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BACKGROUND: Increasing clinician awareness of racial disparities and improving communication may enhance diabetes care among black patients. OBJECTIVE: To evaluate the effect of cultural competency training and performance feedback for primary care clinicians on diabetes care for black patients. DESIGN: Cluster randomized, controlled trial conducted between June 2007 and May 2008. (ClinicalTrials.gov registration number: NCT00436176) SETTING: 8 ambulatory health centers in eastern Massachusetts. PARTICIPANTS: 124 primary care clinicians caring for 2699 (36%) black and 4858 (64%) white diabetic patients. Intervention: Intervention clinicians received cultural competency training and monthly race-stratified performance reports that highlighted racial differences in control of hemoglobin A(1c) (HbA(1c)) and low-density lipoprotein (LDL) cholesterol levels and blood pressure. MEASUREMENTS: Clinician awareness of racial differences in diabetes care and rates of achieving clinical control targets among black patients at 12 months. RESULTS: White and black patients differed significantly in baseline rates of achieving an HbA(1c) level less than 7% (46% vs. 40%), an LDL cholesterol level less than 2.59 mmol/L (<100 mg/dL) (55% vs. 43%), and blood pressure less than 130/80 mm Hg (32% vs. 24%) (all P < 0.050). At study completion, intervention clinicians were significantly more likely than control clinicians to acknowledge the presence of racial disparities in the 8 health centers as a whole (82% vs. 59%; P = 0.003), within their local health center (70% vs. 51%; P = 0.020), and among their own patients (63% vs. 43%; P = 0.037). Black patients of clinicians in the intervention and control groups did not differ at 12 months in rates of controlling HbA(1c) level (48% vs. 45%; P = 0.24), LDL cholesterol level (48% vs. 49%; P = 0.40), or blood pressure (23% vs. 25%; P = 0.47). LIMITATION: 11% of primary care teams did not attend cultural competency training sessions. CONCLUSION: The combination of cultural competency training and race-stratified performance reports increased clinician awareness of racial disparities in diabetes care but did not improve clinical outcomes among black patients. [ABSTRACT FROM AUTHOR]

Background: Lack of awareness may be a significant barrier to participation by low- and middle-income seniors in pharmaceutical cost-assistance programs. Objective: The goal of this study was to determine whether older adults' awareness of 2 major state and federal pharmaceutical cost-assistance programs was associated with the seniors' ability to access and process information about assistance programs. Methods: Data were gathered from a cross-sectional study of independently living, English- or Spanish-speaking adults aged >/=60 years. Participants were interviewed in 30 community-based settings (19 apartment complexes and 11 senior centers) in New York, New York. The analysis focused on adults aged >/=65 years who lacked Medicaid coverage. Multivariable logistic regression was used to model program awareness as a function of information access (family/social support, attendance at senior or community centers and places of worship, viewing of live health insurance presentations, instrumental activities of daily living, site of medical care, computer use, and having a proxy decision maker for health insurance matters) and information-processing ability (education level, English proficiency, health literacy, and cognitive function). The main outcome measure was awareness of New York's state pharmaceutical assistance program (Elderly Pharmaceutical Insurance Coverage [EPIC]]) and the federal Medicare Part D low-income subsidy program (Extra Help). Results: A total of 269 patients were enrolled (mean [SD] age, 76.9 [7.5] years; 32.0% male; 39.9% white). Awareness of the programs differed widely: 77.3%) knew of EPIC! and 22.3% knew of Extra Help. In multivariable analysis, study participants were more likely to have heard of the EPIC program if they had attended a live presentation about health insurance issues (adjusted odds ratio [AOR], 3.40; 95% CI, 1.20-9.61) and less likely if they received care in a clinic (AOR, 0.45; 95% CI, 0.23-0.92). Awareness of Extra Help in the multivariable models was more likely among study participants who had viewed a live health insurance presentation (AOR, 3.35; 95% CI, 1.55-7.24) and less likely for those with inadequate health literacy (AOR, 0.15; 95% CI, 0.03-0.74). Conclusions: Viewing of live health insurance presentations and adequate health literacy were associated with greater awareness of important pharmaceutical cost-assistance programs in this study in low-income, elderly individuals. The findings suggest that use of live presentations, in addition to health literacy materials and messages, may be important strategies in promoting knowledge of and enrollment in state and federal pharmaceutical cost-assistance programs for low-income seniors. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the use of a modified Consumer Assessment of Healthcare Providers and Systems (CAHPS(R)) survey to support quality improvement in a collaborative focused on patient-centred care, assess subsequent changes in patient experiences, and identify factors that promoted or impeded data use. Background Healthcare systems are increasingly using surveys to assess patients' experiences of care but little is established about how to use these data in quality improvement. Design Process evaluation of a quality improvement collaborative. Setting and participants The CAHPS team from Harvard Medical School and the Institute for Clinical Systems Improvement organized a learning collaborative including eight medical groups in Minnesota. Intervention Samples of patients recently visiting each group completed a modified CAHPS(R) survey before, after and continuously over a 12-month project. Teams were encouraged to set goals for improvement using baseline data and supported as they made interventions with bi-monthly collaborative meetings, an online tool reporting the monthly data, a resource manual called The CAHPS(R) Improvement Guide, and conference calls. Main outcome measures Changes in patient experiences. Interviews with team leaders assessed the usefulness of the collaborative resources, lessons and barriers to using data. Results Seven teams set goals and six made interventions. Small improvements in patient experience were observed in some groups, but in others changes were mixed and not consistently related to the team actions. Two successful groups appeared to have strong quality improvement structures and had focussed on relatively simple interventions. Team leaders reported that frequent survey reports were a powerful stimulus to improvement, but that they needed more time and support to engage staff and clinicians in changing their behaviour. Conclusions Small measurable improvements in patient experience may be achieved over short projects. Sustaining more substantial change is likely to require organizational strategies, engaged leadership, cultural change, regular measurement and performance feedback and experience of interpreting and using survey data. [ABSTRACT FROM AUTHOR]

