Association Between Specialist Office Visits and Health Expenditures in Accountable Care Organizations

ACO leakage among gynecologic cancer patients: Incidence, predictors, and impact on annual Medicare expenditure

OBJECTIVE

To examine patterns of Accountable Care Organizations (ACO) leakage, the receipt of healthcare by ACO-assigned patients from institutions outside assigned ACO network, among patients with gynecologic cancer. ACO leakage was estimated as rates of patients seeking care external to their ACO assignment. Factors associated with ACO leakage were identified and cost differences within the first year of cancer diagnosis described.

METHODS

Medicare 5% data (2013-2017) was used to quantify rates of leakage among gynecologic cancer patients with stable ACO assignment. Crude and multivariable adjusted risk ratios of ACO leakage risk factors were estimated using log-binomial regression models. Overall and cancer-specific spending differences by ACO leakage status were compared using Wilcoxon rank-sum test.

RESULTS

Overall incidence of ACO leakage was 28.1% with highest leakage for outpatient care and uterine cancer patients. ACO leakage risk was 56% higher among Black relative to White patients, and 77% more for those in higher relative to lowest quintiles of median household income. Leakage decreased by 3% and 8% with each unit increase in ACO size and number of subspecialists, respectively. Healthcare costs were 19.5% higher for leakage patients.

CONCLUSIONS

ACO leakage rates among gynecologic cancer patients was overall modest, with some regional and temporal variation, higher leakage for certain subgroups and substantially higher Medicare spending in inpatient and outpatient settings for patients with ACO leakage. These findings identify targets for further investigations and strategies to encourage oncologists to participate in ACOs and prevent increased health care costs associated with use of non-ACO providers.

Overview article: Impact of primary and secondary care collaboration on hospitalization for chronic heart failure: Two comparative studies

INTRODUCTION

In the past decade, a legal framework was created in Germany that promotes intense collaboration at the interface between primary and secondary care. This overview article distinguishes between the effects of two complementary programs aimed at improving ambulatory care in Baden-Wuerttemberg: (1) general practitioner-centered care (GPCC), which strengthens the role of general practitioners, and (2) collaborative cardiology care (CCC), which coordinates primary and cardiology care.

METHODS

The overview article presents two already published studies that assess the impact of the programs on hospitalizations in patients with chronic heart failure (CHF) based on claims data from 2016. The hospitalization rate of patients enrolled in GPCC (N=75,096) and CCC (N=13,404) were compared with corresponding control groups (N=65,618 and N=8,776 respectively).

RESULTS

The hospitalization rate in GPCC was lower than in the control group (risk ratio 0.97; 95% CI: 0.95-0.99, P=0.0024). GPCC patients with CHF that received specialist cardiology care as part of CCC had significantly lower hospitalization rates than those receiving standard cardiology care (risk ratio 0.92; 0.88-0.97, P=0.0014).

DISCUSSION

This overwiew study shows that reforming medical care and compensation at the interface between general practice and specialist care can lead to fewer hospital admissions in patients with CHF.

CONCLUSION

Overall, this article underlines the importance of collaboration between primary care physicians and specialists for patients with CHF that are receiving ambulatory care.

Pivoting to the QUAD AIM-Lessons Learned From the Central Texas Market

INTRODUCTION

Since 2009, the Military Health System (MHS) has represented its mission as that of attaining the Quadruple Aim (QUAD AIM): increased readiness, better health, better care, and low per capita costs. The journey to reach the four goals is challenging and ongoing. Leaders in the MHS's Central Texas Market (CTM) sought to understand and overcome the root-cause obstacles that interfered with achieving the QUAD AIM. This process required a self-critical and thoroughly objective review of the behavioral economics of the system. We hypothesized that two corporate behaviors fed upon each other to create a vicious downward spiral. First, as a socialized (salary-based) system, the enterprise has a built-in incentive that covertly competes with the attainment of the QUAD AIM. Because additional work does not result in any material gain for its workers, the system regulates to a comfortable flow. Second, centralized leaders defer important management controls to tactical teammates due to their special medical expertise. This corporate behavior makes overcoming the first one challenging-keeping realization of the QUAD AIM elusive.

