013

Data Review: 2010-2012

• $98 PLOOLRQ LQ WRWDO FRVWV

savings

• 3DQHOV HDUQLQJ incentives achieved DYHUDJH RI 4.7% VDYLQJV, Y. 3.6% KLJKHU FRVWV

IRU WKRVH QRW HDUQLQJ

incentives

• 3.7 % KLJKHU TXDOLW\ VFRUHV IRU SDQHOV WKDW UHFHLYHG LQFHQWLYHV

• 4XDOLW\ VFRUHV IRU

3&0+ SDQHOV URVH E\

9.3 % IURP 2011 WR

2012

Michigan

Blue Cross Blue Shield Michigan PCMH Program48

Published: July 2013

'DWD 5HYLHZ 1RW 6SHFL÷HG

• 8.8% IHZHU DGXOW ('

visits

• 17.7% IHZHU SHGLDWULF (' YLVLWV; 23.8% IHZHU SULPDU\-FDUH VHQVLWLYH ED visits

• 11.2% ORZHU UDWH RI DGXOW SULPDU\ FDUH- sensitive ED visits

• 19.1% IHZHU DGXOW DPEXODWRU\ FDUH- VHQVLWLYH LQSDWLHQW DGPLVVLRQV

New Jersey

Horizon BlueCross BlueShield New Jersey PCMH Pilot Monmouth County Public Employees 49

Published: Dec. 2013

Data Review: 2012-2013

• 33% LQFUHDVH LQ FRORUHFWDO VFUHHQLQJV

(Y. 10% LQFUHDVH LQ QRQ-

3&0+V)

• 23% LQFUHDVH LQ EUHDVW FDQFHU VFUHHQLQJV (Y. 3% LQFUHDVH LQ QRQ-3&0+V)

PAGE 15

Table 2 continued

Initiative Cost & Utilization Population Health

& Prevention

Oregon

Access Patient and

Clinician

Satisfaction

Oregon Coordinated Care Organizations (CCOs) Oregon Health Authority 50

Published: Nov. 2013

Data Review: 2012-2013

• 9% IHZHU (' YLVLWV

• 18% UHGXFWLRQ LQ (' VSHQGLQJ

• 12% IHZHU LQSDWLHQW UHDGPLVVLRQV

• 7% LQFUHDVH LQ SULPDU\ FDUH VSHQGLQJ

á18% LQFUHDVH LQ RXWSDWLHQW SULPDU\ FDUH visits

á36% LQFUHDVH LQ 3&0+ HQUROOPHQW

Pennsylvania

Highmark Patient- Centered Medical Home Pilot 51

Published: Jan. 2013

Data Review: 2011-2012

• 9% IHZHU LQSDWLHQW DGPLVVLRQV

• 13% IHZHU 30-GD\ LQSDWLHQW UHDGPLVVLRQV

• 5% GHFUHDVH LQ WRWDO

3030 FRVWV IRU FRURQDU\ DUWHU\ GLVHDVH SDWLHQWV

• 3.5% GHFUHDVH LQ

WRWDO 3030 FRVWV IRU

diabetics

• 2% GHFUHDVH LQ RYHUDOO KHDOWK FDUH FRVWV

Discussion

7KRXJK WKH PDJQLWXGH DQG FRQVLVWHQF\ RI WKH 3&0+ÚV HIIHFWV YDU\ DFURVV VWXGLHV DQG VHWWLQJV, DQG VDPSOH VL]HV DQG WLPH IUDPHV DUH FRQVWUDLQHG, LQ WKH DJJUHJDWH WKHVH VWXGLHV VKRZ SURJUHVV RQ LPSRUWDQW 7ULSOH $LP PHWULFV. ,Q RUGHU WR LGHQWLI\ FRQVLVWHQFLHV RU JDSV LQ PHDVXUHV DV UHSRUWHG E\ WKH 3&0+ VWXGLHV, ZH WKHQ FDWHJRUL]HG WKH 20
HYDOXDWLRQV LQWR HLJKW PRUH VSHFL÷F RXWFRPH PHDVXUHV DQG DVVHVVHG WKH IUHTXHQF\ RI PHDVXUHV LQ HDFK FDWHJRU\,
ZKLFK FDQ EH IRXQG LQ 7DEOH 3.

Table 3. PCMH Studies from August 2012 to December 2013 that report outcomes (by category and by frequency)

Decreased Cost and Utilization. 2I WKH 20 3&0+ HYDOXDWLRQV, D PDMRULW\ VKRZ UHGXFWLRQV LQ FRVW RU XWLOL]DWLRQ.

