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Rittenhouse DR, Peebles V, Mack C, Alvarez C, Bazemore A. Small Independent Primary Care Practices Serving Socially Vulnerable Urban Populations. Ann Fam Med 2024; 22:89-94. [PMID: 38527816 DOI: 10.1370/afm.3068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 10/06/2023] [Accepted: 11/13/2023] [Indexed: 03/27/2024] Open
Abstract
PURPOSE This mixed methods study sought to describe the extent to which family physicians in urban communities serve socially vulnerable patients and to better understand their practices, their challenges, and the structural supports that could facilitate their patient care. METHODS We conducted a quantitative analysis of questionnaire data from 100% of US physicians recertifying for family medicine from 2017 to 2020. We conducted qualitative analysis of in-depth interviews with 22 physician owners of urban, small, independent practices who reported that the majority of their patients were socially vulnerable. RESULTS In 2020, in urban areas across the United States, 19.3% of family physicians served in independent practices with 1 to 5 clinicians, down from 22.6% in 2017. Nearly one-half of these physicians reported that >10% of their patients were socially vulnerable. Interviews with 22 physicians who reported that the majority of their patients were socially vulnerable revealed 5 themes: (1) substantial time spent addressing access issues and social determinants of health, (2) minimal support from health care entities, such as independent practice associations and health plans, and insufficient connection to community-based organizations, (3) myriad financial challenges, (4) serious concerns about the future, and (5) deep personal commitment to serving socially vulnerable patients in independent practice. CONCLUSIONS Small independent practices serving vulnerable patients in urban communities are surviving because deeply committed physicians are making personal sacrifices. Health equity-focused policies could decrease the burden on these physicians and bolster independent practices so that socially vulnerable patients continue to have options when seeking primary care.
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Petersen DM, O'Malley AS, Felland L, Peebles V, Rittenhouse DR, Powell RE, Rich EC, Sarwar R, Sorensen A, Hoag S, Finucane M, Lipman E, Gellar J, Machta RM, Keith RE. Reducing Acute Hospitalizations at High-Performing CPC+ Primary Care Practice Sites: Strategies, Activities, and Facilitators. Ann Fam Med 2023; 21:313-321. [PMID: 37487736 PMCID: PMC10365870 DOI: 10.1370/afm.2992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 02/07/2023] [Accepted: 02/24/2023] [Indexed: 07/26/2023] Open
Abstract
PURPOSE Despite evidence suggesting that high-quality primary care can prevent unnecessary hospitalizations, many primary care practices face challenges in achieving this goal, and there is little guidance identifying effective strategies for reducing hospitalization rates. We aimed to understand how practices in the Comprehensive Primary Care Plus (CPC+) program substantially reduced their acute hospitalization rate (AHR) over 2 years. METHODS We used Bayesian analyses to identify the CPC+ practice sites having the highest probability of achieving a substantial reduction in the adjusted Medicare AHR between 2016 and 2018 (referred to here as AHR high performers). We then conducted telephone interviews with 64 respondents at 14 AHR high-performer sites and undertook within- and cross-case comparative analysis. RESULTS The 14 AHR high performers experienced a 6% average decrease (range, 4% to 11%) in their Medicare AHR over the 2-year period. They credited various care delivery activities aligned with 3 strategies for reducing AHR: (1) improving and promoting prompt access to primary care, (2) identifying patients at high risk for hospitalization and addressing their needs with enhanced care management, and (3) expanding the breadth and depth of services offered at the practice site. They also identified facilitators of these strategies: enhanced payments through CPC+, prior primary care practice transformation experience, use of data to identify high-value activities for patient subgroups, teamwork, and organizational support for innovation. CONCLUSIONS The AHR high performers observed that strengthening the local primary care infrastructure through practice-driven, targeted changes in access, care management, and comprehensiveness of care can meaningfully reduce acute hospitalizations. Other primary care practices taking on the challenging work of reducing hospitalizations can learn from CPC+ practices and may consider similar strategies, selecting activities that fit their context, personnel, patient population, and available resources.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Erin Lipman
- University of Washington, Seattle, Washington
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3
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Kim JG, Rodriguez HP, Holmboe ES, McDonald KM, Mazotti L, Rittenhouse DR, Shortell SM, Kanter MH. The Reliability of Graduate Medical Education Quality of Care Clinical Performance Measures. J Grad Med Educ 2022; 14:281-288. [PMID: 35754636 PMCID: PMC9200256 DOI: 10.4300/jgme-d-21-00706.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/26/2021] [Accepted: 02/28/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Graduate medical education (GME) program leaders struggle to incorporate quality measures in the ambulatory care setting, leading to knowledge gaps on how to provide feedback to residents and programs. While nationally collected quality of care data are available, their reliability for individual resident learning and for GME program improvement is understudied. OBJECTIVE To examine the reliability of the Healthcare Effectiveness Data and Information Set (HEDIS) clinical performance measures in family medicine and internal medicine GME programs and to determine whether HEDIS measures can inform residents and their programs with their quality of care. METHODS From 2014 to 2017, we collected HEDIS measures from 566 residents in 8 family medicine and internal medicine programs under one sponsoring institution. Intraclass correlation was performed to establish patient sample sizes required for 0.70 and 0.80 reliability levels at the resident and program levels. Differences between the patient sample sizes required for reliable measurement and the actual patients cared for by residents were calculated. RESULTS The highest reliability levels for residents (0.88) and programs (0.98) were found for the most frequently available HEDIS measure, colorectal cancer screening. At the GME program level, 87.5% of HEDIS measures had sufficient sample sizes for reliable measurement at alpha 0.7 and 75.0% at alpha 0.8. Most resident level measurements were found to be less reliable. CONCLUSIONS GME programs may reliably evaluate HEDIS performance pooled at the program level, but less so at the resident level due to patient volume.
