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Johnston KJ, Loux T, Joynt Maddox KE. Risk Selection and Care Fragmentation at Medicare Accountable Care Organizations for Patients With Dementia. Med Care 2023; 61:570-578. [PMID: 37411003 PMCID: PMC10328553 DOI: 10.1097/mlr.0000000000001876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND Patients with dementia are a growing and vulnerable population within Medicare. Accountable care organizations (ACOs) are becoming Medicare's dominant care model, but ACO enrollment and care patterns for patients with dementia are unknown. OBJECTIVE The aim of this study was to compare differences in ACO enrollment for patients with versus without dementia, and in risk profiles and ambulatory care among patients with dementia by ACO enrollment status. RESEARCH DESIGN Cohort study assessing the relationships between patient dementia, following-year ACO enrollment, and ambulatory care patterns. SUBJECTS A total of 13,362 (weighted: 45, 499,049) person-years for patients [2761 (weighted: 6,312,304) for dementia patients] ages 65 years and above in the 2015-2019 Medicare Current Beneficiary Survey. MEASURES We assessed differences in ACO enrollment rates for patients with versus without dementia, and in dementia-relevant ambulatory care visit rates and validated care fragmentation indices among patients with dementia by ACO enrollment status. RESULTS Patients with versus without dementia were less likely to be enrolled in (38.3% vs. 44.6%, P<0.001), and more likely to exit (21.1% vs. 13.7%, P<0.01) ACOs. Among patients with dementia, those enrolled versus not enrolled in ACOs had a more favorable social and health risk profile on 6 of 16 measures (P<0.05). There were no differences in rates of dementia-relevant, primary, or specialty care visits. ACO enrollment was associated with 45.7% higher wellness visit rates (P<0.001), and 13.4% more fragmented primary care (P<0.01) spread across 8.7% more distinct physicians (P<0.05). CONCLUSION Medicare ACOs are less likely to enroll and retain patients with dementia than other patients and provide more fragmented primary care without providing additional dementia-relevant ambulatory care visits.
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Affiliation(s)
- Kenton J Johnston
- General Medical Sciences Division, Washington University School of Medicine
| | - Travis Loux
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University
| | - Karen E Joynt Maddox
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
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2
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Spivack SB, Murray GF, Lewis VA. A Decade of ACOs in Medicare: Have They Delivered on Their Promise? JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2023; 48:63-92. [PMID: 36112955 DOI: 10.1215/03616878-10171090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Accountable care organizations (ACOs) were envisioned as a way to address both health care cost growth and uneven quality in US health care. They emerged in the early 2000s, with the 2010 Affordable Care Act (ACA) establishing a Medicare ACO program. In the decade since their launch, ACOs have grown into one of Medicare's flagship payment reform programs, with millions of beneficiaries receiving care from hundreds of ACOs. While great expectations surrounded ACOs' introduction into Medicare, their impacts to date have been modest. ACOs have achieved some savings and improvements in measured quality, but disagreement persists over the meaning of those results: Do ACOs represent important, incremental steps forward on the path toward a more efficient, high-quality health care system? Or do their modest achievements signal a failure of large-scale progress despite the substantial investments of resources? ACOs have proven to be politically resilient, largely sidestepping the controversies and partisan polarization that have led to the demise of other ACA provisions. But the same features that have enabled ACOs to evade backlash have constrained their impacts and effectiveness. After a decade, ACOs' long-term influence on Medicare and the US health care system remains uncertain.
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To What Extent Are ACO and PCMH Models Advancing the Triple Aim Objective? Implications and Considerations for Primary Care Medical Practices. J Ambul Care Manage 2022; 45:254-265. [PMID: 36006384 DOI: 10.1097/jac.0000000000000434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) have emerged to advance the health care system by achieving the Triple Aim of improving population health, reducing costs, and enhancing the patient experience. This review examines evidence regarding the relationship between these innovative care models and care outcomes, costs, and patient experiences. The 28 articles summarized in this review show that ACO and PCMH models play an important role in achieving the Triple Aim, when compared with conventional care models. However, there can be drawbacks associated with model implementation. The long-term success of these models still merits further investigation.
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Lam MB, Friend TH, Erfani P, Orav EJ, Jha AK, Figueroa JF. ACO Spending and Utilization Among Medicare Patients at the End of Life: an Observational Study. J Gen Intern Med 2022; 37:3275-3282. [PMID: 35022958 PMCID: PMC9550919 DOI: 10.1007/s11606-021-07183-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/28/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND End-of-life (EOL) costs constitute a substantial portion of healthcare spending in the USA and have been increasing. ACOs may offer an opportunity to improve quality and curtail EOL spending. OBJECTIVE To examine whether practices that became ACOs altered spending and utilization at the EOL. DESIGN Retrospective analysis of Medicare claims. PATIENTS We assigned patients who died in 2012 and 2015 to an ACO or non-ACO practice. Practices that converted to ACOs in 2013 or 2014 were matched to non-ACOs in the same region. A total of 23,643 ACO patients were matched to 23,643 non-ACO patients. MAIN MEASURES Using a difference-in-differences model, we examined changes in EOL spending and care utilization after ACO implementation. KEY RESULTS The introduction of ACOs did not significantly impact overall spending for patients in the last 6 months of life (difference-in-difference (DID) = $192, 95%CI -$841 to $1125, P = 0.72). Changes in spending did not differ between ACO and non-ACO patients across spending categories (inpatient, outpatient, physician services, skilled nursing, home health, hospice). No differences were seen between ACO and non-ACO patients in rates of ED visits, inpatient admissions, ICU admission, mean healthy days at home, and mean hospice days at 180 and 30 days prior to death. However, non-ACO patients had a significantly greater increase in hospice utilization compared to ACO patients at 180 days (DID P-value = 0.02) and 30 days (DID P-value = 0.01) prior to death. CONCLUSIONS With the exception of hospice care utilization, spending and utilization were not different between ACOs and non-ACO patients at the EOL. Longer follow-up may be necessary to evaluate the impact of ACOs on EOL spending and care.
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Affiliation(s)
- Miranda B Lam
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Department of Radiation Oncology, Brigham and Women's Hospital / Dana Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, MA, Boston, USA.
| | - Tynan H Friend
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - E John Orav
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ashish K Jha
- School of Public Health, Brown University, Providence, RI, USA
| | - Jose F Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, MA, Boston, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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5
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Kim TH, Thompson J. Market and Organizational Factors Associated with Hospital Leadership of Accountable Care Organizations. Hosp Top 2022; 101:275-287. [PMID: 35400305 DOI: 10.1080/00185868.2022.2040403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The number of Accountable Care Organizations (ACOs) in the U.S. has been rapidly increasing during the past decade. Despite the growth of Accountable Care Organizations (ACOs), little is known about the factors that are associated with hospital leadership of ACOs that contract with public and private payers. PURPOSE Using a resource dependency framework, this study examines the organizational characteristics and environmental factors that are associated with hospitals who are leading an ACO. METHODOLOGY We used the data from the American Hospital Association (AHA) Annual Survey of Hospitals for 2018, the Area Health Resources Files and the Medicare Cost Reports. A multiple logistic regression was used to test associations of the independent variables with the hospital leadership of ACOs. RESULTS We found that nearly one third of the hospitals studied were leading an ACO. System affiliated and not-for-profit hospitals were more likely to be the leaders. Hospitals that lead an ACO offer more clinical services and have better financial performance. Metropolitan core-based statistical areas and per capita income were significantly positively associated with leading an ACO. However, the proportion of population aged 65 and over and the percentage of Medicare advantage penetration were significantly negatively associated with leading an ACO. CONCLUSIONS Hospitals vary in leading an ACO, which may provide critical resources for them by creating an infrastructure that enables accountable care, extends their services into population health and value-based care programs increasingly promoted by public and commercial payers.
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Affiliation(s)
- Tae Hyun Kim
- Department of Healthcare Management, Yonsei University Graduate School of Public Health, Seoul, Republic of Korea
| | - Jon Thompson
- Health Services Administration, James Madison University, Harrisonburg, Virginia, USA
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Adler-Milstein J, Linden A, Hollingsworth JM, Ryan AM. Association of Primary Care Engagement in Value-Based Reform Programs With Health Services Outcomes. JAMA HEALTH FORUM 2022; 3:e220005. [PMID: 35977280 PMCID: PMC8903108 DOI: 10.1001/jamahealthforum.2022.0005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 01/06/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Julia Adler-Milstein
- Department of Medicine, University of California, San Francisco
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco
| | - Ariel Linden
- Department of Medicine, University of California, San Francisco
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco
| | | | - Andrew M. Ryan
- Health Management and Policy, Center for Evaluating Health Reform, School of Public Health, University of Michigan, Ann Arbor
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Lin SC, Yan PL, Moloci NM, Lawton EJ, Ryan AM, Adler-Milstein J, Hollingsworth JM. Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs. Health Aff (Millwood) 2021; 39:310-318. [PMID: 32011939 DOI: 10.1377/hlthaff.2019.00181] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite expectations that Medicare accountable care organizations (ACOs) would curb health care spending, their effect has been modest. One possible explanation is that ACOs' inability to prohibit out-of-network care limits their control over spending. To examine this possibility, we examined the association between out-of-network care and per beneficiary spending using national Medicare data for 2012-15. While there was no association between out-of-network specialty care and ACO spending, each percentage-point increase in receipt of out-of-network primary care was associated with an increase of $10.79 in quarterly total ACO spending per beneficiary. When we broke down total spending by place of service, we found that out-of-network primary care was associated with higher spending in outpatient, skilled nursing facility, and emergency department settings, but not inpatient settings. Our findings suggest an opportunity for the Medicare program to realize substantial savings, if policy makers developed explicit incentives for beneficiaries to seek more of their primary care within network.