$FURVV ERWK SHHU-UHYLHZHG DQG LQGXVWU\-JHQHUDWHG VWXGLHV, WKH WZR PRVW FRPPRQO\ UHSRUWHG PHWULFV UHSRUWHG ZHUH UHGXFWLRQV LQ HPHUJHQF\ GHSDUWPHQW ((') XVH (61% SHHU-UHYLHZ; 57% LQGXVWU\) DQG FRVW UHGXFWLRQV (61% SHHU-UHYLHZ; 57% LQGXVWU\). ,Q WKH LQGXVWU\-JHQHUDWHG VWXGLHV, WKHUH ZDV DOVR D KLJK UDWH RI UHSRUWLQJ UHGXFWLRQV LQ

PAGE 16

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A gap exists in reporting clinician satisfaction data. $OWKRXJK WKHUH LV JURZLQJ HYLGHQFH WKDW WKH

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RI 3&0+ HYDOXDWLRQV JLYHQ WKH LPSRUWDQFH RI VWUHQJWKHQLQJ DQG HQKDQFLQJ WKH SULPDU\ FDUH ZRUNIRUFH. $ KLJK-IXQFWLRQLQJ WHDP ZLWK WKH FDSDFLW\ WR EHWWHU VHUYH SDWLHQWV DQG IDPLOLHV FDQ LQFUHDVH FOLQLFLDQ VDWLVIDFWLRQ DQG PD\ RIIHU ÜLQQRYDWLRQV WKDW FDQ IDFLOLWDWH MR\ LQ SUDFWLFH DQG PLWLJDWH SK\VLFLDQ EXUQ RXW.Ý 55
$V GHPRQVWUDWHG E\ WKH YDULDWLRQ UHSRUWHG DFURVV WKHVH 20 VWXGLHV, WKH GHPDQG IRU D EURDG DQG LQFOXVLYH FRPPRQ VHW RI PHDVXUHV IRU HYDOXDWLQJ 3&0+ LQLWLDWLYHV, VXFK DV WKRVH UHFRPPHQGHG E\
7KH &RPPRQZHDOWK )XQGÚV 3DWLHQW-&HQWHUHG 0HGLFDO +RPH (YDOXDWRUÚV &ROODERUDWLYH, 56 continues
WR EXLOG.

A growing body of evidence points to PCMH success. 7KH VWXGLHV IRXQG KHUH DUH LPSUHVVLYH LQ WHUPV RI WKHLU IDLUO\ FRQVLVWHQW ÷QGLQJV RI UHGXFHG FRVW DQGIRU XWLOL]DWLRQ RI KHDOWK FDUH VHUYLFHV.

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PAGE 17

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“The question is not whether to improve

primary care, and commensurately the entire health system, but how best to do it.”

The Challenge of studying the PCMH

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The right metrics

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PAGE 18

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PAGE 19

SECTION THREE

THE FUTURE OF PRIMARY CARE AND THE PCMH

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The PCMH’s Role in Achieving Delivery System Reform

The foundation of high-performing Accountable Care Organizations

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PAGE 20

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The payment reform imperative

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PAGE 22

MULTI-PAYER INITIATIVES: THE ROLE OF PAYMENT REFORM

VERMONT BLUEPRINT FOR HEALTH

Author: Lisa Dulsky Watkins, MD, Former Associate Director, Vermont Blueprint for Health

The importance of employers and payers investing in the PCMH model is critical because the extent to which various payers – Medicare, Medicaid, commercial plans, and employers – are aligned around these payment models is the extent to which true transformation of the US health care system is possible. These “multi-payer” initiatives convince health care providers that the daunting task of redesigning their clinical practice is worth the time, effort, and investment because a majority of their payer-mix supports the re-design. 77

The Vermont Blueprint for Health 78 is a striking example of the effectiveness of a successful multi-payer reform effort. 79 The statewide adoptions of the spectrum of this multifaceted program can be linked to a long-standing willingness to cultivate collaborative relationships among the various stakeholders. This demonstrable public- SULYDWH SDUWQHUVKLS UHøHFWV D FXOWXUH WKDW QXUWXUHV QHZ LGHDV DQG WKH DELOLW\ WR H[HFXWH WKHP, PRYLQJ IURP WKH theoretical to the implemented.

Over the last decade, Bipartisan support in the public sector had a profound impact on the credibility of Health Reform. Republican Governor Jim Douglas and an increasingly Democratic State Legislature found common ground on key aspects of reform, joined by a commitment to grapple with predictions of escalating costs and increasing morbidity in the aging Vermont population. Initial Blueprint activity was seated at the Vermont Department of (Public) Health, seen widely as a neutral convener of the disparate groups brought together.

Meaningful engagement of the private sector was essential. From the very beginning, commercial insurers, EXVLQHVV JURXSV, DFDGHPLF DQG QRQSUR÷W RUJDQL]DWLRQV, KHDOWK FDUH SURYLGHUV DQG PDQ\ RWKHUV ZHUH LQYLWHG to participate in the myriad planning and advisory committees. Attention was paid to the need for national recognition of practices as PCMHs, the scale of enhanced payments to the practices, the initial development and payment of the locally based care coordination teams, respect for the internal business processes of the participating insurers and accountability of the Blueprint to its funders regarding outcomes.

