1
|
Ali KJ, Goeschel CA, DeLia DM, Blackall LM, Singh H. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare. Diagnosis (Berl) 2024; 11:17-24. [PMID: 37795579 DOI: 10.1515/dx-2023-0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 08/26/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVES No framework currently exists to guide how payers and providers can collaboratively develop and implement incentives to improve diagnostic safety. We conducted a literature review and interviews with subject matter experts to develop a multi-component 'Payer Relationships for Improving Diagnoses (PRIDx)' framework, that could be used to engage payers in diagnostic safety efforts. CONTENT The PRIDx framework, 1) conceptualizes diagnostic safety links to care provision, 2) illustrates ways to promote payer and provider engagement in the design and adoption of accountability mechanisms, and 3) explicates the use of data analytics. Certain approaches suggested by PRIDx were refined by subject matter expert interviewee perspectives. SUMMARY The PRIDx framework can catalyze public and private payers to take specific actions to improve diagnostic safety. OUTLOOK Implementation of the PRIDx framework requires new types of partnerships, including external support from public and private payer organizations, and requires creation of strong provider incentives without undermining providers' sense of professionalism and autonomy. PRIDx could help facilitate collaborative payer-provider approaches to improve diagnostic safety and generate research concepts, policy ideas, and potential innovations for engaging payers in diagnostic safety improvement activities.
Collapse
Affiliation(s)
- Kisha J Ali
- MedStar Institute for Quality and Safety, Columbia, MD, USA
| | - Christine A Goeschel
- MedStar Institute for Quality and Safety, Columbia, MD, USA
- Georgetown University School of Medicine, Washington, DC, USA
| | - Derek M DeLia
- Rutgers University, Bloustein School of Planning and Public Policy, New Brunswick, NJ, USA
| | | | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
2
|
Matchar DB, Lai WX, Kumar A, Ansah JP, Ng YF. A Causal View of the Role and Potential Limitations of Capitation in Promoting Whole Health System Performance. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4581. [PMID: 36901591 PMCID: PMC10002232 DOI: 10.3390/ijerph20054581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 06/18/2023]
Abstract
For several decades, health systems in developed countries have faced rapidly rising healthcare costs without concomitant improvements in health outcomes. Fee for service (FFS) reimbursement mechanisms (RMs), where health systems are paid based on volume, contribute to this trend. In Singapore, the public health service is trying to curb rising healthcare costs by transitioning from a volume-based RM to a capitated payment for a population within a geographical catchment area. To provide insight into the implications of this transition, we developed a causal loop diagram (CLD) to represent a causal hypothesis of the complex relationship between RM and health system performance. The CLD was developed with input from government policymakers, healthcare institution administrators, and healthcare providers. This work highlights that the causal relationships between government, provider organizations, and physicians involve numerous feedback loops that drive the mix of health services. The CLD clarifies that a FFS RM incentivizes high margin services irrespective of their health benefits. While capitation has the potential to mitigate this reinforcing phenomenon, it is not sufficient to promote service value. This suggests the need to establish robust mechanisms to govern common pool resources while minimizing adverse secondary effects.
Collapse
Affiliation(s)
- David Bruce Matchar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore
- Department of Medicine, Duke University, Durham, NC 27708, USA
| | - Wei Xuan Lai
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore
| | - Ashish Kumar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore
| | - John Pastor Ansah
- Center for Community Health Integration, Case Western Reserve University, Cleveland, OH 44106, USA
| | | |
Collapse
|
3
|
Keser C, Montmarquette C, Schmidt M, Schnitzler C. Custom-made health-care: an experimental investigation. HEALTH ECONOMICS REVIEW 2020; 10:41. [PMID: 33337515 PMCID: PMC7749502 DOI: 10.1186/s13561-020-00299-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 12/07/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Physicians' financial interests might conflict with the best service to patients. It is essential to gain a thorough understanding of the effect of remuneration systems on physician behaviour. METHODS We conducted a controlled laboratory experiment using a within-subject design to investigate physician behaviour underpayment heterogeneity. Each physician provided medical care to patients whose treatments were paid for under fee-for-service (FFS) or capitation (CAP). RESULTS We observed that physicians customized their care in response to the payment system. FFS patients received considerably more medical care than did CAP patients with the same illness and treatment preference. Physicians over-served FFS patients and under-served CAP patients. After a CAP payment reduction, we observed neither a quantity reduction under CAP nor a spillover in FFS patients' treatment. CONCLUSIONS The results suggest that, in our experimental model, fee regulation can be used to some extent to control physician spending since we did not identify a behavioural response to the CAP payment cut. Physicians did not recoup lost income by altering treatment behaviour toward CAP and/or FFS patients. Experimental economics is an excellent tool for ensuring the welfare of all those involved in the health system. Further research should investigate payment incentives as a means of developing health care teams that are more efficient.