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Affiliation(s)
- Sunny C Lin
- Sunny C. Lin is an assistant professor of public health at the Oregon Health & Science University-Portland State University School of Public Health, in Portland, Oregon
| | - Phyllis L Yan
- Phyllis L. Yan is a senior statistician in the Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, in Ann Arbor
| | - Nicholas M Moloci
- Nicholas M. Moloci is a statistician lead in the Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School
| | - Emily J Lawton
- Emily J. Lawton is a doctoral candidate in the Department of Health Management and Policy, University of Michigan
| | - Andrew M Ryan
- Andrew M. Ryan is the UnitedHealthcare Professor of Health Care Management, Department of Health Management and Policy, University of Michigan School of Public Health, and director of the Center for Evaluating Health Reform, University of Michigan
| | - Julia Adler-Milstein
- Julia Adler-Milstein is an associate professor of medicine and director of the Clinical Informatics and Improvement Research Center, School of Medicine, University of California San Francisco
| | - John M Hollingsworth
- John M. Hollingsworth ( kinks@med. umich. edu ) is an associate professor of urology and health management and policy at the University of Michigan Medical School and School of Public Health
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8
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Chen J, Benjenk I, Barath D, Anderson AC, Reynolds CF. Disparities in Preventable Hospitalization Among Patients With Alzheimer Diseases. Am J Prev Med 2021; 60:595-604. [PMID: 33832801 PMCID: PMC8068589 DOI: 10.1016/j.amepre.2020.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 11/11/2020] [Accepted: 12/08/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION System-level care coordination strategies can be the most effective to promote continuity of care among people with Alzheimer's disease; however, the evidence is lacking. The objective of this study is to determine whether accountable care organizations are associated with lower rates of potentially preventable hospitalizations for people with Alzheimer's disease and whether hospital accountable care organization affiliation is associated with reduced racial and ethnic disparities in preventable hospitalizations among patients with Alzheimer's disease. METHODS This study employed a cross-sectional study design and used 2015 Healthcare Cost and Utilization Project inpatient claims data from 11 states and the 2015 American Hospital Association Annual Survey. Logistic regression and the Blinder-Oaxaca decomposition method were used. RESULTS African American patients with Alzheimer's disease were less likely to be hospitalized at accountable care organization‒affiliated hospitals than White patients. Among patients with Alzheimer's disease who were hospitalized, hospital accountable care organization affiliation was associated with lower odds of potentially preventable hospitalizations (OR=0.86, p=0.02; OR=0.66, p<0.001 with propensity score matching) after controlling for patient characteristics, hospital characteristics, and state indicators. Hospital accountable care organization affiliation explained 3.01% (p<0.01) of the disparity in potentially preventable hospitalizations between White and African American patients but could not explain disparities between White and Latinx patients. CONCLUSIONS Evidence suggests that accountable care organizations may be able to improve care coordination for people with Alzheimer's disease and to reduce disparities between Whites and African Americans. Further research is needed to determine whether this benefit can be attributed to accountable care organization formation or whether providers that participate in accountable care organizations tend to provide higher-quality care.
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Affiliation(s)
- Jie Chen
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, Maryland; Hospital And Public health interdisciPlinarY research (HAPPY) Lab, School of Public Health, University of Maryland, College Park, Maryland.
| | - Ivy Benjenk
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, Maryland; Hospital And Public health interdisciPlinarY research (HAPPY) Lab, School of Public Health, University of Maryland, College Park, Maryland
| | - Deanna Barath
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, Maryland; Hospital And Public health interdisciPlinarY research (HAPPY) Lab, School of Public Health, University of Maryland, College Park, Maryland
| | - Andrew C Anderson
- Department of Health Policy & Management, Tulane School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
| | - Charles F Reynolds
- Department of Behavioral and Community Health Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Liao JM, Navathe AS, Werner RM. The Impact of Medicare's Alternative Payment Models on the Value of Care. Annu Rev Public Health 2021; 41:551-565. [PMID: 32237986 DOI: 10.1146/annurev-publhealth-040119-094327] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Over the past decade, the Centers for Medicare and Medicaid Services (CMS) have led the nationwide shift toward value-based payment. A major strategy for achieving this goal has been to implement alternative payment models (APMs) that encourage high-value care by holding providers financially accountable for both the quality and the costs of care. In particular, the CMS has implemented and scaled up two types of APMs: population-based models that emphasize accountability for overall quality and costs for defined patient populations, and episode-based payment models that emphasize accountability for quality and costs for discrete care. Both APM types have been associated with modest reductions in Medicare spending without apparent compromises in quality. However, concerns about the unintended consequences of these APMs remain, and more work is needed in several important areas. Nonetheless, both APM types represent steps to build on along the path toward a higher-value national health care system.
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Affiliation(s)
- Joshua M Liao
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington 98195, USA; .,Value and Systems Science Lab, School of Medicine, University of Washington, Seattle, Washington 98195, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Amol S Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.,Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania 19104, USA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Rachel M Werner
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.,Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania 19104, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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10
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Kim Y, Thirukumaran C, Temkin-Greener H, Hill E, Holloway R, Li Y. The Effect of Medicare Shared Savings Program on Readmissions and Variations by Race/Ethnicity and Payer Status (December 9, 2020). Med Care 2021; 59:304-311. [PMID: 33528235 DOI: 10.1097/mlr.0000000000001513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Accountable care organizations in the Medicare Shared Savings Program (MSSP) in the United States attempt to reduce cost and improve quality for their patients by improving care coordination across care settings. We examined the impact of hospital participation in the MSSP on 30-day readmissions for several groups of Medicare inpatients, and by race/ethnicity and payer status. MAIN DATA SOURCE A 2010-2016 Medicare Provider Analysis and Review files. RESEARCH DESIGN With propensity score matched sample of MSSP and non-MSSP-participating hospitals, patient-level linear probability models with difference-in-differences approach were used to compare the changes in readmission rates for Medicare fee-for-service patients initially admitted for ischemic stroke, hip fracture, or total joint arthroplasty in MSSP-participating hospitals with non-MSSP-participating hospitals as well as to compare the changes in disparities in readmission rates over time. PRINCIPAL FINDINGS Hospital participation in MSSP was associated with further reduced readmission rate by 1.1 percentage points (95% confidence interval: -0.02 to 0.00, P<0.05) and 1.5 percentage points (95% confidence interval: -0.03 to 0.00, P=0.08) for ischemic stroke and hip fracture cohorts, respectively, compared with non-MSSP-participating hospitals, after the third year of hospital participation in the MSSP. There was no evidence that MSSP had an impact on racial/ethnic disparities, but increased disparity by payer status (dual vs. Medicare-only) was observed. These findings together suggest that MSSP accountable care organizations may take at least 3 years to achieve reduced readmissions and may increase disparities by payer status.
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Affiliation(s)
- Yeunkyung Kim
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
- HealthCore Inc, Watertown, MA
| | - Caroline Thirukumaran
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
- Departments of Orthopaedics and Rehabilitation
| | - Helena Temkin-Greener
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
| | - Elaine Hill
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
| | - Robert Holloway
- Neurology, University of Rochester Medical Center, Rochester, NY
| | - Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
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11
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Frean M, Covington C, Tietschert M, Bahadurzada H, So J, Singer SJ. Patient Experiences of Integrated Care in Medicare Accountable Care Organizations and Medicare Advantage Versus Traditional Fee-for-Service. Med Care 2021; 59:195-201. [PMID: 33273291 DOI: 10.1097/mlr.0000000000001463] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Health insurance design can influence the extent to which clinical care is well-coordinated. Through alternative payment models, Medicare Advantage (MA) and Accountable Care Organizations (ACOs) have the potential to improve integration relative to traditional fee-for-service (FFS) Medicare. OBJECTIVE To characterize patient experiences of integrated care within Medicare and identify whether MA or ACO beneficiaries perceive greater integration than FFS beneficiaries. DESIGN Retrospective cross-sectional analysis of the 2015 Medicare Current Beneficiary Survey. SUBJECTS Nationally representative sample of 11,978 Medicare beneficiaries. MEASURES Main outcomes included 8 previously derived domains of patient-perceived integrated care (PPIC), measured on a scale of 1-4. RESULTS The final sample was 55% female with a mean (SD) age of 71.1 (11.3). In unadjusted analyses, we observed considerable variation across PPIC domains in the full sample, but little variation across subsamples defined by coverage type within a given PPIC domain. In linear models adjusting for a rich set of patient characteristics, we observe no significant benefits of ACOs nor MA relative to FFS, a finding which is robust to alternative specifications and adjustment for multiple comparisons. We similarly observed no benefits in subgroup analyses restricted to states with relatively high market penetration of ACOs or MA. CONCLUSIONS Despite characteristics of ACOs and MA that theoretically promote integrated care, we find that PPIC is largely similar across coverage types in Medicare.
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Affiliation(s)
- Molly Frean
- Wharton School, University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Jodi So
- Stanford University School of Medicine, Stanford, CA
| | - Sara J Singer
- Stanford University School of Medicine, Stanford, CA
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Yasaitis L, Gupta A, Newcomb C, Kim E, Newcomer L, Bekelman J. An Insurer's Program To Incentivize Generic Oncology Drugs Did Not Alter Treatment Patterns Or Spending On Care. Health Aff (Millwood) 2020; 38:812-819. [PMID: 31059365 DOI: 10.1377/hlthaff.2018.05083] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The high and rising costs of anticancer drugs have received national attention. The prices of brand-name anticancer drugs often dwarf those of established generic drugs with similar efficacy. In 2007-16 UnitedHealthcare sought to encourage the use of several common low-cost generic anticancer drugs by offering providers a voluntary incentivized fee schedule with substantially higher generic drug payments (and profit margins), thereby increasing financial equivalence for providers in the choice between generic and brand-name drugs and regimens. We evaluated how this voluntary payment intervention affected treatment patterns and health care spending among enrollees with breast, lung, or colorectal cancer. We found that the incentivized fee schedule had neither significant nor meaningful effects on the use of incentivized generic drugs or on spending. Practices that adopted the incentivized fee schedule already had higher rates of generic anticancer drug use before switching, which demonstrates selection bias in take-up. Our study provides cautionary evidence of the limitations of voluntary payment reform initiatives in meaningfully affecting health care practice and spending.
