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Johnston KJ, Wen H, Joynt Maddox KE. Inadequate Risk Adjustment Impacts Geriatricians' Performance on Medicare Cost and Quality Measures. J Am Geriatr Soc 2019; 68:297-304. [PMID: 31880310 DOI: 10.1111/jgs.16297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/21/2019] [Accepted: 10/29/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Medicare value-based payment programs evaluate physicians' performance on their patients' annual Medicare costs and clinical outcomes. However, little is known about how geriatricians, who disproportionately provide care for medically complex older adults, perform on these measures. DESIGN A retrospective study using multivariable regression methods to estimate the association of geriatric risk factors with annualized Medicare costs and preventable hospitalization rates and to compare geriatricians' performance on these outcomes to other primary care physicians (PCPs) under standard Medicare risk adjustment and after adding additional adjustment for geriatric risk factors. SETTING Eight years (2006-2013) of cohort data from the Medicare Current Beneficiary Survey. PARTICIPANTS Medicare beneficiaries, aged 65 years and older, with primary care services contributing 27 027 person-years of data. MEASUREMENTS Outcomes were costs and preventable hospitalization rates; geriatric risk factors were patient frailty, long-term institutionalization, dementia, and depression. RESULTS Geriatricians were more likely to care for patients with frailty (22.8% vs 14.1%), long-term institutionalization (12.0% vs 4.7%), dementia (21.6% vs 10.2%), and depression (23.6% vs 17.4%) than other PCPs (P < .001 for each). Under standard Medicare risk adjustment, geriatricians performed more poorly on costs compared to other PCPs (observed-expected [O-E] ratio = 1.24 vs 0.99) and preventable hospitalizations (O-E ratio = 1.16 vs 0.98). Adding frailty, institutionalization, dementia, and depression to risk adjustment improved geriatricians' performance on costs by 25% and on preventable hospitalization rates by 35%, relative to other PCPs. Concurrent-year risk prediction that removed the influence of unpredictable acute events further improved geriatricians' performance vs other PCPs (O-E ratio = 0.99 vs 1.00). CONCLUSION Medicare should consider risk adjusting for frailty, long-term institutionalization, dementia, and depression to avoid inappropriately penalizing geriatricians who care for vulnerable older adults. J Am Geriatr Soc 68:297-304, 2020.
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Affiliation(s)
- Kenton J Johnston
- Department of Health Management and Policy and Center for Outcomes Research, College for Public Health and Social Justice, Saint Louis University, St Louis, Missouri
| | - Hefei Wen
- Department of Population Medicine, Harvard University, Boston, Massachusetts
| | - Karen E Joynt Maddox
- Cardiovascular Division, School of Medicine, Missouri, Washington University, St Louis
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Schapira MM, Williams M, Balch A, Baron RJ, Barrett P, Beveridge R, Collins T, Day SC, Fernandopulle R, Gilberg AM, Henley DE, Nguyen Howell A, Laine C, Miller C, Ryu J, Schwarz DF, Schwartz MD, Stevens J, Teisberg E, Yamaguchi K, Schapira E, Hubbard RA. Seeking Consensus on the Terminology of Value-Based Transformation Through use of a Delphi Process. Popul Health Manag 2019; 23:243-255. [PMID: 31660789 PMCID: PMC7301322 DOI: 10.1089/pop.2019.0093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Collaboration among diverse stakeholders involved in the value transformation of health care requires consistent use of terminology. The objective of this study was to reach consensus definitions for the terms value-based care, value-based payment, and population health. A modified Delphi process was conducted from February 2017 to July 2017. An in-person panel meeting was followed by 3 rounds of surveys. Panelists anonymously rated individual components of definitions and full definitions on a 9-point Likert scale. Definitions were modified in an iterative process based on results of each survey round. Participants were a panel of 18 national leaders representing population health, health care delivery, academic medicine, payers, patient advocacy, and health care foundations. Main measures were survey ratings of definition components and definitions. At the conclusion of round 3, consensus was reached on the following definition for value-based payment, with 13 of 18 panelists (72.2%) assigning a high rating (7– 9) and 1 of 18 (5.6%) assigning a low rating (1–3): “Value-based payment aligns reimbursement with achievement of value-based care (health outcomes/cost) in a defined population with providers held accountable for achieving financial goals and health outcomes. Value-based payment encourages optimal care delivery, including coordination across healthcare disciplines and between the health care system and community resources, to improve health outcomes, for both individuals and populations.” The iterative process elucidated specific areas of agreement and disagreement for value-based care and population health but did not reach consensus. Policy makers cannot assume uniform interpretation of other concepts underlying health care reform efforts.