Collapse
Affiliation(s)
- Claudia Keser
- Department of Economics, Universität Göttingen, Platz der Göttinger Sieben 3, D-37073, Göttingen, Germany.
- CIRANO, 1130, Sherbrooke West, office 1400, Montréal, H3A 2M8, Canada.
| | - Claude Montmarquette
- CIRANO, 1130, Sherbrooke West, office 1400, Montréal, H3A 2M8, Canada
- University of Montreal, Montreal, Canada
| | - Martin Schmidt
- Department of Economics, Universität Göttingen, Platz der Göttinger Sieben 3, D-37073, Göttingen, Germany
- Present address: KIT, Fritz-Erler-Str. 1-3, D-76133, Karlsruhe, Germany
| | - Cornelius Schnitzler
- Department of Economics, Universität Göttingen, Platz der Göttinger Sieben 3, D-37073, Göttingen, Germany
- Present address: Arkansas Economic Development Commission, Unter den Linden 10, D-10117, Berlin, Germany
| |
Collapse
|
4
|
Garcia Mosqueira A, Rosenthal M, Barnett ML. The Association Between Primary Care Physician Compensation and Patterns of Care Delivery, 2012-2015. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2019; 56:46958019854965. [PMID: 31179800 PMCID: PMC6558535 DOI: 10.1177/0046958019854965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
As health systems seek to incentivize physicians to deliver high-value care, the relationship between physician compensation and health care delivery is an important knowledge gap. To examine physician compensation nationally and its relationship with care delivery, we examined 2012-2015 cross-sectional data on ambulatory primary care physician visits from the National Ambulatory Medical Care Survey. Among 175 762 office visits with 3826 primary care physicians, 15.4% of primary care physicians reported salary-based, 4.5% productivity-based, and 12.9% "mixed" compensation, while 61.4% were practice owners. After adjustment, delivery of out-of-visit/office care was more common for practice owners and "mixed" compensation primary care physicians, while there was little association between compensation type and rates of high- or low-value care delivery. Despite early health reform efforts, the overall landscape of physician compensation has remained strongly tethered to fee-for-service. The lack of consistent association between compensation and care delivery raises questions about the potential impact of payment reform on individual physicians' behavior.
Collapse
Affiliation(s)
- Adrian Garcia Mosqueira
- 1 Department of Health Policy and Managment, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Meredith Rosenthal
- 1 Department of Health Policy and Managment, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Michael L Barnett
- 1 Department of Health Policy and Managment, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,2 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
5
|
Schmidt B, Meng MV, Hampson LA. Operating Room Supply Cost Awareness: A Cross-Sectional Analysis. UROLOGY PRACTICE 2019; 6:73-78. [PMID: 31106254 DOI: 10.1016/j.urpr.2018.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Introduction We assessed surgeon knowledge of commonly used instruments and disposable items and described attitudes toward incorporating cost data into daily practice. Methods An electronic, e-mail based survey was distributed to faculty and trainees in the University of California San Francisco (UCSF) Department of Urology. The 26-question survey assessed opinions regarding general operating room supply cost information and specific costs of 10 supplies used for laparoscopic nephrectomy. A response was considered accurate when it fell within 50% of the actual cost. Results The response rate was 71% among faculty (13) and 90% among trainees (17). Overall 55% of faculty and 82% of trainees considered their knowledge of costs "fair" or "poor." The overall accuracy of cost estimation for 10 commonly used supply items was 27% (SD ± 45%), with no significant difference between trainees and faculty (p=0.70). Accuracy was not associated with self-reported cost knowledge (p=0.25) or number of laparoscopic nephrectomies performed (p=0.47). Of the faculty 33% and of the trainees 41% reported that having more knowledge of costs would motivate them to decrease their operating room supply costs, and 42% of faculty raised the idea of an incentive program. Overall 75% of study participants believe that there is "too little" or "not enough" emphasis placed on cost awareness. Conclusions Trainees and faculty generally have poor knowledge of operating room supply costs. In our academic setting we noted an interest among faculty and residents to make cost data more accessible. These data would provide an opportunity for surgeons to act as cost arbiters in the operating room.