/LYHO\ SODQQLQJ GLVFXVVLRQV HQVXHG, ZLWK UHSUHVHQWDWLYHV RI SULYDWH DQG SXEOLF RUJDQL]DWLRQV VKDSLQJ WKH GHVLJQ, implementation and evaluation strategies to be undertaken. Their commitment to voluntarily support the Blueprint was evident. There are self-insured employers already participating in the Blueprint despite their ERISA exemptions, and discussion with others as well as with private payers as the impact on cost and quality

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insurers,80 but there remains the impact of the process undertaken in good faith.

7KH øH[LELOLW\ RI 9HUPRQW 0HGLFDLGÚV *OREDO &RPPLWPHQW :DLYHU (1115 'HPRQVWUDWLRQ) HQDEOHG WKH 6WDWH WR SD\ IRU 0HGLFDUH EHQH÷FLDULHV LQ WKH SLORW SKDVH RI WKH %OXHSULQW, XQGHUVFRULQJ WKH 6WDWHÚV FRPPLWPHQW WR making the program “all-payer” through the lens of the practices and payers.81 5HFRJQL]LQJ WKDW WKH DEVHQFH of CMS as a payer was a critical problem in statewide implementation, Vermont leaders were instrumental in the call for its involvement. The CMS Multi-payer Advanced Primary Care Demonstration, for which Vermont VXFFHVVIXOO\ DSSOLHG, EULQJV WKLV FULWLFDO HQWLW\ LQWR WKH IROG DV DQ LQQRYDWRU DORQJ ZLWK 9HUPRQWÚV SDUWQHUV.82

CONCLUSION

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PAGE 23

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PAGE 24

APPENDIX A: Summary of PCMH evidence by category and organized by State/Location, with references, 2009-2013

LEGEND

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PAGE 25

APPENDIX A (Cont’d)

PAGE 26

APPENDIX A (Cont’d)

PAGE 27

APPENDIX A (Cont’d)

PAGE 28

APPENDIX A (Cont’d)

PAGE 29

APPENDIX A (Cont’d)

PAGE 30

APPENDIX B. The Year in Review: Case Study Snapshots

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National Program, 5 million patients

Publication Date: July 2013

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Michigan (statewide), 3 million patients

Publication Date: July 2013

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PAGE 31

UPMC Health Plan

Pennsylvania, 23,390 patients

Publication Date: July 2013

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CareFirst Blue Cross Blue Shield

Maryland, 1 million patients

Publication Date: June 2013

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PAGE 32

Oregon Health Authority Coordinated Care Organizations (CCOs)

Statewide Medicaid Program, 600,000 patients

Publication Date: November 2013

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PAGE 33

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1 5HLG, 5.-., &ROHPDQ, .., -RKQVRQ, (.$., )LVKPDQ, 3.$., +VX, &., 6RPDQ, 0.3., 7UHVFRWW, &.(., (ULNVRQ, 0., & /DUVRQ, (.%. (2010).

7KH *URXS +HDOWK 0HGLFDO +RPH DW <HDU 7ZR &RVW 6DYLQJV, +LJKHU 3DWLHQW 6DWLVIDFWLRQ, DQG /HVV %XUQRXW IRU 3URYLGHUV.

Health Affairs, 29(5), 835-843.

2 0DHQJ, '.'., *UDKDP, -., *UDI, 7.5., /LEHUPDQ, -.1., 'HUPHV, 1.%., 7RPFDYDJH, -., & 6WHHOH, *.'. (2012). 5HGXFLQJ /RQJ-7HUP

&RVW E\ 7UDQVIRUPLQJ 3ULPDU\ &DUH (YLGHQFH )URP *HLVLQJHUÚV 0HGLFDO +RPH 0RGHO. American Journal of Managed Care,

18(3), 149-155.

3 3DXVWLDQ, 0. /., $OH[DQGHU, -. $., (O 5HGD, '. .., :LVH, &. *., *UHHQ, /. $., & )HWWHUV, 0. '. (2013). 3DUWLDO DQG ,QFUHPHQWDO

3&0+ 3UDFWLFH 7UDQVIRUPDW LRQ ,PSOLFDWLRQV IRU 4XDOLW\ DQG &RVWV. Health Services Research.

4 &HQWHUV IRU 0HGLFDUH & 0HGLFDLG 6HUYLFHV. (2013). 3LRQHHU $FFRXQWDEOH &DUH 2UJDQL]DWLRQV 6XFFHHG LQ ,PSURYLQJ &DUH,

/RZHULQJ &RVWV.

5 6LORZ-&DUUROO, 6. & (GZDUGV, -.1. (2013). (DUO\ $GRSWHUV RI WKH $FFRXQWDEOH &DUH 0RGHO $ )LHOG 5HSRUW RQ ,PSURYHPHQWV LQ +HDOWK &DUH 'HOLYHU\. The Commonwealth Fund.