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Affiliation(s)
- Marilyn M Schapira
- University of Pennsylvania Perelman School of Medicine, Department of Medicine and the Philadelphia VA Medical Center, Philadelphia, Pennsylvania, USA
| | | | - Alan Balch
- National Patient Advocate Foundation, Washington, District of Columbia, USA
| | - Richard J Baron
- American Board of Internal Medicine, Philadelphia, Pennsylvania, USA
| | - Patricia Barrett
- National Committee for Quality Assurance, Washington, District of Columbia, USA
| | | | - Tracie Collins
- University of Kansas School of Medicine Wichita, Wichita, Kanas, USA
| | - Susan C Day
- Penn Medicine, Penn Internal Medicine University City, Philadelphia, Pennsylvania, USA
| | | | | | | | | | - Christine Laine
- Annals of Internal Medicine, Philadelphia, Pennsylvania, USA
| | - Christina Miller
- Health Promotion Council of Southeast Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Mark D Schwartz
- New York University School of Medicine, Department of Population Health, New York, New York, USA
| | | | - Elizabeth Teisberg
- Dell Medical School, Value Institute for Health and Care, The University of Texas at Austin, Austin, Texas, USA
| | | | - Emily Schapira
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, New York, USA
| | - Rebecca A Hubbard
- University of Pennsylvania Perelman School of Medicine, Department of Biostatistics, Epidemiology, & Informatics, Philadelphia, Pennsylvania, USA
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Goldstein IH, Hribar MR, Read-Brown S, Chiang MF. Association of the Presence of Trainees With Outpatient Appointment Times in an Ophthalmology Clinic. JAMA Ophthalmol 2019; 136:20-26. [PMID: 29121175 DOI: 10.1001/jamaophthalmol.2017.4816] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Physicians face pressure to improve clinical efficiency, particularly with electronic health record (EHR) adoption and gradual shifts toward value-based reimbursement models. These pressures are especially pronounced in academic medical centers, where delivery of care must be balanced with medical education. However, the association of the presence of trainees with clinical efficiency in outpatient ophthalmology clinics is not known. Objective To quantify the association of the presence of trainees (residents and fellows) and efficiency in an outpatient ophthalmology clinic. Design, Setting, and Participants This single-center cohort study was conducted from January 1 through December 31, 2014, at an academic department of ophthalmology. Participants included 49 448 patient appointments with 33 attending physicians and 40 trainees. Exposures Presence vs absence of trainees in an appointment or clinic session, as determined by review of the EHR audit log. Main Outcomes and Measures Patient appointment time, as determined by time stamps in the EHR clinical data warehouse. Linear mixed models were developed to analyze variability among clinicians and patients. Results Among the 33 study physicians (13 women [39%] and 20 men [61%]; median age, 44 years [interquartile range, 39-53 years]), appointments with trainees were significantly longer than appointments in clinic sessions without trainees (mean [SD], 105.0 [55.7] vs 80.3 [45.4] minutes; P < .001). The presence of a trainee in a clinic session was associated with longer mean appointment time, even in appointments for which the trainee was not present (mean [SD], 87.2 [49.2] vs 80.3 [45.4] minutes; P < .001). Among 33 study physicians, 3 (9%) had shorter mean appointment times when a trainee was present, 1 (3%) had no change, and 29 (88%) had longer mean appointment times when a trainee was present. Linear mixed models showed the presence of a resident was associated with a lengthening of appointment time of 17.0 minutes (95% CI, 15.6-18.5 minutes; P < .001), and the presence of a fellow was associated with a lengthening of appointment time of 13.5 minutes (95% CI, 12.3-14.8 minutes; P < .001). Conclusions and Relevance Presence of trainees was associated with longer appointment times, even for patients not seen by a trainee. Although numerous limitations to this study design might affect the interpretation of the findings, these results highlight a potential challenge of maintaining clinical efficiency in academic medical centers and raise questions about physician reimbursement models.