Collapse
Affiliation(s)
- Bogdana Schmidt
- Department of Urology, University of California-San Francisco, San Francisco, California
| | - Maxwell V Meng
- Department of Urology, University of California-San Francisco, San Francisco, California
| | - Lindsay A Hampson
- Department of Urology, University of California-San Francisco, San Francisco, California
| |
Collapse
|
6
|
Gray B, Vandergrift J, Landon B, Reschovsky J, Lipner R. Associations Between American Board of Internal Medicine Maintenance of Certification Status and Performance on a Set of Healthcare Effectiveness Data and Information Set (HEDIS) Process Measures. Ann Intern Med 2018; 169:97-105. [PMID: 29893788 DOI: 10.7326/m16-2643] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The value of the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program has been questioned as a marker of physician quality. OBJECTIVE To assess whether physician MOC status is associated with performance on selected Healthcare Effectiveness Data and Information Set (HEDIS) process measures. DESIGN Annual comparisons of HEDIS process measures among physicians who did or did not maintain certification 20 years after initial certification. SETTING Fee-for-service Medicare. PARTICIPANTS 1260 general internists who were initially certified in 1991 and provided care for 85 931 Medicare patients between 2009 and 2012. MEASUREMENTS Annual percentage of a physician's Medicare patients meeting each of 5 HEDIS annual or biennial standards and a composite indicating meeting all 3 HEDIS diabetes standards. RESULTS Among the 1260 physicians, 786 maintained their certification from 1991 to 2012 and 474 did not. The mean annual percentage of HEDIS-eligible diabetic patients who completed semiannual hemoglobin A1c testing was 58.4% among physicians who maintained certification and 54.4% among those who did not (regression-adjusted difference, 4.2 percentage points [95% CI, 2.0 to 6.5 percentage points]; P < 0.001). Diabetic patients of physicians who maintained certification more frequently met the annual standard for low-density lipoprotein (LDL) cholesterol measurement (83.1% vs. 80.5%; regression-adjusted difference, 2.3 percentage points [CI, 0.6 to 4.1 percentage points]; P = 0.008) and all 3 diabetic standards (46.0% vs. 41.6%; regression-adjusted difference, 3.1 percentage points [CI, 0.5 to 5.7 percentage points]; P = 0.019). The regression-adjusted difference in biennial eye examinations was statistically insignificant (P = 0.112). Measures for LDL cholesterol testing in patients with coronary heart disease and biennial mammography were also met more frequently among physicians who maintained certification (79.4% vs. 77.4% and 72.0% vs. 67.8%, respectively), with regression-adjusted differences of 1.7 percentage points (CI, 0.2 to 3.3 percentage points; P = 0.032) and 4.6 percentage points (CI, 2.9 to 6.3 percentage points; P < 0.001), respectively. LIMITATION Potential confounding by unobserved patient, physician, and practice characteristics; inability to determine clinical significance of observed differences. CONCLUSION Maintaining certification was positively associated with physician performance scores on a set of HEDIS process measures. PRIMARY FUNDING SOURCE American Board of Internal Medicine.