METHODS

Beginning in July of 2019, CTM leaders strove to replace the two identified corporate behaviors with more productive ones. First, in place of regulating to comfort, we directed teammates to focus wholly on achieving the QUAD AIM. Second, we exerted leadership from the top down to attain the QUAD AIM's four goals. Because the vicious cycle manifested itself differently in the realms of primary, inpatient, and specialty care, we adapted the application of our virtuous behaviors to match the problem set in each realm. In primary care, we replaced fee-for-service incentives with value-based ones. In inpatient care, we eliminated hidden incentives that resulted in inappropriate and unnecessary transfers. In specialty care, we consolidated the management of referrals, templating, and scheduling-taking central control of system productivity. The interventions in each realm required the introduction of new workflows, policies, and dashboards to ensure change.

RESULTS

Over a 2-year period, the CTM made a quantum to leap toward attaining the QUAD AIM. In our community based primary care homes, we significantly improved our operations as quantified by the value-based metrics of patient satisfaction, Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics, access to care, and leakage. In the inpatient realm, we decreased monthly transfers by 73% (110 s to 30 s) resulting in higher bed censuses and multiple downstream positive impacts. In specialty care, we demonstrated our ability to return our specialty service lines quickly to high levels of production in the coronavirus disease-2019 crisis. Each of these interventions demonstrated large-scale movement toward the QUAD AIM.

CONCLUSIONS

The CTM's actions demonstrate that the QUAD AIM can be attained in military medicine. Doing so requires the recognition of two destructive corporate behaviors. Through decades of hardening, these corporate behaviors have been imprinted upon the MHS, making them practically invisible as guiding currents in economic behavior. Counteracting them with persistent regulation to the QUAD AIM facilitated by proactive top-down leadership offers a solution.

Current status and trends in subspecialty certification in physical medicine and rehabilitation

BACKGROUND

There is a need to better understand the overall state of sub-specialization in physical medicine and rehabilitation (PM&R).

OBJECTIVE

To examine the status and trends in subspecialty certification for each of the seven subspecialties approved for American Board of Physical Medicine and Rehabilitation (ABPMR) diplomates.

DESIGN/SETTING

Retrospective analysis of deidentified information from the ABPMR database.

PARTICIPANTS

Physicians certified by ABPMR through 2019.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

For each subspecialty, we examined: (1) the number of certificates issued to ABPMR diplomates; (2) the recertification rate; (3) the yearly trends for total active, new, and expired certificates; and (4) for ABPMR-administered subspecialties, recertification rates for those entering the subspecialty through fellowship completion versus a "grandfathered" practice pathway.

RESULTS

Of 11,421 ABPMR diplomates in the United States in 2019, a total of 3560 (31.2%) had 3985 active subspecialty certificates. Pain Medicine (PM) was the most common subspecialty certification (15.5% of all ABPMR diplomates) followed by Sports Medicine (SM, 6.6%), Brain Injury Medicine (BIM, 4.8%), Spinal Cord Injury Medicine (SCIM, 4.2%), Pediatric Rehabilitation Medicine (PRM, 2.5%), Neuromuscular Medicine (NMM, 0.7%), and Hospice and Palliative Medicine (HPM, 0.5%). For diplomates with more than one subspecialty certification, PM and SM was the most frequent combination. Both the recertification rate and the end of practice track eligibility influenced certification trends differently for individual subspecialties. The average number of new certificates added annually for every subspecialty was higher before than after the temporary practice track-based eligibility ended; the difference was statistically significant (p < .05) for SCIM, PM, SM, and NMM. The recertification rate for all subspecialties combined was 73.4%. For the subspecialties (SCIM, PRM) for which these data were available, fellowship candidates had higher recertification rates than those grandfathered through a practice track.

