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Chhoda A, McHenry N, Liyen Cartelle A, Bocchino R, Kahan T, Shah I, Zuberi SA, Anderson K, Freedman SD, Sheth SG. Impact of Ethno-racial Factors on Clinical Outcomes and Health Care Utilization in Chronic Pancreatitis. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02017-w. [PMID: 38702491 DOI: 10.1007/s40615-024-02017-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 04/17/2024] [Accepted: 04/28/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Healthcare disparities adversely affect clinical outcomes in racial and ethnic minorities. Chronic pancreatitis (CP) is a complex disorder, and pressures for time and cost-containment may amplify the disparity for minorities in this condition. This study aimed to assess ethno-racial differences in the clinical outcomes of CP patients cared for at our institution. METHODS This is a study of CP patients with available ethno-racial information followed at our pancreas center. We reviewed their demographics, comorbidities, clinical outcomes, and resource utilization: pain, frequent flares (≥ 2/year), local complications, psychosocial variables, exocrine, and endocrine insufficiency, imaging, endoscopic procedures, and surgeries. The outcomes underwent logistic regression to ascertain association(s) with covariates and were expressed as odds ratio (95% confidence intervals). RESULTS Of the 445 CP patients, there were 23 Hispanics, 330 Non-Hispanic Whites, 47 Non-Hispanic Blacks, 16 Asian Americans, and 29 patients from Other/mixed races. Over a median follow-up of 7 years, no significant differences in the pain profile (p = 0.36), neuromodulator use (p = 0.94), and opioid use for intermittent (p = 0.34) and daily pain (p = 0.80) were observed. Frequent flares were associated with Hispanic ethnicity [2.98(1.20-7.36); p = 0.02], despite adjustment for smoking [2.21(1.11-4.41); p = 0.02)] and alcohol [1.88(1.06-3.35); p = 0.03]. Local complications (pseudocysts, mesenteric thrombosis, and biliary obstruction), exocrine and endocrine dysfunction, and healthcare resource utilization (cross-sectional imaging, endoscopic procedures, celiac blocks, or surgeries) were comparable across all ethno-racial groups. CONCLUSIONS Although no significant differences in clinical outcomes, and health resource utilization were noted across ethno-racial groups, Hispanic ethnicity had significant association with CP flares. This study calls for further investigation of an understudied minority population with CP.
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Affiliation(s)
- Ankit Chhoda
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Nicole McHenry
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Anabel Liyen Cartelle
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Rachel Bocchino
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Tamara Kahan
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Ishani Shah
- Division of Gastroenterology, University of Utah Hospital, Salt Lake City, USA
| | - Shaharyar A Zuberi
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Kelsey Anderson
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Steven D Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA.
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Adjei J, Tang M, Lipa S, Oyekan A, Woods B, Mesfin A, Hogan MV. Addressing the Impact of Race and Ethnicity on Musculoskeletal Spine Care in the United States. J Bone Joint Surg Am 2024; 106:631-638. [PMID: 38386767 DOI: 10.2106/jbjs.22.01155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
➤ Despite being a social construct, race has an impact on outcomes in musculoskeletal spine care.➤ Race is associated with other social determinants of health that may predispose patients to worse outcomes.➤ The musculoskeletal spine literature is limited in its understanding of the causes of race-related outcome trends.➤ Efforts to mitigate race-related disparities in spine care require individual, institutional, and national initiatives.
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Affiliation(s)
- Joshua Adjei
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa Tang
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Shaina Lipa
- Department of Orthopedic Surgery, Brigham and Woman's Hospital, Boston, Massachusetts
| | - Anthony Oyekan
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Barrett Woods
- Department of Orthopedic Surgery, Rothman Orthopedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Addisu Mesfin
- Department of Orthopaedic Surgery, Medstar Orthopaedic Institute, Georgetown University School of Medicine, Washington, DC
| | - MaCalus V Hogan
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Abrantes T, Imbriano D, Reimann D, Sullivan J, Wisco O, Chan S, DiMarco C, Gehret N, Grenier N, Imbriano P, Kahn B, Lizbinski L, Massoud C, Negbenebor N, Parra S, Patel D, Reeder M, Robbins A, Takeshita J, Yang EJ, Braxton SC, Elston D. Performance measurement part I: Foundational knowledge for measure development. J Am Acad Dermatol 2024; 90:681-689. [PMID: 37343833 DOI: 10.1016/j.jaad.2023.01.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/21/2022] [Accepted: 01/11/2023] [Indexed: 06/23/2023]
Abstract
As medicine is moving toward performance and outcome-based payment and is transitioning away from productivity-based systems, value is now being appraised in healthcare through "performance measures." Over the past few decades, assessment of clinical performance in health care has been essential in ensuring safe and cost-effective patient care. The Centers for Medicare & Medicaid Services is further driving this change with measurable, outcomes-based national payer incentive payment systems. With the continually evolving requirements in health care reform focused on value-based care, there is a growing concern that clinicians, particularly dermatologists, may not understand the scientific rationale of health care quality measurement. As such, in order to help dermatologists understand the health care measurement science landscape to empower them to engage in the performance measure development and implementation process, the first article in this 2-part continuing medical education series reviews the value equation, historic and evolving policy issues, and the American Academy of Dermatology's approach to performance measurement development to provide the required foundational knowledge for performance measure developers.