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Affiliation(s)
- Jung G. Kim
- Jung G. Kim, PhD, MPH, is Assistant Professor, Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science
| | - Hector P. Rodriguez
- Hector P. Rodriguez, PhD, MPH, is the Kaiser Permanente Professor of Health Policy and Management, University of California, Berkeley School of Public Health
| | - Eric S. Holmboe
- Eric S. Holmboe, MD, is Chief Research, Milestone Development, and Evaluation Officer, Accreditation Council for Graduate Medical Education
| | - Kathryn M. McDonald
- Kathryn M. McDonald, PhD, MM, is the Bloomberg Distinguished Professor of Health Systems, Quality, and Safety, Johns Hopkins Schools of Medicine and Nursing
| | - Lindsay Mazotti
- Lindsay Mazotti, MD, is Assistant Physician-in-Chief, Kaiser Permanente East Bay and Director, Clinical Experience/Associate Professor of Clinical Science, Kaiser Permanente School of Medicine
| | - Diane R. Rittenhouse
- Diane R. Rittenhouse, MD, MPH, is Senior Fellow, Mathematica, and Professor, University of California, San Francisco
| | - Stephen M. Shortell
- Stephen M. Shortell, PhD, MBA, MPH, is Blue Cross of California Distinguished Professor of Health Policy and Management Emeritus, Dean Emeritus, and Professor, Graduate School, University of California, Berkeley School of Public Health
| | - Michael H. Kanter
- Michael H. Kanter, MD, is Chair and Professor of Clinical Science, Kaiser Permanente School of Medicine
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Casalino LP, Li J, Peterson LE, Rittenhouse DR, Zhang M, O’Donnell EM, Phillips RL. Relationship Between Physician Burnout And The Quality And Cost Of Care For Medicare Beneficiaries Is Complex. Health Aff (Millwood) 2022; 41:549-556. [PMID: 35377764 PMCID: PMC9934398 DOI: 10.1377/hlthaff.2021.00440] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite reports of a physician burnout epidemic, there is little research on the relationship between burnout and objective measures of care outcomes and no research on the relationship between burnout and costs of care. Linking survey data from 1,064 family physicians to Medicare claims, we found no consistent statistically significant relationship between seven categories of self-reported burnout and measures of ambulatory care-sensitive admissions, ambulatory care-sensitive emergency department visits, readmissions, or costs. The coefficients for ambulatory care-sensitive admissions and readmissions for all burnout levels, compared with never being burned out, were consistently negative (fewer ambulatory care-sensitive admissions and readmissions), suggesting that, counterintuitively, physicians who report burnout may nevertheless be able to create better outcomes for their patients. Even if true, this hypothesis should not indicate that physician burnout is beneficial or that efforts to reduce physician burnout are unimportant. Our findings suggest that the relationship between burnout and outcomes is complex and requires further investigation.
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Affiliation(s)
| | - Jing Li
- Weill Cornell Medical College
| | - Lars E. Peterson
- American Board of Family Medicine, Washington, D.C., and University of Kentucky, Lexington, Kentucky
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Kim JG, Rodriguez HP, Shortell SM, Fuller B, Holmboe ES, Rittenhouse DR. Factors Associated With Family Medicine and Internal Medicine First-Year Residents' Ambulatory Care Training Time. Acad Med 2021; 96:433-440. [PMID: 32496285 DOI: 10.1097/acm.0000000000003522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE Despite the importance of training in ambulatory care settings for residents to acquire important competencies, little is known about the organizational and environmental factors influencing the relative amount of time primary care residents train in ambulatory care during residency. The authors examined factors associated with postgraduate year 1 (PGY-1) residents' ambulatory care training time in Accreditation Council for Graduate Medical Education (ACGME)-accredited primary care programs. METHOD U.S.-accredited family medicine (FM) and internal medicine (IM) programs' 2016-2017 National Graduate Medical Education (GME) Census data from 895 programs within 550 sponsoring institutions (representing 13,077 PGY-1s) were linked to the 2016 Centers for Medicare and Medicaid Services Cost Reports and 2015-2016 Area Health Resource File. Multilevel regression models examined the association of GME program characteristics, sponsoring institution characteristics, geography, and environmental factors with PGY-1 residents' percentage of time spent in ambulatory care. RESULTS PGY-1 mean (standard deviation, SD) percent time spent in ambulatory care was 25.4% (SD, 0.4) for both FM and IM programs. In adjusted analyses (% increase [standard error, SE]), larger faculty size (0.03% [SE, 0.01], P < .001), sponsoring institution's receipt of Teaching Health Center (THC) funding (6.6% (SE, 2.7), P < .01), and accreditation warnings (4.8% [SE, 2.5], P < .05) were associated with a greater proportion of PGY-1 time spent in ambulatory care. Programs caring for higher proportions of Medicare beneficiaries spent relatively less time in ambulatory care (< 0.5% [SE, 0.2], P < .01). CONCLUSIONS Ambulatory care time for PGY-1s varies among ACGME-accredited primary care residency programs due to the complex context and factors primary care GME programs operate under. Larger ACGME-accredited FM and IM programs and those receiving federal THC GME funding had relatively more PGY-1 time spent in ambulatory care settings. These findings inform policies to increase resident exposure in ambulatory care, potentially improving learning, competency achievement, and primary care access.
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Affiliation(s)
- Jung G Kim
- J.G. Kim is lecturer, University of California, Berkeley School of Public Health, Berkeley, California, and Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, California
| | - Hector P Rodriguez
- H.P. Rodriguez is Henry J. Kaiser Endowed Chair in Organized Health Systems and professor, University of California, Berkeley School of Public Health, Berkeley, California
| | - Stephen M Shortell
- S.M. Shortell is Blue Cross of California Distinguished Professor of Health Policy and Management Emeritus, Dean Emeritus, and professor, Graduate School, University of California, Berkeley School of Public Health, Berkeley, California
| | - Bruce Fuller
- B. Fuller is professor, Education and Public Policy, University of California, Berkeley, California
| | - Eric S Holmboe
- E.S. Holmboe is chief research, milestones development, and evaluation officer, Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - Diane R Rittenhouse
- D.R. Rittenhouse is a senior fellow, Mathematica, and professor, University of California, San Francisco, California
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Rittenhouse DR, Wiley JA, Peterson LE, Casalino LP, Phillips RL. Meaningful Use And Medical Home Functionality In Primary Care Practice. Health Aff (Millwood) 2020; 39:1977-1983. [DOI: 10.1377/hlthaff.2020.00782] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Diane R. Rittenhouse
- Diane R. Rittenhouse is a senior fellow in Health at Mathematica in Oakland, California
| | - James A. Wiley
- James A. Wiley is a professor in the Philip R. Lee Institute for Health Policy Studies at the University of California San Francisco, in San Francisco, California
| | - Lars E. Peterson
- Lars E. Peterson is vice president of research at the American Board of Family Medicine, in Lexington, Kentucky
| | - Lawrence P. Casalino
- Lawrence P. Casalino is the Livingston Farrand Professor and chief of the Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medicine, in New York, New York
| | - Robert L. Phillips
- Robert L. Phillips Jr. is the founding executive director of the American Board of Family Medicine Foundation Center for Professionalism and Value in Health Care, in Washington, D.C
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Rittenhouse DR, Ament AS, Grumbach K. Sponsoring Institution Interests, Not National Plans, Shape Physician Workforce in the United States. Fam Med 2020; 52:551-556. [PMID: 32672833 DOI: 10.22454/fammed.2020.507727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Graduate medical education (GME) determines the composition and distribution of the physician workforce in the United States. Federal and state governments heavily subsidize GME but in most cases do not tie subsidies to national or state physician workforce goals. As a result, GME sponsoring institutions (eg, teaching hospitals, schools of medicine, federally qualified health centers) decide how many and what type of physicians to train. The objective of this study was to better understand the factors that influence decision-making by sponsoring institutions. METHODS Between May and December 2018, we interviewed 35 national or state GME policy leaders and an additional 26 GME leaders from a purposive sample of four sponsoring institutions. We analyzed interviews following a conventional content analysis approach to identify emergent themes. RESULTS When considering investing in GME, we found that sponsoring institutions do not consider national or statewide workforce recommendations. Instead, they weigh multiple factors of concern to their institution, including public GME subsidies, market competition, potential clinical revenues, academic stature, local workforce demands, as well as their own organization's mission/culture, staffing, financial reserves, educational leadership, teaching resources, and size. CONCLUSIONS Unless and until the incentives for sponsoring institutions are strongly aligned with national and state physician workforce priorities based on public need, progress on creating a more balanced physician workforce will not occur.
