Health care spending and quality in year 1 of the alternative quality contract

Incentivizing primary care utilization in China: the impact of health insurance coverage on health-seeking behaviour

China's healthcare system faces significant challenges, notably the underutilization of primary healthcare resources and the inefficient distribution of healthcare services. In response, this article explores the effectiveness of the New Rural Cooperative Medical System (NRCMS) in improving healthcare accessibility and primary care utilization. Employing a multi-period difference-in-differences model and using data from the China Family Panel Studies spanning 2012-20, it aims to empirically examine how health insurance policy incentivizing primary care influences rural residents' health-seeking behaviour and enhances the efficiency of resource utilization. Results indicate that NRCMS significantly improves the probability of rural residents seeking healthcare services at primary healthcare centres (PHCs), especially for outpatient services. This effect can be attributed to the substantially higher outpatient reimbursement rates at PHCs compared to higher-level medical institutions. Conversely, the Urban Resident Basic Medical Insurance fails to increase urban residents' engagement with primary care, reinforcing the role of price sensitivity in healthcare choices among insured lower-income rural population. Furthermore, the study reveals a stronger preference for PHCs among younger, less-educated insured residents and highlights a synergistic effect between the availability of primary healthcare resources and insurance coverage on primary care utilization. These findings offer crucial implications for refining health insurance policies to improve healthcare service accessibility and efficiency.

Financial incentives for integrated care: A scoping review and lessons for evidence-based design

BACKGROUND

In response to the increasing prevalence of people with chronic conditions, healthcare systems restructure to integrate care across providers. However, many systems fail to achieve the desired outcomes. One likely explanation is lack of financial incentives for integrating care.

OBJECTIVES

We aim to identify financial incentives used to promote integrated care across different types of providers for patients with common chronic conditions and assess the evidence on (cost-)effectiveness and the facilitators/barriers to their implementation.

METHODS

This scoping review identifies studies published before December 2021, and includes 33 studies from the United States and the Netherlands.

RESULTS

We identify four types of financial incentives: shared savings, bundled payments, pay for performance, and pay for coordination. Substantial heterogeneity in the (cost-)effectiveness of these incentives exists. Key implementation barriers are a lack of infrastructure (e.g., electronic medical records, communication channels, and clinical guidelines). To facilitate integration, financial incentives should be easy to communicate and implement, and require additional financial support, IT support, training, and guidelines.

CONCLUSIONS

All four types of financial incentives may promote integrated care but not in all contexts. Shared savings appears to be the most promising incentive type for promoting (cost-)effective care integration with the largest number of favourable studies allowing causal interpretations. The limited evidence pool makes it hard to draw firm conclusions that are transferable across contexts.

Utilization, Steering, and Spending in Vertical Relationships Between Physicians and Health Systems

Importance

Vertical relationships (eg, ownership or affiliations, including joint contracting) between physicians and health systems are increasing in the US.

Objective

To analyze how vertical relationships between primary care physicians (PCPs) and large health systems are associated with changes in ambulatory and acute care utilization, referral patterns, readmissions, and total medical spending for commercially insured individuals.

Design, Setting, and Participants

This case-control study with a repeated cross-section, stacked event design analyzed outcomes of patients whose attributed PCP entered a vertical relationship with a large health care system in 2015 or 2017 compared with patients whose attributed PCP was either never or always in a vertical relationship with a large health system from 2013 to 2017 in the state of Massachusetts. The sample consisted of commercially insured patients who met enrollment criteria and who were attributed to PCPs who were included in the Massachusetts Provider Database in 2013, 2015, and 2017 and for whom vertical relationships were measured. Enrollee and claims data were obtained from the 2013 to 2017 Massachusetts All-Payer Claims Database. Statistical analyses were conducted between January 5, 2021, and June 5, 2023.

Exposure

Evaluation-and-management visit with attributed PCP in 2015 to 2017.

Main Outcomes and Measures

Outcomes (which were measured per patient-year [ie, per patient per year from January to December] in this sample) were utilization (count of specialist physician visits, emergency department [ED] visits, and hospitalizations overall and within attributed PCP's health system), spending (total medical expenditures and use of high-price hospitals), and readmissions (readmission rate and use of hospitals with a low readmission rate).

Results

The sample of 4 030 224 observations included 2 147 303 females (53.3%) and 1 881 921 males (46.7%) with a mean (SD) age of 35.07 (19.95) years. Vertical relationships between PCPs and large health systems were associated with an increase of 0.69 (95% CI, 0.34-1.04; P < .001) in specialist visits per patient-year, a 22.64% increase vs the comparison group mean of 3.06 visits, and a $356.67 (95% CI, $77.16-$636.18; P = .01) increase in total medical expenditures per patient-year, a 6.26% increase vs the comparison group mean of $5700.07. Within the health care system of the attributed PCPs, the number of specialist visits changed by 0.80 (95% CI, 0.56-1.05) per patient year (P < .001), a 29.38% increase vs the comparison group mean of 2.73 specialist visits per patient-year. The number of ED visits changed by 0.02 (95% CI, 0.01-0.03) per patient year (P = .001), a 14.19% increase over the comparison group mean of 0.15 ED visits per patient-year. The number of hospitalizations changed by 0.01 (95% CI, 0.00-0.01) per patient-year (P < .001), a 22.36% increase over the comparison group mean of 0.03 hospitalizations per patient-year. There were no differences in readmission outcomes.

