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1 Supplementary Online Content Friedberg MW, Rosenthal MB, Werner RM, Volpp KG, Schneider EC. Effects of a medical home and shared savings intervention on quality and utilization of care. Published online June 1, JAMA Intern Med. doi: /jamainternmed eappendix 1. Criteria for Selecting Primary Care Practices for Participation in the Northeast Region of the Pennsylvania Chronic Care Initiative eappendix 2. Shared Savings Design Used by the Northeast Region of the Pennsylvania Chronic Care Initiative eappendix 3. Measure Specifications eappendix 4. Qualifying Services for Patient Attribution eappendix 5. Propensity-Weighted, Adjusted Differences in Utilization of Care Between Pilot and Comparison Practices Among Continuously Enrolled Patients (n=10548 pilot and n=6815 Comparison Patients) With P Values From Each Part of the 2 Part Models eappendix 6. Selected Structural Changes Among Pilot Practices This supplementary material has been provided by the authors to give readers additional information about their work.

2 eappendix 1. Criteria for Selecting Primary Care Practices for Participation in the Northeast Region of the Pennsylvania Chronic Care Initiative 1. Practitioners are varied among pediatrics, family practice and internal medicine. 2. Practice sites derive a significant portion of their revenue from the participating carriers. 3. Practice site locations are varied (e.g., urban, suburban and rural). 4. Practice ownership is varied (e.g., academic health system, independently owned private practices, community health centers). 5. Practice sites are generally smaller in order to accommodate the targeted average practice size of three lead clinician FTEs, although larger practice sites may be considered if they agree that a maximum of five clinician FTEs at the site will be eligible for supplemental payments.

3 eappendix 2. Shared Savings Design Used by the Northeast Region of the Pennsylvania Chronic Care Initiative In the northeast region of the Pennsylvania Chronic Care Initiative (PACCI), practice eligibility to receive shared savings bonus payments was determined by the number of performance criteria on which the practice met or exceeded, by pilot month 18, the performance thresholds shown in Appendix Table 2A. eappendix Table 2A. Criterion PPC-PCMH recognition by NCQA at no less than Level 1 Plus Percentage of diabetic patients with HbA1c below 9% Percentage of diabetic patients with LDL-C below 100 Percentage of diabetic patients with blood pressure < 130/80 Percentage of hypertensive patients with blood pressure <140/90 Percentage of coronary artery disease patients with LDL-C below day hospital readmission rate Ambulatory Care Sensitive Condition (ACSC) hospitalization rate Primary care practice visit rate Emergency room visit rate Documented care plan Threshold* Binary practice-level measure (yes or no)** 2 percentage point improvement, relative to baseline (before pilot began)*** 2 percentage point improvement, relative to baseline (before pilot began)*** 2 percentage point improvement, relative to baseline (before pilot began)*** 2 percentage point improvement, relative to baseline (before pilot began)*** 2 percentage point improvement, relative to baseline (before pilot began)*** 2 percentage point reduction, relative to baseline (before pilot began) 2 percentage point reduction, relative to baseline (before pilot began) 2 percentage point increase, relative to baseline (before pilot began) 5 percentage point reduction, relative to baseline (before pilot began) For all patients identified as high risk by each participating health plan For 90% of patients identified as high risk by each participating health plan For 75% of hospital discharges Documented self-management support goal setting Practice team clinical telephonic or face-toface patient follow-up within 2 days after hospitalization discharge Documentation that there is a care manager Binary practice-level measure (yes or no) in place and that the care manager is operating consistently with the requirements set forth in the Participation Agreement *Methods for determining practice performance on each criterion other than PPC-PCMH recognition (which was determined by the NCQA) were not specified in the Participation Agreement for the Northeast PACCI and are unknown to the authors.