Collapse
Affiliation(s)
- Bradley Gray
- American Board of Internal Medicine, Philadelphia, Pennsylvania (B.G., J.V., R.L.)
| | - Jonathan Vandergrift
- American Board of Internal Medicine, Philadelphia, Pennsylvania (B.G., J.V., R.L.)
| | - Bruce Landon
- Harvard School of Public Health and Harvard Medical School, Boston, Massachusetts (B.L.)
| | | | - Rebecca Lipner
- American Board of Internal Medicine, Philadelphia, Pennsylvania (B.G., J.V., R.L.)
| |
Collapse
|
7
|
The Influence of Insurance Type on Management of Carpal Tunnel Syndrome: An Analysis of Nationwide Practice Trends. Plast Reconstr Surg 2017; 138:1041-1049. [PMID: 27783000 DOI: 10.1097/prs.0000000000002635] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the impact of insurance type on use of diagnostic testing, treatments, and the efficiency of care for patients with carpal tunnel syndrome. METHODS The 2009 to 2013 Truven MarketScan Databases were used to identify adult patients with carpal tunnel syndrome. Insurance type was categorized as fee-for-service versus capitated managed care. Multivariable regression models were created to evaluate the relationship between insurance type and costs, number of visits, treatment, and electrodiagnostic study use, and controlling for demographic characteristics and comorbidities. RESULTS The cohort included 233,572 patients, of which 86 percent carried fee-for-service insurance. Predicted probabilities were clinically similar between the capitated and fee-for-service insurance types for therapy (0.23 versus 0.24), steroid injection (0.07 versus 0.09), and electrodiagnostic study use (0.44 versus 0.47). The difference in predicted probabilities between the insurance groups was greatest for surgery use (0.22 versus 0.28 for managed care and fee-for-service, respectively). The mean number of visits was similar between the two groups (2.1 versus 2.0 visits). In the controlled analysis, managed care was associated with a 10 percent decrease in cost compared to patients with fee-for-service (p < 0.001). CONCLUSIONS Managed care was associated with a lower probability of surgery than fee-for-service, but similar use of less costly services. These data may be used to predict future practice trends with increased implementation of bundled payment reimbursement. Routine collection of validated patient outcomes measures is critical to assess patient outcomes associated with anticipated reduction of surgical services. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
Collapse
|
8
|
Lochner J, Trowbridge E, Kamnetz S, Pandhi N. Family Physician Clinical Compensation in an Academic Environment: Moving Away From the Relative Value Unit. Fam Med 2016; 48:459-466. [PMID: 27272423 PMCID: PMC5055377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Primary care physician compensation structures have remained largely volume-based, lagging behind changes in reimbursement that increasingly include population approaches such as capitation, bundled payments, and care management fees. We describe a population health-based physician compensation plan developed for two departmental family medicine faculty groups (residency teaching clinic faculty and community clinic faculty) along with outcomes before and after the plan's implementation. METHODS An observational study was conducted. A pre-post email survey assessed satisfaction with the plan, salary, and salary equity. Physician retention, panel size, and relative value unit (RVU) productivity metrics also were assessed before and after the plan's implementation. RESULTS Before implementation of the new plan, 18% of residency faculty and 33% of community faculty were satisfied or very satisfied with compensation structure. After implementation, those numbers rose to 47% for residency physicians and 74% for community physicians. Satisfaction with the amount of compensation also rose from 33% to 68% for residency faculty and from 26% to 87% for community faculty. For both groups, panel size per clinical full-time equivalent increased, and RVUs moved closer to national benchmarks. RVUs decreased for residency faculty and increased for community faculty. CONCLUSIONS Aligning a compensation plan with population health delivery by moving rewards away from RVU productivity and toward panel management resulted in improved physician satisfaction and retention, as well as larger panel sizes. RVU changes were less predictable. Physician compensation is an important component of care model redesign that emphasizes population health.