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Affiliation(s)
- Diane R Rittenhouse
- Mathematica, Oakland, CA.,and the Department of Family and Community Medicine, University of California, San Francisco
| | - Alexandra S Ament
- Department of Family and Community Medicine, University of California, San Francisco
| | - Kevin Grumbach
- Department of Family and Community Medicine, University of California, San Francisco
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Kandel ZK, Rittenhouse DR, Bibi S, Fraze TK, Shortell SM, Rodríguez HP. The CMS State Innovation Models Initiative and Improved Health Information Technology and Care Management Capabilities of Physician Practices. Med Care Res Rev 2020; 78:350-360. [PMID: 31967494 DOI: 10.1177/1077558719901217] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Centers for Medicare and Medicaid Services' (CMS) State Innovation Models (SIMs) initiative funded 17 states to implement health care payment and delivery system reforms to improve health system performance. Whether SIM improved health information technology (HIT) and care management capabilities of physician practices, however, remains unclear. National surveys of physician practices (N = 2,722) from 2012 to 2013 and 2017 to 2018 were linked. Multivariable regression estimated differential adoption of 10 HIT functions and chronic care management processes (CMPs) based on SIM award status (SIM Round 1, SIM Round 2, or non-SIM). HIT and CMP capabilities improved equally for practices in SIM Round 1 (5.3 vs. 6.8 capabilities, p < .001), SIM Round 2 (4.7 vs. 7.0 capabilities, p < .001), and non-SIM (4.2 vs. 6.3 capabilities, p < .001) states. The CMS SIM Initiative did not accelerate the adoption of ten foundational physician practice capabilities beyond national trends.
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Affiliation(s)
| | - Diane R Rittenhouse
- University of California, Berkeley, CA, USA.,University of California, San Francisco, CA, USA
| | - Salma Bibi
- University of California, Berkeley, CA, USA
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Rittenhouse DR, Phillips AZ, Bibi S, Rodriguez HP. Implementation Variation in Natural Experiments of State Health Policy Initiatives. Am J Accountable Care 2019; 7:12-17. [PMID: 31750412 PMCID: PMC6866654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES An increasing number of federal initiatives allow states flexibility in selecting the strategies used to achieve initiative-specific goals. Variation in the foci and intensity of implementation may explain why federal policy initiatives succeed in some states and fail in others. The CMS State Innovation Models (SIM) initiative is a complex policy intervention implemented with substantial variation across states and may have variable impacts. This paper presents a method to characterize and account for that variation in states' implementation foci and intensity in natural policy experiments. STUDY DESIGN A combination of quantitative and qualitative measures of SIM implementation was used to characterize the foci of payment and delivery system reforms across states. METHODS A modified Delphi expert panel process was used to prioritize the features of SIM implementation that would differentiate grantee states with respect to improved health outcomes. Three researchers then reviewed summaries of published evaluations and reports to characterize and score states on each implementation feature. Expert panelists guided the researchers on developing the criteria and weights applied to the focus areas when calculating SIM implementation intensity scores for states. RESULTS Over 3 years of an expert panel process, 4 dimensions of SIM implementation that would most affect health outcomes were prioritized: 1) extent and breadth of stakeholder engagement, (2) extent that SIM implementation was focused on improving behavioral health, (3) amount of SIM funding per capita, and (4) breadth and depth of value-based payment reforms. Scoring states based on the prioritized factors resulted in composite scores that differentiated states into 3 categories: high, moderate, and low implementation intensity. CONCLUSIONS We developed a stakeholder-driven method to measure and account for variation in implementation foci and intensity in a federal policy initiative that was implemented heterogeneously across grantee states. Our method for characterizing state implementation variation may be useful for natural policy experiments examining the variable impact of policy initiatives.
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Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco (DRR), San Francisco, CA; Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley (AZP, SB, HPR), Berkeley, CA
| | - Aryn Z Phillips
- Department of Family and Community Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco (DRR), San Francisco, CA; Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley (AZP, SB, HPR), Berkeley, CA
| | - Salma Bibi
- Department of Family and Community Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco (DRR), San Francisco, CA; Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley (AZP, SB, HPR), Berkeley, CA
| | - Hector P Rodriguez
- Department of Family and Community Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco (DRR), San Francisco, CA; Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley (AZP, SB, HPR), Berkeley, CA
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Pesko MF, Ryan AM, Shortell SM, Copeland KR, Ramsay PP, Sun X, Mendelsohn JL, Rittenhouse DR, Casalino LP. Spending per Medicare Beneficiary Is Higher in Hospital-Owned Small- and Medium-Sized Physician Practices. Health Serv Res 2018; 53:2133-2146. [PMID: 28940537 PMCID: PMC6051973 DOI: 10.1111/1475-6773.12765] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine the relationship of physician versus hospital ownership of small- and medium-sized practices with spending and utilization of care. DATA SOURCE/STUDY SETTING/DATA COLLECTION Survey data for 1,045 primary care-based practices of 1-19 physicians linked to Medicare claims data for 2008 for 282,372 beneficiaries attributed to the 3,010 physicians in these practices. STUDY DESIGN We used generalized linear models to estimate the associations between practice characteristics and outcomes (emergency department visits, index admissions, readmissions, and spending). PRINCIPAL FINDINGS Beneficiaries linked to hospital-owned practices had 7.3 percent more emergency department visits and 6.4 percent higher total spending compared to beneficiaries linked to physician-owned practices. CONCLUSIONS Physician practices are increasingly being purchased by hospitals. This may result in higher total spending on care.
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Affiliation(s)
- Michael F. Pesko
- Department of Healthcare Policy and ResearchWeill Cornell Medical CollegeNew YorkNY
| | - Andrew M. Ryan
- Department of Health Management and PolicyUniversity of Michigan School of Public HealthAnn ArborMI
| | | | | | - Patricia P. Ramsay
- Center for Healthcare Organizational and Innovation ResearchDivision of Health Policy and ManagementUniversity of California, BerkeleyBerkeleyCA
| | - Xuming Sun
- Primary Care Information ProjectNew York City Department of Health and Mental HygieneLong Island City (Queens)NY
| | | | - Diane R. Rittenhouse
- Department of Family and Community MedicineUniversity of California, San FranciscoSan FranciscoCA
| | - Lawrence P. Casalino
- Department of Healthcare Policy and ResearchWeill Cornell Medical CollegeNew YorkNY
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Wiley JA, Rittenhouse DR, Shortell SM, Casalino LP, Ramsay PP, Bibi S, Ryan AM, Copeland KR, Alexander JA. Managing chronic illness: physician practices increased the use of care management and medical home processes. Health Aff (Millwood) 2017; 34:78-86. [PMID: 25561647 DOI: 10.1377/hlthaff.2014.0404] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The effective management of patients with chronic illnesses is critical to bending the curve of health care spending in the United States and is a crucial test for health care reform. In this article we used data from three national surveys of physician practices between 2006 and 2013 to determine the extent to which practices of all sizes have increased their use of evidence-based care management processes associated with patient-centered medical homes for patients with asthma, congestive heart failure, depression, and diabetes. We found relatively large increases over time in the overall use of these processes for small and medium-size practices as well as for large practices. However, the large practices used fewer than half of the recommended processes, on average. We also identified the individual processes whose use increased the most and show that greater use of care management processes is positively associated with public reporting of patient experience and clinical quality and with pay-for-performance.