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Affiliation(s)
- Isaac H Goldstein
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland
| | - Michelle R Hribar
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Sarah Read-Brown
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland
| | - Michael F Chiang
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland.,Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
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Spivack SB, Laugesen MJ, Oberlander J. No Permanent Fix: MACRA, MIPS, and the Politics of Physician Payment Reform. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2018; 43:1025-1040. [PMID: 31091325 DOI: 10.1215/03616878-7104431] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Organized medicine long yearned for the demise of Medicare's Sustainable Growth Rate (SGR) formula for updating physician fees. Congress finally obliged in 2015, repealing the SGR as part of the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA established value-based metrics for physician payment and financial incentives for doctors to join alternative delivery models like patient-centered medical homes. Throughout the law's initial implementation, the politics of accommodation prevailed, with federal officials crafting final rules that made MACRA more favorable for physicians. However, the era of accommodation could be short-lived. The discretion that the Centers for Medicare and Medicaid Services had during the first two years of implementation is ending. Additionally, euphoria over the SGR's repeal has given way to concerns over the new program's value-based purchasing arrangements and uncertainty over their sustainability. MACRA eliminated the SGR, but not the politics of physician payment.
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Gottumukkala RV, Le TQ, Duszak R, Prabhakar AM. Radiologists Are Actually Well Positioned to Innovate in Patient Experience. Curr Probl Diagn Radiol 2018; 47:206-208. [DOI: 10.1067/j.cpradiol.2017.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 09/27/2017] [Indexed: 12/31/2022]
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Mahony GT, Werner BC, Chang B, Grawe BM, Taylor SA, Craig EV, Warren RF, Dines DM, Gulotta LV. Risk factors for failing to achieve improvement after anatomic total shoulder arthroplasty for glenohumeral osteoarthritis. J Shoulder Elbow Surg 2018; 27:968-975. [PMID: 29482959 DOI: 10.1016/j.jse.2017.12.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 12/02/2017] [Accepted: 12/12/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although anatomic total shoulder arthroplasty (TSA) successfully improves pain and function, not all patients improve clinically. This study was conducted to determine patient-related factors for failure to achieve improvement after primary TSA for osteoarthritis at 2 years postoperatively. METHODS This prospective study reviewed an institutional shoulder registry for consecutive patients who underwent primary TSA for osteoarthritis from 2007 to 2013 with baseline and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form scores. A failed outcome was defined as (1) a failure to reach the ASES minimal clinically important difference of 16.1 points or (2) revision surgery within 2 years of the index procedure, or both. Univariate and multivariable analyses of clinical and demographic patient factors were performed using logistic regression. RESULTS Of 459 arthroplasties that met inclusion criteria, 411 were deemed successful by the aforementioned criteria, and 48 (10.5%) failed to achieve a desirable outcome. Clinical risk factors associated with failure included previous surgery to the shoulder (P = .047), presence of a torn rotator cuff (P = .025), and presence of diabetes (P = .036), after adjusting for age, sex, race, and body mass index. A higher preoperative ASES score at baseline was associated with failure (P < .001). CONCLUSION Previous shoulder surgery, a rotator cuff tear requiring repair during TSA, presence of diabetes, surgery on the nondominant arm, and a higher baseline ASES score were associated with a higher risk of failing to achieve improvement after anatomic TSA.
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Affiliation(s)
- Gregory T Mahony
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA
| | - Brian C Werner
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA; Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Brenda Chang
- Epidemiology and Biostatistics, Hospital for Special Surgery, New York, NY, USA
| | - Brian M Grawe
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA; Department of Orthopaedics and Sports Medicine, University of Cincinnati Academic Health Center, Cincinnati, OH, USA.
