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Dyer Z, Alcusky M, Himmelstein J, Ash A, Kerrissey M. Practice Site Heterogeneity within and between Medicaid Accountable Care Organizations. Healthcare (Basel) 2024; 12:266. [PMID: 38275548 PMCID: PMC10815263 DOI: 10.3390/healthcare12020266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/06/2024] [Accepted: 01/13/2024] [Indexed: 01/27/2024] Open
Abstract
The existing literature has considered accountable care organizations (ACOs) as whole entities, neglecting potentially important variations in the characteristics and experiences of the individual practice sites that comprise them. In this observational cross-sectional study, our aim is to characterize the experience, capacity, and process heterogeneity at the practice site level within and between Medicaid ACOs, drawing on the Massachusetts Medicaid and Children's Health Insurance Program (MassHealth), which launched an ACO reform effort in 2018. We used a 2019 survey of a representative sample of administrators from practice sites participating in Medicaid ACOs in Massachusetts (n = 225). We quantified the clustering of responses by practice site within all 17 Medicaid ACOs in Massachusetts for measures of process change, previous experience with alternative payment models, and changes in the practices' ability to deliver high-quality care. Using multilevel logistic models, we calculated median odds ratios (MORs) and intraclass correlation coefficients (ICCs) to quantify the variation within and between ACOs for each measure. We found greater heterogeneity within the ACOs than between them for all measures, regardless of practice site and ACO characteristics (all ICCs ≤ 0.26). Our research indicates diverse experience with, and capacity for, implementing ACO initiatives across practice sites in Medicaid ACOs. Future research and program design should account for characteristics of practice sites within ACOs.
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Affiliation(s)
- Zachary Dyer
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA 01655, USA
| | - Matthew Alcusky
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA 01655, USA
| | - Jay Himmelstein
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA 01655, USA
| | - Arlene Ash
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA 01655, USA
| | - Michaela Kerrissey
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
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2
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Blanken M, Mathijssen J, van Nieuwenhuizen C, Raab J, van Oers H. Cross-sectoral collaboration: comparing complex child service delivery systems. J Health Organ Manag 2022; 36:79-94. [DOI: 10.1108/jhom-07-2021-0281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeTo help ensure that children with social and behavioral health problems get the support services they need, organizations collaborate in cross-sectoral networks. In this article, the authors explore and compare the structure of these complex child service delivery networks in terms of differentiation (composition) and integration (interconnection). In particular, the authors investigate the structure of client referral and identify which organizations are most prominent within that network structure and could therefore fulfill a coordinating role.Design/methodology/approach The authors used a comparative case study approach and social network analysis on three interorganizational networks consisting of 65 to 135 organizations within the Dutch child service delivery system. Semi-structured interviews with the network managers were conducted, and an online questionnaire was sent out to the representatives of all network members.Findings The networks are similarly differentiated into 11 sectors with various tasks. Remarkably, network members have contact with an average of 20–26 organizations, which is a fairly high number to be handled successfully. In terms of integration, the authors found a striking diversity in the structures of client referral and not all organizations with a gatekeeper task hold central positions.Originality/value Due to the scarcity of comparative whole network research in the field, the strength of this study is a deeper understanding of the differentiation and integration of complex child service delivery systems. These insights are crucial in order to deliver needed services and to minimize service silos and fragmentation.
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Lin MY, Hanchate AD, Frakt AB, Burgess JF, Carey K. Do accountable care organizations differ according to physician-hospital integration?: A retrospective observational study. Medicine (Baltimore) 2021; 100:e25231. [PMID: 33761713 PMCID: PMC9281958 DOI: 10.1097/md.0000000000025231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 02/26/2021] [Indexed: 01/05/2023] Open
Abstract
Physician-hospital integration among accountable care organizations (ACOs) has raised concern over impacts on prices and spending. However, characteristics of ACOs with greater integration between physicians and hospitals are unknown. We examined whether ACOs systematically differ by physician-hospital integration among 16 commercial ACOs operating in Massachusetts.Using claims data linked to information on physician affiliation, we measured hospital integration with primary care physicians for each ACO and categorized them into high-, medium-, and low-integrated ACOs. We conducted cross-sectional descriptive analysis to compare differences in patient population, organizational characteristics, and healthcare spending between the three groups. In addition, using multivariate generalized linear models, we compared ACO spending by integration level, adjusting for organization and patient characteristics. We identified non-elderly adults (aged 18-64) served by 16 Massachusetts ACOs over the period 2009 to 2013.High- and medium-integrated ACOs were more likely to be an integrated delivery system or an organization with a large number of providers. Compared to low-integrated ACOs, higher-integrated ACOs had larger inpatient care capacity, smaller composition of primary care physicians, and were more likely to employ physicians directly or through an affiliated hospital or physician group. A greater proportion of high-/medium-integrated ACO patients lived in affluent neighborhoods or areas with a larger minority population. Healthcare spending per enrollee in high-integrated ACOs was higher, which was mainly driven by a higher spending on outpatient facility services.This study shows that higher-integrated ACOs differ from their counterparts with low integration in many respects including higher healthcare spending, which persisted after adjusting for organizational characteristics and patient mix. Further investigation into the effects of integration on expenditures will inform the ongoing development of ACOs.
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Affiliation(s)
- Meng-Yun Lin
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC
- Boston University School of Public Health, 715 Albany Street, Boston
| | - Amresh D. Hanchate
- Boston University School of Public Health, 715 Albany Street, Boston
- Boston University School of Medicine, 801 Massachusetts Avenue
| | - Austin B. Frakt
- Boston University School of Public Health, 715 Albany Street, Boston
- Partnered Evidence-based Policy Resource Center
| | - James F. Burgess
- Boston University School of Public Health, 715 Albany Street, Boston
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA
| | - Kathleen Carey
- Boston University School of Public Health, 715 Albany Street, Boston
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4
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Furukawa MF, Machta RM, Barrett KA, Jones DJ, Shortell SM, Scanlon DP, Lewis VA, O’Malley AJ, Meara ER, Rich EC. Landscape of Health Systems in the United States. Med Care Res Rev 2020; 77:357-366. [PMID: 30674227 PMCID: PMC7187756 DOI: 10.1177/1077558718823130] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite the prevalence of vertical integration, data and research focused on identifying and describing health systems are sparse. Until recently, we lacked an enumeration of health systems and an understanding of how systems vary by key structural attributes. To fill this gap, the Agency for Healthcare Research and Quality developed the Compendium of U.S. Health Systems, a data resource to support research on comparative health system performance. In this article, we describe the methods used to create the Compendium and present a picture of vertical integration in the United States. We identified 626 health systems in 2016, which accounted for 70% of nonfederal general acute care hospitals. These systems varied by key structural attributes, including size, ownership, and geographic presence. The Compendium can be used to study the characteristics of the U.S. health care system and address policy issues related to provider organizations.