6 &HQWHUV IRU 0HGLFDUH & 0HGLFDLG 6HUYLFHV. (2013). 3LRQHHU $FFRXQWDEOH &DUH 2UJDQL]DWLRQV 6XFFHHG LQ ,PSURYLQJ &DUH,

/RZHULQJ &RVWV.

7 3HLNHV, '., =XWVKL, $., *HQHYUR, -., 6PLWK, .., 3DUFKPDQ, 0., & 0H\HUV, '. (2012). (DUO\ (YLGHQFH RQ WKH 3DWLHQW-&HQWHUHG

0HGLFDO +RPH. )LQDO 5HSRUW. Agency for Healthcare Research and Quality, SXEOLFDWLRQ 12-0020-().

8 %DUU, 0.6. (2008). 7KH QHHG WR 7HVW WKH 3DWLHQW-&HQWHUHG 0HGLFDO +RPH. -$0$, 300(7), 834×835.

9 3HLNHV, '., =XWVKL, $., *HQHYUR, -./., 3DUFKPDQ, 0./., & 0H\HUV, '.6. (2012). (DUO\ (YDOXDWLRQV RI WKH 0HGLFDO +RPH

%XLOGLQJ RQ D 3URPLVLQJ 6WDUW. American Journal of Managed Care, 18(2), 105×116.

10 7KH :RUOG %DQN. (2013). +HDOWK H[SHQGLWXUH, WRWDO (% RI *'3).

11 'DYLV, .., 6FKRHQ, &., & 6WUHPLNLV, .. (2010). 0LUURU, 0LUURU RQ WKH :DOO +RZ WKH 3HUIRUPDQFH RI WKH 8.6. +HDOWK &DUH

6\VWHP &RPSDUHV ,QWHUQDWLRQDOO\, 2010 8SGDWH. The Commonwealth Fund.

12 The Commonwealth Fund &RPPLVVLRQ RQ D +LJK 3HUIRUPDQFH +HDOWK 6\VWHP. (2013). &RQIURQWLQJ &RVWV 6WDELOL]LQJ 8.6.

+HDOWK 6SHQGLQJ :KLOH 0RYLQJ 7RZDUG D +LJK 3HUIRUPDQFH +HDOWK &DUH 6\VWHP. The Commonwealth Fund.

13 6WDU÷HOG, %., 6KL, /., & 0DFLQNR, -. (2005). &RQWULEXWLRQ RI 3ULPDU\ &DUH WR +HDOWK 6\VWHPV DQG +HDOWK. The Milbank

Quarterly, 83(3), 457×502.

14 )ULHGEHUJ, 0.:., +XVVH\, 3.6., & 6FKQHLGHU, (.&. (2010). 3ULPDU\ &DUH D &ULWLFDO 5HYLHZ RI WKH (YLGHQFH RQ 4XDOLW\ DQG

&RVWV RI +HDOWK &DUH. Health Affairs, 29(5), 766-772.

15 0DUPRW, 0. & :LONLQVRQ, 5. ((GV.). (2009). Social Determinants of Health. 86$ 2[IRUG 8QLYHUVLW\ 3UHVV.

16 &HQWHUV IRU 0HGLFDUH & 0HGLFDLG 6HUYLFHV. (2010). 0XOWL-3D\HU $GYDQFHG 3ULPDU\ &DUH ,QLWLDWLYH.

17 $IIRUGDEOH &DUH $FW, 3XE. /. 1R, 111-148. i 5508 (2011).

18 6KDOMLDQ, 0. & *LEVRQ, $. (2013). 7KH 3ULPDU\ &DUH &RQVHQVXV $ &RPSDULVRQ RI +HDOWK 6\VWHP 7UDQVIRUPDWLRQ 3URSRVDOV.

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19 3DWLHQW-&HQWHUHG 3ULPDU\ &DUH &ROODERUDWLYH. (2013). +LVWRU\.

20 $$)3, $$3, $&3, $2$. (2011). *XLGHOLQHV IRU 3DWLHQW-&HQWHUHG 0HGLFDO +RPH (3&0+) 5HFRJQLWLRQ DQG $FFUHGLWDWLRQ

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22 1&4$. (2013). 1&4$ 0HGLFDO +RPHV 3DVV 6,000 0DUN.

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23 -D«Q, &.5., )HUUHU, 5./., 0LOOHU, :./., 3DOPHU, 5.)., :RRG, 5., 'DYLOD, 0., 6WHZDUW, (.(., &UDEWUHH, %.)., 1XWWLQJ, 3.$., & 6WDQJH,

..&. (2010). 3DWLHQW 2XWFRPHV DW 26 0RQWKV LQ WKH 3DWLHQW-&HQWHUHG 0HGLFDO +RPH 1DWLRQDO 'HPRQVWUDWLRQ 3URMHFW.