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Affiliation(s)
- Laura Yasaitis
- Laura Yasaitis is a fellow of the Penn Center for Cancer Care Innovation at the Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, in Philadelphia
| | - Atul Gupta
- Atul Gupta is an assistant professor in the Department of Health Care Management at the Wharton School, University of Pennsylvania
| | - Craig Newcomb
- Craig Newcomb is a biostatistician in the Center for Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine
| | - Era Kim
- Era Kim is an analyst at UnitedHealthcare and the Institute for Health Informatics, University of Minnesota, in Rochester
| | - Lee Newcomer
- Lee Newcomer is a consultant at Lee N. Newcomer Consulting, in Wayzata, Minnesota
| | - Justin Bekelman
- Justin Bekelman ( ) is an associate professor and director of the Penn Center for Cancer Care Innovation at the Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine
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13
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Upadhyay S, Weech-Maldonado R, Opoku-Agyeman W. The effects of hospital-physician financial integration on adverse incident rate: An agency theory perspective. Health Serv Manage Res 2020; 34:199-207. [PMID: 32903095 DOI: 10.1177/0951484820948647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patient safety is an important aspect of quality of care. Physicians' alignment with hospitals by means of financial integration may possibly help hospitals achieve their quality goals. Most research examines the effects of financial integration on financial performance. There is a need to understand whether financial integration has an effect on quality and safety. PURPOSE The aim of this study is to examine the association between hospital physician financial integration (employment, joint ventures, and ownership) and Adverse Incident Rate.Methodology: A longitudinal panel study design was used. A random effects model with hospital, year, and state effects was used. Our sample contained 3,528 hospitals observations within U.S. from 2013-2015. FINDINGS Contrary to our hypotheses, hospital physician financial integration does not influence AIR. Besides financial integration, hospitals need to have a high commitment towards quality and safety to influence a lower AIR.
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Affiliation(s)
- Soumya Upadhyay
- Department of Healthcare Administration and Policy, School of Public Health University of Nevada Las VegasLas Vegas, NV, USA
| | - Robert Weech-Maldonado
- Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, USA
| | - William Opoku-Agyeman
- School of Health and Applied Human Sciences College of Health and Human Services, University of North Carolina Wilmington, Wilmington, NC, USA
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14
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Abstract
Background: Accountable care organizations (ACOs) are becoming a common payment and delivery model. Despite widespread interest, little empirical research has examined what efforts or strategies ACOs are using to change care and reduce costs. Knowledge of ACOs' clinical efforts can provide important context for understanding ACO performance, particularly to distinguish arenas where ACOs have and have not attempted care transformation. Purpose: The aim of the study was to understand ACOs' efforts to change clinical care during the first 18 months of ACO contracts. Methods: We conducted semistructured interviews between July and December 2013. Our sample includes ACOs that began performance contracts in 2012, including Medicare Shared Savings Program and Pioneer participants, stratified across key factors. In total, we conducted interviews with executives from 30 ACOs. Iterative qualitative analysis identified common patterns and themes. Results: ACOs in the first year of performance contracts are commonly focusing on four areas: first, transforming primary care through increased access and team-based care; second, reducing avoidable emergency department use; third, strengthening practice-based care management; and fourth, developing new boundary spanner roles and activities. ACOs were doing little around transforming specialty care, acute and postacute care, or standardizing care across practices during the first 18 months of ACO performance contracts. Practice Implications: Results suggest that cost reductions associated with ACOs in the first years of contracts may be related to primary care. Although in the long term many hope ACOs will achieve coordination across a wide array of care settings and providers, in the short term providers under ACO contracts are focused largely on primary care-related strategies. Our work provides a template of the common areas of clinical activity in the first years of ACO contracts, which may be informative to providers considering becoming an ACO. Further research will be needed to understand how these strategies are associated with performance.
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Strategies for Delivering Value-Based Care: Do Care Management Practices Improve Hospital Performance? J Healthc Manag 2019; 64:430-444. [PMID: 31725571 DOI: 10.1097/jhm-d-18-00049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
EXECUTIVE SUMMARY Value-based payment has the potential to rein in the volume incentive inherent in fee-for-service payment by holding providers accountable for the quality of patient care they deliver. Success under the new payment structure will depend on how effectively key organizational reforms are embraced by providers in the implementation of quality improvement processes for care delivery. This study examined the relationship between implementation of care management processes (CMPs, the specific tactics that enable the practice of value-based care) and hospital performance under value-based payment. Using the American Hospital Association's Survey of Care Systems and Payment and the Centers for Medicare & Medicaid Services' Hospital Compare, we estimated the relationship between hospital implementation of CMPs and performance as it relates to spending, patient satisfaction, readmission reduction, value-based purchasing, and clinical care outcomes. We found that hospitals increased implementation of CMPs from 2013 to 2014, which has led to modest changes in performance. We concluded that care coordination is associated with greater improvements in hospital performance. However, the long-term effects of resulting changes in care delivery may differ from the short-term effects. Thus, study findings underscore the importance of continued evaluation of care management practice as a strategy for optimizing delivery of high-quality, efficient patient care.
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Qi AC, Butler AM, Joynt Maddox KE. The Role Of Social Risk Factors In Dialysis Facility Ratings And Penalties Under A Medicare Quality Incentive Program. Health Aff (Millwood) 2019; 38:1101-1109. [DOI: 10.1377/hlthaff.2018.05406] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Andrew C. Qi
- Andrew C. Qi is a medical student at the Washington University School of Medicine, in Saint Louis, Missouri
| | - Anne M. Butler
- Anne M. Butler is an instructor of medicine at the Washington University School of Medicine, in Saint Louis
| | - Karen E. Joynt Maddox
- Karen E. Joynt Maddox is an assistant professor of medicine (cardiology) at the Washington University School of Medicine, in Saint Louis
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Abstract
BACKGROUND Hospitals affiliated with Accountable Care Organizations (ACOs) may have a greater capacity to collaborate with providers across the care continuum to coordinate care, due to formal risk sharing and payment arrangements. However, little is known about the extent to which ACO affiliated hospitals implement care coordination strategies. OBJECTIVES To compare the implementation of care coordination strategies between ACO affiliated hospitals (n=269) and unaffiliated hospitals (n=502) and examine whether the implementation of care coordination strategies varies by hospital payment model types. MEASURES We constructed a care coordination index (CCI) comprised of 12 indicators that describe evidence-based care coordination strategies. Each indicator was scored on a 5-point Likert scale from 1="not used at all" to 5="used widely" by qualified representatives from each hospital. The CCI aggregates scores from each of the 12 individual indicators to a single summary score for each hospital, with a score of 12 corresponding to the lowest and 60 the highest use of care coordination strategies. RESEARCH DESIGN We used state-fixed effects multivariable linear regression models to estimate the relationship between ACO affiliation, payment model type, and the use care coordination strategies. RESULTS We found ACO affiliated hospitals reported greater use of care coordination strategies compared to unaffiliated hospitals. Fee-for-service shared savings and partial or global capitation payment models were associated with a greater use of care coordination strategies among ACO affiliated hospitals. CONCLUSION Our findings suggest ACO affiliation and multiple payment model types are associated with the increased use of care coordination strategies.
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Borza T, Oerline MK, Skolarus TA, Norton EC, Dimick JB, Jacobs BL, Herrel LA, Ellimoottil C, Hollingsworth JM, Ryan AM, Miller DC, Shahinian VB, Hollenbeck BK. Association Between Hospital Participation in Medicare Shared Savings Program Accountable Care Organizations and Readmission Following Major Surgery. Ann Surg 2019; 269:873-878. [PMID: 29557880 PMCID: PMC6146076 DOI: 10.1097/sla.0000000000002737] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the effect of Medicare Shared Savings Program accountable care organizations (ACOs) on hospital readmission after common surgical procedures. SUMMARY BACKGROUND DATA Hospital readmissions following surgery lead to worse patient outcomes and wasteful spending. ACOs, and their associated hospitals, have strong incentives to reduce readmissions from 2 distinct Centers for Medicare and Medicaid Services policies. METHODS We performed a retrospective cohort study using a 20% national Medicare sample to identify beneficiaries undergoing 1 of 7 common surgical procedures-abdominal aortic aneurysm repair, colectomy, cystectomy, prostatectomy, lung resection, total knee arthroplasty, and total hip arthroplasty-between 2010 and 2014. The primary outcome was 30-day risk-adjusted readmission rate. We performed difference-in-differences analyses using multilevel logistic regression models to quantify the effect of hospital ACO affiliation on readmissions following these procedures. RESULTS Patients underwent a procedure at one of 2974 hospitals, of which 389 were ACO affiliated. The 30-day risk-adjusted readmission rate decreased from 8.4% (95% CI, 8.1-8.7%) to 7.0% (95% CI, 6.7-7.3%) for ACO affiliated hospitals (P < 0.001) and from 7.9% (95% CI, 7.8-8.0%) to 7.1% (95% CI, 6.9-7.2%) for non-ACO hospitals (P < 0.001). The difference-in-differences of the 2 trends demonstrated an additional 0.52% (95% CI, 0.97-0.078%) absolute reduction in readmissions at ACO hospitals (P = 0.021), which would translate to 4410 hospitalizations avoided. CONCLUSION Readmissions following common procedures decreased significantly from 2010 to 2014. Hospital affiliation with Shared Savings ACOs was associated with significant additional reductions in readmissions. This emphasis on readmission reduction is 1 mechanism through which ACOs improve value in a surgical population.
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Affiliation(s)
- Tudor Borza
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Mary K. Oerline
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Ted A. Skolarus
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Edward C. Norton
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Economics, University of Michigan, Ann Arbor, Michigan
- National Bureau of Economic Research, Cambridge, MA
| | - Justin B. Dimick
- Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Bruce L. Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Lindsey A. Herrel
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Chad Ellimoottil
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - John M. Hollingsworth
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Andrew M. Ryan
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Economics, University of Michigan, Ann Arbor, Michigan
| | - David C. Miller
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Vahakn B. Shahinian
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Brent K. Hollenbeck
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
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Performance in the Medicare Shared Savings Program by Accountable Care Organizations Disproportionately Serving Dual and Disabled Populations. Med Care 2019; 56:805-811. [PMID: 30036235 DOI: 10.1097/mlr.0000000000000968] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The growth of accountable care organizations (ACOs) and other alternative payment models has prompted concern about whether these models will disadvantage providers who serve vulnerable populations, particularly those living in poverty or with a disability. OBJECTIVE To examine performance by ACOs in the top quintile of their proportion of beneficiaries dually enrolled in Medicare and Medicaid (high-dual) and the top quintile of disabled beneficiaries (high-disabled). RESEARCH DESIGN This is a retrospective cohort study. SUBJECTS The 333 ACOs in the Medicare Shared Savings Program in 2014, followed through 2016. MEASURES Quality scores, savings per beneficiary, whether or not the ACO shared savings, and amount of shared savings. RESULTS High-dual and high-disabled ACOs had slightly lower quality and similar or higher baseline spending than other ACOs, but achieved greater savings per beneficiary than other ACOs ($212 vs. $51 for high-dual ACOs, P=0.04; $241 vs. $44 for high-disabled ACOs, P=0.012). Further, these ACOs were equally or more likely to earn shared savings; just over 30% of high-dual ACOs earned shared savings compared with 25% of non-high-dual ACOs (P=0.35) and 38% of high-disabled ACOs earned shared savings compared with 23% of non-high-disabled ACOs (P=0.013). In longitudinal analyses, we found a decrease in the differences in quality between high-social risk and other ACOs over time. Savings remained higher for high-dual and high-disabled ACOs relative to other ACOs over 2014-2016 though the gap narrowed over time. CONCLUSIONS High-dual and high-disabled ACOs had similar or higher spending than other ACOs at baseline, but achieved greater savings and were equally or more likely to earn shared savings, suggesting that alternative payment models can have positive financial outcomes for providers who serve vulnerable populations.