Objective: Patient care experience survey data might be useful for managing individual physician malpractice risk, but available evidence is limited. This study assesses whether patients' experiences with individual physicians, as measured by a validated survey, are associated with patient complaints and malpractice lawsuits.Design: Random samples of active patients in physicians' panels, with sample sizes adequate to provide highly reliable, stable information about patients' experiences with each physician (n = 19 202, average respondents per physician = 119) were used to assess the relation of patient survey measures to malpractice risk.Setting: A large multi-specialty physician organization in eastern Massachusetts, USA.Participants: Physicians providing care for at least 5 years in adult primary care and select high-risk specialty departments between January 1996 and December 2005 (n = 161).Main Outcome Measures: Patient complaints (2001-05) and malpractice lawsuits (1996-2005).Results: Compared to primary care physicians, high-risk specialists had a lower patient complaint rate (0.34 vs. 1.36 complaints per patient care full time equivalent; P < 0.001), but a higher lawsuit rate (0.09 vs. 0.05 lawsuits per patient care full time equivalent; P = 0.02). Irrespective of physician specialty, the quality of physician-patient interactions (IRR = 0.61; P < 0.001) and care coordination (IRR = 0.65; P < 0.001) were inversely associated with patient complaints. Patient survey measures were not associated with malpractice lawsuits.Conclusions: The results underscore the challenges organizations face when attempting to use patient survey data to manage individual physician medical malpractice risk. Because lawsuits are infrequent events, calibrating these validated patient survey measures to malpractice lawsuit risk will require large physician samples from diverse practices. [ABSTRACT FROM AUTHOR]

BACKGROUND: Multidisciplinary teams may hold promise for improving primary care quality. This study examined the influence of multidisciplinary teams on patients' assessments of primary care, including access, integration, and clinician-patient interaction quality. METHODS: From January 2004 through March 2005, a large multispecialty practice in Massachusetts obtained data monthly from patients of 145 primary care physicians using a well-validated patient questionnaire. The analytic sample included respondents with at least 2 primary care visits over the study period (n=14,835). For each respondent, administrative data were used to compute visit continuity over the study period and to classify each primary care visit as PCP, on-team, or off-team. Multivariate regression modeled the relationship of visit continuity to each primary care measure. RESULTS: Approximately one-third of patients (35%) saw only their PCP; 15% had only PCP and 'on-team' visits; 9% had a mix of PCP, on-, and off-team visits; and 41% had only 'off-team' visits when not seeing their PCP. Greater PCP continuity was associated with more favorable scores on nearly all measures (P<0.001). An exception was patients' assessments of teams, which were better when on- versus off-team visits occurred (P<0.01). For other measures, the decrements associated with discontinuity were the same irrespective of whether discontinuities involved on- or off-team visits. CONCLUSIONS: The finding that PCP visit discontinuities are associated with more negative care experiences, irrespective of whether discontinuities involve on- or off-team visits, highlights the challenges of incorporating teams into primary care in ways that patients experience as value-added rather than disruptive to primary care relationships. [ABSTRACT FROM AUTHOR]

Background: There is increasing interest in measuring patients' experiences with individual physicians, and empirical evidence supports this area of measurement. However, the high cost of data collection remains a significant barrier. Survey modes with the potential to lower costs, such as Internet and interactive voice response (IVR) telephone, are attractive alternatives to mail, but their comparative response rates and data quality have not been tested.Methods: We randomly assigned adult patients from the panels of 62 primary care physicians in California to complete a brief, validated patient questionnaire by mail, Internet (web), or IVR. After 2 invitations, web and IVR nonrespondents were mailed a paper copy of the survey ("crossover" to mail). We analyzed and compared (n = 9126) the response rates, respondent characteristics, substantive responses, and costs by mode (mail, web and IVR) and evaluated the impact of "crossover" respondents.Results: Response rates were higher by mail (50.8%) than web (18.4%) or IVR (34.7%), but after crossover mailings, response rates in each arm were approximately 50%. Mail and web produced identical scores for individual physicians, but IVR scores were significantly lower even after adjusting for respondent characteristics. There were no significant physician-mode interactions, indicating that statistical adjustment for mode resolves the IVR effect. Web and IVR costs were higher than mail.Conclusions: The equivalence of individual physician results in mail and web modes is noteworthy, as is evidence that IVR results are comparable after adjustment for mode. However, the higher overall cost of web and IVR, as the result of the need for mailings to support these modes, suggests that they do not presently solve cost concerns related to obtaining physician-specific information from patients. [ABSTRACT FROM AUTHOR]

From the earliest definitions of the term primary care to the most recent, all have stressed that primary care is predicated on a sustained relationship between patients and the clinicians who care for them. Primary care differentiates itself from other areas of medicine by attending to the whole person, in the context of the patient's personal and medical history and life circumstances, rather than focusing on a particular disease, organ, or system. Finally, the primary care physician plays a distinctive role in integrating the care that patients receive from within and outside of the primary care setting. Data obtained from patients over the past 15 years demonstrate that most Americans have a physician whom they consider to be their primary physician. This was the case well before the rules of managed care plans required patients to align themselves with a particular primary care physician and to allow that physician to coordinate all of their medical care. However, information from patients indicates that despite primary care relationships that endure over several years, the ideals of whole-person, integrated care are largely unmet in patients' primary care experiences. Moreover, considerable evidence indicates that the quality of primary care relationships has eroded over the past several years. This article highlights the relative strengths and weaknesses of primary care, as experienced and reported by patients, and posits three areas that must be addressed for primary care to live up to the ideals of sustained partnerships providing whole-person, integrated care. These three areas involve the use of teams in medicine, the establishment of meaningful primary care partnerships, and integration of care in a delivery system that patients experience as increasingly fragmented. [ABSTRACT FROM AUTHOR]

A growing scientific literature highlights concern about the influence of social bias in medical care. Differential treatment of male and female patients has been among the documented concerns. Yet, little is known about the extent to which differential treatment of male and female patients reflects the influence of social bias or of more acceptable factors, such as different patient preferences or different anticipated outcomes of care. This paper attempts to ascertain the underlying basis for an observed differential in physicians' tendency to advice activity restrictions for male and female patients. We explore the extent to which the gender-based treatment differential is attributable to: (1) patients' health profile, (2) patients' role responsibilities, (3) patients' illness behaviors, and (4) physician characteristics. These four categories of variables correspond to four prominent social science hypotheses concerning gender differences in health and health care utilization (i.e, biological basis hypothesis, fixed role hypothesis, socialization hypothesis, physician bias hypothesis). Data are drawn from the Medical Outcomes Study (MOS), a longitudinal observational study of 1546 patients of 349 physicians practicing in three U.S. cities. Multivariate logistic regression is used to evaluate the likelihood of physician-prescribed activity restrictions for male and female patients, and to explore the absolute and relative influence of patient and physician factors on the observed treatment differential. Results reveal that the odds of prescribed activity restrictions are 3.6 times higher for female patients than for males with equivalent characteristics. The observed differential is not explained by differences in male and female patients' health or role responsibilities. Gender differences in illness behavior and physician gender biases both appear to contribute to the observed differential. Female patients exhibit more illness behavior than males, and these behaviors increase physicians' tendency to prescribe activity restrictions. After accounting for illness behavior differences and all other factors, the odds of prescribed activity restrictions among female patients of male physicians is four times that of equivalent male patients of those physicians. Medical practice, education, and research must strive to identify and remove the likely unconscious role of social bias in medical decision making. [ABSTRACT FROM AUTHOR]