| | - Samuel A Taylor
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA
| | - Edward V Craig
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA
| | - Russell F Warren
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA
| | - David M Dines
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA
| | - Lawrence V Gulotta
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA
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The use of patient-reported outcome tools in Gynecologic Oncology research, clinical practice, and value-based care. Gynecol Oncol 2018; 148:12-18. [DOI: 10.1016/j.ygyno.2017.11.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/04/2017] [Accepted: 11/06/2017] [Indexed: 01/10/2023]
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Sista AK, Friedman OA, Dou E, Denvir B, Askin G, Stern J, Estes J, Salemi A, Winokur RS, Horowitz JM. A pulmonary embolism response team's initial 20 month experience treating 87 patients with submassive and massive pulmonary embolism. Vasc Med 2017; 23:65-71. [PMID: 28920554 DOI: 10.1177/1358863x17730430] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pulmonary Embolism Response Teams (PERTs) have emerged to provide rapid multidisciplinary assessment and treatment of PE patients. However, descriptive institutional experience and preliminary outcomes data from such teams are sparse. PERT activations were identified through a retrospective review. Only confirmed submassive or massive PEs were included in the data analysis. In addition to baseline variables, the therapeutic intervention, length of stay (LOS), in-hospital mortality, and bleeding rate/severity were recorded. A total of 124 PERT activations occurred over 20 months: 43 in the first 10 months and 81 in the next 10. A total of 87 submassive (90.8%) and massive (9.2%) PE patients were included. The median age was 65 (51-75 IQR) years. Catheter-directed thrombolysis (CDT) was administered to 25 patients, systemic thrombolysis (ST) to six, and anticoagulation alone (AC) to 54. The median ICU stay and overall LOS were 6 (3-10 IQR) and 7 (4-14 IQR) days, respectively, with no association with any variables except a brain natriuretic peptide (BNP) >100 pg/mL ( p=0.008 ICU LOS; p=0.047 overall LOS). Twelve patients (13.7%) died in the hospital, nine of whom had metastatic or brain cancer, with a median overall LOS of 13 (11-17 IQR) days. There were five major bleeds: one in the CDT group, one in the ST group, and three in the AC group. Overall, (1) PERT activations increased after the first 10 months; (2) BNP >100 pg/mL was associated with a longer LOS; (3) rates of mortality and bleeding did not correlate with treatment; and (4) the majority of in-hospital deaths occurred in patients with advanced cancer.
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Affiliation(s)
- Akhilesh K Sista
- 1 Department of Radiology, Division of Vascular and Interventional Radiology, New York University School of Medicine, New York, NY, USA
| | - Oren A Friedman
- 2 Department of Surgery, Division of Cardiothoracic Surgery and Department of Medicine, Division of Pulmonary and Critical Care Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Eda Dou
- 3 Department of Radiology, Weill Cornell School of Medicine, New York, NY, USA
| | - Brendan Denvir
- 3 Department of Radiology, Weill Cornell School of Medicine, New York, NY, USA
| | - Gulce Askin
- 4 Department of Health Policy & Research, Division of Biostatistics and Epidemiology, Weill Cornell School of Medicine, New York, NY, USA
| | - Jamie Stern
- 3 Department of Radiology, Weill Cornell School of Medicine, New York, NY, USA
| | - Jaclyn Estes
- 3 Department of Radiology, Weill Cornell School of Medicine, New York, NY, USA
| | - Arash Salemi
- 5 Department of Cardiothoracic Surgery, Weill Cornell School of Medicine, New York, NY, USA
| | - Ronald S Winokur
- 3 Department of Radiology, Weill Cornell School of Medicine, New York, NY, USA
| | - James M Horowitz
- 6 Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, NY, USA
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Results of the 2015 Scoliosis Research Society Survey on Single Versus Dual Attending Surgeon Approach for Adult Spinal Deformity Surgery. Spine (Phila Pa 1976) 2017; 42:932-942. [PMID: 28609324 DOI: 10.1097/brs.0000000000002070] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN An electronic survey administered to Scoliosis Research Society (SRS) membership. OBJECTIVE To characterize surgeon practices and views regarding the use of two attending surgeons for adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA The use of two experienced attending surgeons can decrease the operative time, estimated blood loss, and perioperative complication rates. However, the current practice patterns for the use of two attending surgeons remains unknown. METHODS An electronic, 27-question survey regarding single/dual attending surgeons was administered to the SRS membership. Determinants included: surgeon/practice demographics, assistant type/level of training, and questions regarding use of two attending surgeons. Overall reporting and comparisons between groups were made: US versus international, academic versus private practice, and experience <15 years versus >15 years. RESULTS A total of 199 surgeons responded from 27 different countries. Overall and between the groups, the respondents significantly reported believing that two attending spine surgeons improves safety, decreases complications, and improves outcomes (P < 0.01). Approximately, 67.3% reported using a second attending ≤25% of the time (33.2% do not), and 24.1% use one ≥51% of the time (similar between groups); 51.1% that have a second attending feel it's limited by reimbursement and access concerns and 71.9% have difficulty getting the second attending reimbursed. 72.3% use a second attending for ALL of the following reasons (no difference between groups): "it's safer/reduces complications," "it decreases operative time," "it decreases blood loss," "it results in improved outcomes," "it's less work and stress for me." If reimbursement was equal/assured for a second attending, 67.5% would use one "more often" or "always." CONCLUSION The respondents feel that having a second attending surgeon improves patient care, however most do not use one often. Reasons include reimbursement/access concerns and the majority would use one if reimbursement was equal and assured. Based on the current literature and these results, there is a need for working with third party payers to improve dual surgeon reimbursement rates in complex cases. LEVEL OF EVIDENCE 5.
