Care Experiences of Patients with Multiple Chronic Conditions in a Payer-Based Patient-Centered Medical Home

Abstract

Individuals with multiple chronic health conditions require additional support and medical services, incur higher health care costs, and often have a higher risk of hospitalization. The goal of this study was to examine care experiences of patients with multiple chronic conditions in the CareFirst patient-centered medical home (PCMH). The study used a repeated cross-sectional research design and included 1308 adult CareFirst plan members with multiple chronic conditions. Patient care experiences were collected using a structured telephone survey in 2015 and 2017. Composite scores and individual question responses for patient–provider communication, coordination of care, access to care, and self-management support were analyzed to determine differences between survey years. Overall, patients reported positive care experiences with communication, self-management support, and care coordination. Access to care indicators received lower composite scores. Between 2015 and 2017, patients reported higher ratings for appointment reminders, communicating test results, providers listening carefully, and care plan effectiveness. Patients who completed their CareFirst PCMH care plan had higher care experience scores than patients who did not. A key finding of this study is that care plan completion is associated with positive care experiences, indicating the importance of the care plan to this PCMH model. Lower scores on access to care measures suggest a need for improved pathways for patients to obtain care during nontraditional office hours. Payer-based PCMH models that include enhanced care coordination and additional provider payments to support these activities may be beneficial to patients with multiple chronic conditions.

Introduction

More than half of American adults have at least 1 chronic health condition and almost one third have multiple chronic conditions. The most prevalent chronic diseases among American adults include hypertension, hyperlipidemia, respiratory conditions, arthritis, depression, diabetes, asthma, and coronary artery disease.^1,2 Patients with multiple chronic conditions may require additional support and medical services, incur higher health care costs,³ and have a higher risk of hospitalization.⁴ These patients also are more likely to report delays in access to care and insufficient assistance with managing their conditions. Previous studies found that patients with multiple chronic conditions did not have their needs fully met in traditional primary care settings.^5,6

Although challenges remain in the treatment of patients with multiple chronic conditions, research points to specific attributes of care that are important for patients to effectively control their conditions. These attributes include an ongoing relationship with a primary care provider, strong patient–provider communication, a coordinated approach to care management, and connections to support services.⁷ A continuous relationship between a primary care provider and patient enables the care team to have a better understanding of patients' medical histories and preferences. Previous research found that a continuous relationship with a care provider resulted in improved patient experience,⁸ patient compliance with medication and appointments, and patient disclosure of medical and social issues.⁹ Patient–provider communication is critical for patient comprehension of their condition(s) and treatment options, as well as for engaging patients in self-care.¹⁰ Strong patient–provider communication has been shown to be associated with optimal self-care,¹¹ better continuity of care, and increased delivery of preventive services.¹² Well-coordinated care also is critical for patients with multiple chronic illnesses in order to manage health services across providers and settings. Nurse care coordinators have been used by providers as part of a team that works closely with patients to develop individual care plans, set goals, and support patients and family caregivers with self-management care responsibilities.¹³ Care coordinators also can connect patients with other health and social support services such as appointments with medical and behavioral health specialists or specialized weight loss and nutrition programs.

Since 2008, different models of the patient-centered medical home (PCMH) have emerged to improve quality and efficiency of primary care delivery in the United States. Key attributes of a PCMH model of care include: an ongoing patient–physician relationship, team-based care, care coordination, performance measurement and reporting, expanded access to services, and enhanced reimbursement to support PCMH activities.¹⁴ These attributes position the PCMH as a valuable model for high-need patients with multiple chronic conditions.^15,16

Research on patient experiences with PCMH models is sparse, but has been slowly emerging. Prior studies have revealed mixed evidence on whether PCMH models improve patient-reported experience of care with regard to patient–provider communication, care coordination, access to care, and overall experience.^17

–23 Several studies that examined high-risk patients in PCMH practices found positive patient experience results.^24,25 A study of Michigan's multipayer demonstration found that high-risk patients with severe or chronic conditions in PCMH practices reported better experiences than patients in non-PCMH practices for access to care, care coordination, and self-management support.²⁶ These studies concluded that the PCMH model may be beneficial in several domains of patient experience for high-risk patients with severe or chronic conditions.