Objective: To examine differences in the quality of primary care delivered in prepaid and fee-for-service (FFS) health care systems.Study Design: Longitudinal study of 1208 adult patients with chronic disease whose health insurance was through a traditional indemnity (FFS) plan, an independent practice association (IPA), or a health maintenance organization (HMO). Both IPA and HMO represent prepaid care systems. Patient- and physician-provided information was obtained by self-administered questionnaires.Setting: A total of 303 physician offices (family medicine, general internal medicine, endocrinology, or cardiology) in solo and group practices in three US cities.Outcomes Measures: Seven indicators of primary care quality--accessibility (financial and organizational), continuity, comprehensiveness, coordination, and accountability (interpersonal and technical) of care. Performance on each was evaluated in FFS, IPA, and HMO settings. Analyses controlled for patient and physician characteristics.Results: Financial access was highest in prepaid systems. Organizational access, continuity, and accountability were highest in the FFS system. Coordination was highest and comprehensiveness was lowest in HMOs.Conclusions: The results mark notable differences in core dimensions of primary care quality in each of three payment systems and raise questions regarding the associated cost inefficiencies and outcomes of care. In the current health care delivery reform climate, these findings call for consideration of the relative strengths and weaknesses of each system. We suggest strategies for elevating performance in each. [ABSTRACT FROM AUTHOR]

Context: The US Preventive Services Task Force recommends that physicians assess patients' health risk behaviors, addressing those needing modification.Objective: To examine the relationship between patient income, health risk behaviors, the prevalence of physician discussion of these behaviors, and the receptiveness of patients to their physicians' advice.Design: Employee survey.Participants: A random sample of 6549 Massachusetts state employees in 12 health plans.Main Outcome Measures: Data were obtained using a patient-completed mail survey. Trend tests were used to discern differences in the prevalence of health risk behaviors, physician discussion of these behaviors, and patient receptiveness to discussions by patient income.Results: Although unhealthy behaviors were common among all income groups, physician discussion of health risk behaviors fell far short of the universal risk assessment recommended by the US Preventive Services Task Force. Low-income patients were more likely to be obese and smoke than high-income patients and were less likely to wear seat belts and exercise. In contrast, stress and alcohol consumption increased with income, while the proportion of heavy drinkers did not vary significantly. Physicians were more likely to discuss diet and exercise with high-income patients in need of these discussions than with low-income patients, but were more likely to discuss smoking with low-income patients who smoked than with high-income patients who smoked. Among patients with whom discussions occurred, low-income patients were much more likely to report attempting to change their behavior based on physician advice.Conclusions: Physician counseling of patients regarding health risk behaviors should be greatly improved if the US Preventive Services Task Force recommendations are to be fulfilled. Improvement is especially needed in regard to alcohol consumption, safe sex, and seat belt use. Physicians also need to be more vigilant in properly identifying and counseling low-income patients at risk in regard to diet and exercise and high-income patients who smoke. [ABSTRACT FROM AUTHOR]

As policymakers debate adding a drug benefit to Medicare, many states are attempting to provide drug coverage for low-income seniors through Medicaid and state-funded pharmacy assistance programs. This 2001 survey of seniors in eight states finds marked differences among states in the percentage of seniors with coverage and in the sources providing coverage. Among low-income seniors, a range of 20 percent (New York and California) to 38 percent (Michigan and Texas) lacked drug coverage. In all states Medicaid was an important source of coverage for the poor, but the depth of Medicaid drug coverage varied widely across states. Even states with pharmacy assistance programs fell far short of closing the prescription coverage gap for low-income seniors. Finally, the study finds that classifying beneficiaries as either having coverage or not misses major differences in depth of coverage, with some sources of coverage appearing only marginally better than no coverage at all. With erosion of state and private sources of prescription benefits expected, the findings speak to the need for a national policy solution. [ABSTRACT FROM AUTHOR]

OBJECTIVE: 'Four Habits' is the first larger generic clinical communication program to have a documented effect. It has not been evaluated outside USA. In a pilot study, Norwegian hospital physicians assessed its usefulness, and we developed a questionnaire where patients reported 'Four Habits'-specific physician behaviour. METHODS: We ran a 3-day course with 16 participants and three US facilitators. The questionnaire mapping 'Four Habits' with 23 items was distributed by participating physicians to 210 patients. Participating physicians met in evaluative focus groups 3 months after the course. RESULTS: The questionnaire was condensed to 10 items after factorial analysis. The resulting scale performed well. A large amount of missing data on some items suggested that patients found it difficult to evaluate details of 'Four Habits'-specific physician behaviour. Participants found that the 'Four Habits' short course led to improvement of their encounters. Some elements of the method were not perceived as relevant for all types of encounters (habits II and III). CONCLUSION: 'Four Habits' is applicable outside US with some adjustments. A shortened version of the questionnaire will be used in a planned randomized controlled trial. [ABSTRACT FROM AUTHOR]