Collapse
Affiliation(s)
- Jennifer Lochner
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Primary Care Academics Transforming Healthcare Collaborative, UW Health, Madison, WI
| | - Elizabeth Trowbridge
- Division of General Internal Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Primary Care Academics Transforming Healthcare Collaborative, UW Health, Madison, WI
| | - Sandra Kamnetz
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Primary Care Academics Transforming Healthcare Collaborative, UW Health, Madison, WI
| | - Nancy Pandhi
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Primary Care Academics Transforming Healthcare Collaborative, UW Health, Madison, WI
| |
Collapse
|
9
|
Norton G, McDonough CM, Cabral HJ, Shwartz M, Burgess JF. Classification of patients with incident non-specific low back pain: implications for research. Spine J 2016; 16:567-76. [PMID: 26282103 PMCID: PMC4987706 DOI: 10.1016/j.spinee.2015.08.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 06/16/2015] [Accepted: 08/11/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Comparing research studies of low back pain is difficult because of heterogeneity. There is no consensus among researchers on inclusion criteria or the definition of an episode. PURPOSE This study aimed to determine pattern(s) of recurrent non-specific low back pain from data collected over 27 months. STUDY DESIGN/SETTING This study used retrospective cohort study using administrative claims from multiple payers. Although claims are designed for capturing costs, not clinical complexity, they are valid for describing utilization patterns, which are not affected by potential "upcoding." PATIENT SAMPLE The patient sample consisted of population-based, nationally generalizable sample of 65,790 adults with continuous medical and pharmaceutical commercial health insurance who received health care for incident, non-specific low back pain. Potential subjects were excluded for plausible cause of the pain, severe mental illness, or cognitive impairment. OUTCOME MEASURES Diagnostic and therapeutic health-care services, including medical, surgical, pharmaceutical, and complementary, received in inpatient, outpatient, and emergency settings were the outcome measures for this study. METHODS The methods used for this study were latent class analysis of health-care utilization over 27 months (9 quarters) following index diagnosis of non-specific low back pain occurring in January-March 2009 and an analysis sample with 60% of subjects (n=39,597) and validation sample of 40% (n=26,193). RESULTS Four distinct groups of patients were identified and validated. One group (53.4%) of patients recovered immediately. One third of patients (31.7%) may appear to recover over 6 months, but maintain a 37-48% likelihood of receiving care for low back pain in every subsequent quarter, implying frequent relapse. Two remaining groups of patients each maintain very high probabilities of receiving care in every quarter (65-78% and 84-90%), predominantly utilizing therapeutic services and pain medication, respectively. Probabilistic grouping relative to alternatives was very high (89.6-99.3%). Grouping was not related to demographic or clinical characteristics. CONCLUSIONS The four distinct sets of patient experiences have clear implications for research. Inclusion criteria should specify incident or recurrent cases. A 6-month clean period may not be sufficiently long to assess incidence. Reporting should specify the proportion recovering immediately to prevent mean recovery rates from masking between-group differences. Continuous measurement of pain or disability may be more reliable than measuring outcomes at distinct endpoints.
Collapse
Affiliation(s)
- Giulia Norton
- Boston University School of Public Health, 715 Albany St., Boston, Massachusetts 02118, USA.
| | - Christine M McDonough
- Boston University School of Public Health, 715 Albany St., Boston, Massachusetts 02118, USA; Boston University Health & Disability Research Institute, 715 Albany St., Boston, Massachusetts 02118, USA; Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, 1 Rope Ferry Road, Hanover, New Hampshire 03755, USA
| | - Howard J Cabral
- Boston University School of Public Health, 715 Albany St., Boston, Massachusetts 02118, USA
| | - Michael Shwartz
- Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, 150 South Huntington Ave., Boston, Massachusetts 02130, USA; Boston University School of Management, 595 Commonwealth Ave, Boston, Massachusetts 02215, USA
| | - James F Burgess
- Boston University School of Public Health, 715 Albany St., Boston, Massachusetts 02118, USA; Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, 150 South Huntington Ave., Boston, Massachusetts 02130, USA
| |
Collapse
|
10
|
Reschovsky JD, Rich EC, Lake TK. Factors Contributing to Variations in Physicians' Use of Evidence at The Point of Care: A Conceptual Model. J Gen Intern Med 2015; 30 Suppl 3:S555-61. [PMID: 26105673 PMCID: PMC4512965 DOI: 10.1007/s11606-015-3366-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
There is ample evidence that many clinical decisions made by physicians are inconsistent with current and generally accepted evidence. This leads to the underuse of some efficacious diagnostic, preventive or therapeutic services, and the overuse of others of marginal or no value to the patient. Evolving new payment and delivery models place greater emphasis on the provision of evidence-based services at the point of care. However, changing physician clinical behaviors is likely to be difficult and slow. Policy makers therefore need to design interventions that are most effective in promoting greater evidence-based care. To help identify modifiable factors that can influence clinical decisions at the point of care, we present a conceptual model and literature review of physician decision making. We describe the multitude of factors--drawn from different disciplines--that have been shown to influence physician point-of-care decisions. We present a conceptual framework for organizing these factors, dividing them into patient, physician, practice site, physician organization, network, market, and public policy influences. In doing so, we review some of the literature that speak to these factors. We then identify areas where additional research is especially needed, and discuss the challenges and opportunities for health services and policy researchers to gain a better understanding of these factors, particularly those that are potentially modifiable by policymakers and organizational leaders.