Annals of Family Medicine, 8(1), 657-667.

24 0F1HOOLV, 5.-., *HQHYUR, -./., & 0H\HUV, '.6. (2013). /HVVRQV /HDUQHG )URP WKH 6WXG\ RI 3ULPDU\ &DUH 7UDQVIRUPDWLRQ.

Annals of Family Medicine, 11(1), 61-65.

25 %XUWRQ, 5.$., 'HYHUV, ..-., & %HUHQVRQ, %. (2012). 3DWLHQW-&HQWHUHG 0HGLFDO +RPH 5HFRJQLWLRQ 7RROV $ &RPSDULVRQ RI

7HQ 6XUYH\VÚ &RQWHQW DQG 2SHUDWLRQDO 'HWDLOV. The Urban Institute.

26 1&4$. (2013). 3DWLHQW-&HQWHUHG 0HGLFDO +RPH 5HFRJQLWLRQ.

27 $FFUHGLWDWLRQ $VVRFLDWLRQ IRU $PEXODWRU\ +HDOWK &DUH, ,1&. (2013). 0HGLFDO +RPH.

28 85$&. 85$&ÚV 3DWLHQW &HQWHUHG +HDOWK &DUH +RPH 3URJUDP.

29 %XUWRQ, 5.$., 'HYHUV, ..-., & %HUHQVRQ, %. (2012). 3DWLHQW-&HQWHUHG 0HGLFDO +RPH 5HFRJQLWLRQ 7RROV $ &RPSDULVRQ RI 7HQ

6XUYH\VÚ &RQWHQW DQG 2SHUDWLRQDO 'HWDLOV. The Urban Institute.

30 0F1HOOLV, 5.-., *HQHYUR, -./., & 0H\HUV, '.6. (2013). /HVVRQV /HDUQHG )URP WKH 6WXG\ RI 3ULPDU\ &DUH 7UDQVIRUPDWLRQ.

Annals of Family Medicine, 11(1), 61-65.

31 %XUWRQ, 5.$., 'HYHUV, ..-., & %HUHQVRQ, %. (2012). 3DWLHQW-&HQWHUHG 0HGLFDO +RPH 5HFRJQLWLRQ 7RROV $ &RPSDULVRQ RI 7HQ

6XUYH\VÚ &RQWHQW DQG 2SHUDWLRQDO 'HWDLOV. The Urban Institute.

32 'ULVFROO './., +LUDWVXND 9., -RKQVWRQ -.0., HW DO. 3URFHVV DQG 2XWFRPHV RI 3DWLHQW-&HQWHUHG 0HGLFDO &DUH :LWK $ODVND

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33 5DVNDV 5.6., /DWWV /.0., +XPPHO -.5., :HQQHUV, '., /HYLQH, +., 1XVVEDXP, 6.5. (2012). (DUO\ 5HVXOWV 6KRZ :HOO3RLQWÚV

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6\VWHP. 0LOLWDU\ 0HGLFLQH. 2013;178(2) 146-152.; &KULVWHQVHQ (:, 'RUUDQFH .$ HW DO. ,PSDFW RI D 3DWLHQW-&HQWHUHG

0HGLFDO +RPH RQ $FFHVV, 4XDOLW\, DQG &RVW. 0LOLWDU\ 0HGLFLQH. 2013;178(2) 135-141.

36 5RVODQG, $.0., 1HOVRQ, .., 6XQ, +., 'RODQ, (.'., 0D\QDUG, &., %U\VRQ, &., 6WDUN, 5., 6FKHFWPDQ, '., (2013). 7KH 3DWLHQW-

&HQWHUHG 0HGLFDO +RPH LQ WKH 9HWHUDQV +HDOWK $GPLQLVWUDWLRQ. $PHULFDQ -RXUQDO RI 0DQDJHG &DUH, 1-4.

37 5DVNDV 5.6., /DWWV /.0., +XPPHO -.5., :HQQHUV, '., /HYLQH, +., 1XVVEDXP, 6.5. (2012). (DUO\ 5HVXOWV 6KRZ :HOO3RLQWÚV

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7UDQVLWLRQLQJ WR 3DWLHQW &HQWHUHG 0HGLFDO +RPHV $ 5DQGRPL]HG 7ULDO. -RXUQDO RI *HQHUDO ,QWHUQDO 0HGLFLQH, 28(6), 778-

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40 2ULJLQDWHG LQ SDUW E\ WKH 1HZ <RUN &LW\ 'HSDUWPHQW RI +HDOWKÚV 3ULPDU\ &DUH ,QIRUPDWLRQ 3URMHFW; 5DVNDV 5.6., /DWWV /.0.,

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+RPH 3LORWV +DYH 0HW 6RPH *RDOV )RU &RVWV, 8WLOL]DWLRQ, $QG 4XDOLW\. +HDOWK $IIDLUV, 31(9).