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Affiliation(s)
- Tatiana Abrantes
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Dillon Imbriano
- University of New England College of Osteopathic Medicine, Biddeford, Maine
| | | | | | - Oliver Wisco
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island.
| | - Stephanie Chan
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Christopher DiMarco
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nicole Gehret
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nicole Grenier
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Paul Imbriano
- Berkshire Medical Center of Massachusetts, Pittsfield, Massachusetts
| | - Benjamin Kahn
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Leonardo Lizbinski
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Cathy Massoud
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nicole Negbenebor
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Sylvia Parra
- Dermatology and Skin Surgery Incorporated of Sumter, Sumter, South Carolina
| | | | - Margo Reeder
- The University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Allison Robbins
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Junko Takeshita
- The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Eric J Yang
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Dirk Elston
- The Medical University of South Carolina, Charleston, South Carolina
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Newton D, Bader AM. Value-Based Health Care in Perioperative Medicine: Process Maps and Costing to Determine Best Practices. Anesthesiol Clin 2024; 42:75-86. [PMID: 38278594 DOI: 10.1016/j.anclin.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
Perioperative care in the United States is largely based on current fee-for-service models. Fee-for-service models are not based on the true cost of services provided, charges do not equal costs, and reimbursement varies based on insurer. Value-based health care is defined as patient-centered outcomes over cost of providing these services. Process mapping and time-driven activity-based costing can be used to define actual cost of services provided. Outcomes after discharge can be measured, so that the overall value of care provided can be assessed and improved based on the outcomes and costs identified.
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Affiliation(s)
- David Newton
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
| | - Angela M Bader
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Olm-Shipman C, Moheet AM. Quality Improvement in Neurocritical Care. Crit Care Clin 2023; 39:17-28. [DOI: 10.1016/j.ccc.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Goldberg ZN, Nash DB. The Emerging Value-Based Care Industry: Paving the Road Ahead. Am J Med Qual 2022; 37:472-474. [PMID: 35647932 DOI: 10.1097/jmq.0000000000000067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Zachary N Goldberg
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - David B Nash
- Jefferson College of Population Health, Philadelphia, PA
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Wang XJ, Borah B, Rojas R, Kamath MJ, Moriarty J, Allen AM, Kamath PS. Patients Hospitalized for Complications of Cirrhosis may Have Benefited From Medicaid Expansion Under the Affordable Care Act. Mayo Clin Proc Innov Qual Outcomes 2022; 6:291-301. [PMID: 35722655 PMCID: PMC9198455 DOI: 10.1016/j.mayocpiqo.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective The benefit of the Affordable Care Act (ACA) for patients with cirrhosis is unclear. We determined the impact of ACA expansion on outcomes in patients hospitalized for complications of cirrhosis. Patients and Methods We compared hospitalizations; in-hospital outcomes; and readmissions among patients with cirrhosis identified using International Classification of Diseases, Ninth Revision, and International Classification of Diseases, 10th Revision, codes in states that expanded Medicaid under ACA (expanded [E] states) and those that did not (nonexpanded [NE] states). Data from the State Inpatient Databases were obtained for 3 pairs of contiguous E and NE states with both pre-ACA expansion and post-ACA expansion data. The difference-in-difference analysis was performed to compare the pre- and post-ACA data between the E and NE states. The outcomes were admission rates, hospital complications, resource utilization, length of stay, in-hospital mortality, discharge destination, cost of initial hospitalization, and readmission characteristics. Results There were 228,349 admissions (E states, 149,705; NE states, 78,644). After ACA implementation, the E states had lower rates of admission increase per 100,000 population (22.9 in E states vs 25.5 in NE states, P=.005), sepsis (relative risk, 0.884; P=.0084), and hepatic coma (relative risk, 0.763; P<.001) than the NE states. The length of stay was lower by 0.21 days (P=.00028), with a $587.40 lower cost per hospitalization (P=.00091), in the E states than in the NE states. The readmission rates within 30, 60, and 90 days decreased in the E states after ACA implementation but increased in the NE states after ACA implementation. Conclusion Among patients hospitalized for cirrhosis, quality indicators, such as the rate of admission increase, complications, costs, and readmissions, were more favorable in the states that expanded Medicaid. Medicaid expansion under ACA may have benefited patients with cirrhosis.