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Affiliation(s)
| | | | | | | | | | | | - Valerie A. Lewis
- The Dartmouth Institute for Health Policy and Clinical
Practice, Lebanon, NH, USA
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy and Clinical
Practice, Lebanon, NH, USA
| | - Ellen R. Meara
- The Dartmouth Institute for Health Policy and Clinical
Practice, Lebanon, NH, USA
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5
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Chang CH, Mainor A, Colla C, Bynum J. Utilization by Long-Term Nursing Home Residents Under Accountable Care Organizations. J Am Med Dir Assoc 2020; 22:406-412. [PMID: 32693998 DOI: 10.1016/j.jamda.2020.05.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/20/2020] [Accepted: 05/23/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Nursing home care is common and costly. Accountable care organization (ACO) payment models, which have incentives for care that is better coordinated and less reliant on acute settings, have the potential to improve care for this high-cost population. We examined the association between ACO attribution status and utilization and Medicare spending among long-term nursing home residents and hypothesized that attribution of nursing home residents to an ACO will be associated with lower total spending and acute care use. DESIGN Observational propensity-matched study. SETTING AND PARTICIPANTS Medicare fee-for-service beneficiaries who were long-term nursing home residents residing in areas with ≥5% ACO penetration. METHODS ACO attribution and covariates used in propensity matching were measured in 2013 and outcomes were measured in 2014, including hospitalization (total and ambulatory care sensitive conditions), outpatient emergency department visits, and Medicare spending. RESULTS Nearly one-quarter (23.3%) of nursing home residents who survived into 2014 (n = 522,085, 76.1% of 2013 residents) were attributed to an ACO in 2013 in areas with ≥5% ACO penetration. After propensity score matching, ACO-attributed residents had significantly (P < .001) lower hospitalization rates per 1000 (total: 402.9 vs 419.9; ambulatory care sensitive conditions: 64.4 vs 71.4) and fewer outpatient ED visits (29.9 vs 33.3 per 100) but no difference in total spending ($14,071 vs $14,293 per resident, P = .058). Between 2013 and 2014, a sizeable proportion of residents' attribution status switched (14.6%), either into or out of an ACO. CONCLUSIONS AND IMPLICATIONS ACO nursing home residents had fewer hospitalizations and ED visits, but did not have significantly lower total Medicare spending. Among residents, attribution was not stable year over year.
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Affiliation(s)
- Chiang-Hua Chang
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.
| | - Alexander Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Carrie Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Julie Bynum
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
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6
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Stolzmann K, Meterko M, Miller CJ, Belanger L, Seibert MN, Bauer MS. Survey Response Rate and Quality in a Mental Health Clinic Population: Results from a Randomized Survey Comparison. J Behav Health Serv Res 2020; 46:521-532. [PMID: 29948573 DOI: 10.1007/s11414-018-9617-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Given the limited ability of informatics-based assessment technologies to reach individuals with serious mental health conditions, this study evaluated the feasibility and data quality of mail-out healthcare surveys in this population to assist in measure selection for a multi-site controlled implementation trial. Veterans were randomly selected from those who had received services at a mental health clinic in the Department of Veterans Affairs, and were randomly assigned to one of three questionnaire lengths. Survey length (48-127 items) was not associated with differences in response rate, percent of items missing, or data quality. However, internal consistency reliability was variable among scales and survey lengths. Additional analyses indicate the above measures of survey data quality may differ among respondents who are non-white and younger and have psychotic disorders. These results can inform survey protocols to ensure maximal representation of this vulnerable population in health planning and policy assessment.
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Affiliation(s)
- Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Avenue, (152M), Boston, MA, 02130, USA.
| | - Mark Meterko
- Performance Measurement, VHA Office of Analytics and Business Intelligence (OABI), ENRM Veterans Affairs Medical Center, 200 Springs Road, Bedford, MA, 01730, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health and Management, Boston, USA
| | - Christopher J Miller
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Avenue, (152M), Boston, MA, 02130, USA
- Department of Psychiatry, Harvard Medical School, Boston, USA
| | - Lindsay Belanger
- Oregon Health and Sciences University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239-3098, USA
| | - Marjorie Nealon Seibert
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Avenue, (152M), Boston, MA, 02130, USA
| | - Mark S Bauer
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Avenue, (152M), Boston, MA, 02130, USA
- Department of Psychiatry, Harvard Medical School, Boston, USA
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7
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Chukmaitov AS, Harless DW, Bazzoli GJ, Deng Y. Factors associated with hospital participation in Centers for Medicare and Medicaid Services' Accountable Care Organization programs. Health Care Manage Rev 2020; 44:104-114. [PMID: 28915166 PMCID: PMC5854497 DOI: 10.1097/hmr.0000000000000182] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In 2012, the Centers for Medicare and Medicaid Services (CMS) initiated the Medicare Shared Savings Program (MSSP) and Pioneer Accountable Care Organization (ACO) programs. Organizations in the MSSP model shared cost savings they generated with CMS, and those in the Pioneer program shared both savings and losses. It is largely unknown what hospital and environmental characteristics are associated with the development of CMS ACOs with one- or two-sided risk models. PURPOSE The aim of this study was to assess the organizational and environmental characteristics associated with hospital participation in the MSSP and Pioneer ACOs. METHODOLOGY Hospitals participating in CMS ACO programs were identified using primary and secondary data. The ACO hospital sample was linked with the American Hospital Association, Health Information and Management System Society, and other data sets. Multinomial probit models were estimated that distinguished organizational and environmental factors associated with hospital participation in the MSSP and Pioneer ACOs. RESULTS Hospital participation in both CMS ACO programs was associated with prior experience with risk-based payments and care management programs, advanced health information technology, and location in higher-income and more competitive areas. Whereas various health system types were associated with hospital participation in the MSSP, centralized health systems, higher numbers of physicians in tightly integrated physician-organizational arrangements, and location in areas with greater supply of primary care physicians were associated with Pioneer ACOs. Favorable hospital characteristics were, in the aggregate, more important than favorable environmental factors for MSSP participation. CONCLUSION MSSP ACOs may look for broader organizational capabilities from participating hospitals that may be reflective of a wide range of providers participating in diverse markets. Pioneer ACOs may rely on specific hospital and environmental characteristics to achieve quality and spending targets set for two-sided contracts. PRACTICE IMPLICATIONS Hospital and ACO leaders can use our results to identify hospitals with certain characteristics favorable to their participation in either one- or two-sided ACOs.