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Johnston KJ, Hockenberry JM. Are Two Heads Better Than One or Do Too Many Cooks Spoil the Broth? The Trade-Off between Physician Division of Labor and Patient Continuity of Care for Older Adults with Complex Chronic Conditions. Health Serv Res 2017; 51:2176-2205. [PMID: 27891605 DOI: 10.1111/1475-6773.12600] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the effects of physician division of labor and patient continuity of care (COC) on the care quality and outcomes of older adults with complex chronic conditions. DATA SOURCES/STUDY SETTING Seven years (2006-2012) of panel data from the Medicare Current Beneficiary Survey (MCBS). STUDY DESIGN Regression models were used to estimate the effect of the specialty-type of physicians involved in annual patient evaluation and management, as well as patient COC, on simultaneous care processes and following year outcomes. DATA COLLECTION/EXTRACTION METHODS Multiyear cohorts of Medicare beneficiaries with diabetes and/or heart failure were retrospectively identified to create a panel of 15,389 person-year observations. PRINCIPAL FINDINGS Involvement of both primary care physicians and disease-relevant specialists is associated with better compliance with process-of-care guidelines, but patients seeing disease-relevant specialists also receive more repeat cardiac imaging (p < .05). Patient COC is associated with less repeat cardiac imaging and compliance with some recommended care processes (p < .05), but the effects are small. Receiving care from a disease-relevant specialist is associated with lower rates of following year functional impairment, institutionalization in long-term care, and ambulatory care sensitive hospitalization (p < .05). CONCLUSIONS Annual involvement of disease-relevant specialists in the care of beneficiaries with complex chronic conditions leads to more resource use but has a beneficial effect on outcomes.
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Affiliation(s)
- Kenton J Johnston
- Department of Health Management and Policy and Center for Outcomes Research, College for Public Health and Social Justice, Saint Louis University, St Louis, MO
| | - Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA
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Brandt BF, Schmitz CC. The US National Center for Interprofessional Practice and Education Measurement and Assessment Collection. J Interprof Care 2017; 31:277-281. [DOI: 10.1080/13561820.2017.1286884] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Barbara F. Brandt
- National Center for Interprofessional Practice and Education, University of Minnesota, Minneapolis, Minnesota, USA
| | - Constance C. Schmitz
- National Center for Interprofessional Practice and Education, University of Minnesota, Minneapolis, Minnesota, USA
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Tanenbaum SJ. Can Payment Reform Be Social Reform? The Lure and Liabilities of the "Triple Aim". JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2017; 42:53-71. [PMID: 27729444 DOI: 10.1215/03616878-3702770] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The formulation of the triple aim responds to three problems facing the US health care system: high cost, low quality, and poor health status. The purpose of this article is to analyze the potential of the health care system to achieve the triple aim and, specifically, the attempt to improve population health by rewarding providers who contain costs. The first section of the article will consider the task of improving population health through the health care system. The second section of the article will discuss CMS's efforts to pay providers to achieve the triple aim, that is, to improve health care and population health while containing cost. These include Maryland's Global Revenue Budget model, bundled payments, and ACOs, and they highlight the extent to which this version of integration is underwritten by savings achieved by providers for the Medicare program. The conclusion section of the article will consider the politics of payment reform as social reform. It will address proposals that health care payers and providers lead in addressing the social contributors to ill health and urge payment reformers to appreciate more fully the politics and policies of other sectors and the dynamics of their inclusion in population health improvement.
