1
|
Abstract
Policy Points Strategically purchasing health care has been and continues to be a popular policy idea around the world. Key asymmetries in information, market power, political power, and financial power hinder the effective implementation of strategic purchasing. Strategic purchasing has consistently failed to live up to its promises for these reasons. Future strategies based on strategic purchasing should tailor their expectations to its real effectiveness. CONTEXT Strategic purchasing of health care has been a popular policy idea around the world for decades, with advocates claiming that it can lead to improved quality, patient satisfaction, efficiency, accountability, and even population health. In this article, we report the results of an inquiry into the implementation and effects of strategic purchasing. METHODS We conducted three in-depth case studies of England, the Netherlands, and the United States. We reviewed definitions of purchasing, including its slow acquisition of adjectives such as strategic, and settled on a definition of purchasing that distinguishes it from the mere use of contracts to regulate stable interorganizational relationships. The case studies review the career of strategic purchasing in three different systems where its installation and use have been a policy priority for years. FINDINGS No existing health care system has effective strategic purchasing because of four key asymmetries: market power asymmetry, information asymmetry, financial asymmetry, and political power asymmetry. CONCLUSIONS Further investment in policies that are premised on the effectiveness of strategic purchasing, or efforts to promote it, may not be worthwhile. Instead, policymakers may need to focus on the real sources of power in a health care system. Policy for systems with existing purchasing relationships should take into account the asymmetries, ways to work with them, and the constraints that they create.
Collapse
Affiliation(s)
| | | | - EWOUT VAN GINNEKEN
- European Observatory on Health Systems and PoliciesBerlin University of Technology
| |
Collapse
|
2
|
DiGiorgio AM, Mummaneni PV, Park P, Chan AK, Bisson EF, Bydon M, Foley KT, Glassman SD, Shaffrey CI, Potts EA, Shaffrey ME, Coric D, Knightly JJ, Wang MY, Fu KM, Asher AL, Virk MS, Kerezoudis P, Alvi MA, Guan J, Haid RW, Slotkin JR. Correlation of return to work with patient satisfaction after surgery for lumbar spondylolisthesis: an analysis of the Quality Outcomes Database. Neurosurg Focus 2020; 48:E5. [DOI: 10.3171/2020.2.focus191022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 02/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEReturn to work (RTW) and satisfaction are important outcome measures after surgery for degenerative spine disease. The authors queried the prospective Quality Outcomes Database (QOD) to determine if RTW correlated with patient satisfaction.METHODSThe QOD was queried for patients undergoing surgery for degenerative lumbar spondylolisthesis. The primary outcome of interest was correlation between RTW and patient satisfaction, as measured by the North American Spine Society patient satisfaction index (NASS). Secondarily, data on satisfied patients were analyzed to see what patient factors correlated with RTW.RESULTSOf 608 total patients in the QOD spondylolisthesis data set, there were 292 patients for whom data were available on both satisfaction and RTW status. Of these, 249 (85.3%) were satisfied with surgery (NASS score 1–2), and 224 (76.7%) did RTW after surgery. Of the 68 patients who did not RTW after surgery, 49 (72.1%) were still satisfied with surgery. Of the 224 patients who did RTW, 24 (10.7%) were unsatisfied with surgery (NASS score 3–4). There were significantly more people who had an NASS score of 1 in the RTW group than in the non-RTW group (71.4% vs 42.6%, p < 0.05). Failure to RTW was associated with lower level of education, worse baseline back pain (measured with a numeric rating scale), and worse baseline disability (measured with the Oswestry Disability Index [ODI]).CONCLUSIONSThere are a substantial number of patients who are satisfied with surgery even though they did not RTW. Patients who were satisfied with surgery and did not RTW typically had worse preoperative back pain and ODI and typically did not have a college education. While RTW remains an important measure after surgery, physicians should be mindful that patients who do not RTW may still be satisfied with their outcome.
