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DHRUVA SANKETS, BACHHUBER MARCUSA, SHETTY ASHWIN, GUIDRY HAYDEN, GUDUGUNTLA VINAY, REDBERG RITAF. A Policy Approach to Reducing Low-Value Device-Based Procedure Use. Milbank Q 2022; 100:1006-1027. [PMID: 36573334 PMCID: PMC9836248 DOI: 10.1111/1468-0009.12595] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Policy Points Low-value care is common in clinical practice, leading to patient harm and wasted spending. Much of this low-value care stems from the use of medical device-based procedures. We describe here a novel academic-policymaker collaboration in which evidence-based clinical coverage for device-based procedures is implemented through prior authorization-based policies for Louisiana's Medicaid beneficiary population. This process involves eight steps: 1) identifying low-value medical device-based procedures based on clinical evidence review, 2) quantifying utilization and reimbursement, 3) reviewing clinical coverage policies to identify opportunities to align coverage with evidence, 4) using a low-value device selection index, 5) developing an evidence synthesis and policy proposal, 6) stakeholder engagement and input, 7) policy implementation, and 8) policy evaluation. This strategy holds significant potential to reduce low-value device-based care.
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Affiliation(s)
- SANKET S. DHRUVA
- University of California, San Francisco School of Medicine
- Philip R. Lee Institute for Health Policy StudiesUniversity of CaliforniaSan Francisco
| | - MARCUS A. BACHHUBER
- Louisiana State University Health Sciences Center School of Medicine
- Louisiana Department of Health
| | - ASHWIN SHETTY
- Louisiana State University Health Sciences Center School of Medicine
| | - HAYDEN GUIDRY
- Louisiana State University Health Sciences Center School of Medicine
| | | | - RITA F. REDBERG
- University of California, San Francisco School of Medicine
- Philip R. Lee Institute for Health Policy StudiesUniversity of CaliforniaSan Francisco
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2
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Zhou W, Jian W, Wang Z, Pan J, Hu M, Yip W. Impact of global budget combined with pay-for-performance on the quality of care in county hospitals: a difference-in-differences study design with a propaensity-score-matched control group using data from Guizhou province, China. BMC Health Serv Res 2021; 21:1296. [PMID: 34856985 PMCID: PMC8641159 DOI: 10.1186/s12913-021-07338-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Provider payment system has a profound impact on health system performance. In 2016, a number of counties in rural Guizhou, China, implemented global budget (GB) for county hospitals with quality control measures. The aim of this study is to measure the impact of GB combined with pay-for-performance on the quality of care of inpatients in county-level hospitals in China. METHODS Inpatient cases of four diseases, including pneumonia, chronic asthma, acute myocardial infarction and stroke, from 16 county-level hospitals in Guizhou province that implemented GB in 2016 were selected as the intervention group, and similar inpatient cases from 10 county-level hospitals that still implemented fee-for-services were used as the control group. Propensity matching score (PSM) was used for data matching to control for age factors, and difference-in-differences (DID) models were constructed using the matched samples to perform regression analysis on quality of care for the four diseases. RESULTS After the implementation of GB, rate of sputum culture in patients with pneumonia, rate of aspirin at discharge, rate of discharge with β-blocker and rate of smoking cessation advice in patients with acute myocardial infarction increased. Rate of oxygenation index assessment in patient with chronic asthma decreased 20.3%. There are no significant changes in other indicators of process quality. CONCLUSIONS The inclusion of pay-for-performance in the global budget payment system will help to reduce the quality risks associated with the reform of the payment system and improve the quality of care. Future reform should also consider the inclusion of the pay-for-performance mechanism.