A national survey in 2006 found that Part D secured drug coverage for most seniors who were without it in 2005, prior to the Medicare drug benefit. Seniors without drug coverage in 2006 generally fell into two groups: those in relatively good health and those potentially difficult to reach. Compared with seniors covered through employer plans or the Department of Veterans Affairs, Part D enrollees had higher out-of-pocket spending and greater cost-related nonadherence. Low-income subsidies offered protection against high out-of-pocket spending; without them, one-third of Part D enrollees at or below 150 percent of poverty paid more than $100 a month for their medications. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence of clinical significance reporting in contemporary comparative effectiveness research (CER)., Background: In CER, a statistically significant difference between study groups may or may not be clinically significant. Misinterpreting statistically significant results could lead to inappropriate recommendations that increase health care costs and treatment toxicity., Methods: CER studies from 2022 issues of the Annals of Surgery , Journal of the American Medical Association , Journal of Clinical Oncology , Journal of Surgical Research , and Journal of the American College of Surgeons were systematically reviewed by 2 different investigators. The primary outcome of interest was whether the authors specified what they considered to be a clinically significant difference in the "Methods.", Results: Of 307 reviewed studies, 162 were clinical trials and 145 were observational studies. Authors specified what they considered to be a clinically significant difference in 26 studies (8.5%). Clinical significance was defined using clinically validated standards in 25 studies and subjectively in 1 study. Seven studies (2.3%) recommended a change in clinical decision-making, all with primary outcomes achieving statistical significance. Five (71.4%) of these studies did not have clinical significance defined in their methods. In randomized controlled trials with statistically significant results, sample size was inversely correlated with effect size ( r = -0.30, P = 0.038)., Conclusions: In contemporary CER, most authors do not specify what they consider to be a clinically significant difference in study outcome. Most studies recommending a change in clinical decision-making did so based on statistical significance alone, and clinical significance was usually defined with clinically validated standards., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Ever-increasing concern about the cost and burden of quality measurement and reporting raises the question: How much do patients benefit from provider arrangements that incentivize performance improvements? We used national performance data to estimate the benefits in terms of lives saved and harms avoided if US health plans improved performance on 2 widely used quality measures: blood pressure control and colorectal cancer screening. We modeled potential results both in California Marketplace plans, where a value-based purchasing initiative incentivizes improvement, and for the US population across 4 market segments (Medicare, Medicaid, Marketplace, commercial). The results indicate that if the lower-performing health plans improve to 66th percentile benchmark scores, it would decrease annual hypertension and colorectal cancer deaths by approximately 7% and 2%, respectively. These analyses highlight the value of assessing performance accountability initiatives for their potential lives saved and harms avoided, as well as their costs and efforts., Competing Interests: Conflicts of interest Please see ICMJE form(s) for author conflicts of interest. These have been provided as supplementary materials., (© The Author(s) 2024. Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc.)

Background: Population-based global payment gives health care providers a spending target for the care of a defined group of patients. We examined changes in spending, utilization, and quality through 8 years of the Alternative Quality Contract (AQC) of Blue Cross Blue Shield (BCBS) of Massachusetts, a population-based payment model that includes financial rewards and penalties (two-sided risk)., Methods: Using a difference-in-differences method to analyze data from 2006 through 2016, we compared spending among enrollees whose physician organizations entered the AQC starting in 2009 with spending among privately insured enrollees in control states. We examined quantities of sentinel services using an analogous approach. We then compared process and outcome quality measures with averages in New England and the United States., Results: During the 8-year post-intervention period from 2009 to 2016, the increase in the average annual medical spending on claims for the enrollees in organizations that entered the AQC in 2009 was $461 lower per enrollee than spending in the control states (P<0.001), an 11.7% relative savings on claims. Savings on claims were driven in the early years by lower prices and in the later years by lower utilization of services, including use of laboratory testing, certain imaging tests, and emergency department visits. Most quality measures of processes and outcomes improved more in the AQC cohorts than they did in New England and the nation in unadjusted analyses. Savings were generally larger among subpopulations that were enrolled longer. Enrollees of organizations that entered the AQC in 2010, 2011, and 2012 had medical claims savings of 11.9%, 6.9%, and 2.3%, respectively, by 2016. The savings for the 2012 cohort were statistically less precise than those for the other cohorts. In the later years of the initial AQC cohorts and across the years of the later-entry cohorts, the savings on claims exceeded incentive payments, which included quality bonuses and providers' share of the savings below spending targets., Conclusions: During the first 8 years after its introduction, the BCBS population-based payment model was associated with slower growth in medical spending on claims, resulting in savings that over time began to exceed incentive payments. Unadjusted measures of quality under this model were higher than or similar to average regional and national quality measures. (Funded by the National Institutes of Health.)., (Copyright © 2019 Massachusetts Medical Society.)

As population-based payment models become increasingly common, it is crucial to understand how such payment models affect health disparities. We evaluated health care quality and spending among enrollees in areas with lower versus higher socioeconomic status in Massachusetts before and after providers entered into the Alternative Quality Contract, a two-sided population-based payment model with substantial incentives tied to quality. We compared changes in process measures, outcome measures, and spending between enrollees in areas with lower and higher socioeconomic status from 2006 to 2012 (outcome measures were measured after the intervention only). Quality improved for all enrollees in the Alternative Quality Contract after their provider organizations entered the contract. Process measures improved 1.2 percentage points per year more among enrollees in areas with lower socioeconomic status than among those in areas with higher socioeconomic status. Outcome measure improvement was no different between the subgroups; neither were changes in spending. Larger or comparable improvements in quality among enrollees in areas with lower socioeconomic status suggest a potential narrowing of disparities. Strong pay-for-performance incentives within a population-based payment model could encourage providers to focus on improving quality for more disadvantaged populations., (Project HOPE—The People-to-People Health Foundation, Inc.)

On July 14, 2015, ProPublica published its Surgeon Scorecard , which displays "Adjusted Complication Rates" for individual, named surgeons for eight surgical procedures performed in hospitals. Public reports of provider performance have the potential to improve the quality of health care that patients receive. A valid performance report can drive quality improvement and usefully inform patients' choices of providers. However, performance reports with poor validity and reliability are potentially damaging to all involved. This article critiques the methods underlying the Scorecard and identifies opportunities for improvement. Until these opportunities are addressed, the authors advise users of the Scorecard -most notably, patients who might be choosing their surgeons-not to consider the Scorecard a valid or reliable predictor of the health outcomes any individual surgeon is likely to provide. The authors hope that this methodological critique will contribute to the development of more-valid and more-reliable performance reports in the future.