4 **Level 1 Plus defined as meeting the 2008 NCQA PPC-PCMH Level 1 standards, plus the following 2008 NCQA PPC-PCMH standards at the specified levels of performance: 3C (Care Management: Practice Organization) at 75%, 3D (Care Management for Important Conditions) at 100%, and 4B (Patient Self-Management Support) at 50%. ***If a practice s performance was equal to or exceeded the NCQA Mid-Atlantic region All Lines of Business 90th percentile rate for the measure for the most recently reported measurement year, the practice did not need to demonstrate a 2 percentage point improvement. Using the thresholds in Appendix Table 2A, shared savings bonuses for each practice were calculated as shown in Appendix Table 2B. eappendix Table 2B. Number of performance thresholds met (of Shared savings bonus payment 14 possible thresholds) 14 50%* of observed savings** %* of observed savings %* of observed savings 9 41%* of observed savings 8 or fewer Practice not eligible for shared savings *Minus the combined value of the Care Management ($1.50 per patient per year) and Practice Support ($1.50 per patient per year) payments to the practice. **Observed savings were determined annually by each participating health plan. Each plan could develop its own savings calculation method within the following parameters specified in the Participation Agreement for the Northeast PACCI: Savings [are] determined annually by comparing risk-adjusted actual to expected medical costs for the Practice s patient population, with an adjustment for outliers, and subtracting from any resulting savings the value of Care Management and Practice Support Payments during the measurement year. Savings will be calculated based on the experience of the Practice s patients who are enrolled with a Carrier. Carriers are solely responsible for determining the methodology for calculating actual and expected medical costs.

5 eappendix 3. Measure Specifications Quality measures Measure name Definition Breast Cancer Screening Percentage of women aged years who had at least one mammogram in the measurement year or year prior to the measurement year. Colorectal Cancer Screening Percentage of adults 50 to 80 years of age who had 1 or more of the following during the measurement year: fecal occult blood test, flexible sigmoidoscopy, double contrast barium enema or air contrast barium enema, or colonoscopy. Comprehensive Diabetes Care: HbA1c Testing Comprehensive Diabetes Care: Eye Exams Comprehensive Diabetes Care: Cholesterol Screening Comprehensive Diabetes Care: Monitoring Diabetic Nephropathy Percentage of patients aged years with diabetes (type 1 and type 2) who had a hemoglobin A1c test during the measurement year. Percentage of patients aged years with diabetes (type 1 and type 2) who had a retinal or dilated eye exam by an eye care professional in the measurement year or a negative retinal exam (no evidence of retinopathy) by an eye care professional in the measurement year. Percentage of patients aged years with diabetes (type 1 and type 2) who had a low-density lipoprotein cholesterol test during the measurement year. Percentage of patients aged years with diabetes (type 1 and type 2) who received nephropathy screening, had a nephrologist visit, or had evidence of nephropathy as documented through administrative data during the measurement year. Definitions taken from National Committee for Quality Assurance (NCQA). HEDIS Health plan employer data & information set. Vol. 2, Technical specifications. Washington (DC): National Committee for Quality Assurance (NCQA); Detailed lists of comorbid conditions, competing diagnoses, and other exclusion criteria are contained in the original measure documentation available from the NCQA.

6 eappendix 3. Measure specifications, continued Utilization measures Measure name Hospitalization rate, all-cause Hospitalization rate, ambulatory care-sensitive Emergency department visit rate, all-cause Emergency department visit rate, ambulatory care-sensitive Ambulatory care visit rate Definition Count of unique hospitalizations for any reason per month. Count of unique hospitalizations per month that meet one or more criteria for being ambulatory care-sensitive according to the Agency for Healthcare Research and Quality Prevention Quality Indicators Technical Specifications, Version 4.0. Specifications available from Agency for Healthcare Research and Quality, Count of unique emergency department visits for any reason per month. Count of unique emergency department visits per month that have any evidence of being avoidable or primary care treatable according to the NYU ED Algorithm, specifications available from For each ED visit, the NYU algorithm assigns a probability that the visit is in one of 4 categories: 1- Non-Emergent; 2- Emergent, Primary Care Treatable; 3- Emergent, ED Care Needed, Preventable/Avoidable; 4- Emergent, ED Care Needed, Not Preventable/Avoidable. For this measure, we count an ED visit as ambulatory caresensitive if it has a nonzero probability of belonging in any of the first 3 categories. Count of unique ambulatory visits (excluding emergency department visits) for any reason per month.