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POINT: Is It Time for Pulmonary Concierge Practices? Yes. Chest 2017; 151:255-257. [DOI: 10.1016/j.chest.2016.09.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 09/21/2016] [Indexed: 12/25/2022] Open
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Green DE, Hamory BH, Terrell GE, O'Connell J. A Case Report: Cornerstone Health Care Reduced the Total Cost of Care Through Population Segmentation and Care Model Redesign. Popul Health Manag 2017; 20:309-317. [PMID: 28106518 DOI: 10.1089/pop.2016.0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Over the course of a single year, Cornerstone Health Care, a multispecialty group practice in North Carolina, redesigned the underlying care models for 5 of its highest-risk populations-late-stage congestive heart failure, oncology, Medicare-Medicaid dual eligibles, those with 5 or more chronic conditions, and the most complex patients with multiple late-stage chronic conditions. At the 1-year mark, the results of the program were analyzed. Overall costs for the patients studied were reduced by 12.7% compared to the year before enrollment. All fully implemented programs delivered between 10% and 16% cost savings. The key area for savings factor was hospitalization, which was reduced by 30% across all programs. The greatest area of cost increase was "other," a category that consisted in large part of hospice services. Full implementation was key; 2 primary care sites that reverted to more traditional models failed to show the same pattern of savings.
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Affiliation(s)
- Dale E Green
- 1 University of Georgia College of Public Health , Athens, Georgia
| | | | - Grace E Terrell
- 3 Cornerstone Health Enablement Strategic Solutions , High Point, North Carolina
| | - Jasmine O'Connell
- 3 Cornerstone Health Enablement Strategic Solutions , High Point, North Carolina
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Bhat SB, Lazarus M, Getz C, Williams GR, Namdari S. Economic Decision Model Suggests Total Shoulder Arthroplasty is Superior to Hemiarthroplasty in Young Patients with End-stage Shoulder Arthritis. Clin Orthop Relat Res 2016; 474:2482-2492. [PMID: 27457626 PMCID: PMC5052199 DOI: 10.1007/s11999-016-4991-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 07/13/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Young patients with severe glenohumeral arthritis pose a challenging management problem for shoulder surgeons. Two controversial treatment options are total shoulder arthroplasty (TSA) and hemiarthroplasty. This study aims to characterize costs, as expressed by reimbursements for episodes of acute care, and outcomes associated with each treatment. QUESTIONS/PURPOSES We asked: for patients 30 to 50 years old with severe end-stage glenohumeral arthritis refractory to conservative management, (1) are more years of patient-derived satisfactory outcome by the Neer criteria and quality-adjusted life-years (QALYs) achieved using a TSA or a hemiarthroplasty; (2) does a TSA or a hemiarthroplasty result in a greater number of revision procedures; and (3) does a TSA or a hemiarthroplasty result in greater associated costs to society? METHODS The incidence of glenohumeral arthritis among 30- to 50-year-old patients, outcomes, reoperation probabilities, and associated costs from TSA and hemiarthroplasty were derived from the literature. A Markov chain decision tree model was developed from these estimates with number of revisions, cost of management for patients to 70 years old as defined by reimbursement for acute-care episodes, years with "satisfactory" or "excellent" outcome by the modified Neer criteria, and QALYs gained as principle outcome measures. A Monte Carlo simulation was conducted with a cohort representing the at-risk population for shoulder arthritis between 30 and 50 years old in the United States. RESULTS During the lifetime of a cohort of 5279 patients, hemiarthroplasty as the initial treatment resulted in 59,574 patient years of satisfactory or excellent results (11.29 per patient) and average QALYs gained of 6.55, whereas TSA as the initial treatment resulted in 85,969 patient years of satisfactory or excellent results (16.29 per patient) and average QALYs gained of 7.96. During the lifetime of a cohort of 5279 patients, a hemiarthroplasty as the initial treatment led to 2090 lifetime revisions (0.4 per patient), whereas a TSA as the initial treatment led to 1605 lifetime revisions (0.3 per patient). During the lifetime of a cohort of 5279 patients, a hemiarthroplasty as initial treatment resulted in USD 132,500,000 associated direct reimbursements (USD 25,000 per patient), whereas a TSA as initial treatment resulted in USD 125,500,000 associated direct reimbursements (USD 23,700 per patient). CONCLUSIONS Treatment of end-stage glenohumeral arthritis refractory to conservative treatment in patients 30 to 50 years old in the United States with TSA, instead of hemiarthroplasty, would result in greater cost savings, avoid a substantial number of revision procedures, and result in greater years of satisfactory or excellent patient outcomes and greater QALYs gained. On a population level, TSA is the cost-effective treatment for glenohumeral arthritis in patients 30 to 50 years old. LEVEL OF EVIDENCE Level II, economic and decision analysis study.