In 2011, CareFirst BlueCross BlueShield (CareFirst) implemented a PCMH program in its commercial insurance plans that targeted high-need adult patients with multiple chronic conditions. CareFirst is a large health insurer serving more than 3.2 million members in Maryland, the District of Columbia, and northern Virginia. The goals of the CareFirst PCMH program are to improve quality and coordination of care for patients with multiple chronic conditions and to reduce growth in the total cost of care. The program focuses on case management for comorbid conditions and offers enhanced coordination of care, linkages to community services, self-management support, and clinician decision support for health resource utilization. The CareFirst PCMH model involves insurer-sponsored nurse care coordinators who work with physicians to develop a care plan for patients in the program. The care plan includes: a patient narrative, social and family history, medications, allergies, diagnostic and lab results, vital signs, encounter history, clinician assessment and treatment plan, and care coordination team information. The nurse care coordinator works with physicians to conduct medication reconciliation for each patient with continuous monitoring, follow-up, and reassessment.

The CareFirst PCMH model also includes electronic decision-support tools for providers that present information on specialists and other referral services including cost of care estimates. The model offers an enhanced fee schedule and potential bonus payments for providers who participate in the program. The program encompasses 90% of primary care providers in CareFirst's mid-Atlantic service area, including 4400 enrolled primary care physicians and nurse practitioners.²⁷ Between 2015 and 2017, CareFirst refined the PCMH program by providing additional training and support for nurse care coordinators, introducing program consultants to provide technical assistance and data analysis to participating practices, and expanding opportunities for open dialogue between primary care practices and CareFirst administrators.

Multiple studies of payer-based PCMH programs have reported findings on clinical outcomes, cost, and provider viewpoints.^28
–30 However, few studies have evaluated patient experiences with payer-based PCMH programs. The primary goal of this study was to examine the care experiences of patients with primary care providers in a payer-based PCMH program at 2 points in time.

Methods

Overview

This study is based on a repeated cross-sectional research design. Data on patient care experiences were collected from CareFirst plan members using a structured telephone survey conducted in 2015 and 2017. Data on patient demographics, chronic health conditions, and illness burden scores were obtained from the health plan's enrollment and claims data files. All research protocols and data collection instruments were approved by the George Mason University Institutional Review Board.

Sampling and recruitment

The analytic sample included adult patients who were covered by CareFirst insurance and whose primary care provider participated in the CareFirst PCMH program. Eligible individuals comprised patients with multiple chronic conditions. Patients participating in the study were stratified into 3 groups according to their care plan status. Patients were categorized as “Stabilized” when their condition was stable or the care plan was completed and as “Partial Goals” if their individualized care plans were partially completed. A third group of patients were categorized as “Refused” if they refused to consent to a CareFirst care plan and did not participate in the CareFirst PCMH program.

Survey development and administration

The research team constructed a survey to measure patient care experience based on 2 validated instruments: the Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS) 12-month survey and the Canadian Survey of Experiences with Primary Health Care (CSE-PHC). CG-CAHPS, by the US Agency for Healthcare Research and Quality, is a national survey used to assess patients' experiences with health care providers and staff in doctors' offices. CG-CAHPS results can be used to measure care experiences provided by individual providers, sites of care, or groups of providers.³¹ CSE-PHC, designed by the Health Council of Canada and the Canadian Institute for Health Information, is a survey that measures patients' experiences with health care services and access to health care. The CSE-PHC instrument was designed specifically for respondents diagnosed with chronic conditions to capture their general experiences and their participation in managing their own health care.³² Several questions were developed by the research team to assess unique features of the CareFirst PCMH program, and asked whether a care plan was developed for the patient and whether the care plan helped the patient manage her/his care at home. The survey instrument captured patient perceptions in 4 key domains of patient experience: patient–provider communication, care coordination, access to care, and self-management support.