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Affiliation(s)
- Xiao Jing Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Bijan Borah
- Division of Health Care Policy and Research, Section of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Ricardo Rojas
- Division of Health Care Policy and Research, Section of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - James Moriarty
- Division of Health Care Policy and Research, Section of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Alina M Allen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Catastrophic Health Expenditures With Pregnancy and Delivery in the United States. Obstet Gynecol 2022; 139:509-520. [PMID: 35271537 PMCID: PMC9124691 DOI: 10.1097/aog.0000000000004704] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/30/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe prevalence, trends, and risk factors for catastrophic health expenditures in the year of delivery among birth parents (delivering people). METHODS We conducted a retrospective, cross-sectional study of the Medical Expenditure Panel Survey from 2008-2016. We identified newborn birth parents and a 2:1 nearest-neighbor propensity-matched control cohort of nonpregnant reproductive-aged individuals, then assessed for catastrophic health expenditures (spending greater than 10% of family income) in the delivery year. We applied survey weights to extrapolate to the noninstitutionalized U.S. population and used the adjusted Wald test for significance testing. We compared risk of catastrophic health expenditures between birth parents and the control cohort and described time trends and risk factors for catastrophic spending with subgroup comparisons. RESULTS We analyzed 4,056 birth parents and 7,996 reproductive-aged females without pregnancy in a given year. Birth parents reported higher rates of unemployment (52.6% vs 46.6%, P<.001), and high rates of gaining (22.4%) and losing (25.6%) Medicaid in the delivery year. Birth parents were at higher risk of catastrophic health expenditures (excluding premiums: 9.2% vs 6.8%, odds ratio [OR] 1.95, 95% CI 1.61-2.34; including premiums: 21.3% vs 18.4%, OR 1.53, 95% CI 1.32-1.82). Birth parents living on low incomes had the highest risk of catastrophic health expenditures (18.8% vs 0.7% excluding premiums for 138% or less vs greater than 400% of the federal poverty level, relative risk [RR] 26.9; 29.8% vs 5.9% including premiums, RR 5.1). For birth parents living at low incomes, public insurance was associated with lower risks of catastrophic health expenditures than private insurance, particularly when including premium spending (incomes 138% of the federal poverty level or lower: 18.8% public vs 67.9% private, RR 0.28; incomes 139-250% of the federal poverty level: 6.5% public vs 41.1% private, RR 0.16). The risk of catastrophic spending for birth parents did not change significantly over time from before to after Affordable Care Act implementation. CONCLUSION Pregnancy and delivery are associated with increased risk of catastrophic health expenditures in the delivery year. Medicaid and public coverage were more protective from high out-of-pocket costs than private insurance, particularly among low-income families.
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Henretty KN, He F. Trends in Orthopedic Surgeon Practice Consolidation From 2008 to 2019. J Arthroplasty 2022; 37:409-413. [PMID: 34780926 DOI: 10.1016/j.arth.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/01/2021] [Accepted: 11/08/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In the past decade, physician practices have merged into larger group practices (ie, horizontal consolidation) and have been acquired by hospitals and health systems (ie, vertical consolidation), leaving fewer practices independent. The implications of these changes can be profound, affecting the prices for and spending on physician services, access to care, patients' choice of providers, and quality of care. METHODS We used IQVIA data on orthopedic surgeon practice sites that included information on health system or hospital ownership, group medical practice participation, and average patient volume. We calculated the number and size of group medical practices as measures of horizontal consolidation and the percentage of practice sites owned by a health system or hospital as a measure of vertical consolidation. We also calculated the Herfindahl-Hirschman Index to measure market concentration. RESULTS We found significant horizontal and vertical consolidation nationally and across all regions of the United States. This consolidation has led to much more concentrated markets, as measured by Herfindahl-Hirschman Index, for orthopedic surgeon services. These trends are consistent with studies looking at consolidation of other types of providers. CONCLUSION Orthopedic surgeon practices, like other provider types, have consolidated at a rapid rate over the past decade. A variety of factors may have contributed, including the move away from fee-for-service to alternative payment arrangements, changes in Medicare payment policies, private equity activity, and evolving physician preferences. Due to the potential impacts of this consolidation, more research is needed to examine some of these contributing factors.