Collapse
Affiliation(s)
- James D Reschovsky
- Mathematica Policy Research, 1100 1st Street NE, 12th Floor, Washington, DC, 20002, USA,
| | | | | |
Collapse
|
11
|
Norton G, McDonough CM, Cabral H, Shwartz M, Burgess JF. Cost-utility of cognitive behavioral therapy for low back pain from the commercial payer perspective. Spine (Phila Pa 1976) 2015; 40:725-33. [PMID: 25950282 PMCID: PMC4991357 DOI: 10.1097/brs.0000000000000830] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Markov cost-utility model. OBJECTIVE To evaluate the cost-utility of cognitive behavioral therapy (CBT) for the treatment of persistent nonspecific low back pain (LBP) from the perspective of US commercial payers. SUMMARY OF BACKGROUND DATA CBT is widely deemed clinically effective for LBP treatment. The evidence is suggestive of cost-effectiveness. METHODS We constructed and validated a Markov intention-to-treat model to estimate the cost-utility of CBT, with 1-year and 10-year time horizons. We applied likelihood of improvement and utilities from a randomized controlled trial assessing CBT to treat LBP. The trial randomized subjects to treatment but subjects freely sought health care services. We derived the cost of equivalent rates and types of services from US commercial claims for LBP for a similar population. For the 10-year estimates, we derived recurrence rates from the literature. The base case included medical and pharmaceutical services and assumed gradual loss of skill in applying CBT techniques. Sensitivity analyses assessed the distribution of service utilization, utility values, and rate of LBP recurrence. We compared health plan designs. Results are based on 5000 iterations of each model and expressed as an incremental cost per quality-adjusted life-year. RESULTS The incremental cost-utility of CBT was $7197 per quality-adjusted life-year in the first year and $5855 per quality-adjusted life-year over 10 years. The results are robust across numerous sensitivity analyses. No change of parameter estimate resulted in a difference of more than 7% from the base case for either time horizon. Including chiropractic and/or acupuncture care did not substantively affect cost-effectiveness. The model with medical but no pharmaceutical costs was more cost-effective ($5238 for 1 yr and $3849 for 10 yr). CONCLUSION CBT is a cost-effective approach to manage chronic LBP among commercial health plans members. Cost-effectiveness is demonstrated for multiple plan designs. LEVEL OF EVIDENCE 2.
Collapse
Affiliation(s)
- Giulia Norton
- Boston University School of Public Health, Boston, MA
| | - Christine M. McDonough
- Boston University School of Public Health, Boston, MA
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH
| | - Howard Cabral
- Boston University School of Public Health, Boston, MA
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research, Department of Veterans Affairs
- Boston University School of Management, Boston, MA
| | - James F. Burgess
- Boston University School of Public Health, Boston, MA
- Center for Healthcare Organization and Implementation Research, Department of Veterans Affairs
| |
Collapse
|
12
|
Landon BE, O'Malley AJ, McKellar MR, Reschovsky JD, Hadley J. Physician compensation strategies and quality of care for Medicare beneficiaries. THE AMERICAN JOURNAL OF MANAGED CARE 2014; 20:804-811. [PMID: 25365683 PMCID: PMC10411505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To examine the relationship between the compensation strategies of primary care physicians (PCPs) and the quality and outcomes of care delivered to Medicare beneficiaries. STUDY DESIGN Cross-sectional analysis of physician survey data linked to Medicare claims. We used a previously constructed typology that was developed based on the survey to categorize physician compensation strategies. METHODS We combined data from the 2004-2005 Community Tracking Study Physician Survey on PCP compensation methods with administrative claims from the Medicare program. We analyzed the proportion of eligible beneficiaries receiving each of 7 preventive services and rates of preventable admissions for acute and chronic conditions. We measured the latter using Prevention Quality Indicators (PQIs), available from the Agency for Healthcare Research and Quality. RESULTS The 2211 PCP respondents included 937 internists and 1274 family or general physicians who were linked to more than 250,000 Medicare enrollees. Employed physicians with productivity and other incentives were more likely to deliver care of high quality when compared with salaried physicians. For instance, the odds of appropriate monitoring for diabetics ranged from 1.26 to 1.47 (all P < .01). Physicians in highly capitated environments had similar or better quality compared with physicians in other environments across most measures. The association between compensation strategies and outcomes of care as measured by PQIs was inconsistent, although owners with no other incentives had consistent higher rates of acute and chronic PQI admission (eg, for the chronic PQI composite: odds ratio = 1.07; 95% CI, 1.02-1.12). CONCLUSIONS Physician compensation strategies are associated with the quality of preventive services delivered to Medicare patients, but inconsistently associated with outcomes of care. Increasing use of global payment strategies is not likely to lead to lower quality.
