Understanding how health systems facilitate primary care redesign

Impact of capitation on physicians' behavior among patients with hypertension: an interrupted time series study in rural China

OBJECTIVE

The purpose of this study is to explore the change in physicians' hypertension treatment behavior before and after the reform of the capitation in county medical community.

METHODS

Spanning from January 2014 to December 2019, monthly data of outpatient and inpatient were gathered before and after the implementation of the reform in April 2015. We employed interrupted time series analysis method to scrutinize the instantaneous level and slope changes in the indicators associated with physicians' behavior.

RESULTS

Several indicators related to physicians' behavior demonstrated enhancement. After the reform, medical cost per visit for inpatient exhibited a reverse trajectory (-53.545, 95%CI: -78.620 to -28.470, p < 0.01). The rate of change in outpatient drug combination decelerated (0.320, 95%CI: 0.149 to 0.491, p < 0.01). The ratio of infusion declined for both outpatient and inpatient cases (-0.107, 95%CI: -0.209 to -0.004, p < 0.1; -0.843, 95%CI: -1.154 to -0.532, p < 0.01). However, the results revealed that overall medical cost per visit and drug proportion for outpatient care continued their initial upward trend. After the reform, the decline of drug proportion for outpatient care was less pronounced compared to the period prior to the reform, and length of stay also had a similar trend.

CONCLUSION

To some extent, capitation under the county medical community encourages physicians to control the cost and adopt a more standardized diagnosis and treatment behavior. This study provides evidence to consider the impact of policy changes on physicians' behavior when designing payment methods and healthcare systems aimed at promoting PHC.

Effective policy research of county and township health sector integration in China: Empirical evidence from the difference-in-differences model

Medical service fragmentation is a common problem worldwide, and many countries have adopted integration to solve the difficulty. Contrary to developed countries, developing countries such as China must consider how to implement integration under a relatively weak medical foundation. This study aims to evaluate the effect of the "Compact Union of County and Township Health Sectors" policy on the medical service capacity of a typical integration model represented by Shanxi Province in China and determine the path the policy followed. By using Shanxi's county-level medical integration as a quasi-natural experiment, this study establishes a difference-in-differences model to investigate the effect of the policy using official data. A series of tests are conducted to verify the robustness of the result. Finally, the policy pathway is tested. The results show that the third-level surgeries and outpatient service utilization of leading hospitals and township institutions increased. Still, inpatient service utilization and fourth-level surgeries did not show a significant change in either type of institution. Moreover, the enhancement of leading hospitals' service capacity comes mainly through improving asset efficiency and personal income, while the improvement of township institutions' capacity comes primarily through increased personal income. Compact integration of county-level medical institutions can stimulate and improve service capacity by improving asset efficiency and personal income, even with a weak medical foundation. However, to achieve continuous service capacity improvement, the professional level of county-level institutions must be strengthened with a superior hospital's assistance, and personnel's enthusiasm for active innovation must be cultivated.

Changes in Barriers That Cause Unmet Healthcare Needs in the Life Cycle of Adulthood and Their Policy Implications: A Need-Selection Model Analysis of the Korea Health Panel Survey Data

Using 68,930 observations selected from 16,535 adults in the Korea Health Panel Survey (2014-2018), this study explored healthcare barriers that prevent people from meeting their healthcare needs most severely during adulthood, and the characteristics that are highly associated with the barrier. This study derived two outcome variables: a dichotomous outcome variable on whether an individual has experienced healthcare needs, and a quadchotomous outcome variable on how an individual's healthcare needs ended. An analysis was conducted using a multivariable panel multinomial probit model with sample selection. The results showed that the main cause of unmet healthcare needs was not financial difficulties but non-financial barriers, which were time constraints up to a certain age and the lack of caring and support after that age. People with functional limitations were at a high risk of experiencing unmet healthcare needs due to a lack of caring and support. To reduce unmet healthcare needs in South Korea, the government should focus on lowering non-financial barriers to healthcare, including time constraints and lack of caring and support. It seems urgent to strengthen the foundation of "primary care", which is exceptionally scarce now, and to expand it to "community-based integrated care" and "people-centered care".