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Affiliation(s)
- Wuping Zhou
- Department of Health Policy and Management, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Weiyan Jian
- Department of Health Policy and Management, School of Public Health, Peking University Health Science Center, Beijing, China.
| | - Zhifan Wang
- Department of Health Policy and Management, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Jay Pan
- West China Research Center for Rural Health Development, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Min Hu
- School of Public Health, Fudan University, Shanghai, China
| | - Winnie Yip
- Harvard School of Public Health, Boston, MA, USA
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3
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Song Z. Taking account of accountable care. Health Serv Res 2021; 56:573-577. [PMID: 34105147 PMCID: PMC8313947 DOI: 10.1111/1475-6773.13689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 12/28/2022] Open
Affiliation(s)
- Zirui Song
- Department of Health Care PolicyHarvard Medical SchoolBostonMassachusettsUSA
- Department of MedicineMassachusetts General HospitalBostonMassachusettsUSA
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Zaresani A, Scott A. Is the evidence on the effectiveness of pay for performance schemes in healthcare changing? Evidence from a meta-regression analysis. BMC Health Serv Res 2021; 21:175. [PMID: 33627112 PMCID: PMC7905606 DOI: 10.1186/s12913-021-06118-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 01/25/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND This study investigated if the evidence on the success of the Pay for Performance (P4P) schemes in healthcare is changing as the schemes continue to evolve by updating a previous systematic review. METHODS A meta-regression analysis using 116 studies evaluating P4P schemes published between January 2010 to February 2018. The effects of the research design, incentive schemes, use of incentives, and the size of the payment to revenue ratio on the proportion of statically significant effects in each study were examined. RESULTS There was evidence of an increase in the range of countries adopting P4P schemes and weak evidence that the proportion of studies with statistically significant effects have increased. Factors hypothesized to influence the success of schemes have not changed. Studies evaluating P4P schemes which made payments for improvement over time, were associated with a lower proportion of statistically significant effects. There was weak evidence of a positive association between the incentives' size and the proportion of statistically significant effects. CONCLUSION The evidence on the effectiveness of P4P schemes is evolving slowly, with little evidence that lessons are being learned concerning the design and evaluation of P4P schemes.
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Affiliation(s)
- Arezou Zaresani
- University of Manitoba, Institute for Labor Studies (IZA) and Tax and Transfer Policy Institute (TTPI), 15 Chancellors Circle, Fletcher Argue Building, Winnipeg, Manitoba, Canada.
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Viganego F, Um EK, Ruffin J, Fradley MG, Prida X, Friebel R. Impact of Global Budget Payments on Cardiovascular Care in Maryland: An Interrupted Time Series Analysis. Circ Cardiovasc Qual Outcomes 2021; 14:e007110. [PMID: 33622052 DOI: 10.1161/circoutcomes.120.007110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Global budget payments (GBP) are considered effective in containing health care expenditures; however, information on their impact on quality of cardiovascular care is limited. We aimed to evaluate the effects of GBP on utilization, outcomes, and costs for 3 major cardiovascular conditions. Methods We analyzed claims data of hospital admissions in Maryland from fiscal year 2013 to 2018. Using segmented regression, we evaluated temporal trends in hospitalizations, length of stay, percutaneous coronary intervention and coronary artery bypass grafting volumes, case mix-adjusted 30-day readmission rates, risk-standardized mortality rates, and hospitalization charges in patients with principal diagnosis of heart failure, acute ischemic stroke, and acute myocardial infarction (AMI) in relation to GBP implementation. Trends in global cardiovascular procedure charges/volumes were also studied. Results Hospitalization rates for congestive heart failure and AMI remained unaffected by GBP, while the gradient of ischemic stroke admissions decreased (Ptrend <0.0001). Length of stay slightly increased for patients with congestive heart failure (Ptrend=0.03). Inpatient coronary artery bypass grafting surgeries decreased (Ptrend <0.0001). We observed a significant decrease in casemix-adjusted 30-day readmission rate in the AMI cohort beyond the prepolicy trend (Ptrend=0.0069). There were no significant changes in mortality for any of the 3 conditions. Hospitalization charges increased for ischemic stroke (Ptrend <0.0001), remained constant for congestive heart failure (Ptrend=0.1), and decreased for AMI (Ptrend=0.0005). We observed a significant increase in electrocardiography rate charges (Ptrend <0.0001), coincidentally with a reduction in volumes (Ptrend=0.0003). Conclusions Introducing GBP in Maryland had no perceivable adverse effects on inpatient outcomes and quality indicators for 3 major cardiovascular conditions. Savings were observed in the AMI cohort, possibly due to reduced unnecessary readmissions, efficiency improvements, or shifts to outpatient care. Reduced cardiovascular procedure volumes were counterbalanced by a proportional rise in charges. State-level adoption of GBP with pay-for-performance incentives may be effective for cost containment without adversely impacting quality of cardiovascular care.