Collapse
Affiliation(s)
- Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115. E-mail:
| | | | | | | | | |
Collapse
|
13
|
Landon BE, O'Malley AJ, McKellar MR, Hadley J, Reschovsky JD. Higher practice intensity is associated with higher quality of care but more avoidable admissions for medicare beneficiaries. J Gen Intern Med 2014; 29:1188-94. [PMID: 24740516 PMCID: PMC4099467 DOI: 10.1007/s11606-014-2840-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 12/19/2013] [Accepted: 03/10/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The relationship between practice intensity and the quality and outcomes of care has not been studied. OBJECTIVE To examine the relationship between primary care physicians' costliness both for defined episodes of care and for defined patients and the quality and outcomes of care delivered to Medicare beneficiaries. STUDY DESIGN Cross sectional analysis of physician survey data linked to Medicare claims. Physician costliness measures were calculated by comparing the episode specific and overall costs of care for their patients with the care delivered by other physicians. PARTICIPANTS We studied physicians participating in the 2004-2005 Community Tracking Study Physician Survey linked with administrative claims from the Medicare program for the years 2004-2006. MAIN MEASURES Proportion of eligible beneficiaries receiving each of seven preventive services and rates of preventable admissions for acute and chronic conditions. KEY RESULTS The 2,211 primary care physician respondents included 937 internists and 1,274 family or general physicians who were linked to more than 250,000 Medicare enrollees. Patients treated by more costly physicians (whether measured by the overall costliness index or the episode-level index) were more likely to receive recommended preventive services, but were also more likely to experience preventable admissions. For instance, physicians in the lowest quartile of costliness performed appropriate monitoring for hemoglobin A1C for diabetics 72.8% of the time, as compared with 81.9% for physicians in the highest quartile of costliness (p < 0.01). In contrast, patients treated by the physicians in the lowest quartile of episode costliness were admitted at a rate of 1.8/100 for both acute and chronic Prevention Quality Indicators (PQIs), as compared with 2.9/100 for both acute and chronic PQIs for those treated by physicians in the highest quartile of costliness (p < 0.001). CONCLUSIONS Physician practice patterns are associated with the quality of preventive services delivered to Medicare patients. Ongoing efforts to influence physician practice patterns may have differential effects on different aspects of quality.