Background: Spending and quality under global budgets remain unknown beyond 2 years. We evaluated spending and quality measures during the first 4 years of the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC)., Methods: We compared spending and quality among enrollees whose physician organizations entered the AQC from 2009 through 2012 with those among persons in control states. We studied spending changes according to year, category of service, site of care, experience managing risk contracts, and price versus utilization. We evaluated process and outcome quality., Results: In the 2009 AQC cohort, medical spending on claims grew an average of $62.21 per enrollee per quarter less than it did in the control cohort over the 4-year period (P<0.001). This amount is equivalent to a 6.8% savings when calculated as a proportion of the average post-AQC spending level in the 2009 AQC cohort. Analogously, the 2010, 2011, and 2012 cohorts had average savings of 8.8% (P<0.001), 9.1% (P<0.001), and 5.8% (P=0.04), respectively, by the end of 2012. Claims savings were concentrated in the outpatient-facility setting and in procedures, imaging, and tests, explained by both reduced prices and reduced utilization. Claims savings were exceeded by incentive payments to providers during the period from 2009 through 2011 but exceeded incentive payments in 2012, generating net savings. Improvements in quality among AQC cohorts generally exceeded those seen elsewhere in New England and nationally., Conclusions: As compared with similar populations in other states, Massachusetts AQC enrollees had lower spending growth and generally greater quality improvements after 4 years. Although other factors in Massachusetts may have contributed, particularly in the later part of the study period, global budget contracts with quality incentives may encourage changes in practice patterns that help reduce spending and improve quality. (Funded by the Commonwealth Fund and others.).

In 2009, Blue Cross Blue Shield of Massachusetts implemented a global budget-based payment system, the Alternative Quality Contract (AQC), in which provider groups assumed accountability for spending. We investigate the impact of global budgets on the utilization of prescription drugs and related expenditures. Our analyses indicate no statistically significant evidence that the AQC reduced the use of drugs. Although the impact may change over time, early evidence suggests that it is premature to conclude that global budget systems may reduce access to medications., (© The Author(s) 2014.)

Objective: To examine the 2-year effect of Blue Cross Blue Shield of Massachusetts' global budget arrangement, the Alternative Quality Contract (AQC), on pediatric quality and spending for children with special health care needs (CSHCN) and non-CSHCN., Methods: Using a difference-in-differences approach, we compared quality and spending trends for 126,975 unique 0- to 21-year-olds receiving care from AQC groups with 415,331 propensity-matched patients receiving care from non-AQC groups; 23% of enrollees were CSHCN. We compared quality and spending pre (2006-2008) and post (2009-2010) AQC implementation, adjusting analyses for age, gender, health risk score, and secular trends. Pediatric outcome measures included 4 preventive and 2 acute care measures tied to pay-for-performance (P4P), 3 asthma and 2 attention-deficit/hyperactivity disorder quality measures not tied to P4P, and average total annual medical spending., Results: During the first 2 years of the AQC, pediatric care quality tied to P4P increased by +1.8% for CSHCN (P < .001) and +1.2% for non-CSHCN (P < .001) for AQC versus non-AQC groups; quality measures not tied to P4P showed no significant changes. Average total annual medical spending was ~5 times greater for CSHCN than non-CSHCN; there was no significant impact of the AQC on spending trends for children., Conclusions: During the first 2 years of the contract, the AQC had a small but significant positive effect on pediatric preventive care quality tied to P4P; this effect was greater for CSHCN than non-CSHCN. However, it did not significantly influence (positively or negatively) CSHCN measures not tied to P4P or affect per capita spending for either group.

Objectives: The objective was to identify the effect of the Alternative Quality Contract (AQC), a global payment system implemented by Blue Cross Blue Shield (BCBS) of Massachusetts in 2009, on emergency department (ED) presentations., Methods: Blue Cross Blue Shield of Massachusetts claims from 2006 through 2009 for 332,624 enrollees whose primary care physicians (PCPs) enrolled in the AQC, and 1,296,399 whose PCPs were not enrolled in the AQC, were evaluated. A pre-post, intervention-control, propensity-scored difference-in-difference approach was used to isolate the AQC effect on ED visits. The analysis adjusted for age, sex, health status, and secular trends to compare ED use between the treatment and control groups., Results: Overall, secular trends showed that the number of ED visits decreased slightly for both treatment and control groups. The adjusted analysis of the AQC group showed decreases from 0.131 to 0.127 visits per member/quarter, and the control group decreased from 0.157 to 0.152 visits per member/quarter. The difference-in-difference analysis showed the AQC had no statistically significant effect on total ED use compared to the control group., Conclusions: In the first year of this AQC, we did not find evidence of change in aggregate ED use. Similar global budget programs may not alter ED use in the initial implementation period., (© 2013 by the Society for Academic Emergency Medicine.)

Background: In 2009-2010, Blue Cross Blue Shield of Massachusetts entered into global payment contracts (the Alternative Quality contract, AQC) with 11 provider organizations. We evaluated the impact of the AQC on spending and utilization of several categories of medical technologies, including one considered high value (colonoscopies) and three that include services that may be overused in some situations (cardiovascular, imaging, and orthopedic services)., Methods: Approximately 420,000 unique enrollees in 2009 and 180,000 in 2010 were linked to primary care physicians whose organizations joined the AQC. Using three years of pre-intervention data and a large control group, we analyzed changes in utilization and spending associated with the AQC with a propensity-weighted difference-in-differences approach adjusting for enrollee demographics, health status, secular trends, and cost-sharing., Results: In the 2009 AQC cohort, total volume of colonoscopies increased 5.2 percent (p=0.04) in the first two years of the contract relative to control. The contract was associated with varied changes in volume for cardiovascular and imaging services, but total spending on cardiovascular services in the first two years decreased by 7.4% (p=0.02) while total spending on imaging services decreased by 6.1% (p<0.001) relative to control. In addition to lower utilization of higher-priced services, these decreases were also attributable to shifting care to lower-priced providers. No effect was found in orthopedics., Conclusions: As one example of a large-scale global payment initiative, the AQC was associated with higher use of colonoscopies. Among several categories of services whose value may be controversial, the contract generally shifted volume to lower-priced facilities or services.

Variability in medical practice in the United States leads to higher costs without achieving better patient outcomes. Clinical practice guidelines, which are intended to reduce variation and improve care, have several drawbacks that limit the extent of buy-in by clinicians. In contrast, standardized clinical assessment and management plans (SCAMPs) offer a clinician-designed approach to promoting care standardization that accommodates patients' individual differences, respects providers' clinical acumen, and keeps pace with the rapid growth of medical knowledge. Since early 2009 more than 12,000 patients have been enrolled in forty-nine SCAMPs in nine states and Washington, D.C. In one example, a SCAMP was credited with increasing clinicians' rate of compliance with a recommended specialist referral for children from 19.6 percent to 75 percent. In another example, SCAMPs were associated with an 11-51 percent decrease in total medical expenses for six conditions when compared with a historical cohort. Innovative tools such as SCAMPs should be carefully examined by policy makers searching for methods to promote the delivery of high-quality, cost-effective care.