Conclusions

Results of this case-control study suggest that vertical relationships between PCPs and large health systems were associated with steering of patients into health systems and increased spending on patient care, but no difference in readmissions was found.

Value-Based Purchasing Design And Effect: A Systematic Review And Analysis

During the past two decades in the United States, all major payer types-commercial, Medicare, Medicaid, and multipayer coalitions-have introduced value-based purchasing (VBP) contracts to reward providers for improving health care quality while reducing spending. This systematic review qualitatively characterized the financial and nonfinancial features of VBP programs and examined how such features combine to create a level of program intensity that relates to desired quality and spending outcomes. Higher-intensity VBP programs are more frequently associated with desired quality processes, utilization measures, and spending reductions than lower-intensity programs. Thus, although there may be reasons for payers and providers to opt for lower-intensity programs (for example, to increase voluntary participation), these choices apparently have consequences for spending and quality outcomes.

Tacking upwind: reducing spending among high-risk commercially insured patients

OBJECTIVES

The study examined a commercial accountable care organization (ACO) population and then assessed the impact of an integrated care management program on medical spending and clinical event rates.

STUDY DESIGN

Retrospective cohort study of high-risk individuals (n = 487) in a population of 365,413 individuals aged 18 to 64 years within the Mass General Brigham health system who were part of commercial ACO contracts with 3 large insurers between 2015 and 2019.

METHODS

Using medical spending claims and other enrollment data, the study assessed the demographic and clinical characteristics, medical spending, and clinical event rates of patients in the ACO and its high-risk care management program. The study then examined the impact of the program using a staggered difference-in-difference design with individual-level fixed effects and compared outcomes of those who had entered the program with those of similar patients who had not entered.

RESULTS

The commercially insured ACO population was healthy on average but included several hundred high-risk patients (n = 487). After adjustment, patients within the ACO's integrated care management program for high-risk patients had lower monthly medical spending (by $1361 per person per month) as well as lower emergency department visit and hospitalization rates compared with similar patients who had yet to start the program. Accounting for early ACO departure decreased the magnitude of the program effects as expected.

CONCLUSIONS

Commercial ACO populations may be healthy on average but still include some high-risk patients. Identifying which patients might benefit from more intensive care management could be critical for reaping the potential savings.

Population turnover and leakage in commercial ACOs

OBJECTIVES

Commercial accountable care organization (ACO) contracts attempt to mitigate spending growth, but past evaluations have been limited to continuously enrolled ACO members in health maintenance organization (HMO) plans, excluding many members. The objective of this study was to examine the magnitude of turnover and leakage within a commercial ACO.

STUDY DESIGN

A historical cohort study using detailed information from multiple commercial ACO contracts within a large health care system between 2015 and 2019.

METHODS

Individuals insured through 1 of the 3 largest commercial ACO contracts during the study period, 2015-2019, were included. We examined patterns of entry and exit and the characteristics that predicted remaining in the ACO compared with leaving the ACO. We also examined predictors of the amount of care delivered in the ACO compared with outside the ACO.

RESULTS

Among the 453,573 commercially insured individuals in the ACO, approximately half left the ACO within the initial 24 months after entry. Approximately one-third of spending was for care occurring outside the ACO. Patients who remained in the ACO differed from those who left earlier, including being older, having a non-HMO plan, having lower predicted spending at entry, and having more medical spending for care performed within the ACO during the initial quarter of membership.

CONCLUSIONS

Both turnover and leakage hamper the ability of ACOs to manage spending. Modifications that address potentially intrinsic vs avoidable sources of population turnover and increase patient incentives for care within vs outside of ACOs could help address medical spending growth within commercial ACO programs.

Implementation of the Maryland Global Budget Revenue Model and Variation in the Expenditures and Outcomes of Surgical Care: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the effect of the Global Budget Revenue (GBR) program on outcomes after surgery.

BACKGROUND

There is limited data summarizing the effect of the GBR program on surgical outcomes as compared with traditional fee-for-service systems.

METHODS

The Medline, Embase, Scopus, and Web of Science databases were used to conduct a systematic literature search on April 5, 2022. We identified full-length reports of comparative studies involving patients who underwent surgery in Maryland after implementation of the GBR program. A random effects model calculated the overall pooled estimate for each outcome which included complications, rates of readmission and mortality, length of stay, and costs.

RESULTS

Fourteen studies were included in the qualitative synthesis, with 8 unique studies included in the meta-analysis. Our analytical sample was comprised of 170,011 Maryland patients, 78,171 patients in the pre-GBR group, and 91,840 patients in the post-GBR group. The pooled analysis identified modest reductions in costs [standardized mean difference (SMD) -0.34; 95% CI, -0.42, -0.25; P <0.001], complications [odds ratio (OR): 0.57; 95% CI, 0.36-0.92, P =0.02], readmission (OR: 0.78; 95% CI, 0.72-0.85, P <0.001), mortality (OR: 0.58; 95% CI, 0.47-0.72, P <0.001), and length of stay (standardized mean difference: -0.26; 95% CI, -0.32, -0.2, P <0.001) after surgery.

