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Background: Obesity is a leading cause of morbidity and mortality in the United States (US). Primary care medical practices can educate patients about the health effects of obesity and help patients with obesity lose and manage their weight. However, implementation of weight management in primary care is challenging. We sought to examine how practices that implement weight management services do so feasibly., Methods: Multiple methods including site visits, observations, interviews, and document reviews were utilized to identify and learn from primary care practices located across the US. A qualitative multidimensional classification of empirical cases was performed to identify unique delivery features that were feasible to implement in primary care., Results: Across 21 practices, 4 delivery models were identified: group, integrated into standard primary care, hiring an "other" professional, and using a specific program. Model characteristics included who delivered the weight management services, whether delivered to an individual or group, the types of approaches used, and how the care was reimbursed or paid. Most practices integrated weight management services and primary care delivery, although some created specific carve-out programs., Conclusion: This study identified 4 models that may serve to overcome challenges in delivering weight management services in primary care. Based on practice characteristics, preferences, and resources, primary care practices can identify a model for successfully implementing weight management services that best fits their context and needs. It is time for primary care to truly address obesity care as the health issue it is and make it a standard of care for all patients with obesity., Competing Interests: Conflict of interest: None., (© Copyright by the American Board of Family Medicine.)

Background: Mental health care must improve in this country. With the worsening shortage of psychiatrists and other mental health professionals, the next generation of physicians in primary care will need to be better trained in mental health care., Objectives: We estimate the direct cost of implementing an evidence-based Train-the-Trainer (3T) program to disseminate mental health training to allopathic medical school faculty; once trained, faculty can teach a much-enhanced curriculum of mental health care to medical students and residents., Methods: A combination of published standardized unit costs and an activity-based costing approach is used to estimate the direct costs (labor and nonlabor) for implementing the 3T program., Results: The estimated direct cost of implementing the 3T program at one prototypical school, including the 12-month start-up period (1.1 million) and 18-month rollout period (8.6 million), is ∼9.7 million dollars., Conclusions: Successfully adopted in all US allopathic medical schools, the 3T program will provide over 3800 attitudinally competent and mental health skills-qualified primary care faculty members. They would then be available to train nearly 100,000 medical students per year and 55,000 primary care residents to be as competent in basic mental health care as in medical care. This 3T program will begin to meet the needs each year for the millions of adults with major mental disorders that now are largely unrecognized and untreated., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To fill the gap in knowledge on systematic differences between primary care practices (PCP) that do or do not provide intensive behavioral therapy (IBT) for obese Medicare patients., Methods: A mixed modality survey (paper and online) of primary care practices obtained from a random sample of Medicare databases and a convenience sample of practice-based research network practices., Key Results: A total of 287 practices responded to the survey, including 140 (7.4% response rate) from the random sample and 147 (response rate not estimable) from the convenience sample. We found differences between the IBT-using and non-using practices in practice ownership, patient populations, and participation in Accountable Care Organizations. The non-IBT-using practices, though not billing for IBT, did offer some other assistance with obesity for their patients. Among those who had billed for IBT, but stopped billing, the most commonly cited reason was billing difficulties. Many providers experienced denied claims due to billing complexities., Conclusions: Although the Centers for Medicare and Medicaid Services established payment codes for PCPs to deliver IBT for obesity in 2011, very few providers submitted fee-for-service claims for these services after almost 10 years. A survey completed by both a random and convenience sample of practices using and not using IBT for obesity payment codes revealed that billing for these services was problematic, and many providers that began using the codes discontinued using them over the past 7 years., (© 2021. Society of General Internal Medicine.)

Background: To address the increasing burden of chronic disease, many primary care practices are turning to care management and the hiring of care managers to help patients coordinate their care and self-manage their conditions. Care management is often, but not always, proving effective at improving patient outcomes, but more evidence is needed., Methods: In this pair-matched cluster randomized trial, 5 practices implemented care management and were compared with 5 comparison practices within the same practice organization. Targeted patients included diabetic patients with a hemoglobin A1c >9% and nondiabetic obese patients. Clinical values tracked were A1c, blood pressure, low-density lipoprotein, microalbumin, and weight., Results: Clinically important improvements were demonstrated in the intervention versus comparison practices, with diabetic patients improving A1c control and obese patients experiencing weight loss. There was a 12% relative increase in the proportion of patients meeting the clinical target of A1c <7% (95% CI, 3%-20%), and 26% of obese nondiabetic patients in chronic care management practices lost 5% or more of their body weight as compared with 10% of comparison patients (adjusted relative improvement, 15%; CI, 2%-28%)., Conclusions: These findings add to the growing evidence-base for the effectiveness of care management as an effective clinical practice with regard to improving diabetes- and obesity-related outcomes.