Prior to survey administration, CareFirst staff sent an introductory letter to eligible patients informing them of the upcoming survey and consent procedures. Alan Newman Research, a consulting firm specializing in telephone surveys, conducted the survey and collected data. Eligible patients were contacted up to 6 times, after which the patient was removed from the potential respondent pool if there was no contact. All participants provided verbal informed consent prior to starting the survey. Several methods were used to reduce surveyor bias and improve data quality, which included training contracted surveyors, live monitoring of telephone surveys, and testing for survey completion time, number of incomplete questions, and question coherence. A $10 gift card was offered to plan members in 2017 upon full completion of the survey to increase response rate.

Data analysis

All data analyses were conducted using Stata version 13 (StataCorp LLC, College Station, TX). An initial analysis was conducted to determine if there were systematic differences in the characteristics of the respondent group and the sample of CareFirst plan members eligible to participate. Results also were stratified by care plan status to determine differences between patient groups. Responses to survey questions were analyzed with a Likert-type scale by using “top-box” scores to establish the proportion of patients who responded with the most favorable response (eg, very satisfied). Composite scores were created for patient–physician communication, care coordination, access to care, and self-management support measures. Two-sample tests of proportions were run to determine if there were significant changes between survey responses in 2015 and 2017. A P value threshold of 0.05 was considered to be statistically significant.

Results

A total of 1306 patient data records with complete survey and claims data were used for the analysis (Table 1). Response rates were calculated using the number of respondents and the total number of eligible patients contacted, resulting in a 33.8% response rate in 2015 and a 55.3% response rate in 2017. Chi-square or Fisher exact tests were used to estimate differences across patient characteristics between respondent groups and eligible sample groups. These tests revealed no significant differences between groups in survey years 2015 and 2017 across patients' geographic area, age, sex, illness burden score, number of chronic conditions, or types of chronic conditions.

Table 1.

Characteristics of Adult Survey Respondents (N = 1308)

Patient characteristics	Survey year 2015	Survey year 2017	P
Patient characteristics	(N = 505)^*	(N = 803)^*	P
Sex, female (%)	57	60	0.28
Age group (%)
18–24 years	1	1
25–44 years	11	11
45–64 years	74	76
65 years or older	14	12	0.94
State (%)
Washington, DC	4	3
Maryland	86	84
Virginia	7	10
Others/missing	3	3	0.73
Illness burden score ^** (mean, SD)	(2.88, 3.36)	(3.13, 3.47)	0.19
Number of chronic conditions (%)
0–1	3	2
2–3	12	13
4–5	29	30
≥6	56	55	0.89
Types of chronic conditions (%)
Acute myocardial infarction	3	5	0.08
Alzheimer's disease	3	1	<0.01
Asthma	22	25	0.22
Atrial fibrillation	7	9	0.20
Chronic obstructive pulmonary disease	11	13	0.28
Depression	31	30	0.70
Diabetes	67	64	0.27
Heart failure	9	9	1.00
Hypertension	84	85	0.63
Ischemic heart disease	28	25	0.23
Stroke/transient ischemic attack	12	11	0.58
Other	3	3	1.00
Care plan status (%)
Stabilized (completed)	49	73
Partial (some goals met)	46	23
Refused	5	4	<0.01

Several patient records were removed from the analysis because of incomplete responses and/or matching data.

Illness Burden Score is based on the member's unique claims history using the trailing 12 months of claims experience.

Numbers in bold indicate estimates of P values that are statistically significant (P < .05).

SD, standard deviation.

However, in both survey years, the care plan status differed between the respondent group and eligible sample group. The 2015 respondent group had a lower percentage of care plan stabilized patients than the eligible sample group (49% vs. 54%). However, the 2017 respondent group had a higher percentage of care plan stabilized patients compared to the eligible sample (73% vs. 67%) in that year. Both the 2015 and 2017 response groups had a lower percentage of care plan refused patients than the eligible sample groups (5% vs. 9% and 4% vs. 7%, respectively).