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Affiliation(s)
- James A Wiley
- James A. Wiley is a professor at the Institute for Health Policy Studies, University of California, San Francisco (UCSF)
| | - Diane R Rittenhouse
- Diane R. Rittenhouse is an associate professor in the Department of Family and Community Medicine, UCSF
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor of Health Policy and Management and faculty director of the Center for Healthcare Organizational and Innovation Research (CHOIR), School of Public Health; and a professor of organizational behavior, Haas School of Business, all at the University of California, Berkeley
| | - Lawrence P Casalino
- Lawrence P. Casalino is the Livingston Farrand Professor in the Department of Public Health, Weill Cornell Medical College, in New York City
| | - Patricia P Ramsay
- Patricia P. Ramsay is a research specialist and administrative director in CHOIR, School of Public Health, UC Berkeley
| | - Salma Bibi
- Salma Bibi is a research analyst in the School of Public Health, UC Berkeley
| | - Andrew M Ryan
- Andrew M. Ryan is an associate professor of public health at the University of Michigan, in Ann Arbor
| | - Kennon R Copeland
- Kennon R. Copeland is senior vice president and director of statistics and methodology at NORC at the University of Chicago, in Bethesda, Maryland
| | - Jeffrey A Alexander
- Jeffrey A. Alexander is a professor emeritus at the University of Michigan, in Ann Arbor
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Rittenhouse DR, Ramsay PP, Casalino LP, McClellan S, Kandel ZK, Shortell SM. Increased Health Information Technology Adoption and Use Among Small Primary Care Physician Practices Over Time: A National Cohort Study. Ann Fam Med 2017; 15:56-62. [PMID: 28376461 PMCID: PMC5217844 DOI: 10.1370/afm.1992] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 06/21/2016] [Accepted: 07/05/2016] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Implementation and meaningful use of health information technology (HIT) has been shown to facilitate delivery system transformation, yet implementation is far from universal. This study examined correlates of greater HIT implementation over time among a national cohort of small primary care practices in the United States. METHODS We used data from a 40-minute telephone panel survey of 566 small primary care practices having 8 or fewer physicians to investigate adoption and use of HIT in 2007-2010 and 2012-2013. We used generalized estimating equations (GEE) to estimate the association of practice characteristics and external incentives with the adoption and use of HIT. We studied 18 measures of HIT functionalities, including record keeping, clinical decision support, patient communication, and health information exchange with hospitals and pharmacies. RESULTS Overall, use of 16 HIT functionalities increased significantly over time, whereas use of 2 decreased significantly. On average, compared with physician-owned practices, hospital-owned practices used 1.48 (95% CI, 1.07-1.88; P <.001) more HIT processes. And relative to smaller practices, practices with 3 to 8 physicians used 2.49 (95% CI, 2.26-2.72; P <.001) more HIT processes. Participation in pay-for-performance programs, participation in public reporting of clinical quality data, and a larger proportion of revenue from Medicare were also associated with greater adoption and use of HIT. CONCLUSIONS The new Medicare Access and CHIP Reauthorization Act (MACRA) will provide payment incentives and technical support to speed HIT adoption and use by small practices. We found that external incentives were, indeed, positively associated with greater adoption and use of HIT. Our findings also support a strategy of targeting assistance to smaller physician practices and those that are physician owned.
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Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine, University of California, San Francisco, California .,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California
| | - Patricia P Ramsay
- School of Public Health, University of California, Berkeley, California
| | - Lawrence P Casalino
- Division of Health Policy and Economics, Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | | | - Zosha K Kandel
- School of Public Health, University of California, Berkeley, California
| | - Stephen M Shortell
- School of Public Health, University of California, Berkeley, California.,Haas School of Business, University of California, Berkeley, California
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Ramsay PP, Shortell SM, Casalino LP, Rodriguez HP, Rittenhouse DR. A Longitudinal Study of Medical Practices' Treatment of Patients Who Use Tobacco. Am J Prev Med 2016; 50:328-335. [PMID: 26365836 DOI: 10.1016/j.amepre.2015.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 06/18/2015] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Many patients who use tobacco have never been encouraged by their healthcare providers to quit. In recent years, incentives have been provided for medical practices to incorporate tobacco-cessation processes into routine care. This study examined growth in use of these processes as well as organizational and policy factors associated with their implementation. METHODS Data from three National Study of Physician Organizations surveys fielded in 2006-2013 were analyzed in 2014. The analyses estimated multivariate longitudinal and cross-sectional linear regression models to assess the relationship between implementation of cessation processes and change in practices' characteristics and external incentives, including state mandates for tobacco-cessation coverage. RESULTS Systematic identification of patients who use tobacco increased in large (26% to 91%, p<0.0001) and small-medium practices (69% to 83%, p<0.0001). Neither routine advice to quit nor referral to counseling and guideline-based point-of-care reminders increased. Practice feedback to physicians on their use of cessation interventions increased (18% to 29%, p<0.0001) for small-medium practices. State-mandated coverage was associated with the use of cessation processes in small-medium practices (p<0.0001), as was pay for performance participation (p<0.0001); public reporting (p<0.0001); Medicaid revenue (p=0.02); and practice size (p<0.0001). Among large practices, predictors were practice size (p<0.0001); hospital ownership (p=0.004); public reporting (p=0.03); and primary care practice (p=0.04). CONCLUSIONS The findings suggest that state-mandated coverage for tobacco-cessation treatment and increased use of external incentives such as pay for performance and public reporting programs may improve care for patients who use tobacco.
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Affiliation(s)
- Patricia P Ramsay
- School of Public Health, University of California Berkeley, Berkeley, California.
| | - Stephen M Shortell
- School of Public Health, University of California Berkeley, Berkeley, California
| | - Lawrence P Casalino
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Hector P Rodriguez
- School of Public Health, University of California Berkeley, Berkeley, California
| | - Diane R Rittenhouse
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
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Casalino LP, Pesko MF, Ryan AM, Mendelsohn JL, Copeland KR, Ramsay PP, Sun X, Rittenhouse DR, Shortell SM. Small primary care physician practices have low rates of preventable hospital admissions. Health Aff (Millwood) 2014; 33:1680-8. [PMID: 25122562 DOI: 10.1377/hlthaff.2014.0434] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Nearly two-thirds of US office-based physicians work in practices of fewer than seven physicians. It is often assumed that larger practices provide better care, although there is little evidence for or against this assumption. What is the relationship between practice size--and other practice characteristics, such as ownership or use of medical home processes--and the quality of care? We conducted a national survey of 1,045 primary care-based practices with nineteen or fewer physicians to determine practice characteristics. We used Medicare data to calculate practices' rate of potentially preventable hospital admissions (ambulatory care-sensitive admissions). Compared to practices with 10-19 physicians, practices with 1-2 physicians had 33 percent fewer preventable admissions, and practices with 3-9 physicians had 27 percent fewer. Physician-owned practices had fewer preventable admissions than hospital-owned practices. In an era when health care reform appears to be driving physicians into larger organizations, it is important to measure the comparative performance of practices of all sizes, to learn more about how small practices provide patient care, and to learn more about the types of organizational structures--such as independent practice associations--that may make it possible for small practices to share resources that are useful for improving the quality of care.