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Affiliation(s)
| | - Eun K Um
- AMSTAT Consulting, LLC, Bethesda, MD (A.E.K.U., J.R.)
| | | | - Michael G Fradley
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, Philadelphia (M.G.F.)
| | - Xavier Prida
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa (X.P.)
| | - Rocco Friebel
- Department of Health Policy, London School of Economics and Political Science, United Kingdom (R.F.)
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6
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Oakes AH, Sen AP, Segal JB. The impact of global budget payment reform on systemic overuse in Maryland. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100475. [PMID: 33027725 DOI: 10.1016/j.hjdsi.2020.100475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/13/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Medical overuse is a leading contributor to the high cost of the US health care system and is a definitive misuse of resources. Elimination of overuse could improve health care efficiency. In 2014, the State of Maryland placed the majority of its hospitals under an all-payer, annual, global budget for inpatient and outpatient hospital services. This program aims to control hospital use and spending. OBJECTIVE To assess whether the Maryland global budget program was associated with a reduction in the broad overuse of health care services. METHODS We conducted a retrospective analysis of deidentified claims for 18-64 year old adults from the IBM MarketScan® Commercial Claims and Encounters Database. We matched 2 Maryland Metropolitan Statistical Areas (MSAs) to 6 out-of-state comparison MSAs. In a difference-in-differences analysis, we compared changes in systemic overuse in Maryland vs the comparison MSAs before (2011-2013) and after implementation (2014-2015) of the global budget program. Systemic overuse was measured using a semiannual Johns Hopkins Overuse Index. RESULTS Global budgets were not associated with a reduction in systemic overuse. Over the first 1.5 years of the program, we estimated a nonsignificant differential change of -0.002 points (95%CI, -0.372 to 0.369; p = 0.993) relative to the comparison group. This result was robust to multiple model assumptions and sensitivity analyses. CONCLUSIONS We did not find evidence that Maryland hospitals met their revenue targets by reducing systemic overuse. Global budgets alone may be too blunt of an instrument to selectively reduce low-value care.
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Affiliation(s)
- Allison H Oakes
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA, USA; Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, PA, USA.
| | - Aditi P Sen
- Johns Hopkins University Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA; Center for Health Services and Outcomes Research of the Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jodi B Segal
- Johns Hopkins University Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA; Center for Health Services and Outcomes Research of the Bloomberg School of Public Health, Baltimore, MD, USA; Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD, USA
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7
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Dinh CT, Linn KA, Isidro U, Emanuel EJ, Volpp KG, Bond AM, Caldarella K, Troxel AB, Zhu J, Yang L, Matloubieh SE, Drye E, Bernheim S, Lee EO, Mugiishi M, Endo KT, Yoshimoto J, Yuen I, Okamura S, Tom J, Navathe AS. Changes in Outpatient Imaging Utilization and Spending Under a New Population-Based Primary Care Payment Model. J Am Coll Radiol 2020; 17:101-109. [DOI: 10.1016/j.jacr.2019.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/10/2019] [Accepted: 08/12/2019] [Indexed: 01/07/2023]
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Maratt JK, Kerr EA, Klamerus ML, Lohman SE, Froehlich W, Bhatia RS, Saini SD. Measures Used to Assess the Impact of Interventions to Reduce Low-Value Care: a Systematic Review. J Gen Intern Med 2019; 34:1857-1864. [PMID: 31250366 PMCID: PMC6712188 DOI: 10.1007/s11606-019-05069-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/02/2019] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
Abstract
IMPORTANCE Studies of interventions to reduce low-value care are increasingly common. However, little is known about how the effects of such interventions are measured. OBJECTIVE To characterize measures used to assess interventions to reduce low-value care. EVIDENCE REVIEW We searched PubMed and Web of Science to identify studies published between 2010 and 2016 that examined the effects of interventions to reduce low-value care. We also searched ClinicalTrials.gov to identify ongoing studies. We extracted data on characteristics of studies, interventions, and measures. We then developed a framework to classify measures into the following categories: utilization (e.g., number of tests ordered), outcome (e.g., mortality), appropriateness (e.g., overuse of antibiotics), patient-reported (e.g., satisfaction), provider-reported (e.g., satisfaction), patient-provider interaction (e.g., informed decision-making elements), value, and cost. We also determined whether each measure was designed to assess unintended consequences. FINDINGS A total of 1805 studies were identified, of which 101 published and 16 ongoing studies were included. Of published studies (N = 101), 68% included at least one measure of utilization, 41% of an outcome, 52% of appropriateness, 36% of cost, 8% patient-reported, and 