Sample characteristics

About three quarters of adult respondents in both surveys were between ages 45 and 64 years (Table 1). In 2015 and 2017 respectively, most respondents were female, lived in Maryland, and had 6 or more chronic conditions (Table 1). Adult respondents' 5 most prevalent chronic conditions were: hypertension, diabetes, depression, ischemic heart disease, and asthma. There were no differences in respondents' characteristics in terms of sex, age, overall health, and number of chronic conditions between survey years. However, statistically significant differences were found for care plan status (49% vs.73% stabilized and 46% vs. 23% partial goals met) and prevalence of Alzheimer's disease (Table 1).

Overall patient experience

The researchers calculated the share of adult patients who gave the most favorable response for each question, and then averaged this result across questions within each domain to create an aggregate composite score. Overall, patients reported favorable experiences of care, with high composite scores for patient–provider communication, self-management support, and care coordination in 2015 and 2017. However, the access to care domain had lower composite scores in both 2015 and 2017 (Table 2).

Table 2.

Survey Questions with Changes in Patient Experience Over Time

	% most favorable rating
	Survey year 2015	Survey year 2017	P
	(N = 505)	(N = 803)	P
Self-management support
Care plan helped patient effectively manage their health condition at home	89.4	95.7	<0.01
Patient has all the information needed for self-care	78.4	79.1	0.67
Provider's office helps patient feel confident regarding self-care	77.8	79.3	0.67
Aggregate score	81.9	84.7	0.17
Communication
Provider listens carefully	84.9	88.9	0.03
Provider explained things in a way that was easy to understand	88.7	90.8	0.24
Provider's office listened to/considered patient preferences	81.0	83.7	0.16
Provider's office gives patient a good understanding of her/his health condition	73.3	73.2	1.00
Provider's office gives patient information about resources in the community	79.2	81.8	0.18
Provider spent enough time with patient	55.6	56.3	1.00
Aggregate score	77.1	79.1	0.41
Access
Obtained appointment when needed	67.8	68.3	1.00
If needed, received care on evenings or weekends	40.0	32.4	0.11
If needed, patient was able to reach provider via email	67.3	63.6	0.51
Aggregate score	58.3	54.8	0.43
Care coordination
Received reminders about upcoming tests or appointments	66.3	69.0	0.26
Provider informed and up-to-date about care from other providers	69.7	71.8	0.47
Provider informed and up-to-date about hospitalizations or outpatient services	74.9	74.9	1.00
Aggregate score	70.3	71.9	0.07

Numbers in bold indicate estimates of P values that are statistically significant (P < .05).

Patient experience over time

The researchers compared aggregate scores on the percent of most favorable ratings for each domain using 2-sample tests of proportions and found no significant differences between survey year 2015 and 2017 (Table 2). Survey data were then analyzed at the question level to measure changes over time. Between 2015 and 2017, improvements were found on numerous questions with several significant differences.

In the self-management support domain, it was found that if a care plan was established, patients reported the care plan was helpful in effectively managing their health conditions at home (Table 2). In the patient–provider communication domain, a significant increase was found in patients' perceptions of how carefully doctors listen to them. There was no change in whether providers spent enough time with patients (Table 2). In the care coordination domain, an increase was found in whether the provider's office staff actively reminded patients about upcoming tests and appointments. Regarding access to care, no significant difference was found between survey years 2015 and 2017. Scores remained low, particularly for patient ratings of the availability of appointments during evenings, weekends, and holidays (Table 2).

Analyses were conducted to examine whether patient characteristics were associated with specific domains of care experience (Table 3). No consistent correlations were found between patient characteristics and experience of care domain composite scores in both 2015 and 2017. In 2015, it was found that patients who completed a care plan were significantly more likely to rate patient–provider communication and self-management support high than patients who were either partially complete or refused to participate in the care plan process. It also was found patients with a high illness burden score rated care coordination high in 2015. In survey year 2017, patients belonging to high and very high illness score groups were more likely to report low ratings for access to care (3.88, 4.0).

Table 3.