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Affiliation(s)
- Askar S Chukmaitov
- Askar S. Chukmaitov, MD, PhD, is Associate Professor, Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, Virginia. E-mail: . David W. Harless, PhD, is Professor, Department of Economics, School of Business, Virginia Commonwealth University, Richmond, Virginia. Gloria J. Bazzoli, PhD, is Bon Secours Professor of Health Administration, Department of Health Administration, School of Allied Health Professions, Virginia Commonwealth University, Richmond, Virginia. Yangyang Deng, MS, is Data Analyst, Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
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8
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Ouayogodé MH, Fraze T, Rich EC, Colla CH. Association of Organizational Factors and Physician Practices' Participation in Alternative Payment Models. JAMA Netw Open 2020; 3:e202019. [PMID: 32239223 PMCID: PMC7118519 DOI: 10.1001/jamanetworkopen.2020.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/07/2020] [Indexed: 11/14/2022] Open
Abstract
Importance Consolidation among physician practices and between hospitals and physician practices has accelerated in the past decade, resulting in higher prices in commercial markets. The resulting integration of health care across clinicians and participation in alternative payment models (APMs), which aim to improve quality while constraining spending, are cited as reasons for consolidation, but little is known about the association between integration and APM participation. Objective To examine the association of organizational characteristics, ownership, and integration with intensity of participation in APMs among physician practices. Design, Setting, and Participants A cross-sectional descriptive study, adjusted for sampling and nonresponse weights, was conducted in US physician practice respondents to the National Survey of Healthcare Organizations and Systems conducted between June 16, 2017, and August 17, 2018; of 2333 responses received (response rate, 46.9%) and after exclusion of ineligible and incomplete responses, the number of practices included in the analysis was 2061. Data analysis was performed from April 1, 2019, to August 31, 2019. Exposures Self-reported physician practice characteristics, including ownership, integration (clinical, cultural, financial, and functional), care delivery capabilities, activities, and environmental factors. Main Outcomes and Measures Participation in APMs: (1) bundled payments, (2) comprehensive primary care and medical home programs, (3) pay-for-performance programs, (4) capitated contracts with commercial health plans, and (5) accountable care organization contracts. Results A total of 49.2% of the 2061 practices included reported participating in 3 or more APMs; most participated in pay-for-performance and accountable care organization models. Covariate-adjusted analyses suggested that operating within a health care system (odds ratio [OR] for medical group: 2.35; 95% CI, 1.70-3.25; P < .001; simple health system: 1.46; 95% CI, 1.08-1.97; P = .02; and complex health system: 1.76; 95% CI, 1.25-2.47; P = .001 relative to independent practices), greater clinical (OR, 4.68; 95% CI, 2.28-9.59; P < .001) and functional (OR, 4.24; 95% CI, 2.00-8.97; P < .001) integration, and being located in the Northeast (OR for Midwest: 0.47; 95% CI, 0.34-0.65; P < .001; South: 0.47; 95% CI, 0.34-0.66; P < .001; and West: 0.64; 95% CI, 0.46-0.91; P = .01) were associated with greater APM participation. Conclusions and Relevance Greater APM participation appears to be supported by integration and system ownership.
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Affiliation(s)
- Mariétou H. Ouayogodé
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison
| | - Taressa Fraze
- Department of Family and Community Medicine, School of Medicine, University of California, San Francisco
| | | | - Carrie H. Colla
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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9
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McDonald R, Riste L, Bailey S, Bradley F, Hammond J, Spooner S, Elvey R, Checkland K. The impacts of GP federations in England on practices and on health and social care interfaces: four case studies. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
General practices have begun working collaboratively in general practitioner federations, which vary in scope, geographical reach and organisational form.
Objectives
The aim was to assess how federating affects practice processes, workforce, innovations in practices and the interface with health and social care stakeholders.
Design
This was a structured cross-sectional comparison of four case studies, using observation of meetings, interviews and analysis of documents. We combined inductive analysis with literature on ‘meta-organisations’ and networks to provide a theoretically informed analysis.
Results
All federations were ‘bottom-up’ voluntary membership organisations but with formal central authority structures. Practice processes were affected substantially in only one site. In this site, practices accepted the rules imposed by federation arrangements in a context of voluntary participation. Federating helped ease workforce pressures in two sites. Progress regarding innovations in practice and working with health and social care stakeholders was slower than federations anticipated. The approach of each federation central authority in terms of the extent to which it (1) sought to exercise control over member practices and (2) was engaged in ‘system proactivity’ (i.e. the degree of proactivity in working across a broader spatial and temporal context) was important in explaining variations in progress towards stated aims. We developed a typology to reflect the different approaches and found that an approach consisting of high levels of both top-down control and system proactivity was effective. One site adopted this ‘authoritative’ approach. In another site, rather than creating expectations of practices, the focus was on supporting them by attempting to solve the immediate problems they faced. This ‘indulgent’ approach was more effective than the approach used in the other two sites. These had a more distant ‘neglectful’ relationship with practices, characterised by low levels of both control over members and system proactivity. Other key factors explaining progress (or lack thereof) were competition between federations (if any), relationship with the Clinical Commissioning Group, money, history, leadership and management issues, size and geography; these interacted in a dynamic way. In the context of a tight deadline and fixed targets, federations were able to respond to the requirements to provide additional services as part of NHS Improving Access to General Practice policy in a way that would not have been possible in the absence of federations. However, this added to pressures faced by busy clinicians and managers.
Limitations
The focus was on only four sites; therefore, any federations that were more active than those federations in these four sites will have been excluded. In addition, although patients were interviewed, because most were unaware of federations, they generally had little to say on the subject.