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Nathan H, Thumma JR, Ryan AM, Dimick JB. Early Impact of Medicare Accountable Care Organizations on Inpatient Surgical Spending. Ann Surg 2019; 269:191-196. [PMID: 29771724 PMCID: PMC7058185 DOI: 10.1097/sla.0000000000002819] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether hospital participation in accountable care organizations (ACOs) is associated with reduced Medicare spending for inpatient surgery. BACKGROUND ACOs have proliferated rapidly and now cover more than 32 million Americans. Medicare Shared Savings Program (MSSP) ACOs have shown modest success in reducing medical spending. Whether they have reduced surgical spending remains unknown. METHODS We used 100% Medicare claims from 2010 to 2014 for patients aged 65 to 99 years undergoing 6 common elective surgical procedures [abdominal aortic aneurysm (AAA) repair, colectomy, coronary artery bypass grafting (CABG), hip or knee replacement, or lung resection]. We compared total Medicare payments for 30-day surgical episodes, payments for individual components of care (index hospitalization, readmissions, physician services, and postacute care), and clinical outcomes for patients treated at MSSP ACO hospitals versus matched controls at non-ACO hospitals. We accounted for preexisting trends independent of ACO participation using a difference-in-differences approach. RESULTS Among 341,675 patients at 427 ACO hospitals and 1,024,090 matched controls at 1531 non-ACO hospitals, patient and hospital characteristics were well-balanced. Average baseline payments were similar at ACO versus non-ACO hospitals. ACO participation was not associated with reductions in total Medicare payments [difference-in-differences estimate=-$72, confidence interval (CI95%): -$228 to +$84] or individual components of payments. ACO participation was also not associated with clinical outcomes. Duration of ACO participation did not affect our estimates. CONCLUSION Although Medicare ACOs have had success reducing spending for medical care, they have not had similar success with surgical spending. Given that surgical care accounts for 30% of total health care costs, ACOs and policymakers must pay greater attention to reducing surgical expenditures.
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Affiliation(s)
- Hari Nathan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Jyothi R. Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Andrew M. Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Justin B. Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
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Dorr DA, Cohen DJ, Adler-Milstein J. Data-Driven Diffusion Of Innovations: Successes And Challenges In 3 Large-Scale Innovative Delivery Models. Health Aff (Millwood) 2019; 37:257-265. [PMID: 29401031 DOI: 10.1377/hlthaff.2017.1133] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Failed diffusion of innovations may be linked to an inability to use and apply data, information, and knowledge to change perceptions of current practice and motivate change. Using qualitative and quantitative data from three large-scale health care delivery innovations-accountable care organizations, advanced primary care practice, and EvidenceNOW-we assessed where data-driven innovation is occurring and where challenges lie. We found that implementation of some technological components of innovation (for example, electronic health records) has occurred among health care organizations, but core functions needed to use data to drive innovation are lacking. Deficits include the inability to extract and aggregate data from the records; gaps in sharing data; and challenges in adopting advanced data functions, particularly those related to timely reporting of performance data. The unexpectedly high costs and burden incurred during implementation of the innovations have limited organizations' ability to address these and other deficits. Solutions that could help speed progress in data-driven innovation include facilitating peer-to-peer technical assistance, providing tailored feedback reports to providers from data aggregators, and using practice facilitators skilled in using data technology for quality improvement to help practices transform. Policy efforts that promote these solutions may enable more rapid uptake of and successful participation in innovative delivery system reforms.
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Affiliation(s)
- David A Dorr
- David A. Dorr ( ) is a professor and vice chair of medical informatics and clinical epidemiology both at Oregon Health & Science University, in Portland
| | - Deborah J Cohen
- Deborah J. Cohen is a professor of family medicine at Oregon Health & Science University
| | - Julia Adler-Milstein
- Julia Adler-Milstein is an associate professor of medicine and director of the Clinical Informatics and Improvement Research Center, School of Medicine, University of California, San Francisco
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Oregon's Coordinated Care Organization Experiment: Are Members' Experiences of Care Actually Changing? J Healthc Qual 2019; 41:e38-e46. [PMID: 30664535 DOI: 10.1097/jhq.0000000000000178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In 2012, Oregon embarked on an ambitious plan to redesign financing and care delivery for Medicaid. Oregon's Coordinated Care Organizations (CCOs) are the first statewide effort to use accountable care principles to pay for Medicaid benefits. We surveyed 8,864 Medicaid-eligible participants approximately 1 year before and 12 months after CCO implementation to assess the impact of CCOs on member-reported outcomes. We compared changes in outcomes over time between Medicaid CCO members, Medicaid fee-for-service (FFS) members, and those who were uninsured. After 1 year, Medicaid beneficiaries enrolled in CCOs reported better access to care, better quality care, and better connections to primary care than Medicaid FFS or uninsured persons. We did not find early evidence of improvements in preventive care and screenings or in ED utilization. Although these are early indicators, results suggest that Oregon's delivery system transformation is having a positive impact on patient experience outcomes.
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Werner RM, Kanter GP, Polsky D. Association of Physician Group Participation in Accountable Care Organizations With Patient Social and Clinical Characteristics. JAMA Netw Open 2019; 2:e187220. [PMID: 30657535 PMCID: PMC6400068 DOI: 10.1001/jamanetworkopen.2018.7220] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Accountable care organizations (ACOs) may increase health care disparities by excluding physician groups that care for socially and clinically vulnerable patients. OBJECTIVE To estimate the association between the patient characteristics of a physician group and the group's participation in a newly formed ACO. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study investigated a 20% random sample of US Medicare fee-for-service beneficiaries attributed to physician groups identified in Medicare claims before ACO participation from January 1, 2010, through December 31, 2011. Physician groups that participated and did not participate in the Medicare Shared Savings Program (MSSP) from January 1, 2012, through December 31, 2014, were identified in the Medicare MSSP 2014 provider file. Data analyses were conducted from September 1, 2017, to March 30, 2018. EXPOSURES Using multivariable regression, the association between physician group participation in the MSSP and the group's patients' characteristics before ACO formation was estimated focusing on measures of the vulnerability of the group's patients. All ACO-participating physician groups were compared with ACO-nonparticipating physician groups for reference, and estimates were made at the physician and patient level. MAIN OUTCOMES AND MEASURES Percentage of a physician group's patient panel that was socially vulnerable (based on race, dual Medicare and Medicaid enrollment, or living in high-poverty zip code) or clinically high risk. RESULTS Among 67 891 physician groups caring for 5 394 181 patients, 7215 physician groups (10.6%) participated in an MSSP ACO by 2014. Comparing mean percentages across practices, the patients of non-ACO-participating physician groups, more patients of ACO-participating physician groups were black (mean percentage across practices, 12.1% vs 10.6%), dually enrolled in Medicare and Medicaid (23.0% vs 19.3%), living in poverty (10.7% vs 11.1%), and high risk (34.2% vs 30.2%). After adjustment, physician groups that participated in an ACO had 5.1 percentage points (95% CI, 0.1-10.0 percentage points; P = .05) more dually enrolled patients and 4.0 percentage points (95% CI, 1.9-6.1 percentage points; P < .001) more high-risk patients. At the patient level, patients who were at high risk were more likely to be attributed to a group that became part of an ACO, with 4.5 percentage points (95% CI, 0.5-8.5 percentage points; P = .03) more high-risk patients being attributed to an ACO, but other associations were not statistically different from zero. CONCLUSIONS AND RELEVANCE Accountable care organizations may be an effective approach to target care among high-risk patients. In this study, physician groups that participated in the MSSP ACO program cared for more clinically vulnerable patients than did nonparticipating groups, and ACO-participating physician groups cared for an equally large number of socially vulnerable patients compared with nonparticipating physician groups.
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Affiliation(s)
- Rachel M. Werner
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Genevieve P. Kanter
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Daniel Polsky
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Lipitz-Snyderman A, Atoria CL, Schleicher SM, Bach PB, Panageas KS. Practice Patterns for Older Adult Patients With Advanced Cancer: Physician Office Versus Hospital Outpatient Setting. J Oncol Pract 2018; 15:e30-e38. [PMID: 30543762 DOI: 10.1200/jop.18.00315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE A shift in outpatient oncology care from the physician's office to hospital outpatient settings has generated interest in the effect of practice setting on outcomes. Our objective was to examine whether medical oncologists' prescribing of drugs and services for older adult patients with advanced cancer is used more in physicians' offices compared with hospital outpatient departments. METHODS This was a retrospective comparative study. SEER-Medicare data (2004 to 2011) were used to identify Medicare beneficiaries diagnosed with advanced breast, colon, esophagus, non-small-cell lung, pancreatic, or stomach cancer. Between physicians' offices and hospital outpatient departments, we compared use of selected likely low-value supportive drugs, low-value therapeutic drugs, chemotherapy-related hospitalizations, and hospice. We used hierarchical modeling to assess differences between settings to account for correlation within physicians. RESULTS Compared with patients treated in a hospital outpatient department, those treated in a physician's office setting were more likely to receive erythropoiesis-stimulating agents (odds ratio, 1.72; 95% CI, 1.53 to 1.94) and granulocyte colony-stimulating factors (odds ratio, 1.28; 95% CI, 1.18 to 1.38). For combination chemotherapy and nanoparticle albumin-bound-paclitaxel in patients with breast cancer, there was a trend toward higher use in physicians' offices, although this was not statistically significant. Chemotherapy-related hospitalizations and hospice did not vary by setting. CONCLUSION We found somewhat higher use of several drugs for patients with advanced cancer in physicians' office settings compared with hospital outpatient departments. Findings support research to dissect the mechanisms through which setting might influence physicians' behavior.