41 5RVHQEHUJ, &.1., 3HHOH, 3, .H\VHU, '., 0F$QDOOHQ, 6., & +ROGHU, '. (2012) 5HVXOWV IURP D SDWLHQW-FHQWHUHG PHGLFDO KRPH SLORW DW 830& +HDOWK 3ODQ KROG OHVVRQV IRU EURDGHU DGRSWLRQ RI WKH PRGHO. +HDOWK $IIDLUV. 31(11).

42 5RVHQWKDO 0.%., )ULHGEHUJ 0.:., 6LQJHU 6.-., (DVWPDQ '., /L =., 6FKQHLGHU (.&. (IIHFW RI D 0XOWLSD\HU 3DWLHQW-&HQWHUHG

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3URJUDP. -$0$ ,QWHUQDO 0HGLFLQH. 173(20).

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43 'D\ -, 6FDPPRQ './., .LP -., HW DO. 4XDOLW\, 6DWLVIDFWLRQ, DQG )LQDQFLDO (I÷FLHQF\ $VVRFLDWHG :LWK (OHPHQWV RI 3ULPDU\ &DUH

3UDFWLFH 7UDQVIRUPDWLRQ 3UHOLPLQDU\ )LQGLQJV. 7KH $QQDOV RI )DPLO\ 0HGLFLQH. 2013;11(6XSSO 1) 650-659.

44 5HLG 5.-., -RKQVRQ (.$., +VX &., HW DO. 6SUHDGLQJ D 0HGLFDO +RPH 5HGHVLJQ (IIHFWV RQ (PHUJHQF\ 'HSDUWPHQW 8VH DQG

+RVSLWDO $GPLVVLRQV. 7KH $QQDOV RI )DPLO\ 0HGLFLQH. 2013;11(6XSSO 1) 619-626.

45 0HGLFDO +RPH 3URJUDP. %OXH &URVV %OXH 6KLHOG $ODEDPD. (2012). 5HWULHYHG IURP KWWSV IIZZZ.EFEVDO.RUJISURYLGHUVI DODEDPD+HDOWK,PSURYHPHQW,QLWLDWLYHIPHGLFDO+RPHIPHGLFDO+RPH3LORW.SGI.

46 9-%,' LQ $FWLRQ $ 3UR÷OH RI &RQQHFWLFXWÚV +HDOWK (QKDQFHPHQW 3URJUDP. 7KH 8QLYHUVLW\ RI 0LFKLJDQ &HQWHU IRU 9DOXH-

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48 %OXH &URVV %OXH 6KLHOG RI 0LFKLJDQ. 3DWLHQW-&HQWHUHG 0HGLFDO +RPH )DFW 6KHHW. -XO\ 2013. 5HWULHYHG IURP KWWS IIZZZ.

YDOXHSDUWQHUVKLSV.FRPIZS-FRQWHQWIXSORDGVI2013I07I2013-3&0+-)DFW-6KHHW.SGI.

49 +RUL]RQ %OXH &URVV %OXH 6KLHOG RI 1HZ -HUVH\. +RUL]RQ %OXH &URVV %OXH 6KLHOG RI 1HZ -HUVH\ :RUNV :LWK 0RQPRXWK

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50 2UHJRQ +HDOWK $XWKRULW\. (2013). 2UHJRQÚV +HDOWK 6\VWHP 7UDQVIRUPDWLRQ 4XDUWHUO\ 3URJUHVV 5HSRUW. 5HWULHYHG IURP KWWS IIZZZ.RUHJRQ.JRYIRKDI0HWULFVI'RFXPHQWVIUHSRUW-QRYHPEHU-2013.SGI.

51 3HUUL, /. (2013). +LJKPDUN WR H[SDQG SDWLHQW-FHQWHUHG PHGLFDO KRPH HIIRUWV WR LPSURYH FDUH DQG KHDOWK RXWFRPHV IRU PHPEHUV. +LJKPDUN. 5HWULHYHG IURP KWWSV IIZZZ.KLJKPDUN.FRPIKPN2IQHZVURRPISUHVVUHOHDVHVI2013ISU012313.VKWPO.

52 5HLG, 5. -., )LVKHUPDQ, 3.$., <X, 2., 5RVV, 7.5., 7XIDQR, -.7., 6RPDQ, 0.3., & /DUVRQ, (.%. (2009). 3DWLHQW-&HQWHUHG 0HGLFDO

+RPH 'HPRQVWUDWLRQ $ 3URVSHFWLYH, 4XDVL-([SHULPHQWDO, %HIRUH DQG $IWHU (YDOXDWLRQ. Journal of Ambulatory Care

Management, 15(9), 71-87.

53 0F&DUWK\, '., 0XHOOHU, .., & :UHQQ, -. (2009). *HLVLQJHU +HDOWK 6\VWHP $FKLHYLQJ WKH 3RWHQWLDO RI 6\VWHP ,QWHJUDWLRQ WKURXJK ,QQRYDWLRQ, /HDGHUVKLS, 0HDVXUHPHQW, DQG ,QFHQWLYHV. The Commonwealth Fund, 1233(9), 1-16.