Collapse
Affiliation(s)
- Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA, 02115, USA,
| | | | | | | | | |
Collapse
|
14
|
Hadley J, Reschovsky JD, O’Malley JA, Landon BE. Factors associated with geographic variation in cost per episode of care for three medical conditions. HEALTH ECONOMICS REVIEW 2014; 4:8. [PMID: 24949281 PMCID: PMC4052668 DOI: 10.1186/s13561-014-0008-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 03/21/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To identify associations between market factors, especially relative reimbursement rates, and the probability of surgery and cost per episode for three medical conditions (cataract, benign prostatic neoplasm, and knee degeneration) with multiple treatment options. METHODS We use 2004-2006 Medicare claims data for elderly beneficiaries from sixty nationally representative communities to estimate multivariate models for the probability of surgery and cost per episode of care as a function local market factors, including Medicare physician reimbursement for surgical versus non-surgical treatment and the availability of primary care and specialty physicians. We used Symmetry's Episode Treatment Groups (ETG) software to group claims into episodes for the three conditions (n = 540,874 episodes). RESULTS Higher Medicare reimbursement for surgical episodes and greater availability of the relevant specialists are significantly associated with more surgery and higher cost per episode for all three conditions, while greater availability of primary care physicians is significantly associated with less frequent surgery and lower cost per episode. CONCLUSION Relative Medicare reimbursement rates for surgical vs. non-surgical treatments and the availability of both primary care physicians and relevant specialists are associated with the likelihood of surgery and cost per episode.
Collapse
Affiliation(s)
- Jack Hadley
- Department of Health Administration and Policy, George Mason University, 4400 University Drive, MS 2G7 Fairfax, VA 22030, USA
| | - James D Reschovsky
- Mathematica Policy Research, 1100 1st Street, NE, 12th Floor, Washington, DC 20002-4221, USA
| | - James A O’Malley
- The Dartmouth Institute and Geisel Medical School at Dartmouth, Dartmouth University, Lebanon, NH 03766, USA
| | - Bruce E Landon
- Department of Health Care Policy, Harvard University School of Medicine, 180 Longwood Avenue, Boston, Massachusetts 02115, USA
| |
Collapse
|
15
|
McWilliams JM, Chernew ME, Zaslavsky AM, Hamed P, Landon BE. Delivery system integration and health care spending and quality for Medicare beneficiaries. JAMA Intern Med 2013; 173:1447-56. [PMID: 23780467 PMCID: PMC3800215 DOI: 10.1001/jamainternmed.2013.6886] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The Medicare accountable care organization (ACO) programs rely on delivery system integration and health care provider risk sharing to lower spending while improving quality of care. OBJECTIVE To compare spending and quality between larger and smaller provider groups and examine how size-related differences vary by 2 factors considered central to ACO performance: group primary care orientation and financial risk sharing by health care providers. EVIDENCE REVIEW Using 2009 Medicare claims and linked American Medical Association Group Practice data, we assigned 4.29 million beneficiaries to health care provider groups based on primary care use. We categorized group size according to eligibility thresholds for the Shared Savings (≥5000 assigned beneficiaries) and Pioneer (≥15,000) ACO programs and distinguished hospital-based from independent groups. We assessed the primary care orientation of larger groups' specialty mix and used health maintenance organization market penetration and data from the Community Tracking Study to measure the extent of financial risk accepted by different types of provider groups in different areas for managed care patients. We estimated linear regression models comparing spending and quality between larger and smaller health care provider groups, allowing size-related differences to vary by measures of group primary care orientation and risk sharing. Spending and quality measures included total medical spending, spending by type of service, 5 process measures of quality, and 30-day readmissions, all adjusted for sociodemographic and clinical characteristics. FINDINGS Compared with smaller groups, larger hospital-based groups had higher total per-beneficiary spending in 2009 (mean difference, +$849), higher 30-day readmission rates (+1.3 percentage points), and similar performance on 4 of 5 process measures of quality. In contrast, larger independent physician groups performed better than smaller groups on all process measures and exhibited significantly lower per-beneficiary spending in counties where risk sharing by these groups was more common (-$426). Among all groups sufficiently large to participate in ACO programs, a strong primary care orientation was associated with lower spending, fewer readmissions, and better quality of diabetes care. CONCLUSIONS AND RELEVANCE Spending was lower and quality of care better for Medicare beneficiaries served by larger independent physician groups with strong primary care orientations in environments where health care providers accepted greater risk.
Collapse
Affiliation(s)
- J Michael McWilliams
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts2Department of Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | | |
Collapse
|
16
|
Chernew ME, Hong JS. Commentary on the spread of new payment models. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2013; 1:12-4. [PMID: 26249635 DOI: 10.1016/j.hjdsi.2013.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 04/25/2013] [Accepted: 04/30/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, USA.
| | - Johan S Hong
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, USA
| |
Collapse
|
17
|
|