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Affiliation(s)
- Lawrence P Casalino
- Lawrence P. Casalino is the Livingston Farrand Professor in the Department of Healthcare Policy and Research at Weill Cornell Medical College, in New York, New York
| | - Michael F Pesko
- Michael F. Pesko is an assistant professor in the Department of Healthcare Policy and Research, Weill Cornell Medical College
| | - Andrew M Ryan
- Andrew M. Ryan is an associate professor in the Department of Healthcare Policy and Research, Weill Cornell Medical College
| | - Jayme L Mendelsohn
- Jayme L. Mendelsohn worked on this project as a research coordinator in the Department of Healthcare Policy and Research, Weill Cornell Medical College. She is currently a postbaccalaureate premedical student at Bryn Mawr
| | - Kennon R Copeland
- Kennon R. Copeland is senior vice president and director in the Department of Statistics and Methodology, NORC at the University of Chicago, in Illinois
| | - Patricia Pamela Ramsay
- Patricia Pamela Ramsay is a research specialist at the School of Public Health, University of California, Berkeley
| | - Xuming Sun
- Xuming Sun worked on this project as a research biostatistician in the Department of Healthcare Policy and Research, Weill Cornell Medical College. She is currently working as a statistician in the New York City Department of Health and Mental Hygiene
| | - Diane R Rittenhouse
- Diane R. Rittenhouse is an associate professor in the Department of Family and Community Medicine and Center for Excellence in Primary Care, University of California, San Francisco
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor of Health Policy and Management at the School of Public Health, University of California, Berkeley
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Casalino LP, Wu FM, Ryan AM, Copeland K, Rittenhouse DR, Ramsay PP, Shortell SM. Independent practice associations and physician-hospital organizations can improve care management for smaller practices. Health Aff (Millwood) 2014; 32:1376-82. [PMID: 23918481 DOI: 10.1377/hlthaff.2013.0205] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pay-for-performance, public reporting, and accountable care organization programs place pressures on physicians to use health information technology and organized care management processes to improve the care they provide. But physician practices that are not large may lack the resources and size to implement such processes. We used data from a unique national survey of 1,164 practices with fewer than twenty physicians to provide the first information available on the extent to which independent practice associations (IPAs) and physician-hospital organizations (PHOs) might make it possible for these smaller practices to share resources to improve care. Nearly a quarter of the practices participated in an IPA or a PHO that accounted for a significant proportion of their patients. On average, practices participating in these organizations provided nearly three times as many care management processes for patients with chronic conditions as nonparticipating practices did (10.4 versus 3.8). Half of these processes were provided only by IPAs or PHOs. These organizations may provide a way for small and medium-size practices to systematically improve care and participate in accountable care organizations.
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Affiliation(s)
- Lawrence P Casalino
- Department of Public Health, Weill Cornell Medical College, New York City, NY, USA.
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Rittenhouse DR, Schmidt LA, Wu KJ, Wiley J. Incentivizing primary care providers to innovate: building medical homes in the post-Katrina New Orleans safety net. Health Serv Res 2013; 49:75-92. [PMID: 23800148 DOI: 10.1111/1475-6773.12080] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate safety-net clinics' responses to a novel community-wide Patient-Centered Medical Home (PCMH) financial incentive program in post-Katrina New Orleans. DATA SOURCES/STUDY SETTING Between June 2008 and June 2010, we studied 50 primary care clinics in New Orleans receiving federal funds to expand services and improve care delivery. STUDY DESIGN Multiwave, longitudinal, observational study of a local safety-net primary care system. DATA COLLECTION Clinic-level data from a semiannual survey of clinic leaders (89.3 percent response rate), augmented by administrative records. PRINCIPAL FINDINGS Overall, 62 percent of the clinics responded to financial incentives by achieving PCMH recognition from the National Committee on Quality Assurance (NCQA). Higher patient volume, higher baseline PCMH scores, and type of ownership were significant predictors of achieving NCQA recognition. The steepest increase in adoption of PCMH processes occurred among clinics achieving the highest, Level 3, NCQA recognition. Following NCQA recognition, 88.9 percent stabilized or increased their use of PCMH processes, although several specific PCMH processes had very low rates of adoption overall. CONCLUSIONS Findings demonstrate that widespread PCMH implementation is possible in a safety-net environment when external financial incentives are aligned with the goal of practice innovation.
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Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA
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Abstract
PURPOSE We sought to compare and contrast patterns of change toward patient-centered medical homes (PCMHs) in 5 New Orleans primary care safety net clinics in the aftermath of Hurricane Katrina. We assessed the general direction of change in practice to discover possible reasons for differences in patterns of change, and to identify impediments to change. METHODS Data collection consisted of 5 semiannual telephone interviews with clinic leadership over 2.5 years supplemented by administrative audits. We used standard survey indexes of PCMH to monitor practice change. We conducted site visits and unstructured in-person interviews with clinicians and staff of the 5 clinics. RESULTS PCMH index scores improved during the observation period with variations in rates of change and initial levels of PCMH. Qualitative analysis suggested possible explanations for this differential success: (1) early vs later starts in practice change, (2) funding based on patient outcomes, (3) demands that compete with practice change, (4) qualities of clinic leadership, and (5) relations with the communities where patients live. Barriers to practice change included high demand for services, deficient linkages between hospital and specialty care, lack of staff resources, and a need to focus on clinic finances. CONCLUSIONS The PCMH model can successfully address the needs of safety net populations. Stable leadership committed to serving safety net patients via the PCMH model is important for successful practice transformation. Beyond clinic walls, cultivating deep ties to the communities that clinics serve also supports the PCMH model.
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Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine, Philip R. Lee Institute for Health, Policy Studies, University of California, San Francisco, San Francisco, California 94143, USA.
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McClellan SR, Casalino LP, Shortell SM, Rittenhouse DR. When does adoption of health information technology by physician practices lead to use by physicians within the practice? J Am Med Inform Assoc 2013; 20:e26-32. [PMID: 23396512 DOI: 10.1136/amiajnl-2012-001271] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We sought to determine the extent to which adoption of health information technology (HIT) by physician practices may differ from the extent of use by individual physicians, and to examine factors associated with adoption and use. MATERIALS AND METHODS Using cross-sectional survey data from the National Study of Small and Medium-Sized Physician Practices (July 2007-March 2009), we examined the extent to which organizational capabilities and external incentives were associated with the adoption of five key HIT functionalities by physician practices and with use of those functionalities by individual physicians. RESULTS The rate of physician practices adopting any of the five HIT functionalities was 34.1%. When practices adopted HIT functionalities, on average, about one in seven physicians did not use those functionalities. One physician in five did not use prompts and reminders following adoption by their practice. After controlling for other factors, both adoption of HIT by practices and use of HIT by individual physicians were higher in primary care practices and larger practices. Practices reporting an emphasis on patient-centered management were not more likely than others to adopt, but their physicians were more likely to use HIT. DISCUSSION Larger practices were most likely to have adopted HIT, but other factors, including specialty mix and self-reported patient-centered management, had a stronger influence on the use of HIT once adopted. CONCLUSIONS Adoption of HIT by practices does not mean that physicians will use the HIT.