Background: Use of Shared Decision-Making (SDM) and Decision Aids (DAs) has been encouraged but is not regularly implemented in primary care. The Office-Guidelines Applied to Practice (Office-GAP) intervention is an application of a previous model revised to address guidelines based care for low-income populations with diabetes and coronary heart disease (CHD)., Objective: To evaluate Office-GAP Program feasibility and preliminary efficacy on medication use, patient satisfaction with physician communication and confidence in decision in low-income population with diabetes and coronary heart disease (CHD) in a Federally Qualified Healthcare Center (FQHC)., Method: Ninety-five patients participated in an Office-GAP program. A quasi-experimental design study, over 6 months with 12-month follow-up. Office-GAP program integrates health literacy, communication skills education for patients and physicians, patient/physician decision support tools and SDM into routine care., Main Measures: 1) Implementation rates of planned program elements 2) Patient satisfaction with communication and confidence in decision, and 3) Medication prescription rates. We used the GEE method for hierarchical logistic models, controlling for confounding., Results: Feasibility of the Office-GAP program in the FQHC setting was established. We found significant increase in use of Aspirin/Plavix, statin and beta-blocker during follow-up compared to baseline: Aspirin OR 1.5 (95 % CI: 1.1, 2.2) at 3-months, 1.9 (1.3, 2.9) at 6-months, and 1.8 (1.2, 2.8) at 12-months. Statin OR 1.1 (1.0, 1.3) at 3-months and 1.5 (1.1, 2.2) at 12-months; beta-blocker 1.8 (1.1, 2.9) at 6-months and 12-months. Program elements were consistently used (≥ 98 % clinic attendance at training and tool used). Patient satisfaction with communication and confidence in decision increased., Conclusions: The use of Office-GAP program to teach SDM and use of DAs in real time was demonstrated to be feasible in FQHCs. It has the potential to improve satisfaction with physician communication and confidence in decisions and to improve medication use. The Office-GAP program is a brief, efficient platform for delivering patient and provider education in SDM and could serve as a model for implementing guideline based care for all chronic diseases in outpatient clinical settings. Further evaluation is needed to establish feasibility outside clinical study, reach, effectiveness and cost-effectiveness of this approach.

Background: The real world implementation of chronic care management model varies greatly. One aspect of this variation is the delivery mode. Two contrasting strategies include provider-delivered care management (PDCM) and health plan-delivered care management (HPDCM)., Objective: We aimed to compare the effectiveness of PDCM vs. HPDCM on improving clinical outcomes for patients with chronic diseases., Design: We used a quasi-experimental two-group pre-post design using the difference-in-differences method., Patients: Commercially insured patients, with any of the five chronic diseases-congestive heart failure, chronic obstructive pulmonary disease, coronary heart disease, diabetes, or asthma, who were outreached to and engaged in either PDCM or HPDCM were included in the study., Main Measures: Outreached patients were those who received an attempted or actual contact for enrollment in care management; and engaged patients were those who had one or more care management sessions/encounters with a care manager. Effectiveness measures included blood pressure, low density lipoprotein (LDL), weight loss, and hemoglobin A1c (for diabetic patients only). Primary endpoints were evaluated in the first year of follow-up., Key Results: A total of 4,000 patients were clustered in 165 practices (31 in PDCM and 134 in HPDCM). The PDCM approach demonstrated a statistically significant improvement in the proportion of outreached patients whose LDL was under control: the proportion of patients with LDL < 100 mg/dL increased by 3 % for the PDCM group (95 % CI: 1 % to 6 %) and 1 % for the HPDCM group (95 % CI: -2 % to 5 %). However, the 2 % difference in these improvements was not statistically significant (95 % CI: -2 % to 6 %). The HPDCM approach showed 3 % [95 % CI: 2 % to 6 %] improvement in overall diabetes care among outreached patients and significant reduction in obesity rates compared to PDCM (4 %, 95 % CI: 0.3 % to 8 %)., Conclusions: Both care management delivery modes may be viable options for improving care for patients with chronic diseases. In this commercially insured population, neither PDCM nor HPDCM resulted in substantial improvement in patients' clinical indicators in the first year. Different care management strategies within the provider-delivered programs need further investigation.

Objectives: We aimed to describe and contrast the targeting methods and engagement outcomes for health plan-delivered disease management with those of a provider-delivered care management program., Study Design: Health plan epidemiologists partnered with university health services researchers to conduct a quasi-experimental, mixed-methods study of a 2-year pilot. We used semi-structured interviews to assess the characteristics of program-targeting strategies, and calculated target and engagement rates from clinical encounter data., Methods: Five physician organizations (POs) with 51 participating practices implemented care management. Health plan member lists were sent monthly to the practices to accept patients, and then the practices sent back data reports regarding targeting and engagement in care management. Among patients accepted by the POs, we compared those who were targeted and engaged by POs with those who met health plan targeting criteria., Results: The health plan's targeting process combined claims algorithms and employer group preferences to identify candidates for disease management; on the other hand, several different factors influenced PO practices' targeting approaches, including clinical and personal knowledge of the patients, health assessment information, and availability of disease-relevant programs. Practices targeted a higher percentage of patients for care management than the health plan (38% vs 16%), where only 7% of these patients met the targeting criteria of both. Practices engaged a higher percentage of their targeted patients than the health plan (50% vs 13%)., Conclusions: The health plan's claims-driven targeting approach and the clinically based strategies of practices both provide advantages; an optimal model may be to combine the strengths of each approach to maximize benefits in care management.