CONCLUSION

This report informs stakeholders about the state and evolution of subspecialty certification in PM&R over time.

Maternity care clinician inclusion in Medicaid Accountable Care Organizations

BACKGROUND

Medicaid Accountable Care Organizations (ACO) are increasingly common, but the network breadth for maternity care is not well described. The inclusion of maternity care clinicians in Medicaid ACOs has significant implications for access to care for pregnant people, who are disproportionately insured by Medicaid.

PURPOSE

To address this, we evaluate obstetrician-gynecologists (OB/GYN), maternal-fetal medicine specialists (MFM), certified nurse midwives (CNM), and acute care hospital inclusion in Massachusetts Medicaid ACOs.

METHODOLOGY/APPROACH

Using publicly available provider directories for Massachusetts Medicaid ACOs (n = 16) from December 2020 -January 2021, we quantify obstetrician-gynecologists, maternal-fetal medicine specialists, CNMs, and acute care hospital with obstetric department inclusion in each Medicaid ACO. We compare maternity care provider and acute care hospital inclusion across and within ACO type. For Accountable Care Partnership Plans, we compare maternity care clinician and acute care hospital inclusion to ACO enrollment.

RESULTS

Primary Care ACO plans include 1185 OB/GYNs, 51 MFMs, and 100% of Massachusetts acute care hospitals, but CNMs were not easily identifiable in the directories. Across Accountable Care Partnership Plans, a mean of 305 OB/GYNs (median: 97; range: 15-812), 15 MFMs (Median: 8; range: 0-50), 85 CNMs (median: 29; range: 0-197), and half of Massachusetts acute care hospitals (median: 23.81%; range: 10%-100%) were included.

CONCLUSION AND PRACTICE IMPLICATIONS

Substantial differences exist in maternity care clinician inclusion across and within ACO types. Characterizing the quality of included maternity care clinicians and hospitals across ACOs is an important target of future research. Highlighting maternal healthcare as a key area of focus for Medicaid ACOs-including equitable access to high-quality obstetric providers-will be important to improving maternal health outcomes.

A Linear Decomposition Approach to Explain Excess Direct Healthcare Expenditures Associated with Pain Among Adults with Osteoarthritis

Objective:

Many patients with osteoarthritis experience pain which can lead to higher healthcare expenditures. It is important to understand the factors that drive the excess expenditures associated with pain in osteoarthritis.

Design:

Cross-sectional.

Study sample:

Our study sample consisted of adults (age ⩾ 18 years) from the Medical Expenditure Panel Survey (MEPS, 2018).

Methods:

Adults who were alive during the calendar year and had pain status were included in this study (N = 2804 weighted N = 32.03 million). Osteoarthritis was identified from the medical conditions file and household file. We used multivariable ordinary least squares regression to identify the statistically significant association of pain with direct healthcare expenditures. The Blinder-Oaxaca post-linear decomposition on log-transformed total direct healthcare expenditures was used to estimate the extent to which differences in characteristics contribute to the excess expenditures associated with pain.

Results:

Adults with osteoarthritis and pain had higher average expenditures ($21 814 vs $10 827, P < .001; 9.318 vs 8.538 in logtransformed expenditures) compared to those without pain. Pooled regression weights explained 62.9% of excess expenditures differences in characteristics between the 2 groups. The 2 main drivers of excess healthcare expenditures among adults with osteoarthritis and pain were (i) comorbidities (diabetes, asthma, chronic obstructive pulmonary disease, depression, heart diseases, cancer, and non-cancer pain conditions and (ii) prescription medications (NSAIDs, opioids, and polypharmacy).

Conclusion:

Need factors such as comorbid conditions, and prescription treatment explained the excess healthcare expenditures among adults with osteoarthritis and pain. The study findings suggest that reducing polypharmacy and appropriate management of comorbid conditions may be a pathway to reduce excess expenditures among adults with osteoarthritis and pain.