Effect of mental health collaborative care models on primary care provider outcomes: an integrative review

BACKGROUND

Collaborative care models (CCMs) have robust research evidence in improving mental health outcomes for diverse patient populations with complex health care needs. However, the impact of CCMs on primary care provider (PCP) outcomes are not well described.

OBJECTIVE

This integrative review synthesizes the evidence regarding the effect of mental health CCMs on PCP outcomes.

METHODS

PubMed, CINAHL, Web of Science, and PsycInfo were systematically searched using key terms, with inclusion criteria of English language, peer-reviewed literature, primary care setting, PCP outcomes, and mental health CCM. This resulted in 1,481 total records, with an additional 14 records identified by review of reference lists. After removal of duplicates, 1,319 articles were reviewed based on title and abstract, 190 full-text articles were assessed, and a final selection of 15 articles were critically appraised and synthesized.

RESULTS

The articles included a wide variety of sample sizes, designs, settings, and patient populations, with most studies demonstrating low or moderate quality evidence. Although CCMs had an overwhelmingly positive overall effect on PCP outcomes such as knowledge, satisfaction, and self-efficacy, multiple logistical barriers were also identified that hindered CCM implementation such as time and workflow conflicts. Adaptability of the CCM as well as PCP enthusiasm enhanced positive outcomes. Newer-to-practice PCPs were more likely to participate in CCM initiatives.

CONCLUSION

Accumulating evidence supports CCM expansion, to improve both patient and PCP outcomes. Logistical efforts may enhance CCM adaptability and workflow. Further studies are needed to specifically examine the effect of CCMs on PCP burnout and retention.

Prevalence and Characteristics of Providers' Care Coordination Communication With Schools

OBJECTIVES

Care coordination between schools and medical providers promotes child health, particularly for children with physical, emotional, and behavioral challenges. The purpose of this study was to assess caregivers' reports of provider-school communication for their children. Further, the study assessed if communication rates varied by child demographic or health conditions.

METHODS

This study was a cross-sectional analysis of the 2016-2017 National Survey of Children's Health focused on school-aged children (age 6-17 years; n = 18,160). Weighted frequencies overall and stratified by provider-school communication status are reported. Multivariable logistic regression examined associations of provider-school communication.

RESULTS

Only 23.5% of the total sample reported provider-school communication. The highest caregiver-reported communication prevalence was for children with diabetes (68.0%). Behavioral/mental health conditions, chronic physical health conditions or having increased medical complexity and needs were significantly associated with increased communication compared to those without these conditions. Odds Ratio (OR) and 95% Confidence Intervals (CI) for children with a behavioral/mental health condition were OR: 1.28; CI: 1.02 to 1.61, for children with a chronic physical health condition were OR: 1.37; CI: 1.15 to 1.63 and for children with special health care needs or with medical complexity were OR: 2.15; CI: 1.75 to 2.64 and OR: 1.77; CI: 1.09 to 2.87, respectively. Significant communication differences existed for every health condition (P < 0.05) except for children who had a blood disorder (P = 0.365).

CONCLUSIONS

Caregiver perception of provider-school communication is low and differences in reported rates existed between health conditions and complexity status. Further work is needed to support provider-school-family communication for children with physical, mental, behavioral, and complex health conditions.

Is Bigger Better?: A Closer Look at Small Health Systems in the United States

BACKGROUND

Research on US health systems has focused on large systems with at least 50 physicians. Little is known about small systems.

OBJECTIVES

Compare the characteristics, quality, and costs of care between small and large health systems.

RESEARCH DESIGN

Retrospective, repeated cross-sectional analysis.

SUBJECTS

Between 468 and 479 large health systems, and between 608 and 641 small systems serving fee-for-service Medicare beneficiaries, yearly between 2013 and 2017.

MEASURES

We compared organizational, provider and beneficiary characteristics of large and small systems, and their geographic distribution, using multiple Medicare and Internal Revenue Service administrative data sources. We used mixed-effects regression models to estimate differences between small and large systems in claims-based Healthcare Effectiveness Data and Information Set (HEDIS) quality measures and HealthPartners' Total Cost of Care measure using a 100% sample of Medicare fee-for-service claims. We fit linear spline models to examine the relationship between the number of a system's affiliated physicians and its quality and costs.