Composite Scores of Patient Experience Domains Across Patient Characteristics, 2015 and 2017

Patient characteristics	Access to care 2015 2017		Provider communication 2015 2017		Care coordination 2015 2017		Self-management support 2015 2017
Composite Mean	4.16	4.10	4.58	4.60	4.27	4.35	4.61	4.65
Illness score^*
Low	4.20	4.21	4.59	4.63	4.08	4.33	4.58	4.71
Medium	4.20	4.24	4.62	4.59	4.26	4.39	4.67	4.70
High	4.18	4.01	4.57	4.58	4.33	4.26	4.58	4.57
Very High	4.05	3.93	4.57	4.57	4.39	4.41	4.58	4.63
P	0.60	0.01	0.91	0.83	0.05	0.40	0.71	0.23
Number of chronic conditions
0–1	3.97	3.89	4.74	4.34	4.47	4.38	4.91	4.24
2–3	3.99	4.21	4.46	4.67	4.47	4.29	4.48	4.75
4–5	4.22	4.17	4.61	4.62	4.35	4.34	4.56	4.69
≥6	4.17	4.04	4.59	4.57	4.26	4.37	4.64	4.62
P	0.51	0.29	0.30	0.18	0.18	0.86	0.17	0.07
Care plan status
Stabilized	4.24	4.09	4.66	4.61	4.29	4.36	4.72	4.67
Partial	4.08	4.16	4.52	4.54	4.24	4.29	4.51	4.60
Refused	4.01	3.88	4.45	4.63	4.28	4.44	4.34	4.56
P	0.24	0.41	0.02	0.39	0.86	0.58	<0.01	0.40

Illness scores are grouped in low, medium, high, and very high categories based on whether they belong to the top 25th percentile, 25–50, 50–75, and >75th percentile group.

Numbers in bold indicate estimates of P values that are statistically significant (P < .05).

Additional analyses were performed to determine whether there were differences in patient experience based on patients' chronic health conditions. For the most part, no large differences were found in patient experience based on specific chronic conditions. However, it was found that patients with chronic obstructive pulmonary disease (COPD) were significantly more likely to report low ratings for access to care (3.88) in 2017. Patients with COPD also were significantly more likely to rate low on patient–provider communication. In addition, patients with COPD or depression in 2017 were significantly more likely to rate low on self-management support.

Discussion

The CareFirst PCMH model was implemented in 2011 and at the time of this study was a mature program designed to improve quality and coordination of care for patients with multiple chronic conditions. This study analyzed data on patient experiences using surveys conducted in 2015 and 2017. Overall, patients reported favorable experiences of care, with high composite scores for patient–provider communication, care coordination, and self-management support. These findings are noteworthy because patients with multiple chronic conditions previously have reported more difficulties getting their needs met than other patients.⁶

One of the most important findings from this study was that, in both survey years, patients completing the CareFirst PCMH care plan rated their care experiences higher than patients who had partially completed the care plan. Although the repeated cross-sectional study design does not allow for casual inferences, the findings suggest a critical link between patients who completed a care plan and favorable experiences of care. These results could indicate that either completion of the care plan resulted in a better care experience or those patients with a better care experience felt more motivated to complete the care plan. Further research is necessary to examine casual pathways among these relationships. This finding builds on existing research on the CareFirst PCMH model that found participating physicians believed the nurse care coordinators and their work with patients, which includes maintenance of a care plan, was the most valuable component of the program.³⁰ This finding also suggests a need for CareFirst to expand PCMH efforts to better engage patients with partial goals met and those who are noncompliant with the care plan.

This study did not find significant improvements between 2015 and 2017 on composite scores for care coordination, patient–physician communication or self-management support. However, when individual questions were analyzed, it was found that providers in the CareFirst PCMH program improved care experiences on several indicators important to patients with multiple chronic conditions. An increase was found in patient perception and awareness of reminders for upcoming tests and appointments, providers listening carefully to patients, and effectiveness of the care plan in managing health conditions at home. Improvement in these areas indicates patient perceptions of aspects of patient–physician communication and self-management support were fostered by the more mature CareFirst PCMH model in 2017.