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Affiliation(s)
| | | | | | - Peter B Bach
- 1 Memorial Sloan Kettering Cancer Center, New York, NY
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Baxter S, Johnson M, Chambers D, Sutton A, Goyder E, Booth A. Understanding new models of integrated care in developed countries: a systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06290] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BackgroundThe NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.ObjectivesThe study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.DesignThe study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.SettingAny setting.ParticipantsPatients receiving a health-care service and/or staff delivering services.InterventionsChanges to service delivery that increase integration and co-ordination of health and health-related services.Main outcome measuresOutcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.Study designEmpirical work of a quantitative or qualitative design.Data sourcesWe searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.Review methodsThe identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.ResultsWe included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.LimitationsDefining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.ConclusionsThere is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.Future workLinks between elements of new models and outcomes require further study, together with research in a wider variety of populations.Study registrationThis study is registered as PROSPERO CRD37725.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Susan Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Maxine Johnson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Greater Reductions in Readmission Rates Achieved by Urban Hospitals Participating in the Medicare Shared Savings Program. Med Care 2018; 56:686-692. [DOI: 10.1097/mlr.0000000000000945] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Baxter S, Johnson M, Chambers D, Sutton A, Goyder E, Booth A. The effects of integrated care: a systematic review of UK and international evidence. BMC Health Serv Res 2018; 18:350. [PMID: 29747651 PMCID: PMC5946491 DOI: 10.1186/s12913-018-3161-3] [Citation(s) in RCA: 284] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/29/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context. METHODS The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence. RESULTS One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users. CONCLUSIONS Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand. TRIAL REGISTRATION Prospero registration number: 42016037725 .
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Affiliation(s)
- Susan Baxter
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S14DA UK
| | - Maxine Johnson
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S14DA UK
| | - Duncan Chambers
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S14DA UK
| | - Anthea Sutton
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S14DA UK
| | - Elizabeth Goyder
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S14DA UK
| | - Andrew Booth
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S14DA 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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Abstract
The accountable care organization (ACO) concept is advocated as a promising value-based payment model that could successfully realign the current payment system to financially reward improvements in quality and efficiency. Focusing on the care of hospitalized patients and controlling a substantive portion of variable hospital expenses, hospitalists are poised to play an essential role in system-level transformational change to achieve clinical integration. Especially through hospital and health system quality improvement (QI) initiatives, hospitalists can directly impact and share accountability for measures ranging from care coordination to implementation of evidence-based care and the patient and family caregiver experience. Regardless of political terrain, financial constraints in healthcare will foster continued efforts to promote formation of ACOs that aim to deliver coordinated, evidence-based, and patient-centered care. Hospitalists possess the clinical experience of caring for complex patients with multiple comorbidities and the QI skills needed to lead efforts in this new ACO era.
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Affiliation(s)
- Jing Li
- Center for Health Services Research, University of Kentucky, USA
- Office for Value & Innovation in Healthcare Delivery, UK HealthCare, Lexington, Kentucky, USA
| | - Mark J Williams
- Center for Health Services Research, University of Kentucky, USA.
- Office for Value & Innovation in Healthcare Delivery, UK HealthCare, Lexington, Kentucky, USA
- Division of Hospital Medicine, University of Kentucky, Lexington, Kentucky, USA
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Yasaitis LC, Pajerowski W, Polsky D, Werner RM. Physicians' Participation In ACOs Is Lower In Places With Vulnerable Populations Than In More Affluent Communities. Health Aff (Millwood) 2018; 35:1382-90. [PMID: 27503961 DOI: 10.1377/hlthaff.2015.1635] [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
Early evidence suggested that accountable care organizations (ACOs) could improve health care quality while constraining costs, and ACOs are expanding throughout the United States. However, if disadvantaged patients have unequal access to physicians who participate in ACOs, that expansion may exacerbate health care disparities. We examined the relationship between physicians' participation in both Medicare and commercial ACOs across the country and the sociodemographic characteristics of their likely patient populations. Physicians' participation in ACOs varied widely across hospital referral regions, from nearly 0 percent to over 85 percent. After we adjusted for individual physician and practice characteristics, we found that physicians who practiced in ZIP Code Tabulation Areas where a higher percentage of the population was black, living in poverty, uninsured, or disabled or had less than a high school education-compared to other areas-had significantly lower rates of ACO participation than other physicians. Our findings suggest that vulnerable populations' access to physicians participating in ACOs may not be as great as access for other groups, which could exacerbate existing disparities in health care quality.
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Affiliation(s)
- Laura C Yasaitis
- Laura C. Yasaitis is a postdoctoral research fellow at the Perelman School of Medicine and a fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, in Philadelphia
| | - William Pajerowski
- William Pajerowski is a doctoral candidate at the Wharton School and a fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Daniel Polsky
- Daniel Polsky is executive director of and the Robert D. Eilers Professor in Health Care Management and Economics at the Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Rachel M Werner
- Rachel M. Werner is a professor of medicine and health care management at the University of Pennsylvania and a staff physician at the Crescenz Veterans Affairs Medical Center, in Philadelphia
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Galbraith AA, Meyers DJ, Ross‐Degnan D, Burns ME, Vialle‐Valentin CE, Larochelle MR, Touw S, Zhang F, Rosenthal M, Balaban RB. Long-Term Impact of a Postdischarge Community Health Worker Intervention on Health Care Costs in a Safety-Net System. Health Serv Res 2017; 52:2061-2078. [PMID: 29130267 PMCID: PMC5682134 DOI: 10.1111/1475-6773.12790] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Patient navigators (PNs) may represent a cost-effective strategy to improve transitional care and reduce hospital readmissions. We evaluated the impact of a PN intervention on health system costs in the 180 days after discharge for high-risk patients in a safety-net system. DATA SOURCE/SETTING Primary and secondary data from an academic safety-net health system. STUDY DESIGN We compared per-patient utilization and costs, overall and by age, for high-risk, medical service patients randomized to the PN intervention relative to usual care between October 2011 and April 2013. Intervention patients received hospital visits and telephone outreach from PNs for 30 days after every qualifying discharge. DATA COLLECTION/EXTRACTION METHODS We used administrative and electronic encounter data, and a survey of nurses; costs were imputed from the Medicare fee schedule. PRINCIPAL FINDINGS Total costs per patient over the 180 days postindex discharge for those aged ≥60 years were significantly lower for PN patients compared to controls ($5,676 vs. $7,640, p = .03); differences for patients aged <60 ($9,942 vs. $9,046, p = .58) or for the entire cohort ($7,092 vs. $7,953, p = .27) were not significant. CONCLUSIONS Patient navigator interventions may be useful strategies for specific groups of patients in safety-net systems to improve transitional care while containing costs.
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Affiliation(s)
- Alison A. Galbraith
- Center for Healthcare Research in PediatricsHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMA
- Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMA
- Division of General PediatricsBoston Children's HospitalBostonMA
| | - David J. Meyers
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRI
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMA
| | - Dennis Ross‐Degnan
- Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMA
| | - Marguerite E. Burns
- Department of Population Health SciencesUniversity of Wisconsin School of Medicine and Public HealthMadisonWI
| | | | | | | | - Fang Zhang
- Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMA
| | - Meredith Rosenthal
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRI
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Larsen KN, Kristensen SR, Søgaard R. Autonomy to health care professionals as a vehicle for value-based health care? Results of a quasi-experiment in hospital governance. Soc Sci Med 2017; 196:37-46. [PMID: 29127851 DOI: 10.1016/j.socscimed.2017.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 11/02/2017] [Accepted: 11/04/2017] [Indexed: 10/18/2022]
Abstract
Health care systems increasingly aim to create value for money by simultaneous incentivizing of quality along with classical goals such as activity increase and cost containment. It has recently been suggested that letting health care professionals choose the performance metrics on which they are evaluated may improve value of care by facilitating greater employee initiative, especially in the quality domain. There is a risk that this strategy leads to loss of performance as measured by the classical goals, if these goals are not prioritized by health care professionals. In this study we investigate the performance of eight hospital departments in the second largest region of Denmark that were delegated the authority to choose their own performance focus during a three-year test period from 2013 to 2016. The usual activity-based remuneration was suspended and departments were instructed to keep their global budgets and maintain activity levels, while managing according to their newly chosen performance focuses. Our analysis is based on monthly observations from two years before to three years after delegation. We collected data for 32 new performance indicators chosen by hospital department managements; 11 new performance indicators chosen by a centre management under which 5 of the departments were organised; and 3 classical indicators of priority to the central administration (activity, productivity, and cost containment). Interrupted time series analysis is used to estimate the effect of delegation on these indicators. We find no evidence that this particular proposal for giving health care professionals greater autonomy leads to consistent quality improvements but, on the other hand, also no consistent evidence of harm to the classical goals. Future studies could consider alternative possibilities to create greater autonomy for hospital departments.
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Affiliation(s)
- Kristian Nørgaard Larsen
- Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus, Denmark; Health Economics, DEFACTUM, Central Denmark Region, Olof Palmes Allé 15, 8200 Aarhus, Denmark
| | - Søren Rud Kristensen
- Manchester Centre for Health Economics, The University of Manchester, Oxford Road, M13 9PL Manchester, UK
| | - Rikke Søgaard
- Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus, Denmark.
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Ortendahl JD, Pulgar SJ, Mirakhur B, Cox D, Bentley TG, Phan AT. Budget impact of somatostatin analogs as treatment for metastatic gastroenteropancreatic neuroendocrine tumors in US hospitals. CLINICOECONOMICS AND OUTCOMES RESEARCH 2017; 9:495-503. [PMID: 28860831 PMCID: PMC5566387 DOI: 10.2147/ceor.s140866] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective With the introduction of new therapies, hospitals have to plan spending limited resources in a cost-effective manner. To assist in identifying the optimal treatment for patients with locally advanced or metastatic gastroenteropancreatic neuroendocrine tumors, budget impact modeling was used to estimate the financial implications of adoption and diffusion of somatostatin analogs (SSAs). Patients and methods A hypothetical cohort of 500 gastroenteropancreatic neuroendocrine tumor patients was assessed in an economic model, with the proportion with metastatic disease treated with an SSA estimated using published data. Drug acquisition, preparation, and administration costs were based on national pricing databases and published literature. Octreotide dosing was based on published estimates of real-world data, whereas for lanreotide, real-world dosing was unavailable and we therefore used the highest indicated dosing. Alternative scenarios reflecting the proportion of patients receiving lanreotide or octreotide were considered to estimate the incremental budget impact to the hospital. Results In the base case, 313 of the initial 500 gastroenteropancreatic neuroendocrine tumor patients were treated with an SSA. The model-predicted per-patient cost was US$83,473 for lanreotide and US$89,673 for octreotide. With a hypothetical increase in lanreotide utilization from 5% to 30% of this population, the annual model-projected hospital costs decreased by US$488,615. When varying the inputs in one-way sensitivity analyses, the results were most sensitive to changes in dosing assumptions. Conclusion Results suggest that factors beyond drug acquisition cost can influence the budget impact to a hospital. When considering preparation and administration time, and real-world dosing, use of lanreotide has the potential to reduce health care expenditures associated with metastatic gastroenteropancreatic neuroendocrine tumor treatments.
