A New Community Health Center/Academic Medicine Partnership for Medicaid Cost Control, Powered by the Mega Teaching Health Center

Impact of Academic Medical Centers on Surgical Outcomes of Neighboring Nonacademic Medical Centers

BACKGROUND

We aimed to investigate the geographic variation of academic medical centers (AMCs) across different healthcare markets and the impact on surgical outcomes in nearby non-AMCs.

STUDY DESIGN

Patients who underwent major surgery between 2016 and 2021 were identified from the Medicare Standard Analytic Files. Healthcare markets were delineated using Dartmouth Atlas hospital referral regions. Multivariable regression was used to examine the association between the presence of market-level AMCs and surgical outcomes in neighboring non-AMCs.

RESULTS

A total of 388,431 Medicare beneficiaries underwent major surgery (coronary artery bypass grafting: 97,346, 25.1%; abdominal aortic aneurysm repair: 67,000, 17.3%; pneumonectomy: 30,500, 7.9%; pancreatectomy: 5,341, 1.4%; colectomy: 188,244, 48.5%) at 2,757 non-AMCs. Median age was 74 years (interquartile range 70 to 80 years), and roughly one-half of patients were men (215,569, 55.5%). Notably, 43.1% of individuals underwent surgery in markets with low AMC presence, 48.0% in markets with moderate AMC presence, and 8.9% in markets with high AMC presence. On multivariable analysis, compared with low AMC markets, high AMC presence was associated with decreased risk of extended length of stay (-1.51%, 95% CI -2.03 to -1.00; p < 0.001), postoperative complications (-1.20%, 95% CI -1.76 to -0.65; p < 0.001), 90-day readmission (-2.39%, 95% CI -2.90 to -1.88; p < 0.001), and mortality (-0.64% 95% CI -0.98 to -0.30; p < 0.001). Additionally, high AMC market presence was associated with a 2.93% (-2.93%, 95% CI -3.17 to -2.68; p < 0.001) decrease in expenditures for the index surgical procedure.

CONCLUSIONS

High market presence of AMCs was associated with lower morbidity and mortality rates at nearby non-AMCs. The influence of AMCs on clinical outcomes likely extends beyond direct patient care, indicating spillover effects of AMCs on outcomes for patients in neighboring non-AMCs.

Adopting academic rank in a rural community practice affiliated with an academic medical center

BACKGROUND

United States rural community-based practices are increasingly participating in undergraduate and graduate medical education to train the workforce of the future, and are required or encouraged to provide academic appointments to physicians who have typically not held an academic appointment. Mechanisms to identify faculty and award academic appointments across an entire health system have not been reported.

METHODS

Our rural community regional practice identified academic appointments as important for participating in medical education. Over a three-year period, our regional leadership organized a formal education committee that led a variety of administrative changes to promote the adoption of academic rank. Data on attainment of academic appointments was obtained from our Academic Appointment and Promotion Committee, and cross referenced with data from our regional human resources department using self-reported demographic data.

RESULTS

We describe a successful adoption strategy for awarding academic rank in a rural regional practice in which the percentage of physician staff with academic rank increased from 41.1 to 92.8% over a 3-year period.

CONCLUSIONS

Our experience shows that process changes can rapidly increase and then sustain academic appointments for physicians over time. More rural health systems may want to consider the use of academic rank to support educational programs while enhancing physician satisfaction, recruitment and retention.

Tubal factor infertility and its impact on reproductive freedom of African American women

In the past, the reproductive freedom of African American women was hindered by forced reproduction and sterilization campaigns. Unfortunately, these involuntary practices have now mostly been replaced by inequality because of disproportionate tubal factor infertility rates within African American communities. Our work aimed to describe the inequities in increased rates of pelvic inflammatory disease and tubal factor infertility as it relates to African American women. In addition, we highlighted the need for improved access to screening and treatment of sexually transmitted infections, access to barrier contraception, and health literacy related to the understanding and prevention of tubal factor infertility in African American women.