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Affiliation(s)
- Suneel B. Bhat
- Rothman Institute Department of Orthopaedics, Thomas Jefferson University Hospital, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107 USA
| | - Mark Lazarus
- Rothman Institute Department of Orthopaedics, Thomas Jefferson University Hospital, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107 USA
| | - Charles Getz
- Rothman Institute Department of Orthopaedics, Thomas Jefferson University Hospital, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107 USA
| | - Gerald R. Williams
- Rothman Institute Department of Orthopaedics, Thomas Jefferson University Hospital, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107 USA
| | - Surena Namdari
- Rothman Institute Department of Orthopaedics, Thomas Jefferson University Hospital, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107 USA
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Cologne KG, Byers S, Rosen DR, Hwang GS, Ortega AE, Ault GT, Lee SW. Factors Associated with a Short (<2 Days) or Long (>10 Days) Length of Stay after Colectomy: A Multivariate Analysis of over 400 Patients. Am Surg 2016. [DOI: 10.1177/000313481608201022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A prospectively maintained database of 415 patients undergoing colectomy was evaluated. We performed a logistic regression analysis to identify factors associated with 1) length of stay (LOS) of 2 days or less and 2) LOS of 10 days or more. Investigated variables included demographics, American Society of Anesthesiology (ASA) score, diagnosis, operative procedure, approach and time, transfusion requirements, and occurrence of any complications. Factors associated with a LOS of two days or less included ASA [odds ratio (OR): 0.34, 95% confidence interval (CI): 0.208–0.576], use of transversus abdominis plane block (OR: 5.259, 95% CI: 2.825–9.791), and operative time (OR: 0.98, 95% CI: 0.974–0.986). Age >65 had an OR of 1.73, though this did not reach statistical significance. Factors associated with LOS >10 days included ASA (OR: 2.152, 95% CI: 1.245–3.721), anastomotic leak (OR: 2.163, 95% CI: 1.486–3.148), ileus (OR: 8.790, 95% CI: 4.501–17.165), and surgical site infection (OR: 5.846, 95% CI: 2.764–12.362). Cancer and transfusion status were associated but did not reach statistical significance. Although operative time was longer in left-sided resections, no differences in LOS were observed. In conclusion, numerous factors are associated with short or long LOS and may help stratify resource utilization after colectomy. Further study is needed to confirm our findings.
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Affiliation(s)
- Kyle G. Cologne
- From the Division of Colorectal Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Sean Byers
- From the Division of Colorectal Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - David R. Rosen
- From the Division of Colorectal Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Grace S. Hwang
- From the Division of Colorectal Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Adrian E. Ortega
- From the Division of Colorectal Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Glenn T. Ault
- From the Division of Colorectal Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Sang W. Lee
- From the Division of Colorectal Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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17
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18
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Affiliation(s)
- John I Allen
- Department of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut.
| | - Carlton C Allen
- Astromaterial Curator, National Aeronautics and Space Administration (NASA) Johnson Space Center (retired), Placitas, New Mexico
| | - Joel V Brill
- Predictive Health, LLC, Paradise Valley, Arizona
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Embi PJ, Tsevat J. In Reply to Severance. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:10. [PMID: 26714133 DOI: 10.1097/acm.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Peter J Embi
- Associate professor of biomedical informatics, internal medicine, and public health, and associate dean for research informatics, Ohio State University College of Medicine, Columbus, Ohio; . Professor of medicine and associate dean for clinical and translational research, University of Cincinnati College of Medicine and Cincinnati VA Medical Center, Cincinnati, Ohio
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