Seven provider organizations in Massachusetts entered the Blue Cross Blue Shield Alternative Quality Contract in 2009, followed by four more organizations in 2010. This contract, based on a global budget and pay-for-performance for achieving certain quality benchmarks, places providers at risk for excessive spending and rewards them for quality, similar to the new Pioneer Accountable Care Organizations in Medicare. We analyzed changes in spending and quality associated with the Alternative Quality Contract and found that the rate of increase in spending slowed compared to control groups, more so in the second year than in the first. Overall, participation in the contract over two years led to savings of 2.8 percent (1.9 percent in year 1 and 3.3 percent in year 2) compared to spending in nonparticipating groups. Savings were accounted for by lower prices achieved through shifting procedures, imaging, and tests to facilities with lower fees, as well as reduced utilization among some groups. Quality of care also improved compared to control organizations, with chronic care management, adult preventive care, and pediatric care within the contracting groups improving more in year 2 than in year 1. These results suggest that global budgets with pay-for-performance can begin to slow underlying growth in medical spending while improving quality of care.

Objective: To assess the relationship between clinical care metrics and patient experiences of care among patients with chronic disease., Design: Cross-sectional survey and clinical performance data., Setting: Eighty-nine medical groups across California caring for patients with chronic disease., Participants: Using patient surveys, we identified 51 129 patients with a chronic disease., Main Outcome Measures: Using patient surveys, we produced five composite measures of patient experiences of care and self-management support (scale 0-100). Using Health Plan Employer Data and Information Set data, we analyzed care for asthma, diabetes and cardiovascular disease, producing one composite summarizing clinical processes of care and one composite summarizing outcomes of care. We calculated adjusted Spearman's correlation coefficients to assess the relationship between patient experiences of care, clinical processes and clinical outcomes., Results: Clinical performance was higher for process measures compared with outcomes measures, ranging from 91% for appropriate asthma medication use to 59% for controlling low-density lipoprotein cholesterol in the presence of diabetes. Performance on patient experiences of care measures was the highest for the quality of clinical interactions (88.5) and the lowest for delivery of self-management support (68.8). Three of the 10 patient experience-clinical performance composite correlations were statistically significant. These three correlations involved composites summarizing integration of care and quality of clinical interactions, and ranged from a low of 0.30 to a high of 0.39., Conclusions: Chronic care delivery is variable across diseases and domains of care. Improving care integration processes and communication between health-care providers and their patients may lead to improved clinical outcomes.

Background: Cost-related underuse of medications is common among older adults, who seldom discuss medication costs with their physicians. Some older adults may use free drug samples or industry-sponsored patient assistance programs (PAP) in hopes of lowering out-of-pocket costs, although the long-term effect of these programs on drug spending is unclear., Objective: To examine older adults' use of industry-sponsored strategies to reduce out-of-pocket drug costs and the association between doctor-patient communication and use of these programs., Design: Cross-sectional analysis of a 2006 nationally representative survey of Medicare beneficiaries., Participants: 14,322 community-dwelling Medicare beneficiaries age ≥65., Main Measures: We conducted bivariate and multivariate analyses of the association between receipt of free samples and participation in PAPs with sociodemographic characteristics, health status, access to care, drug coverage, medication cost burden, and doctor-patient communication., Key Results: 51.4% of seniors reported receiving at least one free sample over the last 12 months and 29.2% reported receiving free samples more than once. In contrast, only 1.3% of seniors reported participating in an industry-sponsored PAP. Higher income respondents were more likely to report free sample receipt than low-income respondents (50.8% vs. 43.8%, p < 0.001) and less likely to report participating in a PAP (0.42% vs. 2.2%, p < 0.001). In multivariate analyses, those who reported talking to their doctor about the cost of their medications had more than twice the odds of receiving samples as those who did not (OR 2.17, 95% CI 1.95-2.42)., Conclusions: In 2006, over half of seniors in Medicare received free samples, but only 1.3% reported receiving any medications from a patient assistance program. Doctor-patient communication is strongly associated with use of these programs, which has important implications for clinical care regardless of whether these programs are viewed as drivers of prescription costs or a remedy for them.

Objective: To investigate organizational facilitators and barriers to patient-centered care in US health care institutions renowned for improving the patient care experience., Design: A qualitative study involving interviews of senior staff and patient representatives. Semi-structured interviews focused on organizational processes, senior leadership, work environment, measurement and feedback mechanisms, patient engagement and information technology and access., Setting: Eight health care organizations across the USA with a reputation for successfully promoting patient-centered care., Participants: Forty individuals, including chief executives, quality directors, chief medical officers, administrative directors and patient committee representatives., Results: Interviewees reported that several organizational attributes and processes are key facilitators for making care more patient-centered: (i) strong, committed senior leadership, (ii) clear communication of strategic vision, (iii) active engagement of patient and families throughout the institution, (iv) sustained focus on staff satisfaction, (v) active measurement and feedback reporting of patient experiences, (vi) adequate resourcing of care delivery redesign, (vii) staff capacity building, (viii) accountability and incentives and (ix) a culture strongly supportive of change and learning. Interviewees reported that changing the organizational culture from a 'provider-focus' to a 'patient-focus' and the length of time it took to transition toward such a focus were the principal barriers against transforming delivery for patient-centered care., Conclusions: Organizations that have succeeded in fostering patient-centered care have gone beyond mainstream frameworks for quality improvement based on clinical measurement and audit and have adopted a strategic organizational approach to patient focus.

Background: Doctors' ability to communicate with patients varies. Patient questionnaires are often used to assess doctors' communication skills., Objective: To investigate whether the Four Habits Patient Questionnaire (4HPQ) can be used to assess the different skill levels of doctors., Design: A cross-sectional study of 497 hospital encounters with 71 doctors. Encounters were videotaped and patients completed three post-visit questionnaires., Setting: A 500-bed general teaching hospital in Norway., Main Outcome: The proportion of video-observed between-doctor variance that could be predicted by 4HPQ., Results: There were strong correlations between all patient-reported outcomes (range 0.71-0.80 at the doctor level, p < 0.01). 4HPQ correlated significantly with video-observed behaviour at the doctor level (Pearson's r = 0.42, p<0.01) and the encounter level (Pearson's r = 0.27, p < 0.01). The proportion of between-doctor variance not detectable by 4HPQ was 88%. The reason for this discordance was large within-doctor between-encounter variance observed in the videos, and small between-patient variance in patient reports. The maximum positive predictive value for the identification of poorly performing doctors (92%) was achieved with a cut-off score for 4HPQ of 82% (ie, patient assessments were concordant with expert observers for these doctors)., Conclusion: Using a patient-reported questionnaire of doctors' communication skills, favourable assessments of doctors by patients were mostly discordant with the views of expert observers. Only very poor performance identified by patients was in agreement with the views of expert observers. The results suggest that patient reports alone may not be sufficient to identify all doctors whose communication skills need improvement training.