Associations Between Physician Continuous Professional Development and Referral Patterns: A Systematic Review and Meta-Analysis

PURPOSE

Both overuse and underuse of clinician referrals can compromise high-value health care. The authors sought to systematically identify and synthesize published research examining associations between physician continuous professional development (CPD) and referral patterns.

METHOD

The authors searched MEDLINE, Embase, PsycInfo, and the Cochrane Database on April 23, 2020, for comparative studies evaluating CPD for practicing physicians and reporting physician referral outcomes. Two reviewers, working independently, screened all articles for inclusion. Two reviewers reviewed all included articles to extract information, including data on participants, educational interventions, study design, and outcomes (referral rate, intended direction of change, appropriateness of referral). Quantitative results were pooled using meta-analysis.

RESULTS

Of 3,338 articles screened, 31 were included. These studies enrolled at least 14,458 physicians and reported 381,165 referral events. Among studies comparing CPD with no intervention, 17 studies with intent to increase referrals had a pooled risk ratio of 1.91 (95% confidence interval: 1.50, 2.44; P < .001), and 7 studies with intent to decrease referrals had a pooled risk ratio of 0.68 (95% confidence interval: 0.55, 0.83; P < .001). Five studies did not indicate the intended direction of change. Subgroup analyses revealed similarly favorable effects for specific instructional approaches (including lectures, small groups, Internet-based instruction, and audit/feedback) and for activities of varying duration. Four studies reported head-to-head comparisons of alternate CPD approaches, revealing no clear superiority for any approach. Seven studies adjudicated the appropriateness of referral, and 9 studies counted referrals that were actually completed (versus merely requested).

CONCLUSIONS

Although between-study differences are large, CPD is associated with statistically significant changes in patient referral rates in the intended direction of impact. There are few head-to-head comparisons of alternate CPD interventions using referrals as outcomes.

Evolving Radiologist Participation in Medicare Shared Savings Program Accountable Care Organizations

PURPOSE

The aim of this study was to temporally characterize radiologist participation in Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs).

METHODS

Using CMS Physician and Other Supplier Public Use Files, ACO provider-level Research Identifiable Files, and Shared Savings Program ACO Public-Use Files for 2013 through 2018, characteristics of radiologist ACO participation were assessed over time.

RESULTS

Between 2013 and 2018, the percentage of Medicare-participating radiologists affiliated with MSSP ACOs increased from 10.4% to 34.9%. During that time, the share of large ACOs (>20,000 beneficiaries) with participating radiologists averaged 87.0%, and the shares of medium ACOs (10,000-20,000) and small ACOs (<10,000) with participating radiologists rose from 62.5% to 66.0% and from 26.3% to 51.6%, respectively. The number of physicians in MSSP ACOs with radiologists was substantially larger than those without radiologists (mean range across years, 573-945 versus 107-179). Primary care physicians constituted a larger percentage of the physician population for ACOs without radiologists (average across years, 66.3% versus 38.5%), and ACOs with radiologists had a higher rate of specialist representation (56.0% versus 33.7%). Beneficiary age, race, and sex demographics were similar among radiologist-participating versus nonparticipating ACOs.

CONCLUSIONS

In recent years, radiologist participation in MSSP ACOs has increased substantially. ACOs with radiologist participation are large and more diverse in their physician specialty composition. Nonparticipating radiologists should prepare accordingly.