Conclusions
General practices working collaboratively can produce benefits, but this takes time and effort. The approach of the federation central authority (authoritative, indulgent or neglectful) was hugely influential in affecting processes and outcomes. However, progress was generally slower than anticipated, and negligible in one case.
Future work
Future work would benefit from multimethod designs, which provide in-depth, longitudinal, qualitative and quantitative methods, to shed light on processes and impacts.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ruth McDonald
- Alliance Manchester Business School, University of Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Lisa Riste
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Simon Bailey
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Fay Bradley
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Jonathan Hammond
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Sharon Spooner
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Rebecca Elvey
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Kath Checkland
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
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10
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Wong SP, Sharda N, Zietlow KE, Heflin MT. Planning for a Safe Discharge: More Than a Capacity Evaluation. J Am Geriatr Soc 2020; 68:859-866. [PMID: 31905244 DOI: 10.1111/jgs.16315] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/09/2019] [Accepted: 12/12/2019] [Indexed: 11/29/2022]
Abstract
Discharge decision making for hospitalized older adults can be a complicated process involving functional assessments, capacity evaluation, and coordination of resources. Providers may feel pressured to recommend that an older adult with complex care needs be discharged to a skilled nursing facility rather than home, potentially contradicting the patient's wishes. This can lead to a professional and ethical dilemma for providers, who value patient autonomy and shared decision making. We describe a discharge decision-making framework focused on interprofessional evaluation and management, longitudinal follow-up, and education and support for patients and families. By gathering and synthesizing information, eliciting goals and preferences, and identifying community resources, the healthcare team can help maximize independence for vulnerable older adults. J Am Geriatr Soc 68:859-866, 2020.
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Affiliation(s)
- Serena P Wong
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Neema Sharda
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Kahli E Zietlow
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Mitchell T Heflin
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
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11
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Markovitz AA, Rozier MD, Ryan AM, Goold SD, Ayanian JZ, Norton EC, Peterson TA, Hollingsworth JM. Low-Value Care and Clinician Engagement in a Large Medicare Shared Savings Program ACO: a Survey of Frontline Clinicians. J Gen Intern Med 2020; 35:133-141. [PMID: 31705479 PMCID: PMC6957659 DOI: 10.1007/s11606-019-05511-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 06/03/2019] [Accepted: 10/01/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although the Medicare Shared Savings Program (MSSP) created new incentives for organizations to improve healthcare value, Accountable Care Organizations (ACOs) have achieved only modest reductions in the use of low-value care. OBJECTIVE To assess ACO engagement of clinicians and whether engagement was associated with clinicians' reported difficulty implementing recommendations against low-value care. DESIGN Cross-sectional survey of ACO clinicians in 2018. PARTICIPANTS 1289 clinicians in the Physician Organization of Michigan ACO, including generalist physicians (18%), internal medicine specialists (16%), surgeons (10%), other physician specialists (27%), and advanced practice providers (29%). Response rate was 34%. MAIN MEASURES Primary exposures included clinicians' participation in ACO decision-making, awareness of ACO incentives, perceived influence on practice, and perceived quality improvement. Our primary outcome was clinicians' reported difficulty implementing recommendations against low-value care. RESULTS Few clinicians participated in the decision to join the ACO (3%). Few clinicians were aware of ACO incentives, including knowing the ACO was accountable for both spending and quality (23%), successfully lowered spending (9%), or faced upside risk only (3%). Few agreed (moderately or strongly) the ACO changed compensation (20%), practice (19%), or feedback (15%) or that it improved care coordination (17%) or inappropriate care (13%). Clinicians reported they had difficulty following recommendations against low-value care 18% of the time; clinicians reported patients had difficulty accepting recommendations 36% of the time. Increased ACO awareness (1 standard deviation [SD]) was associated with decreased difficulty (- 2.3 percentage points) implementing recommendations (95% confidence interval [CI] - 3.8, - 0.7), as was perceived quality improvement (1 SD increase, - 2.1 percentage points, 95% CI, - 3.4, - 0.8). Participation in ACO decision-making and perceived influence on practice were not associated with recommendation implementation. CONCLUSIONS Clinicians participating in a large Medicare ACO were broadly unaware of and unengaged with ACO objectives and activities. Whether low clinician engagement limits ACO efforts to reduce low-value care warrants further longitudinal study.
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Affiliation(s)
- Adam A Markovitz
- University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Michael D Rozier
- Department of Health Management and Policy, Saint Louis University, St. Louis, MO, USA
| | - Andrew M Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Susan D Goold
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - John Z Ayanian
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, MI, USA
| | - Edward C Norton
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Department of Economics, University of Michigan, Ann Arbor, MI, USA.,National Bureau of Economic Research, Cambridge, MA, USA
| | - Timothy A Peterson
- Physician Organization of Michigan Accountable Care Organization, Ann Arbor, MI, USA.,Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - John M Hollingsworth
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI, USA.
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Stone EM, Daumit GL, Kennedy-Hendricks A, McGinty EE. The Policy Ecology of Behavioral Health Homes: Case Study of Maryland's Medicaid Health Home Program. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2020; 47:60-72. [PMID: 31506860 PMCID: PMC7040852 DOI: 10.1007/s10488-019-00973-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Behavioral health homes, shown to improve receipt of evidence-based medical services among people with serious mental illness in randomized clinical trials, have had limited results in real-world settings; nonetheless, these programs are spreading rapidly. To date, no studies have considered what set of policies is needed to support effective implementation of these programs. As a first step toward identifying an optimal set of policies to support behavioral health home implementation, we use the policy ecology framework to map the policies surrounding Maryland's Medicaid behavioral health home program. Results suggest that existing policies fail to address important implementation barriers.