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Affiliation(s)
- Jesse D Ortendahl
- Health Economics, Partnership for Health, LLC, Beverly Hills, CA, USA
| | - Sonia J Pulgar
- Health Economics and Outcomes Research, Ipsen Biopharmaceuticals, Basking Ridge, NJ, USA
| | - Beloo Mirakhur
- Medical Affairs, Oncology, Ipsen Biopharmaceuticals, Basking Ridge, NJ, USA
| | - David Cox
- Medical Affairs, Oncology, Ipsen Biopharmaceuticals, Basking Ridge, NJ, USA
| | - Tanya Gk Bentley
- Health Economics, Partnership for Health, LLC, Beverly Hills, CA, USA
| | - Alexandria T Phan
- GI Medical Oncology, University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA
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Identifying Increased Risk of Readmission and In-hospital Mortality Using Hospital Administrative Data: The AHRQ Elixhauser Comorbidity Index. Med Care 2017; 55:698-705. [PMID: 28498196 DOI: 10.1097/mlr.0000000000000735] [Citation(s) in RCA: 515] [Impact Index Per Article: 73.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE We extend the literature on comorbidity measurement by developing 2 indices, based on the Elixhauser Comorbidity measures, designed to predict 2 frequently reported health outcomes: in-hospital mortality and 30-day readmission in administrative data. The Elixhauser measures are commonly used in research as an adjustment factor to control for severity of illness. DATA SOURCES We used a large analysis file built from all-payer hospital administrative data in the Healthcare Cost and Utilization Project State Inpatient Databases from 18 states in 2011 and 2012. METHODS The final models were derived with bootstrapped replications of backward stepwise logistic regressions on each outcome. Odds ratios and index weights were generated for each Elixhauser comorbidity to create a single index score per record for mortality and readmissions. Model validation was conducted with c-statistics. RESULTS Our index scores performed as well as using all 29 Elixhauser comorbidity variables separately. The c-statistic for our index scores without inclusion of other covariates was 0.777 (95% confidence interval, 0.776-0.778) for the mortality index and 0.634 (95% confidence interval, 0.633-0.634) for the readmissions index. The indices were stable across multiple subsamples defined by demographic characteristics or clinical condition. The addition of other commonly used covariates (age, sex, expected payer) improved discrimination modestly. CONCLUSIONS These indices are effective methods to incorporate the influence of comorbid conditions in models designed to assess the risk of in-hospital mortality and readmission using administrative data with limited clinical information, especially when small samples sizes are an issue.
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Abstract
The Medicare Shared Savings Program (MSSP) continues to expand and now includes 434 accountable care organizations (ACOs) serving more than 7 million beneficiaries. During 2014, 86 of these ACOs earned over $300 million in shared savings payments by promoting higher-quality patient care at a lower cost.Whether organizational characteristics, regional cost of care, or experience in the MSSP are associated with the ability to achieve shared savings remains uncertain.Using financial results from 2013 and 2014, we examined all 339 MSSP ACOs with a 2012, 2013, or 2014 start-date. We used a cross-sectional analysis to examine all ACOs and used a multivariate logistic model to predict probability of achieving shared savings.Experience, as measured by years in the MSSP program, was associated with success and the ability to earn shared savings varied regionally. This variation was strongly associated with differences in regional Medicare fee-for-service per capita costs: ACOs in high cost regions were more likely to earn savings. In the multivariate model, the number of ACO beneficiaries, inclusion of a hospital or involvement of an academic medical center, was not associated with likelihood of earning shared savings, after accounting for regional baseline cost variation.These results suggest ACOs are learning and improving from their experience. Additionally, the results highlight regional differences in ACO success and the strong association with variation in regional per capita costs, which can inform CMS policy to help promote ACO success nationwide.
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Affiliation(s)
| | - Matthew DeCamp
- Berman Institute of Bioethics and Division of General Internal Medicine, Johns Hopkins University
| | - Scott A. Berkowitz
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Evolving healthcare delivery paradigms and the optimization of ‘value’ in anesthesiology. Curr Opin Anaesthesiol 2017; 30:223-229. [DOI: 10.1097/aco.0000000000000430] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Jackson GL, Roumie CL, Rakley SM, Kravetz JD, Kirshner MA, Del Monte PS, Bowen ME, Oddone EZ, Weiner BJ, Shaw RJ, Bosworth HB. Linkage between theory-based measurement of organizational readiness for change and lessons learned conducting quality improvement-focused research. Learn Health Syst 2017; 1:e10013. [PMID: 31245556 PMCID: PMC6516710 DOI: 10.1002/lrh2.10013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 07/28/2016] [Accepted: 08/18/2016] [Indexed: 11/21/2022] Open
Abstract
Organizations have different levels of readiness to implement change in the patient care process. The Hypertension Telemedicine Nurse Implementation Project for Veterans (HTN-IMPROVE) is an example of an innovation that seeks to enhance delivery of care for patients with hypertension. We describe the link between organizational readiness for change (ORC), assessed as the project began, and barriers and facilitators occurring during the process of implementing a primary care innovation. Each of 3 Veterans Affairs medical centers provided a half-time nurse and implemented a nurse-delivered, telephone-based self-management support program for patients with uncontrolled hypertension. As the program was starting, we assessed the ORC and factors associated with ORC. On the basis of consensus of medical center and research partners, we enumerated implementation process barriers and facilitators. The primary ORC barrier was unclear long-term commitment of nursing to provide continued resources to the program. Three related barriers included the need to address: (1) competing organizational demands, (2) differing mechanisms to integrate new interventions into existing workload, and (3) methods for referring patients to disease and self-management support programs. Prior to full implementation, however, stakeholders identified a high level of commitment to conduct nurse-delivered interventions fully using their skills. There was also a significant commitment from the core implementation team and a desire to improve patient outcomes. These facilitators were observed during the implementation of HTN-IMPROVE. As demonstrated by the link between barriers to and facilitators of implementation anticipated though the evaluation of ORC and what was actually observed during the process of implementation, this project demonstrates the practical utility of assessing ORC prior to embarking on the implementation of significant new clinical innovations.
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Affiliation(s)
- George L. Jackson
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
- Division of General Internal MedicineDuke UniversityDurhamNC
| | - Christianne L. Roumie
- VA Tennessee Valley Geriatric Research Education Clinical Center (GRECC), Health Services Research & DevelopmentVA Tennessee Valley Healthcare SystemNashvilleTN
- Department of MedicineVanderbilt UniversityNashvilleTN
| | - Susan M. Rakley
- Division of General Internal MedicineDuke UniversityDurhamNC
- Durham VA Medical CenterDurhamNC
| | - Jeffrey D. Kravetz
- VA Connecticut Healthcare SystemWest HavenCT
- School of MedicineYale UniversityNew HavenCT
| | - Miriam A. Kirshner
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
| | | | - Michael E. Bowen
- Departments of Internal Medicine, Clinical Sciences, and PediatricsUniversity of Texas Southwestern Medical CenterDallasTX
| | - Eugene Z. Oddone
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
- Division of General Internal MedicineDuke UniversityDurhamNC
| | - Bryan J. Weiner
- Department of Health Policy and Management, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNC
| | - Ryan J. Shaw
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
- School of NursingDuke UniversityDurhamNC
| | - Hayden B. Bosworth
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
- Division of General Internal MedicineDuke UniversityDurhamNC
- School of NursingDuke UniversityDurhamNC
- Department of Psychiatry and Behavioral SciencesDuke UniversityDurhamNC
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ADLER‐MILSTEIN JULIA, PFEIFER ERIC. Information Blocking: Is It Occurring and What Policy Strategies Can Address It? Milbank Q 2017; 95:117-135. [PMID: 28266065 PMCID: PMC5339397 DOI: 10.1111/1468-0009.12247] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Policy Points:
Congress has expressed concern about electronic health record (EHR) vendors and health care providers knowingly interfering with the electronic exchange of patient health information. These “information blocking” practices would privately benefit vendors and providers but limit the societal quality and efficiency benefits from EHR adoption.
We found that information blocking is reported to frequently occur among EHR vendors as well as hospitals and health systems, and that it is perceived to be motivated by opportunities for revenue gain.
Because information blocking is largely legal today, the most effective policy response likely involves a combination of direct enforcement and the altering of market conditions that promote information blocking.
ContextCongress has raised concerns about providers and electronic health record (EHR) vendors knowingly engaging in business practices that interfere with electronic health information exchange (HIE). Such “information blocking” is presumed to occur because providers and vendors reap financial benefits, but these practices harm public good and substantially limit the value to be gained from EHR adoption. Crafting a policy response has been difficult because, beyond anecdotes, there is no data that captures the extent of information blocking.MethodsWe conducted a national survey of leaders of HIE efforts who work to enable HIE across provider organizations. We asked them about the frequency of information blocking, its specific forms, and the effectiveness of various policy strategies to address it. We received responses from 60 individuals (57% response rate). We calculated descriptive statistics across responses.FindingsHalf of respondents reported that EHR vendors routinely engage in information blocking, and 25% of respondents reported that hospitals and health systems routinely do so. Among EHR vendors, the most common form of information blocking was deploying products with limited interoperability. Among hospitals and health systems, the most common form was coercing providers to adopt particular EHR or HIE technology. Increasing transparency of EHR vendor business practices and product performance, stronger financial incentives for providers to share information, and making information blocking illegal were perceived as the most effective policy remedies.ConclusionsInformation blocking appears to be real and fairly widespread. Policymakers have some existing levers that can be used to curb information blocking and help information flow to where it is needed to improve patient care. However, because information blocking is largely legal today, a strong response will involve new legislation and associated enforcement actions.
