Association Between the Implementation of a Population-Based Primary Care Payment System and Achievement on Quality Measures in Hawaii | Health Care Reform | JAMA | JAMA Network
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Original Investigation
July 2, 2019

Association Between the Implementation of a Population-Based Primary Care Payment System and Achievement on Quality Measures in Hawaii

Author Affiliations
  • 1Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
  • 2Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 3Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
  • 4Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 5Healthcare Transformation Institute, University of Pennsylvania, Philadelphia
  • 6Weill Cornell Medicine, Cornell University, New York, New York
  • 7Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
  • 8New York University School of Medicine, New York, New York
  • 9Yale University School of Medicine, Yale University, New Haven, Connecticut
  • 10Hawaii Medical Service Association, Honolulu
JAMA. 2019;322(1):57-68. doi:10.1001/jama.2019.8113
Key Points

Question  Was the Blue Cross Blue Shield of Hawaii capitation-based primary care payment system, Population-based Payments for Primary Care (3PC), associated with improvement in quality measures in its first year?

Findings  In this observational study of 299 458 members and 419 primary care physicians, the 3PC system was significantly associated with a 2.3–percentage point increase in the risk-standardized probability of meeting an eligible quality measure over the first year.

Meaning  In its first year, the 3PC capitation-based primary care payment system in Hawaii was associated with small improvements in quality, but additional research is needed to assess longer-term outcomes as the program is more fully implemented and to determine whether results are generalizable to other health care markets.

Abstract

Importance  Hawaii Medical Service Association (HMSA), the Blue Cross Blue Shield of Hawaii, introduced Population-based Payments for Primary Care (3PC), a new capitation-based primary care payment system, in 2016. The effect of this system on quality measures has not been evaluated.

Objective  To evaluate whether the 3PC system was associated with changes in quality, utilization, or spending in its first year.

Design, Setting, and Participants  Observational study using HMSA claims and clinical registry data from January 1, 2012, to December 31, 2016, and a propensity-weighted difference-in-differences method to compare 77 225 HMSA members in Hawaii attributed to 107 primary care physicians (PCPs) and 4 physician organizations participating in the first wave of the 3PC and 222 233 members attributed to 312 PCPs and 14 physician organizations that continued in a fee-for-service model in 2016 but had 3PC start dates thereafter.

Exposures  Participation in the 3PC system.

Main Outcomes and Measures  The primary outcome was the change in a composite measure score reflecting the probability that a member achieved an eligible measure out of 13 pooled Healthcare Effectiveness Data and Information Set quality measures. Primary care visits and total cost of care were among 15 secondary outcomes.

Results  In total, the study included 299 458 HMSA members (mean age, 42.1 years; 51.5% women) and 419 primary care physicians (mean age, 54.9 years; 34.8% women). The risk-standardized composite measure scores for 2012 to 2016 changed from 75.1% to 86.6% (+11.5 percentage points) in the 3PC group and 74.3% to 83.5% (+9.2 percentage points) in the non-3PC group (differential change, 2.3 percentage points [95% CI, 2.1 to 2.6 percentage points]; P < .001). Of 15 prespecified secondary end points for utilization and spending, 11 showed no significant difference. Compared with the non-3PC group, the 3PC system was associated with a significant reduction in the mean number of primary care visits (3.3 to 3.0 visits vs 3.3 to 3.1 visits; adjusted differential change, −3.9 percentage points [95% CI, −4.6 to −3.2 percentage points]; P < .001), but there was no significant difference in mean total cost of care ($3344 to $4087 vs $2977 to $3564; adjusted differential change, 1.0% [95% CI, −1.3% to 3.4%]; P = .39).

Conclusions and Relevance  In its first year, the 3PC population-based primary care payment system in Hawaii was associated with small improvements in quality and a reduction in PCP visits but no significant difference in the total cost of care. Additional research is needed to assess longer-term outcomes as the program is more fully implemented and to determine whether results are generalizable to other health care markets.

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