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Affiliation(s)
| | - Fang He
- RTI International, Chicago, IL
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10
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Simon B, Amelung VE. [10 Years Accountable Care Organizations in the USA: Impulses for Health Care Reform in Germany?]. DAS GESUNDHEITSWESEN 2022; 84:e12-e24. [PMID: 35114697 DOI: 10.1055/a-1718-3332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
GOAL OF THE STUDY An intent of the Patient Protection and Affordable Care Acts (ACA), also know as Obama Care, was to slow the expenditure growth in the public Medicare-System by shifting the accountability for health care outcomes and costs to the provider. For this purpose, provider were allowed to form networks, which would then take accountability for a defined population - Accountable Care Organizations (ACOs). Ten years after the introduction of ACOs, this paper looks at the impact of ACOs both on quality of care and costs of care to assess if ACOs can be a model of care delivery for Germany. METHODS In a mixed-method approach, a rapid review was conducted in Health System Evidence and PubMed. This was supported with further papers identified using the snowballing-technique. After screening the abstracts, we included articles containing information on cost- and/or quality impact of US-Medicare-ACOs. The findings of the rapid review were challenged with 16 ACO-experts and stakeholder in the USA. RESULTS In total, we included 60 publications which incorporated 6 reports that were either conducted directly by governmental institutions or ordered by them, along with 3 previous reviews. Among these, 31 contained information on costs of care, 18 contained information on quality of care and 11 had information on both aspects. The publications show that ACOs reduced costs of of care. Cost reductions were achieved compared to historic costs, to populations not cared for in ACOs, and counterfactuals. Quality of care stayed the same or improved. CONCLUSION ACOs contributed to slowing the cost growth in US Medicare without compromising quality of care. Thus, a transferal of this model of care to Germany should be considered. However, various policies have led to ACOs failing to unleash their full potential. Against this background, and against the background of stark differences between US Medicare and the German health care system, a critical reflection of the necessary policies underlying ACOs-like structures in Germany, needs to be undertaken.
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Affiliation(s)
- Benedikt Simon
- Harkness Fellowship, Commonwealth Fund, New York, United States.,Chief Officer Integrated and Digital Care, Asklepios Kliniken GmbH & Co. KGaA, Hamburg, Germany
| | - Volker Eric Amelung
- Institut für Epidemiologie, Sozialmedizin und Gesundheitssystemforschung, Medizinische Hochschule Hannover, Hannover, Germany
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Reid RO, Tom AK, Ross RM, Duffy EL, Damberg CL. Physician Compensation Arrangements and Financial Performance Incentives in US Health Systems. JAMA HEALTH FORUM 2022; 3:e214634. [PMID: 35977236 PMCID: PMC8903115 DOI: 10.1001/jamahealthforum.2021.4634] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/08/2021] [Indexed: 11/25/2022] Open
Abstract
Question Do health system physician compensation arrangements primarily incentivize volume or value? Findings This cross-sectional mixed-methods study of 31 physician organizations affiliated with 22 US health systems found that volume was a component of primary care and specialist compensation for most POs (83.9% and 93.3%, respectively), representing a substantial portion of compensation when included (mean, 68.2% and 73.7%, respectively). While most primary care and specialist compensation arrangements included performance-based incentives, they averaged less than 10% of compensation. Meaning The study results suggest that despite growth in value-based payment arrangements from payers, health systems currently incentivize physicians to maximize volume, thereby maximizing health system revenues. Importance Public and private payers continue to expand use of alternative payment models, aiming to use value-based payment to affect the care delivery of their contracted health system partners. In parallel, health systems and their employment of physicians continue to grow. However, the degree to which health system physician compensation reflects an orientation toward value, rather than volume, is unknown. Objective To characterize primary care physician (PCP) and specialist compensation arrangements among US health system–affiliated physician organizations (POs) and measure the portion of total physician compensation based on quality and cost performance. Design, Setting, and