RESULTS

The number of both small and large systems increased from 2013 to 2017. Small systems had a larger share of practice sites (43.1% vs. 11.7% for large systems in 2017) and beneficiaries (51.4% vs. 15.5% for large systems in 2017) in rural areas or small towns. Quality performance was lower among small systems than large systems (-0.52 SDs of a composite quality measure) and increased with system size up to ∼75 physicians. There was no difference in total costs of care.

CONCLUSIONS

Small systems are a growing source of care for rural Medicare populations, but their quality performance lags behind large systems. Future studies should examine the mechanisms responsible for quality differences.

Characteristics Associated With Financial or Non-financial Barriers to Healthcare in a Universal Health Insurance System: A Longitudinal Analysis of Korea Health Panel Survey Data

While many studies have explored the financial barriers to healthcare, there is little evidence regarding the non-financial barriers to healthcare. This study identified characteristics associated with financial and non-financial barriers to healthcare and quantified the effects of these characteristics in South Korea, using a nationally representative longitudinal survey dataset. Overall, 68,930 observations of 16,535 individuals aged 19 years and above were sampled from Korea Health Panel survey data (2014-2018). From self-reported information about respondents' experiences of unmet healthcare needs, a trichotomous dependent variable-no barrier, non-financial barrier, and financial barrier-was derived. Sociodemographics, physical and health conditions were included as explanatory variables. The average adjusted probability (AAP) of experiencing each barrier was predicted using multivariable and panel multinomial logistic regression analyses. According to the results, the percentage of people experiencing non-financial barriers was much higher than that of people experiencing financial barriers in 2018 (9.6 vs. 2.5%). Women showed higher AAPs of experiencing both non-financial (9.9 vs. 8.3%) and financial barriers (3.6 vs. 2.5%) than men. Men living in the Seoul metropolitan area showed higher AAPs of experiencing non-financial (8.7 vs. 8.0%) and financial barriers (3.4 vs. 2.1%) than those living outside it. Household income showed no significant associations in the AAP of experiencing a non-financial barrier. People with a functional limitation exhibited a higher AAP of experiencing a non-financial barrier, for both men (17.8 vs. 7.8%) and women (17.4 vs. 9.0%), than those without it. In conclusion, people in South Korea, like those in most European countries, fail to meet their healthcare needs more often due to non-financial barriers than financial barriers. In addition, the characteristics associated with non-financial barriers to healthcare differed from those associated with financial barriers. This finding suggests that although financial barriers may be minimised through various policies, a considerable degree of unmet healthcare needs and disparity among individuals is very likely to persist due to non-financial barriers. Therefore, current universal health insurance systems need targeted policy instruments to minimise non-financial barriers to healthcare to ensure effective universal health coverage.

Are health systems redesigning how health care is delivered?

OBJECTIVE

To explore why and how health systems are engaging in care delivery redesign (CDR)-defined as the variety of tools and organizational change processes health systems use to pursue the Triple Aim.

STUDY SETTING

A purposive sample of 24 health systems across 4 states as part of the Agency for Healthcare Research and Quality's Comparative Health System Performance Initiative.

STUDY DESIGN

An exploratory qualitative study design to gain an "on the ground" understanding of health systems' motivations for, and approaches to, CDR, with the goals of identifying key dimensions of CDR, and gauging the depth of change that is possible based on the particular approaches to redesign care being adopted by the health systems.

DATA COLLECTION

Semi-structured telephone interviews with health system executives and physician organization leaders from 24 health systems (n = 162).

PRINCIPAL FINDINGS

We identify and define 13 CDR activities and find that the health systems' efforts are varied in terms of both the combination of activities they are engaging in and the depth of innovation within each activity. Health system executives who report strong internal motivation for their CDR efforts describe more confidence in their approach to CDR than those who report strong external motivation. Health system leaders face uncertainty when implementing CDR due to a limited evidence base and because of the slower than expected pace of payment change.

CONCLUSIONS

The ability to validly and reliably measure CDR activities-particularly across varying organizational contexts and markets-is currently limited but is key to better understanding CDR's impact on intended outcomes, which is important for guiding both health system decision making and policy making.