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Affiliation(s)
- Elizabeth M Stone
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Gail L Daumit
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Alene Kennedy-Hendricks
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Emma E McGinty
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Rosenthal M, Shortell S, Shah ND, Peiris D, Lewis VA, Barrera JA, Usadi B, Colla CH. Physician practices in Accountable Care Organizations are more likely to collect and use physician performance information, yet base only a small proportion of compensation on performance data. Health Serv Res 2019; 54:1214-1222. [PMID: 31742688 PMCID: PMC6863236 DOI: 10.1111/1475-6773.13238] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
IMPORTANCE It is critical to develop a better understanding of the strategies provider organizations use to improve the performance of frontline clinicians and whether ACO participation is associated with differential adoption of these tools. OBJECTIVES Characterize the strategies that physician practices use to improve clinician performance and determine their association with ACOs and other payment reforms. DATA SOURCES The National Survey of Healthcare Organizations and the National Survey of ACOs fielded 2017-2018 (response rates = 47 percent and 48 percent). STUDY DESIGN Descriptive analysis for practices participating and not participating in ACOs among 2190 physician practice respondents. Linear regressions to examine characteristics associated with counts of performance domains for which a practice used data for feedback, quality improvement, or physician compensation as dependent variables. Logistic and fractional regression to examine characteristics associated with use of peer comparison and shares of primary care and specialist compensation accounted for by performance bonuses, respectively. PRINCIPAL FINDINGS ACO-affiliated practices feed back clinician-level information and use it for quality improvement and compensation on more performance domains than non-ACO-affiliated practices. Performance measures contribute little to physician compensation irrespective of ACO participation. CONCLUSION ACO-affiliated practices are using more performance improvement strategies than other practices, but base only a small fraction of compensation on quality or cost.
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Affiliation(s)
- Meredith Rosenthal
- Health Policy and ManagementHarvard University T H Chan School of Public HealthBostonMassachusetts
| | | | - Nilay D. Shah
- Division of Health Care Policy & ResearchMayo ClinicRochesterMinnesota
| | - David Peiris
- Health Systems ScienceUniversity of New South Wales Faculty of MedicineSydneyNSWAustralia
| | - Valerie A. Lewis
- Health Policy and ManagementUniversity of North Carolina at Chapel Hill Gillings School of Global Public HealthChapel HillNorth Carolina
| | - Jacob A. Barrera
- Health Policy and ManagementHarvard University T H Chan School of Public HealthBostonMassachusetts
| | - Benjamin Usadi
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew Hampshire
| | - Carrie H. Colla
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew Hampshire
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15
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Care Coordination and Population Health Management Strategies and Challenges in a Behavioral Health Home Model. Med Care 2019; 57:79-84. [PMID: 30439791 DOI: 10.1097/mlr.0000000000001023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Behavioral health home (BHH) models have been developed to integrate physical and mental health care and address medical comorbidities for individuals with serious mental illnesses. Previous studies identified population health management capacity and coordination with primary care providers as key barriers to BHH implementation. This study examines the BHH leaders' perceptions of and organizational capacity to conduct these functions within the community mental health programs implementing BHHs in Maryland. METHODS Interviews and surveys were conducted with 72 implementation leaders and 627 front-line staff from 46 of 48 Maryland BHH programs. In-depth coding of the population health management and primary care coordination themes identified subthemes related to these topics. RESULTS BHH staff described cultures supportive of evidence-based practices, but limited ability to effectively perform population health management or primary care coordination. Tension between population health management and direct, clinical care, lack of experience, and state regulations for service delivery were identified as key challenges for population health management. Engaging primary care providers was the primary barrier to care coordination. Health information technology and staffing were barriers to both functions. CONCLUSIONS BHHs face a number of barriers to effective implementation of core program elements. To improve programs' ability to conduct effective population health management and care coordination and meaningfully impact health outcomes for individuals with serious mental illness, multiple strategies are needed, including formalized protocols, training for staff, changes to financing mechanisms, and health information technology improvements.
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Bleser WK, Saunders RS, Muhlestein DB, McClellan M. Why Do Accountable Care Organizations Leave The Medicare Shared Savings Program? Health Aff (Millwood) 2019; 38:794-803. [DOI: 10.1377/hlthaff.2018.05097] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- William K. Bleser
- William K. Bleser is a research associate at the Duke-Margolis Center for Health Policy, Duke University, in Washington, D.C
| | - Robert S. Saunders
- Robert S. Saunders is a research director at the Duke-Margolis Center for Health Policy, Duke University, in Washington
| | - David B. Muhlestein
- David B. Muhlestein is chief research officer at Leavitt Partners in Washington, D.C., and an adjunct assistant professor at the Dartmouth Institute, Geisel School of Medicine, Dartmouth College, in Hanover, New Hampshire
| | - Mark McClellan
- Mark McClellan is director of the Duke-Margolis Center for Health Policy in Washington and the Robert J. Margolis Professor of Business, Medicine, and Policy at Duke University in Durham, North Carolina
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Jones TL, Yoder LH, Baernholdt M. Variation in academic preparation and progression of nurses across the continuum of care. Nurs Outlook 2019; 67:381-392. [PMID: 30929958 DOI: 10.1016/j.outlook.2019.02.008] [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: 11/20/2018] [Revised: 01/30/2019] [Accepted: 02/08/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Changing health care needs are driving new models of care that emphasize care coordination, health promotion, and disease management by registered nurses (RNs). A skill-mix favoring professional (baccalaureate or above) over technical (less than baccalaureate) education is promoted by national initiatives. PURPOSE To examine the academic preparation and progression of general practice RNs in practice settings across the care continuum. METHOD Secondary analyses of data from the Texas Board of Nurses RN Licensure databases in 2008 and 2014. FINDINGS Overall the professional skill-mix for general practice RNs improved from 47.1% to 50.2%. Disparities were identified in home health (31.6%), long-term care (27.8%) and nonmetropolitan areas (31.7%). Role change was the strongest correlate of academic progression. DISCUSSION Non-hospital and rural practice settings may be vulnerable to the effects of an undereducated RN workforce. More effective reimbursement policies and employer incentives are needed to drive academic progression and address disparities across practice settings.