Background: In 2009, Blue Cross Blue Shield of Massachusetts (BCBS) implemented a global payment system called the Alternative Quality Contract (AQC). Provider groups in the AQC system assume accountability for spending, similar to accountable care organizations that bear financial risk. Moreover, groups are eligible to receive bonuses for quality., Methods: Seven provider organizations began 5-year contracts as part of the AQC system in 2009. We analyzed 2006-2009 claims for 380,142 enrollees whose primary care physicians (PCPs) were in the AQC system (intervention group) and for 1,351,446 enrollees whose PCPs were not in the system (control group). We used a propensity-weighted difference-in-differences approach, adjusting for age, sex, health status, and secular trends to isolate the treatment effect of the AQC in comparisons of spending and quality between the intervention group and the control group., Results: Average spending increased for enrollees in both the intervention and control groups in 2009, but the increase was smaller for enrollees in the intervention group--$15.51 (1.9%) less per quarter (P=0.007). Savings derived largely from shifts in outpatient care toward facilities with lower fees; from lower expenditures for procedures, imaging, and testing; and from a reduction in spending for enrollees with the highest expected spending. The AQC system was associated with an improvement in performance on measures of the quality of the management of chronic conditions in adults (P<0.001) and of pediatric care (P=0.001), but not of adult preventive care. All AQC groups met 2009 budget targets and earned surpluses. Total BCBS payments to AQC groups, including bonuses for quality, are likely to have exceeded the estimated savings in year 1., Conclusions: The AQC system was associated with a modest slowing of spending growth and improved quality of care in 2009. Savings were achieved through changes in referral patterns rather than through changes in utilization. The long-term effect of the AQC system on spending growth depends on future budget targets and providers' ability to further improve efficiencies in practice. (Funded by the Commonwealth Fund and others.).

In January 2009 Blue Cross Blue Shield of Massachusetts launched a new payment arrangement called the Alternative Quality Contract. The contract stipulates a modified global payment (fixed payments for the care of a patient during a specified time period) arrangement. The model differs from past models of fixed payments or capitation because it explicitly connects payments to achieving quality goals and defines the rate of increase for each contract group's budget over a five-year period, unlike typical annual contracts. All groups participating in the Alternative Quality Contract earned significant quality bonuses in the first year. This arrangement exemplifies the type of experimentation encouraged by the Affordable Care Act. We describe this unique contract and show how it surmounts hurdles previously encountered with other global-payment models.

Objective: To assess the effect of survey distribution protocol (mail versus handout) on data quality and measurement of patient care experiences., Data Sources/study Setting: Multisite randomized trial of survey distribution protocols. Analytic sample included 2,477 patients of 15 clinicians at three practice sites in New York State., Data Collection/extraction Methods: Mail and handout distribution modes were alternated weekly at each site for 6 weeks., Principal Findings: Handout protocols yielded an incomplete distribution rate (74 percent) and lower overall response rates (40 percent versus 58 percent) compared with mail. Handout distribution rates decreased over time and resulted in more favorable survey scores compared with mailed surveys. There were significant mode-physician interaction effects, indicating that data cannot simply be pooled and adjusted for mode., Conclusions: In-office survey distribution has the potential to bias measurement and comparison of physicians and sites on patient care experiences. Incomplete distribution rates observed in-office, together with between-office differences in distribution rates and declining rates over time suggest staff may be burdened by the process and selective in their choice of patients. Further testing with a larger physician and site sample is important to definitively establish the potential role for in-office distribution in obtaining reliable, valid assessment of patient care experiences., (Copyright © Health Research and Educational Trust.)

Background: Chronic pulmonary diseases (CPDs) such as asthma and COPD are associated with particularly high rates of cost-related medication nonadherence (CRN), but the degree to which inhaler costs contribute to this is not known. Here, we examine the relationship between inhaler-specific out-of-pocket costs and CRN in CPD., Methods: Using data obtained in 2006 in a national stratified random sample (N = 16,072) of community-dwelling Medicare beneficiaries aged >or= 65 years, we used logistic regression to examine the relationship between inhaled medications, various types of out-of-pocket costs, and CRN in persons with CPD., Results: The prevalence of CRN in Medicare recipients with CPD using inhalers was 31%. In multivariate models, the odds that respondents with CPD using inhalers would report CRN was 1.43 (95% CI, 1.21-1.69) compared with respondents without CPD who were not using inhalers. Adjustment for out-of-pocket inhaler costs-but not adjustment for total medication costs or non-inhaler costs-eliminated this excess risk of CRN (OR, 0.95; 95% CI, 0.71-1.28). Patients paying > $20 per month for inhalers were at significantly higher risk for CRN compared with those who had no out-of-pocket inhaler costs., Conclusions: Individuals with CPD and high out-of-pocket inhaler costs are at increased risk for CRN relative to individuals on other medications. Physicians should be aware that inhalers can pose a particularly high risk of medication nonadherence for some patients.