Participants This study was a cross-sectional mixed-methods analysis of in-depth multimodal data (compensation document review, interviews with 40 PO leaders, and surveys conducted between November 2017 and July 2019) from 31 POs affiliated with 22 purposefully selected health systems in 4 states. Data were analyzed from June 2019 to September 2020. Main Outcomes and Measures The frequency of PCP and specialist compensation types and the percentage of compensation when included, including base compensation incentives, quality and cost performance incentives, and other financial incentives. The top 3 actions physicians could take to increase their compensation. The association between POs’ percentage of revenue from fee-for-service and their physicians’ volume-based compensation percentage. Results Volume-based compensation was the most common base compensation incentive component for PCPs (26 POs [83.9%]; mean, 68.2% of compensation; median, 81.4%; range, 5.0%-100.0% when included) and specialists (29 POs [93.3%]; mean, 73.7% of compensation; median, 90.5%; range, 2.5%-100.0% when included). While quality and cost performance incentives were common (included by 83.9%-56.7% of POs for PCPs and specialists, respectively), the percentage of compensation based on quality and cost performance was modest (mean, 9.0% [median, 8.3%; range, 1.0%-25.0%] for PCPs and 5.3% [median, 4.5%; range, 0.5%-16.0%] for specialists when included). Increasing the volume of services was the most commonly cited action for physicians to increase compensation, reported as the top action by 22 POs (70.0%) for PCPs and specialists. We observed a very weak, nonsignificant association between the percentage of revenue of POs from fee for service and the PCP and specialist volume-based compensation percentage (r = 0.08; P = .78 and r = −0.04; P = .89, respectively). Conclusions and Relevance The results of this cross-sectional study suggest that PCPs and specialists despite receiving value-based reimbursement incentives from payers, the compensation of health system PCPs and specialists was dominated by volume-based incentives designed to maximize health systems revenue.
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Affiliation(s)
- Rachel O. Reid
- RAND Corporation, Santa Monica, California and Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Ashlyn K. Tom
- RAND Corporation, Santa Monica, California and Boston, Massachusetts
| | - Rachel M. Ross
- RAND Corporation, Santa Monica, California and Boston, Massachusetts
| | - Erin L. Duffy
- RAND Corporation, Santa Monica, California and Boston, Massachusetts
| | - Cheryl L. Damberg
- RAND Corporation, Santa Monica, California and Boston, Massachusetts
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Borras JM, Corral J, Aggarwal A, Audisio R, Espinas JA, Figueras J, Naredi P, Panteli D, Pourel N, Prades J, Lievens Y. Innovation, value and reimbursement in radiation and complex surgical oncology: Time to rethink. Eur J Surg Oncol 2021; 48:967-977. [PMID: 34479744 DOI: 10.1016/j.ejso.2021.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND PURPOSE Complex surgery and radiotherapy are the central pillars of loco-regional oncology treatment. This paper describes the reimbursement schemes used in radiation and complex surgical oncology, reports on literature and policy reviews. MATERIAL AND METHODS A systematic review of the literature of the reimbursement models has been carried out separately for radiotherapy and complex cancer surgery based on PRISMA guidelines. Using searches of PubMed and grey literature, we identified articles from scientific journals and reports published since 2000 on provider payment or reimbursement systems currently used in radiation oncology and complex cancer surgery, also including policy models. RESULTS Most European health systems reimburse radiotherapy using a budget-based, fee-for-service or fraction-based system; while few reimburse services according to an episode-based model. Also, the reimbursement models for cancer surgery are mostly restricted to differences embedded in the DRG system and adjustments applied to the fees, based on the complexity of each surgical procedure. There is an enormous variability in reimbursement across countries, resulting in different incentives and different amounts paid for the same therapeutic strategy. CONCLUSION A reimbursement policy, based on the episode of care as the basic payment unit, is advocated for. Innovation should be tackled in a two-tier approach: one defining the common criteria for reimbursement of proven evidence-based interventions; another for financing emerging innovation with uncertain definitive value. Relevant clinical and economic data, also collected real-life, should support reimbursement systems that mirror the actual cost of evidence-based practice.