7 eappendix 4. Qualifying Services for Patient Attribution Services that qualified for patient attribution were those that were provided by primary care clinicians (specialty designations family practice, general practice, internal medicine, pediatrics, adolescent medicine, geriatric medicine, and nurse practitioner ) and that had one of the following CPT codes: 9920x, 9921x, 9924x, , , , , , , , , G0402, G0438, G0439.

8 eappendix 5. Propensity-Weighted, Adjusted Differences in Utilization of Care Between Pilot and Comparison Practices Among Continuously Enrolled Patients (n=10548 pilot and n=6815 Comparison Patients) With P Values From Each Part of the 2 Part Models Pilot Comparison Difference (95% CI) P value, logistic part P value, negative binomial part Hospitalizations, allcause Rate per 1000 patients per month (95% CI)* Pre-intervention NA** NA NA Intervention year (-3.1, 0.2) Intervention year (-3.3, -0.2) < Intervention year (-3.2, ) Hospitalizations, ambulatory caresensitive Pre-intervention NA NA NA Intervention year (-0.6, 0.2) Intervention year (-0.5, 0.4) Intervention year (-0.6, 0.3) ED visits, all-cause Pre-intervention NA NA NA Intervention year (-6.6, 0.5) Intervention year (-5.6, 1.1) Intervention year (-8.7, -0.9) ED visits, ambulatory caresensitive Pre-intervention NA NA NA Intervention year (-3.8, 1.1) Intervention year (-3.8, 1.3) Intervention year (-5.7, -0.9) Abbreviations: NA, Not Applicable; CI, confidence interval. * Point estimates for utilization and utilization differences are propensity-weighted recycled predictions from two-part logistic and negative binomial regression models adjusting for baseline utilization rates; patient gender, age, Charlson comorbidity score; health plan contributing each observation, and whether each patient was in an HMO product at the time of the observation. Confidence intervals are bootstrap estimates; p- values are from the regression models. **Due to the inclusion of fixed effects for practices, regression models do not estimate pre-intervention differences between pilot and comparison.

9 eappendix 5. Propensity-Weighted, Adjusted Differences in Utilization of Care Between Pilot and Comparison Practices Among Continuously Enrolled Patients (n=10548 pilot and n=6815 Comparison Patients) With P Values From Each Part of the 2 Part Models, continued Pilot Comparison Difference (95% CI) P value, logistic part P value, negative binomial part Ambulatory visits, primary care Rate per 1000 patients per month (95% CI)* Pre-intervention NA** NA NA Intervention year (9.1, 99.4) NA*** Intervention year (51.1, NA ) Intervention year (37.3, NA ) Ambulatory visits, specialist Pre-intervention NA NA NA Intervention year (-16.2, -1.2) Intervention year (-27.5, < ) Intervention year (-26.6, < ) Abbreviations: NA, Not Applicable; CI, confidence interval. *Point estimates for utilization and utilization differences are propensity-weighted recycled predictions from two-part logistic and negative binomial regression models adjusting for baseline utilization rates; patient gender, age, Charlson comorbidity score; health plan contributing each observation, and whether each patient was in an HMO product at the time of the observation. Confidence intervals are bootstrap estimates; p- values are from the regression models. **Due to the inclusion of fixed effects for practices, regression models do not estimate pre-intervention differences between pilot and comparison. ***For primary care visits, only one-part negative binomial models converged (because, due to attribution methods, no patients had zero primary care visits in the pre-intervention period).