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Affiliation(s)
| | - ERIC PFEIFER
- University of Michigan Schools of Information and Public Health
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Martinez JM, Anene A, Bentley TGK, Cangelosi MJ, Meckley LM, Ortendahl JD, Montero AJ. Cost Effectiveness of Metal Stents in Relieving Obstructive Jaundice in Patients with Pancreatic Cancer. J Gastrointest Cancer 2016; 48:58-65. [DOI: 10.1007/s12029-016-9907-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Wu FM, Shortell SM, Lewis VA, Colla CH, Fisher ES. Assessing Differences between Early and Later Adopters of Accountable Care Organizations Using Taxonomic Analysis. Health Serv Res 2016; 51:2318-2329. [PMID: 26927979 PMCID: PMC5134136 DOI: 10.1111/1475-6773.12473] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To compare early and later adopters of the accountable care organization (ACO) model, using the taxonomy of larger, integrated system; smaller, physician-led; and hybrid ACOs. DATA SOURCES The National Survey of ACOs, Waves 1 and 2. STUDY DESIGN Cluster analysis using the two-step clustering approach, validated using discriminant analysis. Wave 2 data analyzed separately to assess differences from Wave 1 and then data pooled across waves. FINDINGS Compared to early ACOs, later adopter ACOs included a greater breadth of provider group types and a greater proportion self-reported as integrated delivery systems. When data from the two time periods were combined, a three-cluster solution similar to the original cluster solution emerged. Of the 251 ACOs, 31.1 percent were larger, integrated system ACOs; 45.0 percent were smaller physician-led ACOs; and 23.9 percent were hybrid ACOs-compared to 40.1 percent, 34.0 percent, and 25.9 percent from Wave 1 clusters, respectively. CONCLUSIONS While there are some differences between ACOs formed prior to August 2012 and those formed in the following year, the three-cluster taxonomy appears to best describe the types of ACOs in existence as of July 2013. The updated taxonomy can be used by researchers, policy makers, and health care organizations to support evaluation and continued development of ACOs.
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Affiliation(s)
- Frances M. Wu
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemCenter for Primary Care and Outcomes ResearchStanford University School of MedicineMenlo ParkCA
| | | | - Valerie A. Lewis
- The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of Medicine at Dartmouth CollegeHanoverNH
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of Medicine at Dartmouth CollegeHanoverNH
| | - Elliott S. Fisher
- The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of Medicine at Dartmouth CollegeHanoverNH
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Alem N, Rinehart J, Lee B, Merrill D, Sobhanie S, Ahn K, Schwarzkopf R, Cannesson M, Kain Z. A case management report: a collaborative perioperative surgical home paradigm and the reduction of total joint arthroplasty readmissions. Perioper Med (Lond) 2016; 5:27. [PMID: 27777752 PMCID: PMC5067901 DOI: 10.1186/s13741-016-0051-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 09/26/2016] [Indexed: 11/28/2022] Open
Abstract
Background Efforts to mitigate costs while improving surgical care quality have received much scrutiny. This includes the challenging issue of readmission subsequent to hospital discharge. Initiatives attempting to preclude readmission after surgery require planned and unified efforts extending throughout the perioperative continuum. Patient optimization prior to discharge, enhanced disease monitoring, and seamless coordination of care between hospitals and community providers is integral to this process. The perioperative surgical home (PSH) has been proposed as a model to improve the delivery of perioperative healthcare via patient-centered risk stratification strategies that emphasize value and evidence-based processes. Results This case report seeks to specifically describe implementation of readmission reduction strategies via a PSH paradigm during total joint arthroplasty (TJA) procedures at the University of California Irvine (UCI) Health. An orthopedic surgeon open to collaborate within a PSH paradigm for TJA procedures was recruited to UCI Health in October of 2012. Institution specific data was then prospectively collected for 2 years post implementation of the novel program. A total of 328 unilateral, elective primary TJA (120 hip, 208 knee) procedures were collectively performed. Demographic analysis reveals the following: mean age of 64 ± 12; BMI of 28.5 ± 6.2; ASA Score distribution of 0.3 % class 1, 23 % class 2, 72 % class 3, and 4.3 % class 4; and 62.5 % female patients. In all, a 30-day unplanned readmission rate of 2.1 % (95 % CI 0.4–3.8) was observed during the study period. As a limitation of this case report, this reported rate does not reflect readmissions that may have occurred at facilities outside UCI Health. Conclusions As healthcare evolves to emphasize value over volume, it is integral to invest efforts in longitudinal patient outcomes including patient disposition subsequent to hospital discharge. As outlined by this case management report, the PSH provides an institution-led means to implement a series of care initiatives that optimize the important metric of readmission following TJA, potentially adding further value to patients, surgical colleagues, and health systems.
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Affiliation(s)
- Navid Alem
- Department of Anesthesiology & Perioperative Care, School of Medicine, University of California, Irvine, 333 City Boulevard West Side, Orange, CA 92868-3301 USA
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, School of Medicine, University of California, Irvine, 333 City Boulevard West Side, Orange, CA 92868-3301 USA
| | - Brian Lee
- Department of Anesthesiology & Perioperative Care, School of Medicine, University of California, Irvine, 333 City Boulevard West Side, Orange, CA 92868-3301 USA
| | - Doug Merrill
- Department of Anesthesiology & Perioperative Care, School of Medicine, University of California, Irvine, 333 City Boulevard West Side, Orange, CA 92868-3301 USA
| | - Safa Sobhanie
- Department of Anesthesiology & Perioperative Care, School of Medicine, University of California, Irvine, 333 City Boulevard West Side, Orange, CA 92868-3301 USA
| | - Kyle Ahn
- Department of Anesthesiology & Perioperative Care, School of Medicine, University of California, Irvine, 333 City Boulevard West Side, Orange, CA 92868-3301 USA
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Medical Center, Hospital For Joint Diseases, New York, USA
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Care, School of Medicine, University of California, Los Angeles, Los Angeles, USA
| | - Zeev Kain
- Center for Stress & Health & Department of Anesthesiology & Perioperative Care, School of Medicine, University of California, Irvine, Orange, USA
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Hofler RA, Ortiz J. Costs of accountable care organization participation for primary care providers: early stage results. BMC Health Serv Res 2016; 16:315. [PMID: 27465693 PMCID: PMC4964022 DOI: 10.1186/s12913-016-1556-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 07/12/2016] [Indexed: 11/10/2022] Open
Abstract
Background Little is known about the impact of joining an Accountable Care Organization (ACO) on primary care provider organization’s costs. The purpose of this study was to determine whether joining an ACO is associated with an increase in a Rural Health Clinic’s (RHC’s) cost per visit. Methods The analyses focused on cost per visit in 2012 and 2013 for RHCs that joined an ACO in 2012 and cost per visit in 2013 for RHCs that joined an ACO in 2013. The RHCs were located in nine states. Data were obtained from Medicare Cost Reports. The analysis was conducted taking a treatment effects approach where the treatment is joining an ACO. Propensity-score matching was employed to provide multiple single and pooled estimates of the average treatment effect on the treated. Results Four-hundred thirty four to 544 RHCs (depending on the type of analysis and the variables used) were used in the several analyses. Seven of the RHCs joined an ACO in 2012 and 14 joined an ACO in 2013. The mean cost per visit for RHCs that did not join an ACO rose 4.40 % from 2011 to 2012 whereas the mean cost per visit for RHCs that joined an ACO rose by triple: 13.5 %. All of the pooled estimates of the average treatment effect on the treated from the propensity-score matching showed that joining an ACO was associated with higher mean cost per visit. The range of the estimated mean cost per visit differences was $17.19 (p value = 0.00) to $25.19 (p value = 0.00). Conclusions This study is one of the first to describe the cost of ACO participation from the perspective of primary care provider organizations. It appears that for at least one type of primary care provider - the RHC - there are substantial costs associated with ACO participation during the first two years.
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Affiliation(s)
- Richard A Hofler
- Department of Economics, University of Central Florida, P.O. Box 161400, Orlando, FL, 32816-1400, USA
| | - Judith Ortiz
- College of Health and Public Affairs, University of Central Florida, P.O. Box 162369, Orlando, FL, 32816, USA.
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McWilliams JM, Hatfield LA, Chernew ME, Landon BE, Schwartz AL. Early Performance of Accountable Care Organizations in Medicare. N Engl J Med 2016; 374:2357-66. [PMID: 27075832 PMCID: PMC4963149 DOI: 10.1056/nejmsa1600142] [Citation(s) in RCA: 264] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND In the Medicare Shared Savings Program (MSSP), accountable care organizations (ACOs) have financial incentives to lower spending and improve quality. We used quasi-experimental methods to assess the early performance of MSSP ACOs. METHODS Using Medicare claims from 2009 through 2013 and a difference-in-differences design, we compared changes in spending and in performance on quality measures from before the start of ACO contracts to after the start of the contracts between beneficiaries served by the 220 ACOs entering the MSSP in mid-2012 (2012 ACO cohort) or January 2013 (2013 ACO cohort) and those served by non-ACO providers (control group), with adjustment for geographic area and beneficiary characteristics. We analyzed the 2012 and 2013 ACO cohorts separately because entry time could reflect the capacity of an ACO to achieve savings. We compared ACO savings according to organizational structure, baseline spending, and concurrent ACO contracting with commercial insurers. RESULTS Adjusted Medicare spending and spending trends were similar in the ACO cohorts and the control group during the precontract period. In 2013, the differential change (i.e., the between-group difference in the change from the precontract period) in total adjusted annual spending was -$144 per beneficiary in the 2012 ACO cohort as compared with the control group (P=0.02), consistent with a 1.4% savings, but only -$3 per beneficiary in the 2013 ACO cohort as compared with the control group (P=0.96). Estimated savings were consistently greater in independent primary care groups than in hospital-integrated groups among 2012 and 2013 MSSP entrants (P=0.005 for interaction). MSSP contracts were associated with improved performance on some quality measures and unchanged performance on others. CONCLUSIONS The first full year of MSSP contracts was associated with early reductions in Medicare spending among 2012 entrants but not among 2013 entrants. Savings were greater in independent primary care groups than in hospital-integrated groups.