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Affiliation(s)
- Terry L Jones
- Virginia Commonwealth University, School of Nursing, Department of Adult Health & Nursing Systems, Richmond, VA.
| | - Linda H Yoder
- University of Texas at Austin, School of Nursing, Division of Adult Health, Austin, TX
| | - Marianne Baernholdt
- Virginia Commonwealth University, School of Nursing, Department of Adult Health & Nursing Systems, Richmond, VA
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Berkson S, Davis S, Karp Z, Jaffery J, Flood G, Pandhi N. Medicare Shared Savings Programs: Higher Cost Accountable Care Organizations are More Likely to Achieve Savings. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2018; 13:248-255. [PMID: 37786615 PMCID: PMC10544836 DOI: 10.1080/20479700.2018.1500760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 07/04/2018] [Indexed: 10/28/2022]
Abstract
In the United States, Medicare's flagship Accountable Care Organization (ACO) program, the Medicare Shared Savings Program (MSSP), is under close scrutiny to improve health care quality and decrease costs. First year measures, released in November 2014, reveal a wide range of financial and quality performance across MSSP participants. In this observational study we used 2013 results for 220 participating ACOs to assess key characteristics associated with generating savings. ACOs with higher baseline expenditures were significantly more likely to generate savings than lower cost ACOs. Average quality scores for ACOs that successfully reported on quality were not different between organizations that did and did not generate savings. These findings suggest ACOs that had lower utilization prior to program enrollment are less likely to be rewarded in the current program. This has important policy implications for the MSSP's ability to attract and retain efficient ACOs and incent efforts to reduce waste and improve quality.
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Affiliation(s)
- Stephanie Berkson
- School of Medicine and Public Health, University of Wisconsin Madison, Madison, WI, USA
| | - Sarah Davis
- School of Medicine and Public Health, University of Wisconsin Madison, Madison, WI, USA
| | - Zaher Karp
- School of Medicine and Public Health, University of Wisconsin Madison, Madison, WI, USA
| | - Jonathan Jaffery
- School of Medicine and Public Health, University of Wisconsin Madison, Madison, WI, USA
| | - Grace Flood
- School of Medicine and Public Health, University of Wisconsin Madison, Madison, WI, USA
| | - Nancy Pandhi
- School of Medicine and Public Health, University of Wisconsin Madison, Madison, WI, USA
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Abstract
Purpose Given the pace of industry change and the rapid diffusion of high reliability organization (HRO) approaches, lags and divergences have arisen between research and practice in healthcare. The purpose of this paper is to explore several of these theory-practice gaps and propose implications for research and practice. Design/methodology/approach Classic and cutting-edge HRO literature is applied to analyze two industry trends: delivery system integration, and the confluence of patient-as-consumer and patient-centered care. Findings Highly reliable integrated delivery systems will likely function very differently from classic HRO organizations. Both practitioners and researchers should address conditions such as how a system is bounded, how reliable the system should be and how interdependencies are handled. Additionally, systems should evaluate the added uncertainty and variability introduced by enhanced agency on the part of patients/families in decision making and in processes of care. Research limitations/implications Dramatic changes in the sociotechnical environment are influencing the coupling and interactivity of system elements in healthcare. Researchers must address the maintenance of reliability across organizations and the migration of decision-making power toward patients and families. Practical implications As healthcare systems integrate, managers attempting to apply HRO principles must recognize how these systems present new and different reliability-related challenges and opportunities. Originality/value This paper provides a starting point for the advancement of research and practice in high-reliability healthcare by providing an in-depth exploration of the implications of two major industry trends.
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Affiliation(s)
- Peter F Martelli
- Sawyer Business School, Suffolk University , Boston, Massachusetts, USA
| | - Peter E Rivard
- Sawyer Business School, Suffolk University , Boston, Massachusetts, USA
| | - Karlene H Roberts
- Haas School of Business, University of California Berkeley , Berkeley, California, USA
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Turner A, Mulla A, Booth A, Aldridge S, Stevens S, Begum M, Malik A. The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [PMID: 29972636 DOI: 10.3310/hsdr06250] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BackgroundThe Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations.ObjectivesThe three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables.DesignThere were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components.Main outcome measuresThe quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience.Data sourcesSearches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence.Review methodsA realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities.ResultsDelivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models.Strengths and limitationsThe project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change.ConclusionsMultispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working.Future workA set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.Study registrationThis study is registered as PROSPERO CRD42016039552.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Alison Turner
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Abeda Mulla
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Shiona Aldridge
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Sharon Stevens
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Mahmoda Begum
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Anam Malik
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
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Winblad U, Mor V, McHugh JP, Rahman M. ACO-Affiliated Hospitals Reduced Rehospitalizations From Skilled Nursing Facilities Faster Than Other Hospitals. Health Aff (Millwood) 2018; 36:67-73. [PMID: 28069848 DOI: 10.1377/hlthaff.2016.0759] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicare's more than 420 accountable care organizations (ACOs) provide care for a considerable percentage of the elderly in the United States. One goal of ACOs is to improve care coordination and thereby decrease rates of rehospitalization. We examined whether ACO-affiliated hospitals were more effective than other hospitals in reducing rehospitalizations from skilled nursing facilities. We found a general reduction in rehospitalizations from 2007 to 2013, which suggests that all hospitals made efforts to reduce rehospitalizations. The ACO-affiliated hospitals, however, were able to reduce rehospitalizations more quickly than other hospitals. The reductions suggest that ACO-affiliated hospitals are either discharging to the nursing facilities more effectively compared to other hospitals or targeting at-risk patients better, or enhancing information sharing and communication between hospitals and skilled nursing facilities. Policy makers expect that reducing readmissions to hospitals will generate major savings and improve the quality of life for the frail elderly. However, further work is needed to investigate the precise mechanisms that underlie the reduction of readmissions among ACO-affiliated hospitals.
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Affiliation(s)
- Ulrika Winblad
- Ulrika Winblad was a Harkness Fellow in 2014-15 at the Center for Gerontology and Healthcare Research at the Brown University School of Public Health, in Providence, Rhode Island. She is an associate professor in the Department of Public Health and Caring Sciences at Uppsala University, in Sweden
| | - Vincent Mor
- Vincent Mor is a professor at the Center for Gerontology and Healthcare Research, Brown University School of Public Health, and a health scientist at the Providence Veterans Affairs Medical Center
| | - John P McHugh
- John P. McHugh is an assistant professor in the Department of Health Policy and Management, Mailman School of Public Health, Columbia University, in New York City
| | - Momotazur Rahman
- Momotazur Rahman is an assistant professor in the Department of Health Services Policy and Practice, Brown University School of Public Health
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Fraze T, Lewis VA, Rodriguez HP, Fisher ES. Housing, Transportation, And Food: How ACOs Seek To Improve Population Health By Addressing Nonmedical Needs Of Patients. Health Aff (Millwood) 2018; 35:2109-2115. [PMID: 27834253 DOI: 10.1377/hlthaff.2016.0727] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Addressing nonmedical needs-such as the need for housing-is critical to advancing population health, improving the quality of care, and lowering the costs of care. Accountable care organizations (ACOs) are well positioned to address these needs. We used qualitative interviews with ACO leaders and site visits to examine how these organizations addressed the nonmedical needs of their patients, and the extent to which they did so. We developed a typology of medical and social services integration among ACOs that disentangles service and organizational integration. We found that the nonmedical needs most commonly addressed by ACOs were the need for transportation and housing and food insecurity. ACOs identified nonmedical needs through processes that were part of the primary care visit or care transformation programs. Approaches to meeting patients' nonmedical needs were either individualized solutions (developed patient by patient) or targeted approaches (programs developed to address specific needs). As policy makers continue to provide incentives for health care organizations to meet a broader spectrum of patients' needs, these findings offer insights into how health care organizations such as ACOs integrate themselves with nonmedical organizations.
