The IMPaCT grant efforts took place during a complex time in health care and within a rich milieu of State and organizational policies. A number of these important contextual factors are discussed in this section.
It is difficult to understate the importance of the Patient Protection and Affordable Care Act to the IMPaCT projects. As noted in the Introduction, the mandate to create PCEPs derives directly from Section 5405 of the Act. However, no money was allocated to these programs under the Act. The AHRQ IMPaCT grants developed and tested effective means to implement this law.
The Patient Protection and Affordable Care Act is also important in so far as it provided incentives and penalties for practices and health systems to adopt electronic health records, specified by three stages of meaningful use criteria. Stage 1 meaningful use was critical to the implementation of population-based health care and the ethos of the primary care medical home model. There was great variation among individual practices in test or spread States in their ability to extract and interpret their own data, complicating QI efforts.
A third element of the Act was the mandate to create Accountable Care Organizations (ACOs). The Act sets out definitions for the establishment, eligibility, and requirements for Medicare ACOs in section 3022. The Act calls for the establishment of a shared savings program that promotes accountability for a patient population, coordinates items and services under Medicare parts A and B, and encourages investment in infrastructure and redesigned care processes for high-quality and efficient service delivery. Adherence to the requirements set out in the Act allows an ACO to participate in the shared savings program and thereby receive extra payments for improvements in quality of care.
A related contextual factor in the adoption of the PCEP models in spread States has been the competition from other organizations forming networks of primary care practices. In some cases these networks are being established by private insurers; in other cases, hospitals are acquiring primary care practices to establish ACOs. In some States (e.g., Pennsylvania), these organizations offered financial incentives to primary care practice for their participation. This competition for practice participation impeded the spread of the IMPaCT models to some degree. That being said, the IMPaCT grants also created connections across initiatives, as discussed previously.
Strategic planning by State government bolstered extension program efforts in several model and spread States. For example, Vermont and North Carolina State governments and government agencies created strategic plans to improve care and coordinate stakeholders. In Vermont, State-level strategy was manifest in the Blueprint for Health. The Blueprint for Health is a “program for integrating a system of health care for patients, improving the health of the overall population, and improving control over health care costs by promoting health maintenance, prevention, and care coordination and management.”12
In North Carolina, CCNC is a public-private partnership sponsored by the North Carolina Department of Health and Human Services and the North Carolina Division of Medical Assistance. CCNC supports 14 networks in designing and implementing QI initiatives for Medicaid and other underserved populations.
In many States, an existing QI partnership provided an organizational structure onto which were built extension elements originating from IMPaCT. The AHECs were frequently a key partner. However, IMPaCT initiatives had to take steps to integrate efforts with those of existing entities. Some national AHEC leaders raised concerns about duplication of efforts. Fragmentation between primary care practice and public health was an initial challenge in some States. Ultimately these conflicts were resolved amicably through the partnership-building efforts previously described.
The physical size and rurality of the States influenced the emphasis of practice facilitation and the ability of IMPaCT projects to undertake some collaborative learning. Face-to-face meetings that created personal relationships were reported to be important for the success of implementation, but were not feasible in all States. Virtual meetings (e.g., via video teleconference) were found to be only moderately successful in Pennsylvania. Vermont, even though it is the most rural State in the contiguous United States, is tiny compared to North Carolina, Oklahoma, and Pennsylvania. Vermont’s smaller size made face-to-face meetings much more feasible simply because of the shorter driving time required for participants.
In some States, such as Pennsylvania and North Carolina, the assistance received through the IMPaCT program that could be used to help to achieve PCMH recognition was viewed as a valuable incentive to participate. Presumably, practices in these areas viewed recognition as a local competitive advantage or stepping stone to participation in a larger health care network. In other States, however, PCMH recognition was perceived as less valuable. For example, in Oklahoma, local needs and priorities drove involvement in QI activities rather than a desire to attain PCMH recognition.
All of the grantees emphasized the importance of stable funding for the PCEPs and identified State (Medicaid) and private insurers as a potential source for ongoing funding after grant initiatives ended. The hope is that insurers would be willing to pay for a PCEP if these programs can demonstrate value (e.g., higher quality of care for chronic diseases, lower costs for chronic disease management). In addition to AHRQ IMPaCT grants, uptake of the extension approach was facilitated in a number of the model and spread States by the availability of the Center for Medicare and Medicaid Innovation’s State Innovation Model funding. In addition, funding from The Commonwealth Fund enabled IMPaCT participants to exchange and document shared learning via an in-person meeting and the health extension toolkit; the 2014 Commonwealth-funded meeting was specifically focused on future funding.