Collapse
Affiliation(s)
- Anthony M. DiGiorgio
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Praveen V. Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Paul Park
- 3Department of Neurologic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew K. Chan
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Erica F. Bisson
- 4Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Mohamad Bydon
- 5Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kevin T. Foley
- 6Department of Neurosurgery, University of Tennessee, Memphis, Tennessee
| | | | - Christopher I. Shaffrey
- 8Departments of Neurological Surgery and Orthopedic Surgery, Duke University, Durham, North Carolina
| | - Eric A. Potts
- 9Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Mark E. Shaffrey
- 10Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Domagoj Coric
- 11Neuroscience Institute, Carolina Neurosurgery and Spine Associates, Carolinas HealthCare System, Charlotte, North Carolina
| | | | - Michael Y. Wang
- 13Department of Neurological Surgery, University of Miami, Florida
| | - Kai-Ming Fu
- 14Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Anthony L. Asher
- 11Neuroscience Institute, Carolina Neurosurgery and Spine Associates, Carolinas HealthCare System, Charlotte, North Carolina
| | - Michael S. Virk
- 14Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | | | - Mohammed Ali Alvi
- 5Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jian Guan
- 15Pacific Neurosciences Center, Torrance, California
| | - Regis W. Haid
- 16Atlanta Brain and Spine Care, Atlanta, Georgia; and
| | | |
Collapse
|
3
|
Goldstein EV. Sophistry in American medicine? Platonic reflections on expertise, influence and the public's health in the democratic context. MEDICAL HUMANITIES 2019; 45:45-51. [PMID: 30007922 DOI: 10.1136/medhum-2018-011469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/13/2018] [Indexed: 06/08/2023]
Abstract
Without question, the American medical craft-the physicians, clinicians and healthcare organisations that comprise the American healthcare sector-provides immense value to patients and contributes expertise on matters relevant to the public's health. However, several conspicuous realities about healthcare in America should give the reader pause. Most problematic are the comparative measures of access to care, quality of care, life expectancy, racial health disparity and cost, all of which demonstrate how many Americans experience relatively lower value public health than other Western liberal democratic states. Since the early 1900s, American medical craft behaviour contributed to suboptimal social investment in public health, successfully influencing greater medical investment and higher healthcare expenditure relative to social welfare investments. Today, American policymakers seek the 'holy grail', a mythical panacea that purports to restrict spending and improve care quality and value, leading the USA to chase 'technocratic solutions to political problems'. This paper explores the claim that the USA is hampered by suboptimal public health decision making. Public health decision making has been historically impacted by the overextended reach of medical craft expertise-technê in Platonic terms of art-as permitted by the American democratic political system. American policymakers must not forget that the debate over technê, epistêmê, sophistry and who should have authority in public affairs is not new. Rather, it is an ancient debate, and now as then, the ancient arguments remain relevant in a democratic context. For particularly helpful insight, one ought to look no further than the lessons of Plato's dialogues. Platonic lessons on expertise and decision making can enlighten our understanding of modern public health decision making, specifically regarding the appropriation, allocation and distribution of health-related resources in the state.
Collapse
|
4
|
Spivack SB, Laugesen MJ, Oberlander J. No Permanent Fix: MACRA, MIPS, and the Politics of Physician Payment Reform. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2018; 43:1025-1040. [PMID: 31091325 DOI: 10.1215/03616878-7104431] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Organized medicine long yearned for the demise of Medicare's Sustainable Growth Rate (SGR) formula for updating physician fees. Congress finally obliged in 2015, repealing the SGR as part of the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA established value-based metrics for physician payment and financial incentives for doctors to join alternative delivery models like patient-centered medical homes. Throughout the law's initial implementation, the politics of accommodation prevailed, with federal officials crafting final rules that made MACRA more favorable for physicians. However, the era of accommodation could be short-lived. The discretion that the Centers for Medicare and Medicaid Services had during the first two years of implementation is ending. Additionally, euphoria over the SGR's repeal has given way to concerns over the new program's value-based purchasing arrangements and uncertainty over their sustainability. MACRA eliminated the SGR, but not the politics of physician payment.
Collapse
|
5
|
Impact of Risk Adjustment on Provider Ranking for Patients With Low Back Pain Receiving Physical Therapy. J Orthop Sports Phys Ther 2018; 48:637-648. [PMID: 29787696 DOI: 10.2519/jospt.2018.7981] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background The impact of risk adjustment on clinic quality ranking for patients treated in physical therapy outpatient clinics is unknown. Objectives To compare clinic ranking, based on unadjusted versus risk-adjusted outcomes for patients with low back pain (LBP) who are treated in physical therapy outpatient clinics. Methods This retrospective cohort study involved a secondary analysis of data from adult patients with LBP treated in outpatient physical therapy clinics from 2014 to 2016. Patients with complete outcomes data at admission and discharge were included to develop the risk-adjustment model. Clinics with complete outcomes data for at least 50% of patients and at least 10 complete episodes of care per clinician per year were included for ranking assessment. The R2 shrinkage and predictive ratio were used to assess overfitting. Agreement between unadjusted and adjusted rankings was assessed with percentile ranking by deciles or 3 distinct quality ranks based on uncertainty assessment. Results The primary sample included 414 125 patients (mean ± SD age, 57 ± 17 years; 60% women) treated by 12 569 clinicians from 3048 clinics from all US states; 82% of patients from 2107 clinics were included in the ranking assessment. The R2 shrinkage was less than 1%, with a predictive ratio of 1. Risk adjustment impacted ranking for 70% or 31% of clinics, based on deciles or 3 distinct quality levels, respectively. Conclusion Important changes in ranking were found after adjusting for basic patient characteristics of those admitted to physical therapy for treatment of LBP. Risk-adjustment profiling is necessary to more accurately reflect quality of care when treating patients with LBP. Level of Evidence Therapy, level 2b. J Orthop Sports Phys Ther 2018;48(8):637-648. Epub 22 May 2018. doi:10.2519/jospt.2018.7981.
Collapse
|
6
|
Smaggus A, Goldszmidt M. High Reliability and 'Cargo Cult QI': response to Sutcliffe et al. BMJ Qual Saf 2017;26:248-51. BMJ Qual Saf 2017; 26:518. [PMID: 28404793 DOI: 10.1136/bmjqs-2017-006748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 03/28/2017] [Indexed: 11/04/2022]
Affiliation(s)
- Andrew Smaggus
- Department of Medicine, Western University, Schulich School of Medicine and Dentistry, London, Canada
| | - Mark Goldszmidt
- Department of Medicine, Western University Schulich School of Medicine and Dentistry, London, Canada
| |
Collapse
|