Another key finding was the relatively low scores for access to care indicators, specifically for availability of appointments during evenings, weekends, and holidays. Survey responses also revealed low scores for whether the provider spent enough time with the patient. These findings indicate a need for expanded hours of operation, alternative scheduling arrangements, and additional patient contact to address patients' concerns and questions. Although extended access to care was one of the original requirements of the CareFirst PCMH program, this finding suggests the requirement for extended access to care may fall short of producing the intended effect. This finding corresponds to research on access to care, specifically getting after-hours care, which adults in the United States rate as very difficult.⁹ Timely access to care is extremely important for patients with multiple chronic conditions, which could help patients avoid complications and better manage their conditions, and may have the potential to lower cost of care by reducing hospitalizations and emergency room visits.^33,34 One method to increase access to care is through a patient portal, which could support patient self-management and coordination of health care services by providing patients access to education materials, reminders for appointments, and opportunities to connect with the care team. A patient portal could increase patient engagement in care and address unmet clinical needs.³⁵

This study did not find consistent correlations between patient characteristics and patient-reported care experiences in both 2015 and 2017. However, this type of ongoing data analysis is important for payers and providers to identify patients who may need additional support and services, such as patients with multiple chronic conditions in this study who reported low scores on access to care. Study findings also suggest that patients with COPD may need additional assistance because they reported especially low ratings for access, communication, and self-management support in 2017. Patients with depression gave low ratings for self-management support in 2017, indicating that these patients needed additional services to manage their condition.

Although patient experiences are routinely measured by health care organizations, these measurements are likely to play a much greater role in how payments to physicians are determined in the future.^36,37 Medicare and commercial payers are experimenting with patient experience data in the design of pay-for-performance programs and alternative delivery and payment models such as Accountable Care Organizations and PCMHs. Given the expanding role of patient experience in future payment reforms, more studies are needed to strengthen the understanding of individual factors and program elements that are most effective in improving care experiences. As efforts to implement payment reform continue, adequate insight is needed into how these reforms affect the quality and costs of care as well as patient experience.^38,39

Limitations

This study had several limitations. First, the findings are not generalizable because patients in the study were members of 1 commercial health plan in the mid-Atlantic region of the United States. Study findings may be subject to selection bias, as participants in the survey may have had different views from those who declined to participate. Study findings, which showed a lack of significant improvement on patient experience composite scores between 2015 and 2017, could be related to a ceiling effect whereby it is difficult to make additional improvements in areas that already have high ratings. A ceiling effect could be a result of high-performance practices with high levels of innovation and service delivery that may not be notably affected by the CareFirst PCMH program. Patient experience also may be dependent on practice characteristics, such as physician practice styles and existing practice facilities, which were not captured in this study.

Conclusions

Patient experience is an important component of quality of care and likely will become a critical aspect of payment reform programs with both commercial and government payers. Numerous models have emerged to improve care and reduce costs associated with care for high-need individuals, including those with multiple chronic conditions. Models being tested by the Centers for Medicare & Medicaid Services include the Medicare Comprehensive Primary Care Plus, Medicare Advantage Value-Based Insurance Design Model, and State Innovation Models, as well as an array of programs from commercial insurers. Payer-based PCMH models, especially those with nurse care coordinators and care plan processes, may be beneficial to the care experience for patients with multiple chronic conditions.

Few studies have assessed the care experiences of patients with multiple chronic diseases in a payer-based PCMH model. The present study adds to the literature by presenting patients' reported care experiences with practices participating in the CareFirst PCMH program. Understanding a patient's experience of care with providers participating in these models is important, although it represents only 1 piece of information on the effectiveness of these programs. Quality of care, total cost of care estimates, and provider perspectives are critical to understand the nuances of which parts of the program worked well, for what types of patients, and for which providers.

Patient perspectives play an important role in the design and assessment of primary care initiatives to improve quality of care for patients with multiple chronic conditions. Continued research on patient experience with payer-based PCMH models is important considering the link between better care experiences and higher levels of adherence to recommended prevention and treatment processes, improved clinical outcomes, and lower utilization of health care services.⁴⁰

Footnotes

Author Disclosure Statement

The authors declare that there are no conflicts of interest.

Funding Information

This study was supported by a research grant from CareFirst BlueCross BlueShield. The grant funder was not involved in the research or the development of this manuscript.

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