3% provider-reported. Funded studies were more likely to use patient-reported measures (17% vs 0%). Of ongoing studies (registered trials) (N = 16), 69% included at least one measure of utilization, 75% of an outcome, 50% of appropriateness, 19% of cost, 50% patient-reported, 13% provider-reported, and 6% patient-provider interaction. Of published studies, 34% included at least one measure of an unintended consequence as compared to 63% of ongoing studies. CONCLUSIONS AND RELEVANCE Most published studies focused on reductions in utilization rather than on clinically meaningful measures (e.g., improvements in appropriateness, patient-reported outcomes) or unintended consequences. Investigators should systematically incorporate more clinically meaningful measures into their study designs, and sponsors should develop standardized guidance for the evaluation of interventions to reduce low-value care.
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Affiliation(s)
- Jennifer K Maratt
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - Eve A Kerr
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Mandi L Klamerus
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Whit Froehlich
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - R Sacha Bhatia
- Department of Internal Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, USA
| | - Sameer D Saini
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
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9
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Cattel D, Eijkenaar F. Value-Based Provider Payment Initiatives Combining Global Payments With Explicit Quality Incentives: A Systematic Review. Med Care Res Rev 2019; 77:511-537. [PMID: 31216945 PMCID: PMC7536531 DOI: 10.1177/1077558719856775] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
An essential element in the pursuit of value-based health care is provider payment reform. This article aims to identify and analyze payment initiatives comprising a specific manifestation of value-based payment reform that can be expected to contribute to value in a broad sense: (a) global base payments combined with (b) explicit quality incentives. We conducted a systematic review of the literature, consulting four scientific bibliographic databases, reference lists, the Internet, and experts. We included and compared 18 initiatives described in 111 articles/documents on key design features and impact on value. The initiatives are heterogeneous regarding the operationalization of the two payment components and associated design features. Main commonalities between initiatives are a strong emphasis on primary care, the use of "virtual" spending targets, and the application of risk adjustment and other risk-mitigating measures. Evaluated initiatives generally show promising results in terms of lower spending growth with equal or improved quality.
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10
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Sandoval GA, Brown AD, Wodchis WP, Anderson GM. The relationship between hospital adoption and use of high technology medical imaging and in-patient mortality and length of stay. J Health Organ Manag 2019; 33:286-303. [PMID: 31122120 DOI: 10.1108/jhom-08-2018-0232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to investigate the relationship between hospital adoption and use of computed tomography (CT) scanners, and magnetic resonance imaging (MRI) machines and in-patient mortality and length of stay. DESIGN/METHODOLOGY/APPROACH This study used panel data (2007-2010) from 124 hospital corporations operating in Ontario, Canada. Imaging use focused on medical patients accounting for 25 percent of hospital discharges. Main outcomes were in-hospital mortality rates and average length of stay. A model for each outcome-technology combination was built, and controlled for hospital structural characteristics, market factors and patient characteristics. FINDINGS In 2010, 36 and 59 percent of hospitals had adopted MRI machines and CT scanners, respectively. Approximately 23.5 percent of patients received CT scans and 3.5 percent received MRI scans during the study period. Adoption of these technologies was associated with reductions of up to 1.1 percent in mortality rates and up to 4.5 percent in length of stay. The imaging use-mortality relationship was non-linear and varied by technology penetration within hospitals. For CT, imaging use reduced mortality until use reached 19 percent in hospitals with one scanner and 28 percent in hospitals with 2+ scanners. For MRI, imaging use was largely associated with decreased mortality. The use of CT scanners also increased length of stay linearly regardless of technology penetration (4.6 percent for every 10 percent increase in use). Adoption and use of MRI was not associated with length of stay. RESEARCH LIMITATIONS/IMPLICATIONS These results suggest that there may be some unnecessary use of imaging, particularly in small hospitals where imaging is contracted out. In larger hospitals, the results highlight the need to further investigate the use of imaging beyond certain thresholds. Independent of the rate of imaging use, the results also indicate that the presence of CT and MRI devices within a hospital benefits quality and efficiency. ORIGINALITY/VALUE To the authors' knowledge, this study is the first to investigate the combined effect of adoption and use of medical imaging on outcomes specific to CT scanners and MRI machines in the context of hospital in-patient care.