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Affiliation(s)
- Josep M Borras
- University of Barcelona, Spain; Catalonian Cancer Plan, Department of Health, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.
| | - Julieta Corral
- Catalonian Cancer Plan, Department of Health, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Ajay Aggarwal
- Guy's and St. Thomas' Hospital NHS Trust, United Kingdom
| | - Riccardo Audisio
- Department of Surgery, Sahlgrenska University Hospital, University of Gothenburg, Sweden
| | - Josep Alfons Espinas
- Catalonian Cancer Plan, Department of Health, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Josep Figueras
- European Observatory on Health Systems and Policies, Belgium
| | - Peter Naredi
- Department of Surgery, Sahlgrenska University Hospital, University of Gothenburg, Sweden
| | - Dimitra Panteli
- Department of Health Care Management, Technische Universität Berlin, Germany
| | | | - Joan Prades
- Catalonian Cancer Plan, Department of Health, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital & Ghent University, Belgium
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14
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Innovation, value and reimbursement in radiation and complex surgical oncology: time to rethink. Radiother Oncol 2021; 169:114-123. [PMID: 34461186 DOI: 10.1016/j.radonc.2021.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND PURPOSE Complex surgery and radiotherapy are the central pillars of loco-regional oncology treatment. This paper describes the reimbursement schemes used in radiation and complex surgical oncology, reports on literature and policy reviews. MATERIAL AND METHODS A systematic review of the literature of the reimbursement models has been carried out separately for radiotherapy and complex cancer surgery based on PRISMA guidelines. Using searches of PubMed and grey literature, we identified articles from scientific journals and reports published since 2000 on provider payment or reimbursement systems currently used in radiation oncology and complex cancer surgery, also including policy models. RESULTS Most European health systems reimburse radiotherapy using a budget-based, fee-for-service or fraction-based system; while few reimburse services according to an episode-based model. Also, the reimbursement models for cancer surgery are mostly restricted to differences embedded in the DRG system and adjustments applied to the fees, based on the complexity of each surgical procedure. There is an enormous variability in reimbursement across countries, resulting in different incentives and different amounts paid for the same therapeutic strategy. CONCLUSION A reimbursement policy, based on the episode of care as the basic payment unit, is advocated for. Innovation should be tackled in a two-tier approach: one defining the common criteria for reimbursement of proven evidence-based interventions; another for financing emerging innovation with uncertain definitive value. Relevant clinical and economic data, also collected real-life, should support reimbursement systems that mirror the actual cost of evidence-based practice.
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Royce TJ, Jones GP, Muralidhar V, Chowdhary M, Holmes GM. US Primary Care vs Specialty Care Trainee Positions and Physician Incomes: Trends From 2001 to 2019. J Grad Med Educ 2021; 13:385-389. [PMID: 34178264 PMCID: PMC8207908 DOI: 10.4300/jgme-d-20-00941.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/23/2020] [Accepted: 02/24/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Much of the Affordable Care Act (ACA) and subsequent US health care policies were designed to address deficiencies in health care access and enhance primary care services. How residency positions and physician incomes have changed in the post-ACA era is not well characterized. OBJECTIVE We evaluated the growth of US trainee positions and physician income, in the pre- vs post-ACA environment by specialty and among primary care vs specialty care. METHODS Total resident complement by specialty and year was extracted from the National Graduate Medical Education (GME) Census and stratified into primary care vs specialty care. Median incomes were extracted from Medical Group Management Association surveys. Piecewise linear regression with interaction terms (pre-ACA, 2001-2010, vs post-ACA, 2011-2019) assessed growth rate by specialty and growth rate differences between primary care and specialty care. Sensitivity analyses were performed by focusing on family medicine and excluding additional GME positions contributed by the introduction of the 2015 single GME accreditation system. RESULTS Resident complements increased for primary care (+0.16%/year pre-ACA to +2.06%/year post-ACA, P < .001) and specialty care (+1.49%/year to +2.07%/year, P = .005). Specialty care growth outpaced primary care pre-ACA (P < .001) but not post-ACA (P = .10). Family medicine had the largest increase in the pre- vs post-ACA era (-0.77%/year vs +2.09%/year, P < .001). Excluding positions contributed by the single GME accreditation system transition did not result in any statistically significant changes to the findings. Income growth increased for primary care (+0.84%/year to +1.37%/year, P = .044), but decreased for specialty care (+1.44%/year to +0.49%/year, P = .011). Specialty care income growth outpaced primary care pre-ACA (P < .001), but not post-ACA (P = .22). CONCLUSIONS We found significant growth differences in resident complement and income among primary care versus specialty care in the pre-/post-ACA eras.