Background: Care management in primary care can be effective in helping patients with chronic disease improve their health; however, primary care practices are often challenged to identify revenue to pay for it. This study explored the impact of direct reimbursement on the provision of care management in a primary care physician organization., Methods: Using data on expenses and health plan reimbursement during the initial 16 months of care management implementation at 5 practices, we calculated the percentage of related costs that were covered by payments. Qualitative data from interviews with practice members were used to identify their perceived barriers to care management reimbursement and the impact of current reimbursement strategies on service delivery., Results: Direct reimbursement for care management covered only 21% of the costs. Reimbursement varied by care manager background, patient diagnoses, insurer, and indication for the visit. Barriers to gaining reimbursement included patient resistance to copay, clinician hesitation to bill for care management visits (for fear the patient may receive a bill), differential reimbursement policies of insurers, and general lack of reimbursement for care management in many cases. Although practice-level quality improvement incentives were an alternative means of supporting care management, because these incentives were not directly tied to the service of care management, they were used for other activities ultimately supporting patient care., Conclusions: This study highlights the need for sufficient reimbursement to initiate and maintain care management for patients in primary care as proposed for service reforms under the Affordable Care Act., (© Copyright 2015 by the American Board of Family Medicine.)

Background: We hypothesized that somatizing patients managed by primary care physicians (PCP) would improve with a relationship-based intervention., Methods: We randomized 30 adults with medically unexplained symptoms to treatment or usual care. Four PCPs were trained to intervene with cognitive-behavioral, pharmacological, and patient-centered management and deployed the intervention with seven scheduled visits over 12 months. Outcomes obtained at baseline and 12 months were: Mental component summary (MCS), the primary endpoint, and measures of physical and psychological symptoms and of satisfaction with the PCP., Results: Patients averaged 52.5 years; 83.3% were female; 79.6% were black. Using a difference of differences approach, we found that the intervention produced a large effect size (ES) (0.82; CI: 0.08 to 1.57) for the MCS in the predicted direction, similar to the ES for physical (-0.80; CI: -1.55 to -0.04) and psychological (-1.06; CI: -1.83 to -0.28) improvement and for increased satisfaction with the PCP (0.94; CI: 0.15 to 1.74). Using ANCOVA in a sensitivity analysis, we found that the ES fell slightly (0.59), while other measures were unchanged., Conclusions: Moderate-large effect sizes support the hypothesis that PCPs can effectively treat somatization. This points to the importance of performing a full RCT.

Objective: This study sought to determine whether an intervention for patients with medically unexplained symptoms in primary care reduced total costs, components of cost, and longer-term costs and whether it led to decreased service use outside the health maintenance organization (HMO)., Methods: A randomized controlled trial involving 206 patients with medically unexplained symptoms was conducted in a staff-model HMO. The protocol emphasized the provider-patient relationship and included cognitive-behavioral therapy and pharmacological management. Cost data for medical treatments were derived from the HMO's electronic database. Patients were interviewed about work days lost and out-of-pocket expenses for medical care outside the HMO., Results: The difference in total costs ($1,071) for the 12-month intervention was not significant. The treatment group had significantly higher costs for antidepressants than the usual-care group ($192 higher) during the intervention, and a larger proportion received antidepressants. The intervention group used less medical care outside the HMO and missed one less work day per month on average (1.23 days), indicating a slight improvement in productivity, but the difference was not significant. The between-group difference in estimated total cost was smaller in the year after the intervention (difference of $341) but were not significant., Conclusions: The total costs for the intervention group were not significantly different, but the group had greater use of antidepressants. Coupled with findings of improved mental health outcomes for this group in a previous study, the results indicate that the intervention may be cost-effective. The longer-term impact needs to be further studied.

Objective: To fill the gap in knowledge on systematic differences between primary care practices (PCP) that do or do not provide intensive behavioral therapy (IBT) for obese Medicare patients. Methods: A mixed modality survey (paper and online) of primary care practices obtained from a random sample of Medicare databases and a convenience sample of practice-based research network practices. Key Results: A total of 287 practices responded to the survey, including 140 (7.4% response rate) from the random sample and 147 (response rate not estimable) from the convenience sample. We found differences between the IBT-using and non-using practices in practice ownership, patient populations, and participation in Accountable Care Organizations. The non-IBT-using practices, though not billing for IBT, did offer some other assistance with obesity for their patients. Among those who had billed for IBT, but stopped billing, the most commonly cited reason was billing difficulties. Many providers experienced denied claims due to billing complexities. Conclusions: Although the Centers for Medicare and Medicaid Services established payment codes for PCPs to deliver IBT for obesity in 2011, very few providers submitted fee-for-service claims for these services after almost 10 years. A survey completed by both a random and convenience sample of practices using and not using IBT for obesity payment codes revealed that billing for these services was problematic, and many providers that began using the codes discontinued using them over the past 7 years. [ABSTRACT FROM AUTHOR]