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Affiliation(s)
- Guillermo A Sandoval
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
| | - Adalsteinn D Brown
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
| | - Geoffrey M Anderson
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
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Sandoval GA, Brown AD, Wodchis WP, Anderson GM. Adoption of high technology medical imaging and hospital quality and efficiency: Towards a conceptual framework. Int J Health Plann Manage 2018; 33. [PMID: 29770971 DOI: 10.1002/hpm.2547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 11/11/2022] Open
Abstract
Measuring the value of medical imaging is challenging, in part, due to the lack of conceptual frameworks underlying potential mechanisms where value may be assessed. To address this gap, this article proposes a framework that builds on the large body of literature on quality of hospital care and the classic structure-process-outcome paradigm. The framework was also informed by the literature on adoption of technological innovations and introduces 2 distinct though related aspects of imaging technology not previously addressed specifically in the literature on quality of hospital care: adoption (a structural hospital characteristic) and use (an attribute of the process of care). The framework hypothesizes a 2-part causality where adoption is proposed to be a central, linking factor between hospital structural characteristics, market factors, and hospital outcomes (ie, quality and efficiency). The first part indicates that hospital structural characteristics and market factors influence or facilitate the adoption of high technology medical imaging within an institution. The presence of this technology, in turn, is hypothesized to improve the ability of the hospital to deliver high quality and efficient care. The second part describes this ability throughout 3 main mechanisms pointing to the importance of imaging use on patients, to the presence of staff and qualified care providers, and to some elements of organizational capacity capturing an enhanced clinical environment. The framework has the potential to assist empirical investigations of the value of adoption and use of medical imaging, and to advance understanding of the mechanisms that produce quality and efficiency in hospitals.
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Affiliation(s)
- Guillermo A Sandoval
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Ontario, Canada
| | - Adalsteinn D Brown
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Ontario, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Ontario, Canada
| | - Geoffrey M Anderson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Ontario, Canada
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Utilization Trends in Diagnostic Imaging for a Commercially Insured Population: A Study of Massachusetts Residents 2009 to 2013. J Am Coll Radiol 2018; 15:834-841. [PMID: 29661520 DOI: 10.1016/j.jacr.2018.02.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/14/2018] [Accepted: 02/22/2018] [Indexed: 01/17/2023]
Abstract
PURPOSE To report utilization trends in diagnostic imaging among commercially insured Massachusetts residents from 2009 to 2013. MATERIALS AND METHODS Current Procedural Terminology codes were used to identify diagnostic imaging claims in the Massachusetts All-Payer Claims Database for the years 2009 to 2013. We reported utilization and spending annually by imaging modality using total claims, claims per 1,000 individuals, total expenditures, and average per claim payments. RESULTS The number of diagnostic imaging claims per insured MA resident increased only 0.6% from 2009 to 2013, whereas nonradiology claims increased by 6% annually. Overall diagnostic imaging expenditures, adjusted for inflation, were 27% lower in 2009 than 2013, compared with an 18% increase in nonimaging expenditures. Average payments per claim were lower in 2013 than 2009 for all modalities except nuclear medicine. Imaging procedure claims per 1,000 MA residents increased from 2009 to 2013 by 13% in MRI, from 147 to 166; by 17% in ultrasound, from 453 to 530; and by 12% in radiography (x-ray), from 985 to 1,100. However, CT claims per 1,000 fell by 37%, from 341 to 213, and nuclear medicine declined 57%, from 89 claims per 1,000 to 38. CONCLUSION Diagnostic imaging utilization exhibited negligible growth over the study period. Diagnostic imaging expenditures declined, largely the result of falling payments per claim in most imaging modalities, in contrast with increased utilization and spending on nonimaging services. Utilization of MRI, ultrasound, and x-ray increased from 2009 to 2013, whereas CT and nuclear medicine use decreased sharply, although CT was heavily impacted by billing code changes.
