BackgroundEnhanced primary care models have diffused slowly and shown uneven results. Because their structural features are costly and challenging for small practices to implement, they offer modest rewards for improved performance, and improvement takes time.ObjectiveTo test whether a patient-centered medical home (PCMH) model that significantly rewarded cost savings and accommodated small primary care practices was associated with lower spending, fewer hospital admissions, and fewer emergency room visits.DesignWe compared medical care expenditures and utilization among adults who participated in the PCMH program to adults who did not participate. We computed difference-in-difference estimates using two-part multivariate generalized linear models for expenditures and negative binomial models for utilization. Control variables included patient demographics, county, chronic condition indicators, and illness severity.ParticipantsA total of 1,433,297 adults aged 18–64 years, residing in Maryland, Virginia, and the District of Columbia, and insured by CareFirst for at least 3 consecutive months between 2010 and 2013.InterventionCareFirst implemented enhanced fee-for-service payments to the practices, offered a large retrospective bonus if annual cost and quality targets were exceeded, and provided information and care coordination support.MeasuresOutcomes were quarterly claims expenditures per member for all covered services, inpatient care, emergency care, and prescription drugs, and quarterly inpatient admissions and emergency room visits.ResultsBy the third intervention year, annual adjusted total claims payments were $109 per participating member (95 % CI: −$192, −$27), or 2.8 % lower than before the program and compared to those who did not participate. Forty-two percent of the overall decline in spending was explained by lower inpatient care, emergency care, and prescription drug spending. Much of the reduction in inpatient and emergency spending was explained by lower utilization of services.ConclusionsA PCMH model that does not require practices to make infrastructure investments and that rewards cost savings can reduce spending and utilization.Electronic supplementary materialThe online version of this article (doi:10.1007/s11606-016-3814-z) contains supplementary material, which is available to authorized users.

Producing bioenergy feedstocks on non-crop land can largely avoid the food price feedbacks of energy biomass production on cropland. The U.S. northern tier grassland-to-forest ecotone offers large areas of marginal land that is not currently cropped. In this ecological transition zone, the relative profitability of grassy vs. woody sources of energy biomass is little studied. This paper reports an exploratory investment analysis of cellulosic biomass production in the northern Great Lakes region. It compares two short-rotation tree crops, willow (Salix sachalinensis F. Schmidt)and hybrid poplar (Populus nigra L. X P. maximowiczii A. Henry), and switchgrass (Panicum virgatum L.) (a native prairie grass) to conventional mixed hay. Because biomass markets are not yet well developed, this study calculates threshold prices and yields at which biomass crops become at least as profitable as mixed grass hay. At 2010-2012 prices and available production technologies, none of the cellulosic crops is competitive with the hay baseline system. The breakeven price of energy biomass ranges from $90-100 per oven-dry Mg -1 for all three energy crops. Breakeven yields are much more variable, due to the high cost of harvesting woody biomass. At 2010-2012 prices, necessary biomass yield increases range from 3.5-fold for switchgrass and willow to over 25-fold for poplar. While the ratio of input costs to revenue remains relatively constant between the northern and southern Great Lakes regions, the opportunity cost of active cropland in the southern zone is much higher, implying an economic comparative advantage for marginal land of the northern tier of the Great Lakes region.

Despite their value, comprehensive diabetes care and screening for common cancers remain underutilized. We examined the association between participation in a patient-centered medical home (PCMH) program with strong financial incentives and receipt of preventive care in the first 5 years after program launch. Using multivariate regression analysis, we compared outcomes for adults under the care of participating primary care providers (PCPs) with adults under the care of nonparticipating PCPs. Outcomes were breast, cervical and colorectal cancer screenings, and elements of diabetes care. The analytic sample included 818,623 adults living in Maryland, Virginia, or the District of Columbia, and enrolled with CareFirst for at least 1 year during 2010–2015. By Year 5, enrollees in the intervention group were 7.9 (95% confidence interval [CI]: 2.8–13.0), 6.1 (95% CI: 1.4–10.7), 3.1 (95% CI: 2.1–4.0), and 7.6 (95% CI: 7.0–8.2) percentage points more likely to undergo HbA1c tests, nephropathy examinations, breast, and cervical cancer screenings, respectively. We found no significant change in the propensity to receive colorectal cancer screening or an eye examination. Our study shows that a PCMH program with strong financial incentives can raise the provision of preventive care but could require additional adjustment.