54 6LQVN\, &.$., :LOODUG-*UDFH, 5., 6FKXW]EDQN, $.0., 6LQVN\, 7.$., 0DUJROLV, '., & %RGHQKHLPHU, 7. (2013). ,Q 6HDUFK RI -R\ LQ

3UDFWLFH $ 5HSRUW RI 23 +LJK-)XQFWLRQLQJ 3ULPDU\ &DUH 3UDFWLFHV. Annals of Family Medicine, 11(3), 272-278.

55 Ibid

56 5RVHQWKDO, 0., $EUDPV, 0., & %LWWRQ, $. (2012). 5HFRPPHQGHG &RUH 0HDVXUHV IRU (YDOXDWLQJ WKH 3DWLHQW-&HQWHUHG

0HGLFDO +RPH &RVW, 8WLOL]DWLRQ, DQG &OLQLFDO 4XDOLW\. The Commonwealth Fund, 1601(12), 1-12.

57 6WDWLVWLFV.FRP. (2013). *ORVVDU\ RI VWDWLVWLFDO WHUPV )DFH 9DOLGLW\.

58 %OXH &URVV %OXH 6KLHOG $VVRFLDWLRQ. (2012). %XLOGLQJ 7RPRUURZÚV +HDOWKFDUH 6\VWHP.

59 ,QVWLWXWH RI 0HGLFLQH. (2012). Better Care at Lower Cost: 7KH 3DWK WR &RQWLQXRXVO\ /HDUQLQJ +HDOWK &DUH LQ $PHULFD.

:DVKLQJWRQ, '& 1DWLRQDO $FDGHP\ RI 6FLHQFHV.

60 .DXIPDQ, $., 3RZHOO, :., $OIHUR, &., 3DFKHFR, 0., 6LOYHUEODWW, +., $QDVWDVRII, -., 5RQTXLOOR, )., /XFHUR, .., &RUULYHDX, (.,

9DQOHLW, %., $OYHUVRQ, '., & 6FRWW, $. (2010). +HDOWK ([WHQVLRQ LQ 1HZ 0H[LFR $Q $FDGHPLF +HDOWK &HQWHU DQG WKH 6RFLDO

'HWHUPLQDQWV RI 'LVHDVH. Annals of Family Medicine, 8(1), 73-81.

61 *UXPEDFK, .. (2013). 7KH 3DWLHQW-&HQWHUHG 0HGLFDO +RPH V 1RW D 3LOO ,PSOLFDWLRQV IRU (YDOXDWLQJ 3ULPDU\ &DUH 5HIRUPV.

JAMA Internal Medicine, 173(22).

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62 *UXPEDFK, .. (2013). 7KH 3DWLHQW-&HQWHUHG 0HGLFDO +RPH V 1RW D 3LOO ,PSOLFDWLRQV IRU (YDOXDWLQJ 3ULPDU\ &DUH 5HIRUPV.

JAMA Internal Medicine, 173(22).

63 0DHQJ, '.'., *UDKDP, -., *UDI, 7.5., /LEHUPDQ, -.1., 'HUPHV, 1.%., 7RPFDYDJH, -., & 6WHHOH, *.'. (2012). 5HGXFLQJ /RQJ-7HUP

&RVW E\ 7UDQVIRUPLQJ 3ULPDU\ &DUH (YLGHQFH )URP *HLVLQJHUÚV 0HGLFDO +RPH 0RGHO. American Journal of Managed Care,

18(3),149-155.

64 3DXVWLDQ, 0. /., $OH[DQGHU, -. $., (O 5HGD, '. .., :LVH, &. *., *UHHQ, /. $., & )HWWHUV, 0. '. (2013). 3DUWLDO DQG ,QFUHPHQWDO

3&0+ 3UDFWLFH 7UDQVIRUPDWLRQ ,PSOLFDWLRQV IRU 4XDOLW\ DQG &RVWV. Health Services Research.

65 ,QVWLWXWH RI 0HGLFLQH. (2011). 7KH +HDOWKFDUH ,PSHUDWLYH /RZHULQJ &RVWV DQG ,PSURYLQJ 2XWFRPHV :RUNVKRS 6HULHV

6XPPDU\.

66 &HQWHUV IRU 0HGLFDUH & 0HGLFDLG 6HUYLFHV. (2013). $FFRXQWDEOH &DUH 2UJDQL]DWLRQV ($&2).

67 *ROG, -. (2013). )$4 2Q $&2V $FFRXQWDEOH &DUH 2UJDQL]DWLRQV, ([SODLQHG. Kaiser Health News.