Community and Academic Physicians Working Together in Integrated Health Care Systems

Objective

To examine best practices and policies for effectively merging community and academic physicians in integrated health care systems.

Methods

Deans of US allopathic medical schools were systematically interviewed between February and June 2017 regarding growth in their faculty practice plan (FPP), including logistics and best practices for integration of community physicians.

Results

The survey was completed by 107 of 143 (74.8) of US medical school deans approached. Of these institutions, 73 met criteria for final analysis (research-based medical schools with FPPs of >300 physicians). Most academic medical center–based FPPs have increased in size over the last 5 years, with further growth anticipated via adding community physicians (85%). Because of disparate practice locations, integration of community and academic physicians has been slow. When fully integrated, community physicians predominantly have a clinical role with productivity incentives. Deans report that cultural issues must be addressed to avoid conflict. Consensus exists that transparent clinical work requirements for all FPP members, clearly defined productivity incentives, additional promotion tracks, and early involvement of department chairs and other leaders enhances trust and creates better synergy among all physician providers.

Conclusion

Findings from this study should help guide FPPs, academic medical center leaders, chief medical officers, and professional and trade organizations in working toward positive physician synergy in consolidated health care organizations. Work and cultural considerations must be addressed to honor distinct talents of each physician group, facilitating smooth transition from disparate groups to healthy synergy.

A Geographic Population-level Analysis of Access to Total Shoulder Arthroplasty in the State of Texas

INTRODUCTION

Managing costs and improving access to care are two important goals of healthcare policy. The purposes of this study were to (1) evaluate the changes in distribution of total shoulder arthroplasty (TSA) cases in the state of Texas from 2010 to 2015 and (2) to evaluate patient access to TSA surgery centers as measured by driving miles.

METHODS

Inpatient (IP) and outpatient (OP) records were obtained from 2010 to 2015 from the Texas Department of State Health Services. All primary elective anatomic or reverse TSAs for patients with Texas-based home residence zip codes were included. Driving miles between patient zip codes and their chosen TSA surgery centers were estimated, and the results were compared between IP (high-volume [HV-IP] or low-volume [LV-IP]) and OP centers. Paired student t-tests, multivariate regressions, and mixed-model analysis of variance (ANOVA) were performed for volume comparisons, interactions between TSA centers types, and yearly trend data, respectively.

RESULTS

Between 2010 and 2015, a total of 21,092 TSA procedures were performed across 321 surgery centers in the state of Texas (19,629 IP [93.1%] and 1,463 OP [6.9%]). During this time, the cumulative volume of IP TSA per 100,000 Texas residents increased by 109.1%, whereas the cumulative volume of OP TSA increased by 143.7%. Approximately 85.5% of included patients resided within 50 miles of any TSA surgery center; however, only 47.0% of the total Texas population resided within 50 miles of any TSA surgery center. This relationship remained true at every time point irrespective of their volume designations (OP, IP, HV-IP, and LV-IP).

CONCLUSION

Despite the overall increase in TSA volume over time, the majority all TSA utilization in the state of Texas occurred in patients who resided within 50 miles of a TSA center. Increasing volume seems to reflect concentration of care into HV-IP and OP centers. Strategies to improve access to TSA care for underserved areas should be considered.

LEVEL OF EVIDENCE

Level II.

The Community Oncology and Academic Medical Center Alliance in the Age of Precision Medicine: Cancer Genetics and Genomics Considerations

Recent public policy, governmental regulatory and economic trends have motivated the establishment and deepening of community health and academic medical center alliances. Accordingly, community oncology practices now deliver a significant portion of their oncology care in association with academic cancer centers. In the age of precision medicine, this alliance has acquired critical importance; novel advances in nucleic acid sequencing, the generation and analysis of immense data sets, the changing clinical landscape of hereditary cancer predisposition and ongoing discovery of novel, targeted therapies challenge community-based oncologists to deliver molecularly-informed health care. The active engagement of community oncology practices with academic partners helps with meeting these challenges; community/academic alliances result in improved cancer patient care and provider efficacy. Here, we review the community oncology and academic medical center alliance. We examine how practitioners may leverage academic center precision medicine-based cancer genetics and genomics programs to advance their patients' needs. We highlight a number of project initiatives at the City of Hope Comprehensive Cancer Center that seek to optimize community oncology and academic cancer center precision medicine interactions.