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Affiliation(s)
- Sean R McClellan
- Health Services and Policy Analysis Program, University of California, Berkeley, California 94720, USA.
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Rittenhouse DR, Schmidt LA, Wu KJ, Wiley J. The post-Katrina conversion of clinics in New Orleans to medical homes shows change is possible, but hard to sustain. Health Aff (Millwood) 2013; 31:1729-38. [PMID: 22869651 DOI: 10.1377/hlthaff.2012.0402] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hurricane Katrina destroyed much of the health care infrastructure in and around New Orleans in 2005. We describe a natural experiment that occurred afterward, amid efforts to rebuild the city's health care system, in which diverse safety-net clinics were transformed into medical homes. Using surveys of clinic leaders and administrative data, we found that clinics made substantial progress in implementing new clinical processes to improve access, quality and safety, and care coordination and integration. But there was wide variation, with some clinics making only minimal progress. Because the transformation was closely tied to the receipt of federal grants and bonus payments, we observed declines in performance toward the end of the study, when clinics faced diminished federal funding and refocused their priorities on survival. Now that federal funds have dried up, moreover, clinics may be losing ground in sustaining their practice changes. The experience shows that payment to support medical home transformation must be robust and stable, and clinics need to be fully integrated into the broader health care system to improve overall coordination of care.
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Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine and Philip R. Lee Institute for Health Policy Studies at University of California, San Francisco, USA.
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21
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Abstract
OBJECTIVE To examine the relationship between practices' reported use of patient-centered medical home (PCMH) processes and patients' perceptions of their care experience. DATA SOURCE Primary survey data from 393 physician practices and 1,304 patients receiving care in those practices. STUDY DESIGN This is an observational, cross-sectional study. Using standard ordinary least-squares and a sample selection model, we estimated the association between patients' care experience and the use of PCMH processes in the practices where they receive care. DATA COLLECTION We linked data from a nationally representative survey of individuals with chronic disease and two nationally representative surveys of physician practices. PRINCIPAL FINDINGS We found that practices' use of PCMH processes was not associated with patient experience after controlling for sample selection as well as practice and patient characteristics. CONCLUSIONS In our study, which was large, but somewhat limited in its measures of the PCMH and of patient experience, we found no association between PCMH processes and patient experience. The continued accumulation of evidence related to the possibilities of the PCMH, how PCMH is measured, and how the impact of PCMH is gauged provides important information for health care decision makers.
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Affiliation(s)
- Grant R Martsolf
- Department of Health Policy and Administration, Pennsylvania State University, 610 N Euclid Ave, Pittsburgh, PA 15206, USA.
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Rittenhouse DR, Casalino LP, Shortell SM. Patient-Centered Medical Homes: The Authors Reply. Health Aff (Millwood) 2011. [DOI: 10.1377/hlthaff.2011.1103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Rittenhouse DR, Casalino LP, Shortell SM, McClellan SR, Gillies RR, Alexander JA, Drum ML. Small and medium-size physician practices use few patient-centered medical home processes. Health Aff (Millwood) 2011; 30:1575-84. [PMID: 21719447 DOI: 10.1377/hlthaff.2010.1210] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The patient-centered medical home has become a prominent model for reforming the way health care is delivered to patients. The model offers a robust system of primary care combined with practice innovations and new payment methods. But scant information exists about the extent to which typical US physician practices have implemented this model and its processes of care, or about the factors associated with implementation. In this article we provide the first national data on the use of medical home processes such as chronic disease registries, nurse care managers, and systems to incorporate patient feedback, among 1,344 small and medium-size physician practices. We found that on average, practices used just one-fifth of the patient-centered medical home processes measured as part of this study. We also identify internal capabilities and external incentives associated with the greater use of medical home processes.
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Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA.
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Abstract
The patient-centered medical home is taking center stage in discussions of primary care innovation as a new delivery model that provides comprehensive, coordinated care across the lifespan. Although the medical home is widely discussed by policymakers, payers, and other stakeholders, the extent to which physician practices have the infrastructure in place to function as medical homes is not known. Using data from the 2006-07 National Study of Physician Organizations, we examine the extent of adoption of medical home infrastructure components among large primary care and multispecialty medical groups and their association with medical group size and ownership.
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Affiliation(s)
- Diane R Rittenhouse
- Family and Community Medicine, University of California (UC), San Francisco, USA.
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Abstract
BACKGROUND The Patient-Centered Medical Home (PCMH) is a widely endorsed model of delivery system reform that emphasizes primary care. Pilot demonstration projects are underway in many states, sponsored by Medicare, Medicaid, major health plans and multi-payer coalitions. METHODS In this paper we consider the development of a long-term policy-relevant research agenda on outcomes of the PCMH. We provide an overview of potential measures of PCMH impact, identify measurement challenges and recommend areas for further study. Although the PCMH should not be expected to solve every problem in the health care system, developing a research agenda for measuring outcomes of delivery system innovations such as the PCMH should be considered in the context of the larger effort to improve the US health care system, with the ultimate goal to improve population health. RESULTS As a framework for our discussion, we have chosen the Institute of Medicine's six specific aims for 21st century health care: (1) safe, (2) effective, (3) patient-centered, (4) timely, (5) efficient and (6) equitable. In addition, we include potential areas of PCMH outcomes that do not easily fall under this framework and consider unintended consequences. CONCLUSION Multi-stakeholder involvement will be essential in developing a long-term policy-relevant research agenda for outcomes of the PCMH.
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Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine, University of California, 500 Parnassus Avenue, MU 308-E, San Francisco, CA, USA.
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Harrison B, Rittenhouse DR, Phillips RL, Grumbach K, Bazemore AW, Dodoo MS. Title VII is critical to the community health center and National Health Service Corps workforce. Am Fam Physician 2010; 81:132. [PMID: 20082508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Rittenhouse DR, Shortell SM, Gillies RR, Casalino LP, Robinson JC, McCurdy RK, Siddique J. Improving chronic illness care: findings from a national study of care management processes in large physician practices. Med Care Res Rev 2010; 67:301-20. [PMID: 20054057 DOI: 10.1177/1077558709353324] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The use of evidence-based care management processes (CMPs) in physician practice is an important component of delivery-system reform.The authors used data from a 2006-2007 national study of large physician organizations-medical groups and independent practice associations (IPAs) to determine the extent to which organizations use CMPs, and to identify external (market) influences and organizational capabilities associated with CMP use. The study found that physician organizations use about half of recommended CMPs, most commonly disease registries, specially trained patient educators, and performance feedback to physicians. Physician organizations that reported participating in quality improvement programs, having a patient-centered focus, and being owned by a hospital or health maintenance organization used more CMPs. IPAs and very large medical groups used more CMPs than smaller groups. Organizations externally evaluated on quality measures used more CMPs than other organizations. These findings can inform efforts to stimulate the adoption of best practices for chronic illness care.