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Affiliation(s)
- Taressa Fraze
- Taressa Fraze is a research scientist at the Dartmouth Institute for Health Policy and Clinical Practice, in Lebanon, New Hampshire
| | - Valerie A Lewis
- Valerie A. Lewis is an assistant professor at the Dartmouth Institute for Health Policy and Clinical Practice
| | - Hector P Rodriguez
- Hector P. Rodriguez is a professor of health policy and management and codirector of the Center for Healthcare Organizational and Innovation Research, both at the School of Public Health, University of California, Berkeley
| | - Elliott S Fisher
- Elliott S. Fisher is director of the Dartmouth Institute for Health Policy and Clinical Practice
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Peiris D, Phipps-Taylor MC, Stachowski CA, Kao LS, Shortell SM, Lewis VA, Rosenthal MB, Colla CH. ACOs Holding Commercial Contracts Are Larger And More Efficient Than Noncommercial ACOs. Health Aff (Millwood) 2018; 35:1849-1856. [PMID: 27702959 DOI: 10.1377/hlthaff.2016.0387] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Accountable care organizations (ACOs) have diverse contracting arrangements and have displayed wide variation in their performance. Using data from national surveys of 399 ACOs, we examined differences between the 228 commercial ACOs (those with commercial payer contracts) and the 171 noncommercial ACOs (those with only public contracts, such as with Medicare or Medicaid). Commercial ACOs were significantly larger and more integrated with hospitals, and had lower benchmark expenditures and higher quality scores, compared to noncommercial ACOs. Among all of the ACOs, there was low uptake of quality and efficiency activities. However, commercial ACOs reported more use of disease monitoring tools, patient satisfaction data, and quality improvement methods than did noncommercial ACOs. Few ACOs reported having high-level performance monitoring capabilities. About two-thirds of the ACOs had established processes for distributing any savings accrued, and these ACOs allocated approximately the same amount of savings to the ACOs themselves, participating member organizations, and physicians. Our findings demonstrate that ACO delivery systems remain at a nascent stage. Structural differences between commercial and noncommercial ACOs are important factors to consider as public policy efforts continue to evolve.
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Affiliation(s)
- David Peiris
- David Peiris is a Harkness Fellow at the Harvard T. H. Chan School of Public Health, in Boston, Massachusetts
| | - Madeleine C Phipps-Taylor
- Madeleine C. Phipps-Taylor is a director of Allocate Software Ltd., in London, United Kingdom. At the time of this study, she was a 2014-15 Harkness Fellow at the School of Public Health at the University of California, Berkeley
| | - Courtney A Stachowski
- Courtney A. Stachowski is a research project specialist at the Dartmouth Institute for Health Policy and Clinical Practice, in Lebanon, New Hampshire
| | - Lee-Sien Kao
- Lee-Sien Kao is an associate at ideas42, in Washington, D.C. At the time of this study, she was a health policy fellow at the Dartmouth Institute for Health Policy and Clinical Practice
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor of Health Policy and Management, a professor of organization behavior, director of the Center for Healthcare Organizational and Innovation Research, and dean emeritus, all at the School of Public Health, University of California, Berkeley
| | - Valerie A Lewis
- Valerie A. Lewis is an assistant professor of health policy at the Dartmouth Institute for Health Policy and Clinical Practice
| | - Meredith B Rosenthal
- Meredith B. Rosenthal is a professor of health economics and policy in the Department of Health Policy and Management at the Harvard T. H. Chan School of Public Health
| | - Carrie H Colla
- Carrie H. Colla is an associate professor of health policy at the Dartmouth Institute for Health Policy and Clinical Practice
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Tietschert MV, Angeli F, van Raak AJA, Ruwaard D, Singer SJ. Cross-Cultural Validation of the Patient Perception of Integrated Care Survey. Health Serv Res 2017; 53:1745-1776. [PMID: 28726236 DOI: 10.1111/1475-6773.12741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To test the cross-cultural validity of the U.S. Patient Perception of Integrated Care (PPIC) Survey in a Dutch sample using a standardized procedure. DATA SOURCES Primary data collected from patients of five primary care centers in the south of the Netherlands, through survey research from 2014 to 2015. STUDY DESIGN Cross-sectional data collected from patients who saw multiple health care providers during 6 months preceding data collection. DATA COLLECTION The PPIC survey includes 59 questions that measure patient perceived care integration across providers, settings, and time. Data analysis followed a standardized procedure guiding data preparation, psychometric analysis, and included invariance testing with the U.S. dataset. PRINCIPAL FINDINGS Latent scale structures of the Dutch and U.S. survey were highly comparable. Factor "Integration with specialist" had lower reliability scores and noninvariance. For the remaining factors, internal consistency and invariance estimates were strong. CONCLUSIONS The standardized cross-cultural validation procedure produced strong support for comparable psychometric characteristics of the Dutch and U.S. surveys. Future research should examine the usability of the proposed procedure for contexts with greater cultural differences.