10 eappendix 6. Selected Structural Changes Among Pilot Practices Baseline Pilot year 3 P value* Performance feedback Number of practices (%)** Quality feedback to PCPs (N=21 19 (90%) 21 (100%) 0.50 practices) Utilization or cost feedback to PCPs 19 (83%) 18 (78%) 0.99 Monthly or more frequent meetings 7 (32%) 21 (95%) <0.001 about quality (N=22) Monthly or more frequent meetings 7 (30%) 13 (56%) about utilization (N=23 Registry use Registry of patients who are overdue for 14 (61%) 22 (96%) screening services Registry of patients who are overdue for 14 (63%) 22 (100%) chronic disease services (N=22) Registry of patients who are out of target 15 (65%) 23 (100%) range for chronic disease laboratory values Registry of patients at high risk of 16 (70%) 23(100%) disease complications or hospitalization (N=23 Care management Care management for patients at high 6 (26%) 24 (100%) <0.001 risk of disease complications or hospitalization Specially-trained non-physician staff 16 (73%) 21 (95%) who help patients better manage their diabetes (N=22) Specially-trained non-physician staff who help patients better manage their asthma (N=22) 9 (41%) 20 (91%) Routine assessment of self-management 5(22%) 23 (100%) <0.001 needs of chronically ill patients Referral system for linking patients to community programs (N=22) 6 (27%) 11 (50%) Abbreviations: NCQA, National Committee for Quality Assurance; NA, Not Applicable; PCP, primary care physician or clinician (including MDs, DOs, and NPs). *Liddell exact test. **Due to item nonresponse, denominators for percentages are not the same for all entries in the table.

11 eappendix 6. Selected Structural Changes Among Pilot Practices, continued Baseline Pilot year 3 P value* Outreach systems to contact patients due for services Number of practices (%)** Breast cancer screening 9 (39%) 22 (96%) <0.001 Cervical cancer screening 9 (39%) 21 (91%) <0.001 Colorectal cancer screening 9 (39%) 22 (96%) <0.001 Diabetes: hemoglobin A1c testing 16 (70%) 22 (96%) Diabetes: cholesterol testing 17 (74%) 22 (96%) Diabetes: eye examination 10 (43%) 22 (96%) <0.001 Diabetes: nephropathy monitoring 9 (39%) 21 (91%) <0.001 Other outreach systems Outreach to patients after hospitalization 10 (43%) 23 (100%) <0.001 Outreach to patients with no appointment 8 (36%) 21 (95%) <0.001 in for an extended period (longer than clinically appropriate) (N=22) Electronic health record capabilities Patient medication lists 23 (100%) 23 (100%) 0.99 Patient problem lists 23 (100%) 23 (100%) 0.99 Consultation notes from specialists 21 (91%) 20 (87%) 0.99 Hospital discharge summaries 21 (91%) 22 (96%) 0.99 Electronic medication prescribing 22 (96%) 23 (100%) 0.99 Electronic laboratory test ordering 11 (48%) 20 (87%) Electronic radiology test ordering 11 (48%) 19 (82%) Alerts if ordered tests are not performed 6 (26%) 16 (70%) Secure electronic messaging to and from 7 (30%) 9 (39%) 0.50 patients Access Weekend care offered regularly (N=22) 6 (27%) 8 (36%) 0.50 Evening care offered 2 nights per week 10 (43%) 13(57%) 0.45 Appointments for new patients within 2 weeks (N=22) 5(23%) 4(18%) 0.99 Abbreviations: NCQA, National Committee for Quality Assurance; NA, Not Applicable; PCP, primary care physician or clinician (including MDs, DOs, and NPs). *Liddell exact test. **Due to item nonresponse, denominators for percentages are not the same for all entries in the table.

To identify physician practices providing primary care, we. used the 2007 statewide physician directory of the Massachusetts

Technical Appendix Study Data and Methods Primary care practices To identify physician practices providing primary care, we used the 2007 statewide physician directory of the Massachusetts Health Quality