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Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, USA
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Robinson JC, Shortell SM, Rittenhouse DR, Fernandes-Taylor S, Gillies RR, Casalino LP. Quality-based payment for medical groups and individual physicians. Inquiry 2009; 46:172-81. [PMID: 19694390 DOI: 10.5034/inquiryjrnl_46.02.172] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This paper measures the extent to which medical groups experience external pay-for-performance incentives based on quality and patient satisfaction and the extent to which these groups pay their primary care and specialist physicians using similar criteria. Over half (52%) of large medical groups received bonus payments from health insurance plans in the period 2006-2007 based on measures of quality and patient satisfaction. Medical groups facing external pay-for-performance incentives are more likely to pay their primary care physicians (odds ratio [OR] 4.5; p<.001) and specialists (OR 2.5; p=.07) based on quality and satisfaction. Groups facing capitation payment incentives to control costs are more likely to pay member physicians on salary and less likely to pay based on productivity (p<.001 for primary care; p<.05 for specialists) than groups paid by insurers on a fee-for-service basis.
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Affiliation(s)
- James C Robinson
- Berkeley Center for Health Technology, School of Public Health, 247 University Hall, University of California, Berkeley, CA 94720-7360, USA.
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31
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Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine and Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, USA
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Rittenhouse DR, Fryer GE, Phillips RL, Miyoshi T, Nielsen C, Goodman DC, Grumbach K. Impact of Title VII training programs on community health center staffing and national health service corps participation. Ann Fam Med 2008; 6:397-405. [PMID: 18779543 PMCID: PMC2532762 DOI: 10.1370/afm.885] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Community health centers (CHCs) are a critical component of the health care safety net. President Bush's recent effort to expand CHC capacity coincides with difficulty recruiting primary care physicians and substantial cuts in federal grant programs designed to prepare and motivate physicians to practice in underserved settings. This article examines the association between physicians' attendance in training programs funded by Health Resources and Services Administration (HRSA) Title VII Section 747 Primary Care Training Grants and 2 outcome variables: work in a CHC and participation in the National Health Service Corps Loan Repayment Program (NHSC LRP). METHODS We linked the 2004 American Medical Association Physician Master-file to HRSA Title VII grants files, Medicare claims data, and data from the NHSC. We then conducted retrospective analyses to compare the proportions of physicians working in CHCs among physicians who either had or had not attended Title VII-funded medical schools or residency programs and to determine the association between having attended Title VII-funded residency programs and subsequent NHSC LRP participation. RESULTS Three percent (5,934) of physicians who had attended Title VII-funded medical schools worked in CHCs in 2001-2003, compared with 1.9% of physicians who attended medical schools without Title VII funding (P<.001). We found a similar association between Title VII funding during residency and subsequent work in CHCs. These associations remained significant (P<.001) in logistic regression models controlling for NHSC participation, public vs private medical school, residency completion date, and physician sex. A strong association was also found between attending Title VII-funded residency programs and participation in the NHSC LRP, controlling for year completed training, physician sex, and private vs public medical school. CONCLUSIONS Continued federal support of Title VII training grant programs is consistent with federal efforts to increase participation in the NHSC and improve access to quality health care for underserved populations through expanded CHC capacity.
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Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine and Center for California Health Workforce Studies, University of California, San Francisco, CA 94143-0900, USA.
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Abstract
BACKGROUND Care management processes (CMPs), tools to improve the efficiency and quality of primary care delivery, are particularly important for low-income patients facing substantial barriers to care. OBJECTIVE To measure the adoption of CMPs by medical groups, Independent Practice Associations, community clinics, and hospital-based clinics in California's Medicaid program and the factors associated with CMP adoption. METHODS Telephone survey of every provider organization with at least 6 primary care physicians and at least 1 Medi-Cal HMO contract, Spring 2003. One hundred twenty-three organizations participated, accounting for 64% of provider organizations serving Medicaid managed care in California. We surveyed 30 measures of CMP use for asthma and diabetes, and for child and adolescent preventive services. RESULTS The mean number of CMPs used by each organization was 4.5 for asthma and 4.9 for diabetes (of a possible 8). The mean number of CMPs for preventive services was 4.0 for children and 3.5 for adolescents (of a possible 7). Organizations with more extensive involvement in Medi-Cal managed care used more CMPs for chronic illness and preventive service. Community clinics and hospital-based clinics used more CMPs for asthma and diabetes than did Independent Practice Associations (IPAs), and profitable organizations used more CMPs for child and adolescent preventive services than did entities facing severe financial constraints. The use of CMPs by Medicaid HMOs and the presence of external (financial and nonfinancial) incentives for clinical performance were strongly associated with use of care management by provider organizations. CONCLUSIONS Physician and provider organizations heavily involved in California's Medicaid program are extensively engaged in preventive and chronic care management programs.
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Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine, University of California, San Francisco 94143-0900, USA.
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Rittenhouse DR, Grumbach K, O'Neil EH, Dower C, Bindman A. Physician Organization And Care Management In California: From Cottage To Kaiser. Health Aff (Millwood) 2004; 23:51-62. [PMID: 15537586 DOI: 10.1377/hlthaff.23.6.51] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Data from a survey of practicing physicians in California's thirteen largest urban counties were used to ascertain differences in care management processes, financial incentives for quality, and practice pressures by type of practice setting. Physicians in the Permanente medical groups have adopted and value quality-oriented, system-level care management tools to a much greater degree than physicians in independent practice association (IPA) networks or traditional "cottage-industry" practices. Our findings raise disturbing questions about how the health system will close the "quality chasm" in medical care without transforming the underlying organization of physician practices.
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Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine, University of California-San Francisco, San Francisco, CA, USA.
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Abstract
OBJECTIVE To validate physicians' self-reported intentions to leave clinical practice and the American Medical Association (AMA) Masterfile practice status variable as measures of physician attrition, and to determine predictors of intention to leave, and actual departure from, clinical practice. DATA SOURCES Survey of specialist physicians in urban California (1998); the AMA Physician Masterfile (2001); and direct ascertainment of physician practice status (2001). STUDY DESIGN Physicians' intention to leave clinical practice by 2001 (self-reported in 1998) was tested as a measure of each physician's actual practice status in 2001 (directly ascertained). Physician practice status according to the 2001 AMA Masterfile was also tested as a measure of physicians' actual practice status in 2001. Multivariate regression was used to predict both physicians' intentions to leave clinical practice and their actual departure. DATA COLLECTION/EXTRACTION METHODS AMA Masterfile data on 2001 practice status were obtained for 967 of 968 physician respondents to the 1998 survey. Actual practice status for 2001 was directly ascertained for 957. PRINCIPAL FINDINGS The sensitivity of Masterfile practice status as a measure of actual departure from clinical practice was 9.0 percent, and the positive predictive value was 52.9 percent. Allowing for a two-year reporting lag did not change this substantially. Self-reported intention to leave clinical practice had a sensitivity of 73.3 percent and a positive predictive value of 35.4 percent as a measure of actual departure from practice. The strongest predictor of both intention to leave clinical practice and actual departure from practice was older age. Physician dissatisfaction had a strong association (OR=5.6) with intention to leave clinical practice, but was not associated with actual departure from practice. CONCLUSIONS Our findings call into question the accuracy of both AMA Masterfile data and physicians' self-reported intentions to leave as measures of physician attrition from clinical practice. Research using these measures should be interpreted with caution. Self-reported intention to leave practice may be more of a proxy for dissatisfaction than an accurate predictor of actual behavior.