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Affiliation(s)
- J Michael McWilliams
- From the Department of Health Care Policy, Harvard Medical School (J.M.M., L.A.H., M.E.C., B.E.L., A.L.S.), the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (J.M.M.), and the Division of General Internal Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center (B.E.L.) - all in Boston
| | - Laura A Hatfield
- From the Department of Health Care Policy, Harvard Medical School (J.M.M., L.A.H., M.E.C., B.E.L., A.L.S.), the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (J.M.M.), and the Division of General Internal Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center (B.E.L.) - all in Boston
| | - Michael E Chernew
- From the Department of Health Care Policy, Harvard Medical School (J.M.M., L.A.H., M.E.C., B.E.L., A.L.S.), the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (J.M.M.), and the Division of General Internal Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center (B.E.L.) - all in Boston
| | - Bruce E Landon
- From the Department of Health Care Policy, Harvard Medical School (J.M.M., L.A.H., M.E.C., B.E.L., A.L.S.), the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (J.M.M.), and the Division of General Internal Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center (B.E.L.) - all in Boston
| | - Aaron L Schwartz
- From the Department of Health Care Policy, Harvard Medical School (J.M.M., L.A.H., M.E.C., B.E.L., A.L.S.), the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (J.M.M.), and the Division of General Internal Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center (B.E.L.) - all in Boston
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Hawken SR, Ryan AM, Miller DC. Surgery and Medicare Shared Savings Program Accountable Care Organizations. JAMA Surg 2016; 151:5-6. [PMID: 26509237 DOI: 10.1001/jamasurg.2015.2772] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Scott R Hawken
- Dow Health Services Research Division, Department of Urology, University of Michigan, Ann Arbor
| | - Andrew M Ryan
- School of Public Health, Department of Health Management and Policy, University of Michigan, Ann Arbor
| | - David C Miller
- Dow Health Services Research Division, Department of Urology, University of Michigan, Ann Arbor
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Makic MBF, Rauen C. Maintaining Your Momentum: Moving Evidence Into Practice. Crit Care Nurse 2016; 36:13-8. [PMID: 27037334 DOI: 10.4037/ccn2016568] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Mary Beth Flynn Makic
- Mary Beth Flynn Makic is an associate professor, College of Nursing, University of Colorado, Aurora, Colorado. Dr Makic is a recognized expert in critical care and evidence-based practice.Carol Rauen is an independent clinical nurse specialist and education consultant. Carol is a recognized expert in critical care nursing and certification instruction.
| | - Carol Rauen
- Mary Beth Flynn Makic is an associate professor, College of Nursing, University of Colorado, Aurora, Colorado. Dr Makic is a recognized expert in critical care and evidence-based practice.Carol Rauen is an independent clinical nurse specialist and education consultant. Carol is a recognized expert in critical care nursing and certification instruction
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Hendrikx RJP, Drewes HW, Spreeuwenberg M, Ruwaard D, Struijs JN, Baan CA. Which Triple Aim related measures are being used to evaluate population management initiatives? An international comparative analysis. Health Policy 2016; 120:471-85. [PMID: 27066729 DOI: 10.1016/j.healthpol.2016.03.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/07/2016] [Accepted: 03/11/2016] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Population management (PM) initiatives are introduced in order to create sustainable health care systems. These initiatives should focus on the continuum of health and well-being of a population by introducing interventions that integrate various services. To be successful they should pursue the Triple Aim, i.e. simultaneously improve population health and quality of care while reducing costs per capita. This study explores how PM initiatives measure the Triple Aim in practice. METHOD An exploratory search was combined with expert consultations to identify relevant PM initiatives. These were analyzed based on general characteristics, utilized measures and related selection criteria. RESULTS In total 865 measures were used by 20 PM initiatives. All quality of care domains were included by at least 11 PM initiatives, while most domains of population health and costs were included by less than 7 PM initiatives. Although their goals showed substantial overlap, the measures applied showed few similarities between PM initiatives and were predominantly selected based on local priority areas and data availability. CONCLUSION Most PM initiatives do not measure the full scope of the Triple Aim. Additionally, variety between measures limits comparability between PM initiatives. Consensus on the coverage of Triple Aim domains and a set of standardized measures could further both the inclusion of the various domains as well as the comparability between PM initiatives.
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Affiliation(s)
- Roy J P Hendrikx
- Tilburg University, Tilburg School of Social and Behavioral Sciences, Tranzo Scientific Center for Care and Welfare, PO Box 90153, 5000 LE Tilburg, The Netherlands.
| | - Hanneke W Drewes
- National Institute for Public Health and the Environment, Center for Nutrition, Prevention and Health Services, Department for Quality of Care and Health Economics, PO Box 1, 3720 BA Bilthoven, The Netherlands.
| | - Marieke Spreeuwenberg
- Maastricht University, Faculty of Health, Medicine and Life Sciences, CAPHRI School for Public Health and Primary Care, Department of Health Services Research, PO Box 616, 6200 MD Maastricht, The Netherlands; Zuyd University of Applied Sciences, Research Centre for Technology in Care, PO Box 550, 6400 AN Heerlen, The Netherlands.
| | - Dirk Ruwaard
- Maastricht University, Faculty of Health, Medicine and Life Sciences, CAPHRI School for Public Health and Primary Care, Department of Health Services Research, PO Box 616, 6200 MD Maastricht, The Netherlands.
| | - Jeroen N Struijs
- National Institute for Public Health and the Environment, Center for Nutrition, Prevention and Health Services, Department for Quality of Care and Health Economics, PO Box 1, 3720 BA Bilthoven, The Netherlands.
| | - Caroline A Baan
- Tilburg University, Tilburg School of Social and Behavioral Sciences, Tranzo Scientific Center for Care and Welfare, PO Box 90153, 5000 LE Tilburg, The Netherlands; National Institute for Public Health and the Environment, Center for Nutrition, Prevention and Health Services, Department for Quality of Care and Health Economics, PO Box 1, 3720 BA Bilthoven, The Netherlands.
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Colla CH, Lewis VA, Tierney E, Muhlestein DB. Hospitals Participating In ACOs Tend To Be Large And Urban, Allowing Access To Capital And Data. Health Aff (Millwood) 2016; 35:431-9. [PMID: 26953297 PMCID: PMC4838188 DOI: 10.1377/hlthaff.2015.0919] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Relationships between physicians and hospitals have changed considerably over the past decade, as hospitals and physician groups have integrated and new public and private payment policies have created financial interdependence. The extent to which accountable care organizations (ACOs) involve hospitals in their operations may prove to be vitally important, because managing hospital care is a key part of improving health care quality and lowering cost growth. Using primary data on ACO composition and capabilities paired with hospital characteristics, we found that 20 percent of US hospitals were part of an ACO in 2014. Hospitals that were in urban areas, were nonprofit, or had a smaller share of Medicare patients were more likely to participate in ACOs, compared to hospitals that were in more rural areas, were for-profit or government owned, or had a larger share of Medicare patients, respectively. Qualitative data identified the following advantages of including a hospital in an ACO: the availability of start-up capital, advanced data sharing, and engagement of providers across the care continuum. Although the 63 percent of ACOs that included hospitals offered more comprehensive services compared to ACOs without hospitals, we found no differences between the two groups in their ability to manage hospital-related aspects of patient care.
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Affiliation(s)
- Carrie H Colla
- Carrie H. Colla is an assistant professor at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, in Lebanon, New Hampshire
| | - Valerie A Lewis
- Valerie A. Lewis is an assistant professor at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine
| | - Emily Tierney
- Emily Tierney is a health policy fellow at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine
| | - David B Muhlestein
- David B. Muhlestein is senior director of research and development at Leavitt Partners, in Salt Lake City, Utah
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Costs of ED episodes of care in the United States. Am J Emerg Med 2016; 34:357-65. [DOI: 10.1016/j.ajem.2015.06.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 05/31/2015] [Accepted: 06/02/2015] [Indexed: 11/23/2022] Open
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Balicer RD, Hoshen M, Cohen‐Stavi C, Shohat‐Spitzer S, Kay C, Bitterman H, Lieberman N, Jacobson O, Shadmi E. Sustained Reduction in Health Disparities Achieved through Targeted Quality Improvement: One-Year Follow-up on a Three-Year Intervention. Health Serv Res 2015; 50:1891-909. [PMID: 25787874 PMCID: PMC4693854 DOI: 10.1111/1475-6773.12300] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess a quality improvement disparity reduction intervention and its sustainability. DATA SOURCES/STUDY SETTING Electronic health records and Quality Index database of Clalit Health Services in Israel (2008-2012). STUDY DESIGN Interrupted time-series with pre-, during, and postintervention disparities measurement between 55 target clinics (serving approximately 400,000 mostly low socioeconomic, minority populations) and all other (126) clinics. DATA COLLECTION/EXTRACTION METHODS Data on a Quality Indicator Disparity Scale (QUIDS-7) of 7 indicators, and on a 61-indicator scale (QUIDS-61). PRINCIPAL FINDINGS The gap between intervention and nonintervention clinics for QUIDS-7 decreased by 66.7 percent and by 70.4 percent for QUIDS-61. Disparity reduction continued (18.2 percent) during the follow-up period. CONCLUSIONS Quality improvement can achieve significant reduction in disparities in a wide range of clinical domains, which can be sustained over time.
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Affiliation(s)
| | - Moshe Hoshen
- Clalit Research InstituteChief Physician's Office in Clalit Health ServicesTel AvivIsrael
| | - Chandra Cohen‐Stavi
- Clalit Research InstituteChief Physician's Office in Clalit Health ServicesTel AvivIsrael
| | | | - Calanit Kay
- Community Health DivisionClalit Health ServicesTel AvivIsrael
| | - Haim Bitterman
- Clalit Research InstituteChief Physician's Office in Clalit Health ServicesTel AvivIsrael
- The Ruth and Bruce Rappaport Faculty of MedicineTechnion Israel Institute of TechnologyHaifaIsrael
| | - Nicky Lieberman
- Community Health DivisionClalit Health ServicesTel AvivIsrael
| | - Orit Jacobson
- Community Health DivisionClalit Health ServicesTel AvivIsrael
| | - Efrat Shadmi
- Clalit Research InstituteChief Physician's Office in Clalit Health ServicesTel AvivIsrael
- Faculty of Social Welfare and Health SciencesUniversity of HaifaHaifaIsrael
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