Community Health Centers: a Key Partner to Achieve Medicaid Expansion

Medicaid expansion is an important feature of the "Affordable Care Act" and also is proposed as a component of some incremental plans for universal healthcare coverage. We describe (1) obstacles encountered with Medicaid coverage, (2) their potential resolution by federally qualified community health centers (CHCs), (3) the current status and limitations of CHCs, and (4) a proposed mega CHC model which could help assure access to care under Medicaid coverage expansion. Proposed development of the mega CHC model involves a three-component system featuring (1) satellite neighborhood outreach clinics, with team care directed by primary care nurse practitioners, (2) a hub central CHC which would closely correspond to the logistics and administration of current CHCs, and (3) a teaching hospital facilitating subspecialty care for CHC patients, with high-quality and cost-effectiveness. We believe that this new model, designated as a mega CHC, will demonstrate that CHCs can achieve their potential as a key partner to insure care under Medicaid expansion.

Developing Community-Based Primary Health Care for Complex and Vulnerable Populations in the Vancouver Coastal Health Region: HealthConnection Clinic

INTRODUCTION

Designing, delivering, and evaluating high-performing primary health care services for complex and vulnerable subpopulations are challenging endeavors. However, there is a relative paucity of research evidence available to support such work.

OBJECTIVE

To provide a case study using HealthConnection Clinic, a public primary care center located in Metropolitan Vancouver's North Shore.

METHODS

Developmental evaluation approach operationalizing the 10 Building Blocks of High-Performing Primary Care framework using qualitative and quantitative methods.

RESULTS

The clinic provided valuable insights to policymakers and researchers related to development of the Building Blocks' foundational elements, particularly engaged leadership, empanelment, and data-driven improvement. The study highlighted the key enablers, achievements, challenges, and barriers related to operationalizing each Building Block. The Building Blocks were a useful heuristic that enabled the development and evaluation of primary care for complex subpopulations. Particularly salient from a Canadian policy perspective was the demonstration that system integration was possible when highly engaged leaders from a Regional Health Authority and a Division of Family Practice shared a common vision and purpose. HealthConnection Clinic's entrepreneurial spirit has enabled the development of innovative, evidence-based tools such as the AMPS complexity assessment tool (attachment, medical conditions, psychological/mental health/addictions challenges, and socioeconomic status), designed to identify and assess biopsychosocial complexity and needs. The study also highlighted the importance of incorporating community orientation and equity into developmental work.

CONCLUSION

The study demonstrates how the Building Blocks approach can be adapted to operationalize high-performing primary care standards in settings serving complex and vulnerable populations.

Community Health Centers Could Provide Better Outsourced Primary Care for Veterans

The "VA Mission Act of 2018" will expand the current "Choice Program" legislation of 2014, which has enabled outsourcing of VA care to private physicians. As the ranks of Veteran patients swell, Congress intended that the Mission Act will help relieve the VHA's significant access problems. We contend that this new legislation will have negative consequences for veterans by diverting support from our VA system of 1300 hospitals and clinics. We recommend modification of this legislation, promoting much greater utilization of Community Health Centers (CHCs) for veterans outsourced primary care. In support of this proposal, we describe (1) features of the "VA Mission Act" relevant to outsourcing, (2) the challenges of the present "Choice Program" and likely future obstacles with the new legislation, and (3) the advantages of expanding CHC VA outsourced primary care. This policy would focus more on providing specialized care for veterans in the VA system, while coordinating with CHCs for the necessary expanded outsourced, holistic primary care. We conclude that failure to develop an incremental, cost-effective alternative as described herein represents a potential threat to adequate future support of our VA hospital system, and thus outstanding care for our veterans.