68 Ibid

69 &HQWHUV IRU 0HGLFDUH & 0HGLFDLG 6HUYLFHV. (2013). 3LRQHHU $FFRXQWDEOH &DUH 2UJDQL]DWLRQV 6XFFHHG LQ ,PSURYLQJ &DUH,

/RZHULQJ &RVWV.

70 6LORZ-&DUUROO, 6. & (GZDUGV, -.1. (2013). (DUO\ $GRSWHUV RI WKH $FFRXQWDEOH &DUH 0RGHO $ )LHOG 5HSRUW RQ ,PSURYHPHQWV LQ +HDOWK &DUH 'HOLYHU\. The Commonwealth Fund.

71 &HQWHUV IRU 0HGLFDUH & 0HGLFDLG 6HUYLFHV. (2013). 3LRQHHU $FFRXQWDEOH &DUH 2UJDQL]DWLRQV 6XFFHHG LQ ,PSURYLQJ &DUH,

/RZHULQJ &RVWV.

72 3KDP, +.+., 2Ú0DOOH\, $.6., %DFK 3.%., 6DLRQW]-0DUWLQH], &., & 6FKUDJ, '. (2009). 3ULPDU\ &DUH 3K\VLFLDQVÚ /LQNV WR 2WKHU

3K\VLFLDQV 7KURXJK 0HGLFDUH 3DWLHQWV 7KH 6FRSH RI &DUH &RRUGLQDWLRQ. Annals of Internal Medicine, 150(4), 236-242.

73 &KHQ, $.+. & <HH, $.). (2011). ,PSURYLQJ 3ULPDU\ &DUH-6SHFLDOW\ &DUH &RPPXQLFDWLRQ /HVVRQV IURP 6DQ )UDQFLVFRÚV

6DIHW\ 1HW &RPPHQW RQ Ü5HIHUUDO DQG &RQVXOWDWLRQ &RPPXQLFDWLRQ EHWZHHQ 3ULPDU\ &DUH DQG 6SHFLDOLVW 3K\VLFLDQV.Ý

Archives of Internal Medicine, 171(1), 65-67.

74 .LQGLJ, '. & 6WRGGDUW, *. (2003). :KDW LV 3RSXODWLRQ +HDOWK" American Journal of Managed Care, 93(3), 380-383.

75 7D\ORU, (.)., /DNH, 7., 1\VHQEDXP, -., 3HWHUVRQ, *., & 0H\HUV, '. (2011). &RRUGLQDWLQJ &DUH LQ WKH 0HGLFDO 1HLJKERUKRRG

&ULWLFDO &RPSRQHQWV DQG $YDLODEOH 0HFKDQLVPV. Agency for Healthcare Research and Quality, Publication 1R. 11-0064.

76 Ibid

77 &HQWHUV IRU 0HGLFDUH & 0HGLFDLG 6HUYLFHV. (2010). 0XOWL-3D\HU $GYDQFHG 3ULPDU\ &DUH 3UDFWLFH.

78 'HSDUWPHQW RI 9HUPRQW +HDOWK $FFHVV. (2013). 9HUPRQW %OXHSULQW IRU +HDOWK 2012 $QQXDO 5HSRUW WR WKH /HJLVODWXUH.

79 7KH 9HUPRQW *HQHUDO $VVHPEO\. (2013). %OXHSULQW IRU +HDOWK /DWHVW %OXHSULQW 5HODWHG 'RFXPHQWV.

80 7KH 9HUPRQW *HQHUDO $VVHPEO\. (2008). NO. 204. AN ACT RELATING TO MANAGED CARE ORGANIZATIONS, THE BLUEPRINT FOR HEALTH, AND IMMUNIZATIONS OF CHILDREN PRIOR TO ATTENDING SCHOOL AND CHILD CARE FACILITIES, AND THE IMMUNIZATIONS REGISTRY. (6.283).

81 6WDWH RI 9HUPRQW. (2005). )LQDO ,QWHUJRYHUQPHQWDO $JUHHPHQW %HWZHHQ $JHQF\ RI +XPDQ 6HUYLFHV DQG 2I÷FH RI 9HUPRQW

+HDOWK $FFHVV )RU WKH $GPLQLVWUDWLRQ DQG 2SHUDWLRQ RI WKH *OREDO &RPPLWPHQW WR +HDOWK :DLYHU.

82 &HQWHUV IRU 0HGLFDUH & 0HGLFDLG 6HUYLFHV. (2010). 0XOWL-3D\HU $GYDQFHG 3ULPDU\ &DUH ,QLWLDWLYH.

83 5RVODQG, $.0., 1HOVRQ, .., 6XQ, +., 'RODQ, (.'., 0D\QDUG, &., %U\VRQ, &., 6WDUN, 5., & 6FKHFWPDQ, '. (2013). 7KH 3DWLHQW-

&HQWHUHG 0HGLFDO +RPH LQ WKH 9HWHUDQV +HDOWK $GPLQLVWUDWLRQ. American Journal of Managed Care, 19(7), H263-272.

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