Intensified ambulatory cardiology care: effects on mortality and hospitalisation-a comparative observational study

Since 2010, an intensified ambulatory cardiology care programme has been implemented in southern Germany. To improve patient management, the structure of cardiac disease management was improved, guideline-recommended care was supported, new ambulatory medical services and a morbidity-adapted reimbursement system were set up. Our aim was to determine the effects of this programme on the mortality and hospitalisation of enrolled patients with cardiac disorders. We conducted a comparative observational study in 2015 and 2016, based on insurance claims data. Overall, 13,404 enrolled patients with chronic heart failure (CHF) and 19,537 with coronary artery disease (CAD) were compared, respectively, to 8,776 and 16,696 patients that were receiving usual ambulatory cardiology care. Compared to the control group, patients enrolled in the programme had lower mortality (Hazard Ratio: 0.84; 95% CI: 0.77-0.91) and fewer all-cause hospitalisations (Rate Ratio: 0.94; 95% CI: 0.90-0.97). CHF-related hospitalisations in patients with CHF were also reduced (Rate Ratio: 0.76; 95% CI: 0.69-0.84). CAD patients showed a similar reduction in mortality rates (Hazard Ratio: 0.81; 95% CI: 0.76-0.88) and all-cause hospitalisation (Rate Ratio: 0.94; 95% CI: 0.91-0.97), but there was no effect on CAD-related hospitalisation. We conclude that intensified ambulatory care reduced mortality and hospitalisation in cardiology patients.

Association between specialist compensation and Accountable Care Organization performance

OBJECTIVE

To determine if Medicare Shared Savings Program Accountable Care Organizations (ACOs) using cost reduction measures in specialist compensation demonstrated better performance.

DATA SOURCES

National, cross-sectional survey data on ACOs (2013-2015) linked to public-use data on ACO performance (2014-2016).

STUDY DESIGN

We compared characteristics of ACOs that did and did not report use of cost reduction measures in specialist compensation and determined the association between using this approach and ACO savings, outpatient spending, and specialist visit rates.

PRINCIPAL FINDINGS

Of 160 ACOs surveyed, 26 percent reported using cost reduction measures to help determine specialist compensation. ACOs using cost reduction in specialist compensation were more often physician-led (68.3 vs 49.6 percent) and served higher-risk patients (mean Hierarchical Condition Category score 1.09 vs 1.05). These ACOs had similar savings per beneficiary year (adjusted difference $82.6 [95% CI -77.9, 243.1]), outpatient spending per beneficiary year (-24.0 [95% CI -248.9, 200.8]), and specialist visits per 1000 beneficiary years (369.7 [95% CI -9.3, 748.7]).

CONCLUSION

Incentivizing specialists on cost reduction was not associated with ACO savings in the short term. Further work is needed to determine the most effective approach to engage specialists in ACO efforts.

Assessing the Short-Term Association Between Rural Hospitals' Participation in Accountable Care Organizations and Changes in Utilization and Financial Performance

PURPOSE

Although much research has been done on accountable care organizations (ACOs), little is known about their impact on rural hospitals. We examine the association between rural hospitals' participation in an ACO and their performance on utilization and financial measures.

METHODS

This quasi-experimental study estimates the relationship between voluntary ACO participation and hospital metrics using propensity score-matched, longitudinal regression models with year and hospital fixed effects. Regression models controlled for secular trends and time-varying hospital and county characteristics. Hospital measures were from the American Hospital Association, RAND Hospital Data, and Leavitt Partners. The initial population comprises 643 rural hospitals that participated in an ACO for at least one year during the 2011 to 2018 study period and 1,541 rural hospitals that did not participate in an ACO. From this population we created a sample of propensity score-matched hospitals consisting of 525 ACO-participating and 525 comparable non-ACO hospitals.

RESULTS

Rural hospitals' participation in an ACO is not associated with changes in hospital utilization or financial measures, nor is there an association between these performance metrics and whether another within-county hospital participated in an ACO. A secondary analysis limited to Critical Access Hospitals provides some evidence that inpatient utilization increases in the second year of ACO participation, though the increases are not significant in year 3 and beyond.

CONCLUSION

We find no evidence that rural hospitals experience substantive changes in outpatient visits, inpatient utilization, or operating margin in the years immediately after joining an ACO.