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Colla CH, Morden NE, Sequist TD, Mainor AJ, Li Z, Rosenthal MB. Payer Type and Low-Value Care: Comparing Choosing Wisely Services across Commercial and Medicare Populations. Health Serv Res 2017; 53:730-746. [PMID: 28217968 DOI: 10.1111/1475-6773.12665] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To compare low-value health service use among commercially insured and Medicare populations and explore the influence of payer type on the provision of low-value care. DATA SOURCES 2009-2011 national Medicare and commercial insurance administrative data. DESIGN We created claims-based algorithms to measure seven Choosing Wisely-identified low-value services and examined the correlation between commercial and Medicare overuse overall and at the regional level. Regression models explored associations between overuse and regional characteristics. METHODS We created measures of early imaging for back pain, vitamin D screening, cervical cancer screening over age 65, prescription opioid use for migraines, cardiac testing in asymptomatic patients, short-interval repeat bone densitometry (DXA), preoperative cardiac testing for low-risk surgery, and a composite of these. PRINCIPAL FINDINGS Prevalence of four services was similar across the insurance-defined groups. Regional correlation between Medicare and commercial overuse was high (correlation coefficient = 0.540-0.905) for all measures. In both groups, similar region-level factors were associated with low-value care provision, especially total Medicare spending and ratio of specialists to primary care physicians. CONCLUSIONS Low-value care appears driven by factors unrelated to payer type or anticipated reimbursement. These findings suggest the influence of local practice patterns on care without meaningful discrimination by payer type.
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Affiliation(s)
| | | | - Thomas D Sequist
- Department of Health Care Policy, Harvard Medical School, Boston, MA.,Partners Healthcare System, Boston, MA.,Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, MA
| | | | - Zhonghe Li
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
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Abstract
This article reviews the literature on the use of financial incentives to improve the provision of value-based health care. Eighty studies of 44 schemes from 10 countries were reviewed. The proportion of positive and statistically significant outcomes was close to .5. Stronger study designs were associated with a lower proportion of positive effects. There were no differences between studies conducted in the United States compared with other countries; between schemes that targeted hospitals or primary care; or between schemes combining pay for performance with rewards for reducing costs, relative to pay for performance schemes alone. Paying for performance improvement is less likely to be effective. Allowing payments to be used for specific purposes, such as quality improvement, had a higher likelihood of a positive effect, compared with using funding for physician income. Finally, the size of incentive payments relative to revenue was not associated with the proportion of positive outcomes.
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Affiliation(s)
- Anthony Scott
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Miao Liu
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Jongsay Yong
- The University of Melbourne, Melbourne, Victoria, Australia
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15
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Colla CH, Mainor AJ, Hargreaves C, Sequist T, Morden N. Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review. Med Care Res Rev 2016; 74:507-550. [PMID: 27402662 DOI: 10.1177/1077558716656970] [Citation(s) in RCA: 208] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The effectiveness of different types of interventions to reduce low-value care has been insufficiently summarized to allow for translation to practice. This article systematically reviews the literature on the effectiveness of interventions to reduce low-value care and the quality of those studies. We found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care. Clinical decision support and performance feedback are promising strategies with a solid evidence base, and provider education yields changes by itself and when paired with other strategies. Further research is needed on the effectiveness of pay-for-performance, insurer restrictions, and risk-sharing contracts to reduce use of low-value care. While the literature reveals important evidence on strategies used to reduce low-value care, meaningful gaps persist. More experimentation, paired with rigorous evaluation and publication, is needed.
