MDPCP Primary Care Practice Capabilities and Care Management Delivery among Maryland Medicare Beneficiaries

Abstract

Care management is one of the core components of comprehensive primary care, which represents the future direction of primary care in the United States. Nearly twenty percent of Medicare beneficiaries experience 30-day readmissions. While primary care is uniquely positioned to provide care management services associated with reducing readmissions, only 50 percent of older adults who have experienced 30-day hospital readmissions receive outpatient care.

The goal of this dissertation was to identify structural and process components associated with the delivery of care management services to Maryland fee-for-service (FFS) Medicare beneficiaries, to examine geographic variation in the delivery of care management services, and to examine the association between the provision of care management services and patient health outcomes.

This dissertation explores the relationship between structural and process components of care delivery and the delivery of care management services with three aims: (1) examine the association between primary care practice structural and process capabilities and the delivery of care management to Medicare beneficiaries and whether this association is altered by primary care practice medically underserved area (MUA) designation, (2) examine the association between Health Equity Advancement Resource and Transformation (HEART) payments and care management comprehensiveness and whether this association is altered by primary care practice care management delivery option, and (3) identify unique trajectories of comprehensive care management performance and examine the association between care management trajectories and readmission rates.

Several key findings and implications are identified through the exploration of these aims. Increased primary care practice-level capabilities were associated with increased care management comprehensiveness. There was geographic variation in the provision of care management services among Maryland FFS Medicare beneficiaries. Next, prospective HEART payments were associated with increased care management comprehensiveness, and this association varied according to MUA designation and care management delivery options. Additionally, intensive partnerships between care transformation organizations (CTOs) and primary care practices improved access to comprehensive care management services. Finally, four unique classes of comprehensive care management performance were identified, and these care management performance classes had distinct patient characteristics and geographic locations. Among the low care management performance class, increased comprehensiveness among care management services was associated with decreased unplanned readmissions over time.

This dissertation provides evidence that geographic variation in the provision of care management exists and includes guidance on how to assess geographic variation in care management services across the United States. These results also provide valuable evidence about how prospective equity-based payments can transform care delivery in primary care settings. Lastly, this dissertation presents a novel method of program performance evaluation that can be applied to all evaluations of Medicare demonstrations.