Background: Under current medical home proposals, primary care practices using specific structural capabilities will receive enhanced payments. Some practices disproportionately serve sociodemographically vulnerable neighborhoods. If these practices lack medical home capabilities, their ineligibility for enhanced payments could worsen disparities in care., Methods: Via survey, 308 Massachusetts primary care practices reported their use of 13 structural capabilities commonly included in medical home proposals. Using geocoded US Census data, we constructed racial/ethnic minority and economic disadvantage indices to describe the neighborhood served by each practice. We compared the structural capabilities of "disproportionate-share" practices (those in the most sociodemographically vulnerable quintile on each index) and others., Results: Racial/ethnic disproportionate-share practices were more likely than others to have staff assisting patient self-management (69% vs 55%; P = .003), on-site language interpreters (54% vs 26%; P < .001), multilingual clinicians (80% vs 51%; P < .001), and multifunctional electronic health records (48% vs 29%; P = .01). Similarly, economic disproportionate-share practices were more likely than others to have physician awareness of patient experience ratings (73% vs 65%; P = .03), on-site language interpreters (56% vs 25%; P < .001), multilingual clinicians (78% vs 51%; P < .001), and multifunctional electronic health records (40% vs 31%; P = .03). Disproportionate-share practices were larger than others. After adjustment for practice size, only language capabilities continued to have statistically significant relationships with disproportionate-share status., Conclusions: Contrary to expectations, primary care practices serving sociodemographically vulnerable neighborhoods were more likely than other practices to have structural capabilities commonly included in medical home proposals. Payments tied to these capabilities may aid practices serving vulnerable populations.

Performance-based payments are increasingly common in primary care. With persistent disparities in the quality of care that different populations receive, however, such payments may steer new resources away from the care of racial and ethnic minorities and people of low socioeconomic status. We simulated performance-based payments to Massachusetts practices serving higher and lower shares of patients from these vulnerable communities in Massachusetts. Typical practices serving higher shares of vulnerable populations would receive less per practice compared to others, by estimated amounts of more than $7,000. These findings suggest that pay-for-performance programs should monitor and address the potential impact of performance-based payments on health care disparities.

Background: In January 2006, 43 million Medicare beneficiaries became eligible for subsidized prescription coverage (Part D) through Medicare. To date, no longitudinal study has afforded information on beneficiaries' prescription coverage transitions and corresponding changes in prescription use and spending., Objective: To evaluate changes in Medicare beneficiaries' prescription coverage, use and spending before and after Part D implementation, including comparison of those who enrolled in Part D with those who did not., Design, Setting and Participants: Longitudinal observational study of non-institutionalized Medicare beneficiaries aged 65 and older (n = 9,573) employing administrative data from the Centers for Medicare and Medicaid Services (CMS) and survey-based data from beneficiaries (2003, 2006). Sampling drew from a 1% national probability sample (2003), oversampling low-income beneficiaries including those dually-enrolled in Medicare and Medicaid. MEASUREMENTS & MAIN RESULTS: Number and type of prescriptions, monthly out-of-pocket prescription spending, and cost-related non-adherence to prescription regimens. Most respondents who lacked prescription coverage in 2003 had acquired it by 2006 (82.6%)-primarily through Part D (63.1%). Part D enrollees who previously lacked coverage or had Medigap coverage appear particularly advantaged by Part D, as evidenced by significantly increased prescription use, lower out-of-pocket spending and lower non-adherence. Those with employer-based coverage experienced significantly increased spending. Among those still lacking coverage in 2006, high rates of cost-related non-adherence (31.8%) were reported by the low-income, chronically ill subgroup., Conclusions: In its first year, Part D coverage appears to have moderated prescription spending and cost-related burden for those who previously had meager benefits or none. Increased spending among those with employer-based coverage may reflect a narrowing of those benefits over this period. Evidence of foregone care among low-income, chronically ill seniors who still lack prescription coverage highlights the importance of targeted outreach to this group for Part D's low-income subsidy program.

Background: Patient experience measures are central to many pay-for-performance (P4P) programs nationally, but the effect of performance-based financial incentives on improving patient care experiences has not been assessed., Methods: The study uses Clinician & Group CAHPS data from commercially insured adult patients (n = 124,021) who had visits with 1,444 primary care physicians from 25 California medical groups between 2003 and 2006. Medical directors were interviewed to assess the magnitude and nature of financial incentives directed at individual physicians and the patient experience improvement activities adopted by groups. Multilevel regression models were used to assess the relationship between performance change on patient care experience measures and medical group characteristics, financial incentives, and performance improvement activities., Results: Over the course of the study period, physicians improved performance on the physician-patient communication (0.62 point annual increase, p < 0.001), care coordination (0.48 point annual increase, p < 0.001), and office staff interaction (0.22 point annual increase, p = 0.02) measures. Physicians with lower baseline performance on patient experience measures experienced larger improvements (p < 0.001). Greater emphasis on clinical quality and patient experience criteria in individual physician incentive formulas was associated with larger improvements on the care coordination (p < 0.01) and office staff interaction (p < 0.01) measures. By contrast, greater emphasis on productivity and efficiency criteria was associated with declines in performance on the physician communication (p < 0.01) and office staff interaction (p < 0.001) composites., Conclusions: In the context of statewide measurement, reporting, and performance-based financial incentives, patient care experiences significantly improved. In order to promote patient-centered care in pay for performance and public reporting programs, the mechanisms by which program features influence performance improvement should be clarified.

Background: Recent proposals to reform primary care have encouraged physician practices to adopt such structural capabilities as performance feedback and electronic health records. Whether practices with these capabilities have higher performance on measures of primary care quality is unknown., Objective: To measure associations between structural capabilities of primary care practices and performance on commonly used quality measures., Design: Cross-sectional analysis., Setting: Massachusetts., Participants: 412 primary care practices., Measurements: During 2007, 1 physician from each participating primary care practice (median size, 4 physicians) was surveyed about structural capabilities of the practice (responses representing 308 practices were obtained). Data on practice structural capabilities were linked to multipayer performance data on 13 Healthcare Effectiveness Data and Information Set (HEDIS) process measures in 4 clinical areas: screening, diabetes, depression, and overuse., Results: Frequently used multifunctional electronic health records were associated with higher performance on 5 HEDIS measures (3 in screening and 2 in diabetes), with statistically significant differences in performance ranging from 3.1 to 7.6 percentage points. Frequent meetings to discuss quality were associated with higher performance on 3 measures of diabetes care (differences ranging from 2.3 to 3.1 percentage points). Physician awareness of patient experience ratings was associated with higher performance on screening for breast cancer and cervical cancer (1.9 and 2.2 percentage points, respectively). No other structural capabilities were associated with performance on more than 1 measure. No capabilities were associated with performance on depression care or overuse., Limitation: Structural capabilities of primary care practices were assessed by physician survey., Conclusion: Among the investigated structural capabilities of primary care practices, electronic health records were associated with higher performance across multiple HEDIS measures. Overall, the modest magnitude and limited number of associations between structural capabilities and clinical performance suggest the importance of continuing to measure the processes and outcomes of care for patients., Primary Funding Source: The Commonwealth Fund.