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Affiliation(s)
- Trevor J. Royce
- Trevor J. Royce, MD, MS, MPH, is Assistant Professor, Department of Radiation Oncology, University of North Carolina at Chapel Hill
| | - Gavin P. Jones
- Gavin P. Jones, MD, is a Resident Physician, Department of Radiation Oncology, University of Kentucky
| | - Vinayak Muralidhar
- Vinayak Muralidhar, MD, MSc, is Chief Resident, Department of Radiation Oncology, Dana Farber Cancer Institute
| | - Mudit Chowdhary
- Mudit Chowdhary, MD, is a Resident Physician, Department of Radiation Oncology, Rush University
| | - George M. Holmes
- George M. Holmes, PhD, is Professor, Department of Health Policy and Management, University of North Carolina at Chapel Hill
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Discussion: The Affordable Care Act and Its Impact on Plastic and Gender-Affirmation Surgery. Plast Reconstr Surg 2021; 147:154e-155e. [PMID: 33370074 DOI: 10.1097/prs.0000000000007500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shrank WH, DeParle NA, Gottlieb S, Jain SH, Orszag P, Powers BW, Wilensky GR. Health Costs And Financing: Challenges And Strategies For A New Administration. Health Aff (Millwood) 2021; 40:235-242. [DOI: 10.1377/hlthaff.2020.01560] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- William H. Shrank
- William H. Shrank is chief medical and corporate affairs officer of Humana in Louisville, Kentucky
| | - Nancy-Ann DeParle
- Nancy-Ann DeParle is a managing partner and cofounder of Consonance Capital Partners, in New York, New York
| | - Scott Gottlieb
- Scott Gottlieb is a resident fellow at the American Enterprise Institute, in Washington, D.C
| | - Sachin H. Jain
- Sachin H. Jain is president and CEO of the SCAN Group and Health Plan and an adjunct professor of medicine, Stanford University School of Medicine, in Stanford, California
| | - Peter Orszag
- Peter Orszag is the CEO of Financial Advisory at Lazard Freres and Co., LLC, in New York, New York
| | - Brian W. Powers
- Brian W. Powers is deputy chief medical officer at Humana in Boston, Massachusetts
| | - Gail R. Wilensky
- Gail R. Wilensky is a senior fellow at Project HOPE, in Bethesda, Maryland
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Minimally important difference in cost savings: Is it possible to identify an MID for cost savings? HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2021; 21:131-144. [PMID: 33437174 PMCID: PMC7790477 DOI: 10.1007/s10742-020-00233-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 11/18/2020] [Accepted: 11/25/2020] [Indexed: 10/25/2022]
Abstract
As healthcare costs continue to increase, studies assessing costs are becoming increasingly common, but researchers planning for studies that measure costs differences (savings) encounter a lack of literature or consensus among researchers on what constitutes "small" or "large" cost savings for common measures of resource use. Other fields of research have developed approaches to solve this type of problem. Researchers measuring improvement in quality of life or clinical assessments have defined minimally important differences (MID) which are then used to define magnitudes when planning studies. Also, studies that measure cost effectiveness use benchmarks, such as cost/QALY, but do not provide benchmarks for cost differences. In a review of the literature, we found no publications identifying indicators of magnitude for costs. However, the literature describes three approaches used to identify minimally important outcome differences: (1) anchor-based, (2) distribution-based, and (3) a consensus-based Delphi methods. In this exploratory study, we used these three approaches to derive MID for two types of resource measures common in costing studies for: (1) hospital admissions (high cost); and (2) clinic visits (low cost). We used data from two (unpublished) studies to implement the MID estimation. Because the distributional characteristics of cost measures may require substantial samples, we performed power analyses on all our estimates to illustrate the effect that the definitions of "small" and "large" costs may be expected to have on power and sample size requirements for studies. The anchor-based method, while logical and simple to implement, may be of limited value in cases where it is difficult to identify appropriate anchors. We observed some commonalities and differences for the distribution and consensus-based approaches, which require further examination. We recommend that in cases where acceptable anchors are not available, both the Delphi and the distribution-method of MID for costs be explored for convergence.
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Blumenthal D, Collins SR, Fowler EJ. The Affordable Care Act at 10 Years - Its Coverage and Access Provisions. N Engl J Med 2020; 382:963-969. [PMID: 32101659 DOI: 10.1056/nejmhpr1916091] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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