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Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine, University of California, San Francisco, 500 Parnassus Avenue, Room MU 308-E, San Francisco, CA 94143-0900, USA
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Hill-Sakurai LE, Schillinger E, Rittenhouse DR, Fahrenbach R, Hudes ES, LeBaron S, Shore WB, Hearst N. Do required preclinical courses with family physicians encourage interest in family medicine? Fam Med 2003; 35:579-84. [PMID: 12947521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Many medical schools, including the University of California, San Francisco (UCSF), added required preclinical course work with family physicians in the 1990s. We examined whether current UCSF students interested in family medicine noted more contact with family physicians and more faculty support of their interest than current Stanford students and 1993 UCSF students, neither of whom had required preclinical course work with family physicians. METHODS A questionnaire was administered to students interested in family medicine at UCSF and Stanford in February 2001, with response rates of 84% and 90%, respectively. Previously published 1993 data from UCSF were also used for comparison. Data were analyzed using chi-square and t statistics as appropriate. RESULTS UCSF students in 2001, despite exposure to required preclinical course work with family physicians, did not perceive greater contact with family physicians than Stanford students. Stanford students perceived greater encouragement from their family medicine faculty but less from faculty overall, compared with 2001 UCSF students. UCSF students in 2001 perceived no more overall faculty encouragement than did UCSF students in 1993. CONCLUSIONS Required preclinical course work with family physicians was not consistently associated with greater student perception of faculty support for students' interest in family medicine, nor was it demonstrated to increase the amount or quality of interested students' interaction with family medicine faculty.
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Affiliation(s)
- Laura E Hill-Sakurai
- Department of Family and Community Medicine, University of California-San Francisco, 500 Parnassus Avenue, MU3E, San Francisco, CA 94143-0900, USA.
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Rittenhouse DR, Braveman P, Marchi K. Improvements in prenatal insurance coverage and utilization of care in California: an unsung public health victory. Matern Child Health J 2003; 7:75-86. [PMID: 12870623 DOI: 10.1023/a:1023812009298] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine trends in prenatal insurance coverage and utilization of care in California over two decades in the context of expansions in Medi-Cal (California's Medicaid) and other public efforts to increase prenatal care utilization. METHODS Retrospective univariate and bivariate analysis of prenatal care coverage and utilization data from 10,192,165 California birth certificates, 1980-99; descriptive analysis of California poverty and unemployment data from the U.S. Census Bureau Current Population Survey; review of public health and social policy literature. RESULTS The proportion of mothers with Medi-Cal coverage for prenatal care increased from 28.2 to 47.5% between 1989 and 1994, and the proportion uninsured throughout pregnancy decreased from 13.2 to 3.2%. Since the mid-1990s, fewer than 3% of women have had no insurance coverage for prenatal care. Between 1989 and 1999, the proportion of women with first trimester initiation of prenatal care increased from 72.6 to 83.6%, reversing the previous decade's trend, and the proportion of women with adequate numbers of visits rose from 70.7 to 83.1%. Improvements in utilization measures were greater among disadvantaged social groups. Improvements in California during the 1990s coincided with a multifaceted public health effort to increase both prenatal care coverage and utilization, and do not appear to be explained by changes in the economy, maternal characteristics, the overall organization/delivery of health care, or other social policies. CONCLUSIONS While this ecologic study cannot produce definitive conclusions regarding causality, these results suggest an important victory for public health in California.
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Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine, University of California-San Francisco, San Francisco, California 94143-0900, USA.
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Abstract
The structural variation of the gekkonid larynx and trachea is examined within a representative subset of 17 species of Afro-Madagascan gekkonines to determine if there are underlying morphological correlates of vocalization. The documented morphology is compared to that of the tokay (Gekko gecko), which has previously been described. Data were obtained from gross anatomical observations, scanning electron microscopy, histological examinations and computer-generated, three-dimensional, skeletal reconstructions. Although there is limited variation among most Afro-Malagasy gekkonids, the larynges of Ptenopus garrulus and Uroplatus fimbriatus exhibit marked degrees of differentiation, suggesting that laryngeal and tracheal morphology may account for the documented vocal variability of gekkonid lizards. Cladistic analyses indicated that parallel adaptive trends characterize the laryngeal morphology of the examined taxa. Alternate designs and refinements to a model of gekkonid phonation are presented, and the evolution of acoustic communication in the Gekkonidae is considered.
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Affiliation(s)
- A P Russell
- Vertebrate Morphology Research Group, Department of Biological Sciences, University of Calgary, Calgary, Alberta, Canada.
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Abstract
Emphysematous cystitis is a rare disorder most commonly seen in women and associated with urinary tract infections and poorly controlled diabetes mellitus. We report the case of a 76-year-old woman who presented with diarrhea and abdominal discomfort, and emphysematous cystitis was revealed on the abdominal X-ray series. This case is unique in that the patient had no evidence of urinary tract infection, diabetes, or recent instrumentation. As the patient was treated for emphysematous cystitis (bladder irrigation and intravenous antibiotics), the diarrhea rapidly resolved and the radiographic abnormalities of the emphysematous cystitis also resolved. This may suggest a causal relationship, although a specific mechanism is unknown.
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Affiliation(s)
- J Weddle
- Department of Surgery and Emergency Medicine, Hillcrest Health Center, Oklahoma City, OK 73119, USA
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Rittenhouse DR, Russell AP, Phillips DS. Morphological modeling via isosurfacing: the laryngeal skeleton of gekkonid lizards as a test case. Acta Anat (Basel) 1996; 155:282-90. [PMID: 8883540 DOI: 10.1159/000147817] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A novel technique for modeling microscopic anatomical structures in three dimensions was developed as part of a survey of gekkonid laryngeal skeletal morphology (Reptilia: Gekkonidae). Excised larynges were transversely sectioned at 10 microns and stained using standard procedures. With a projection microscope, outline drawings of the sectioned laryngeal cartilages were made at regular intervals, depending on the rate and degree of structural change observed while sampling. The drawing set was digitized with a flatbed scanner, and aligned using 'NIH Image' for Macintosh computers. Physical connectivity between successive outlines was provided by inserting one or more artificial slices between those that had been digitized, and draping a skin of rendered contours over all of the interstitial spaces present in the template. The Application Visualization System, a general purpose visualization package for UNIX-based computer systems, was used to visualize and render the resulting 'isosurfaces', which appear as solid three-dimensional objects and can be viewed from any perspective. Since isosurfaced reconstructions can be based on as little as 20% of the cross-sections available, this procedure has the potential to be a valuable research tool for future morphological work at the microscopic level.
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Affiliation(s)
- D R Rittenhouse
- Department of Biological Sciences, University of Calgary, Canada
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