The Comprehensive Primary Care Initiative and Emergency Department and Urgent Care Center Use

Abstract

Improved access to quality primary care is considered a key element in reducing unnecessary visits to emergency departments (EDs) and urgent care clinics (UCCs) and in reducing expenditures. The Comprehensive Primary Care (CPC) initiative tested large‐scale payment and delivery reform in 497 primary care practices in seven regions. Practices received enhanced payment, data feedback, and learning support to improve outcomes. In this study, we analyze the effect of CPC on ED and UCC visits October 2012‐December 2016. We expect the greatest changes to occur with those types of visits most amenable to improved primary care‐primary care substitutable visits (for conditions treatable in a primary care setting), and potentially primary care preventable ED visits (for conditions whose symptoms and exacerbations can be mitigated with effective primary care). We disaggregated visits by day of week to study whether changes were concentrated during regular business days (via increased same‐day/next‐day appointments and more responsiveness during weekdays by the care team) versus weekends and holidays. We expect access improvements to have greater effects on weekdays.We estimated CPC’s four‐year effects on Medicare fee‐for‐service (FFS) beneficiaries’ all‐cause and primary care substitutable (PCS) outpatient ED and UCC use and on potentially primary care preventable (PPCP) ED visits. To categorize visits, we adapted the commonly used claims‐based New York University Emergency Department Algorithm. We estimated difference‐in‐differences regressions comparing changes in outcomes between before CPC began (baseline) and the four years of CPC for attributed Medicare FFS beneficiaries in CPC practices, with changes over the same period for beneficiaries attributed to propensity‐score‐matched comparison practices. Regressions controlled for baseline practice, patient characteristics, and clustering.565,674 Medicare FFS beneficiaries attributed to 497 CPC practices, and 1,165,284 beneficiaries attributed to 908 similar comparison practices.CPC practices had 2 percent decreased growth in all‐cause ED visits, and 3 percent lower growth in both PCS (P = .02) and PPCP ED visits (P = .04), relative to comparison practices. Lower growth in weekday visits (4 percent, P = .002) drove the PCS ED results. UCC visits had 9 percent lower growth for both all‐cause (P = .08) and PCS (P = .07). As expected, there was no difference in ED visits for injuries—which is an excellent falsification test.CPC was associated with lower growth in outpatient ED and UCC visits, driven by reductions in weekday PCS visits (likely reflecting improved access to the practice), and PPCP ED visits (suggesting the importance of improved primary care more generally).Large‐scale initiatives to improve access to quality primary care, such as CPC, hold promise for reducing visits to EDs and UCCs. More research in understanding the contributions of specific care delivery changes, from same‐day appointments to improved health status of patients, primary care practice transformation, and the related response of attributed beneficiaries could help explain the differential impacts on visits by weekday versus nonweekday.Centers for Medicare and Medicaid Services.