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Affiliation(s)
- Maike V Tietschert
- Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Federica Angeli
- Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Arno J A van Raak
- Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Sara J Singer
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA
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Powers BW, Mostashari F, Maxson E, Lynch K, Navathe AS. Engaging small independent practices in value-based payment: Building Aledade's medicare ACOs. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2017; 6:79-87. [PMID: 28651925 DOI: 10.1016/j.hjdsi.2017.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 06/17/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Brian W Powers
- Harvard Medical School, Boston, MA, USA; Harvard Business School, Boston, MA, USA
| | | | | | | | - Amol S Navathe
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA; CMC VA Medical Center, Philadelphia, PA, USA
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Coping with interdependencies related to patient choice: Boundary-spanning at four accountable care organizations. Health Care Manage Rev 2017; 44:115-126. [PMID: 28125456 DOI: 10.1097/hmr.0000000000000147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Accountable care organizations (ACOs) are responsible for outcomes that are only partially under their control because patients may choose to self-refer outside the ACO, overuse resource-intensive services, or underuse evidence-based care. ACOs must devise boundary-spanning practices to manage these interdependencies related to patient choice. PURPOSE The aim of this study was to identify, conceptualize, and categorize ACO efforts to cope with interdependencies related to patient choice. APPROACH We conducted qualitative organizational case studies of four ACOs. We interviewed 89 executives, mid-level managers, and physicians and analyzed the data through multiple rounds of inductive coding. RESULTS We identified 15 boundary-spanning practices, in which two or more ACOs engaged in efforts to understand, cope with, or alter interdependencies related to patient choice. Analysis of these practices revealed five categories of factors that appeared to shape patient choices in ways that may impact ACO performance: the availability of services, interactions with patients, system complexities, care provided to ACO patients by non-ACO providers, and uncertainties related to the environment. Our findings provide a process theory of ACO boundary-spanning: Each individual boundary-spanning practice contributes to a broader strategic goal, through which it may impact a particular aspect of interdependence and thereby reduce underuse, overuse, or leakage (i.e., provision of services outside the ACO). PRACTICE IMPLICATIONS In identifying ACO boundary-spanning practices and proposing how they may impact interdependence, our theory highlights conceptual relationships that researchers can study and test. Similarly, in identifying key aspects of interdependencies related to patient choice and a broad assortment of ACO boundary-spanning practices, our findings provide managers with a tool for evaluating and developing their own boundary-spanning efforts.
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Huber TP, Shortell SM, Rodriguez HP. Improving Care Transitions Management: Examining the Role of Accountable Care Organization Participation and Expanded Electronic Health Record Functionality. Health Serv Res 2016; 52:1494-1510. [PMID: 27549015 DOI: 10.1111/1475-6773.12546] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Examine the extent to which physician organization participation in an accountable care organization (ACO) and electronic health record (EHR) functionality are associated with greater adoption of care transition management (CTM) processes. DATA SOURCES/STUDY SETTING A total of 1,398 physician organizations from the third National Study of Physician Organization survey (NSPO3), a nationally representative sample of medical practices in the United States (January 2012-May 2013). STUDY DESIGN We used data from the third National Study of Physician Organization survey (NSPO3) to assess medical practice characteristics, including CTM processes, ACO participation, EHR functionality, practice type, organization size, ownership, public reporting, and pay-for-performance participation. DATA COLLECTION/EXTRACTION METHODS Multivariate linear regression models estimated the extent to which ACO participation and EHR functionality were associated with greater CTM capabilities, controlling for practice size, ownership, public reporting, and pay-for-performance participation. PRINCIPAL FINDINGS Approximately half (52.4 percent) of medical practices had a formal program for managing care transitions in place. In adjusted analyses, ACO participation (p < .001) and EHR functionality (p < .001) were independently associated with greater use of CTM processes among medical practices. CONCLUSIONS The growth of ACOs and similar provider risk-bearing arrangements across the country may improve the management of care transitions by physician organizations.
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Affiliation(s)
- Thomas P Huber
- School of Public Health, University of California Berkeley, Berkeley, CA
| | - Stephen M Shortell
- School of Public Health, University of California Berkeley, Berkeley, CA
| | - Hector P Rodriguez
- School of Public Health, University of California Berkeley, Berkeley, CA
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Vogus TJ, Singer SJ. Unpacking Accountable Care: Using Organization Theory to Understand the Adoption, Implementation, Spread, and Performance of Accountable Care Organizations. Med Care Res Rev 2016; 73:643-648. [PMID: 27000176 DOI: 10.1177/1077558716640410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 02/29/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Timothy J Vogus
- Vanderbilt Owen Graduate School of Management, Nashville, TN, USA
| | - Sara J Singer
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
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Scheffler RM. Accountable Care Organizations: Integrated Care Meets Market Power. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2015; 40:639-645. [PMID: 26124304 DOI: 10.1215/03616878-3149964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Will accountable care organizations (ACOs) deliver high-quality care at lower costs? Or will their potential market power lead to higher prices and lower quality? ACOs appear in various forms and structures with financial and clinical integration at their core; however, the tools to assess their quality and the incentive structures that will determine their success are still evolving. Both market forces and regulatory structures will determine how these outcomes emerge. This introduction reviews the evidence presented in this special issue to tackle this thorny trade-off. In general the evidence is promising, but the full potential of ACOs to improve the health care delivery system is still uncertain. This introductory review concludes that the current consensus is to let ACOs grow, anticipating that they will make a contribution to improve our poor-quality and high-cost delivery system.
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Fox DM. Commentary - Patients' Rights Matter in Regulating Accountable Care Organizations. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2015; 40:905-910. [PMID: 26124298 DOI: 10.1215/03616878-3150148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Feldman R. The Economics of Provider Payment Reform: Are Accountable Care Organizations the Answer? JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2015; 40:745-760. [PMID: 26124297 DOI: 10.1215/03616878-3150038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A remarkable consensus has developed that the fee-for-service (FFS) approach for paying medical providers must be replaced. This payment approach is said to increase the volume of services without improving care coordination. In response to these calls, Medicare and private payers are experimenting with payment systems that combine the basic element of FFS - a fee for each service - with arrangements that allow providers to share the savings if they hold total spending per patient below a targeted amount. Medicare's accountable care organizations (ACOs) embody the shared savings approach to payment reform. Private payers have introduced total cost of care contracting (TCOC) in several locations. This article questions the consensus that FFS must go. If the fees are too high, then someone needs to "bite the bullet" and reduce fees in key areas. Hoping to control overspending by investment in ACOs is wishful thinking. I describe the theory and practice of shared savings payment systems and summarize recent TCOC contracting initiatives in the private sector. Medicare's shared savings approach is likely to be less effective than private contracts. Cutting providers' fees would be more efficient. Finally, the new payment models in the Affordable Care Act will not ease the problem of high prices for private payers.
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