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Affiliation(s)
- Carrie H Colla
- 1 Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | | | - Thomas Sequist
- 2 Harvard Medical School, Boston, MA, USA.,3 Brigham and Women's Hospital, Boston, MA, USA.,4 Partners HealthCare, Boston, MA, USA
| | - Nancy Morden
- 1 Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,5 Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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16
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Frontiers in Medical Device Design: An Approach for Making Arthroplasty Affordable Globally. J Am Acad Orthop Surg 2015; 23:e58-9. [PMID: 26320163 DOI: 10.5435/jaaos-d-15-00350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Indexed: 02/01/2023] Open
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17
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Affiliation(s)
- Xiaoyan Huang
- From Providence Heart Clinic, Portland, OR (X.H.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (M.B.R.).
| | - Meredith B Rosenthal
- From Providence Heart Clinic, Portland, OR (X.H.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (M.B.R.)
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18
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Song Z, Rose S, Safran DG, Landon BE, Day MP, Chernew ME. Changes in health care spending and quality 4 years into global payment. N Engl J Med 2014; 371:1704-14. [PMID: 25354104 PMCID: PMC4261926 DOI: 10.1056/nejmsa1404026] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Spending and quality under global budgets remain unknown beyond 2 years. We evaluated spending and quality measures during the first 4 years of the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC). METHODS We compared spending and quality among enrollees whose physician organizations entered the AQC from 2009 through 2012 with those among persons in control states. We studied spending changes according to year, category of service, site of care, experience managing risk contracts, and price versus utilization. We evaluated process and outcome quality. RESULTS In the 2009 AQC cohort, medical spending on claims grew an average of $62.21 per enrollee per quarter less than it did in the control cohort over the 4-year period (P<0.001). This amount is equivalent to a 6.8% savings when calculated as a proportion of the average post-AQC spending level in the 2009 AQC cohort. Analogously, the 2010, 2011, and 2012 cohorts had average savings of 8.8% (P<0.001), 9.1% (P<0.001), and 5.8% (P=0.04), respectively, by the end of 2012. Claims savings were concentrated in the outpatient-facility setting and in procedures, imaging, and tests, explained by both reduced prices and reduced utilization. Claims savings were exceeded by incentive payments to providers during the period from 2009 through 2011 but exceeded incentive payments in 2012, generating net savings. Improvements in quality among AQC cohorts generally exceeded those seen elsewhere in New England and nationally. CONCLUSIONS As compared with similar populations in other states, Massachusetts AQC enrollees had lower spending growth and generally greater quality improvements after 4 years. Although other factors in Massachusetts may have contributed, particularly in the later part of the study period, global budget contracts with quality incentives may encourage changes in practice patterns that help reduce spending and improve quality. (Funded by the Commonwealth Fund and others.).
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Affiliation(s)
- Zirui Song
- From the Department of Medicine, Massachusetts General Hospital (Z.S.), Department of Health Care Policy, Harvard Medical School (Z.S., S.R., B.E.L., M.E.C.), Blue Cross Blue Shield of Massachusetts (D.G.S., M.P.D.), the Department of Medicine, Tufts University School of Medicine (D.G.S.), and the Department of Medicine, Beth Israel Deaconess Medical Center (B.E.L.) - all in Boston; and the National Bureau of Economic Research, Cambridge, MA (Z.S., M.E.C.)
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Song Z. Accountable Care Organizations in the U.S. Health Care System. JOURNAL OF CLINICAL OUTCOMES MANAGEMENT : JCOM 2014; 21:364-371. [PMID: 25960631 PMCID: PMC4422096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Zirui Song
- Department of Medicine, Massachusetts General Hospital, Boston, MA. Harvard Medical School, Boston, MA
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20
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Accelerating change: Fostering innovation in healthcare delivery at academic medical centers. Healthcare (Basel) 2014; 2:9-13. [DOI: 10.1016/j.hjdsi.2013.12.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 12/05/2013] [Accepted: 12/12/2013] [Indexed: 01/17/2023] Open
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21
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Frakt AB. The end of hospital cost shifting and the quest for hospital productivity. Health Serv Res 2013; 49:1-10. [PMID: 24102445 DOI: 10.1111/1475-6773.12105] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Austin B Frakt
- VA Boston Healthcare System, Boston, MA; Boston University School of Medicine and School of Public Health, Boston, MA; Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
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