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Background: Through the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration, Medicare, Medicaid, and private payers offered supplemental payments to 849 primary care practices that became patient-centered medical homes (PCMHs) in eight states; practices also received technical assistance and data reports. Average Medicare payments were capped at $10 per beneficiary per month in each state.Objective: Since there was variation in the eight participating states' demonstration designs, experiences, and outcomes, we conducted a qualitative multi-case analysis to identify the key factors that differentiated states that were estimated to have generated net savings for Medicare from states that did not.Participants: States' MAPCP Demonstration initiatives were comprehensively profiled in case studies based on secondary document review, three rounds of annual interviews with state staff, payers, practices, and other stakeholders, and other data sources.Approach: Case study findings were summarized in a case-ordered predictor-outcome matrix, which identified the presence or absence of key demonstration design features and experiences and arrayed states based on the amount of net savings or losses they generated for Medicare. We then used this matrix to identify initiative features that were present in at least three of the four states that generated net savings and absent from at least three of the four states that did not generate savings.Results: A majority of the states that generated net savings: required practices to be recognized PCMHs to enter the demonstration, did not allow late entrants into the demonstration, used a consistent demonstration payment model across participating payers, and offered practices opportunities to earn performance bonuses. Practices in states that generated net savings also tended to report receiving the demonstration payments and bonuses they expected to receive, without any issues.Conclusions: Designers of future PCMH initiatives may increase their likelihood of generating net savings by incorporating the demonstration features we identified. [ABSTRACT FROM AUTHOR]

Coastal ecosystems provide important ecosystem services for millions of people. Climate change is modifying coastal ecosystem food web structure and function and threatens these essential ecosystem services. We used a combination of two new and one existing ecosystem food web models and altered scenarios that are possible with climate change to quantify the impacts of climate change on ecosystem stability in three coastal bays in Maine, United States. We also examined the impact of climate change on bivalve fisheries and aquaculture. Our modeled scenarios explicitly considered the predicted effects of future climatic change and human intervention and included: 1) the influence of increased terrestrial dissolved organic carbon loading on phytoplankton biomass; 2) benthic community change driven by synergisms between climate change, historical overfishing, and increased species invasion; and 3) altered trophic level energy transfer driven by ocean warming and acidification. The effects of climate change strongly negatively influenced ecosystem energy flow and ecosystem stability and negatively affected modeled bivalve carrying capacity in each of our models along the Maine coast of the eastern United States. Our results suggest that the interconnected nature of ecosystem food webs make them extremely vulnerable to synergistic effects of climate change. To better inform fisheries and aquaculture management, the effects of climate change must be explicitly incorporated. • Food web models and scenarios were used to forecast effects of climate change. • Modeled bays were vulnerable to the effects of climate change. • In two of three study bays the ability to support bivalve aquaculture disappeared. [ABSTRACT FROM AUTHOR]

Background: Through the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration, Medicare, Medicaid, and private payers offered supplemental payments to 849 primary care practices that became patient-centered medical homes (PCMHs) in eight states; practices also received technical assistance and data reports. Average Medicare payments were capped at $10 per beneficiary per month in each state., Objective: Since there was variation in the eight participating states' demonstration designs, experiences, and outcomes, we conducted a qualitative multi-case analysis to identify the key factors that differentiated states that were estimated to have generated net savings for Medicare from states that did not., Participants: States' MAPCP Demonstration initiatives were comprehensively profiled in case studies based on secondary document review, three rounds of annual interviews with state staff, payers, practices, and other stakeholders, and other data sources., Approach: Case study findings were summarized in a case-ordered predictor-outcome matrix, which identified the presence or absence of key demonstration design features and experiences and arrayed states based on the amount of net savings or losses they generated for Medicare. We then used this matrix to identify initiative features that were present in at least three of the four states that generated net savings and absent from at least three of the four states that did not generate savings., Results: A majority of the states that generated net savings: required practices to be recognized PCMHs to enter the demonstration, did not allow late entrants into the demonstration, used a consistent demonstration payment model across participating payers, and offered practices opportunities to earn performance bonuses. Practices in states that generated net savings also tended to report receiving the demonstration payments and bonuses they expected to receive, without any issues., Conclusions: Designers of future PCMH initiatives may increase their likelihood of generating net savings by incorporating the demonstration features we identified.