CONCLUSIONS

Implementation of the GBR program is associated with improved outcomes and reductions in costs among Maryland patients who underwent surgical procedures. This is particularly salient given the increasing need to disseminate and scale population-based payment models that improve patient care while controlling health care costs.

The Emerging Role of Alternative Payment Models in Promoting Mental Healthcare Equity

Healthcare programs based on alternative payment models (APMs) have gained in prominence for their increasingly well-established impact on quality and cost outcomes. While APMs also appear to have potential utility in addressing healthcare disparities, it remains unclear how they should best be leveraged for this purpose. Because the landscape of mental healthcare presents unique challenges, it is crucial that lessons from past programs are integrated into the design of APMs in mental healthcare so the promise of their impact on the goal of equity might be fulfilled.

Value-Based Payment Models In The Commercial Insurance Sector: A Systematic Review

Value-based payment models are a prominent strategy in health reform. Although Medicare payment models have been extensively evaluated, much less is known about value-based payment models in the commercial insurance sector. We performed the first systematic review of the quality, spending, and utilization effects of commercial models, extracting results from fifty-nine studies. Forty-one of these studies evaluated outcomes. More studies had positive results for quality outcomes (81 percent of studies) than for spending (56 percent) and utilization (58 percent). Less rigorous studies were more likely to find positive results. Given the mixed nature of the findings, commercial insurers should identify ways to strengthen value-based payment programs or leverage other strategies to improve health care value.

The Effect of Network-Level Payment Models on Care Network Performance: A Scoping Review of the Empirical Literature

Introduction

Traditional payment models reward volume rather than value. Moving away from reimbursing separate providers to network-level reimbursement is assumed to support structural changes in health care organizations that are necessary to improve patient care. This scoping review evaluates the performance of care networks that have adopted network-level payment models.

Methods

A scoping review of the empirical literature was conducted according to the five-step York framework. We identified indicators of performance, categorized them in four categories (quality, utilization, spending and other consequences) and scored whether performance increased, decreased, or remained stable due to the payment model.

Results

The 76 included studies investigated network-level capitation, disease-based bundled payments, pay-for-performance and blended global payments. The majority of studies stem from the USA. Studies generally concluded that performance in terms of quality and utilization increased or remained stable. Most payment models were associated with improved spending performance. Overall, our review shows that network-level payment models are moderately successful in improving network performance.

Discussion/conclusion

As health care networks are increasingly common, it seems fruitful to continue experimenting with reimbursement models for health care networks. It is also important to broaden the scope to not only scrutinize outcomes, but also the contexts and mechanisms that lead to certain outcomes.

What Can Canada Learn From Accountable Care Organizations: A Comparative Policy Analysis

Introduction

Accountable Care Organizations (ACOs), implemented in the United States (US), aim to reduce costs and integrate care by aligning incentives among providers and payers. Canadian governments are interested adopting such models to integrate care, though comparative studies assessing the applicability and transferability of ACOs in Canada are lacking. In this comparative study, we performed a narrative literature review to examine how Canadian health systems could support ACO models.

Methods

We reviewed empirical studies (published 2011-2020) that evaluated ACO impacts in the US. Thematic analysis and critical appraisal were performed to identify factors associated with positive ACO impacts. These factors were compared with the Canadian context to assess the applicability and transferability of ACO models within Canada.

Findings

Physician-led models, global budgets and financial incentives, and focus on collaborative care may optimize ACO impacts. While reforms towards alternative payments and team-based care are not unprecedented in Canada, significant further reforms to physician remuneration, intersectoral collaboration, and accountability for performance are required to support ACO-like models.

Conclusion

This comparative study uncovered several insights on the applicability and transferability of ACOs to the Canadian context. Further comparative research outside the US is needed to infer the essential components of successful ACO models.

Reducing cytogenetic testing in the era of next generation sequencing: Are we choosing wisely?

INTRODUCTION

In most laboratories, next generation sequencing (NGS) has been added without consideration for redundancy compared to conventional cytogenetics (CG). We tested a streamlined approach to genomic testing in patients with suspected myeloid and plasma cell neoplasms using next generation sequencing ("NGS first") as the primary testing modality and limiting cytogenetics (CG) to samples with morphologic abnormalities in the marrow aspirate.

METHODS

Based on morphologic interpretation of bone marrow aspirate and flow cytometry, samples were triaged into four groups: (a) Samples with dysplasia or excess blasts had both NGS and karyotyping; (b) Samples without excess blasts or dysplasia had NGS only; (c) Repeat samples with previous NGS and/or CG studies were not retested; (d) Samples for suspected myeloma with less than 5% plasma cell had CG testing cancelled.

RESULTS

Seven hundred eleven adult bone marrow (BM) samples met the study criteria. The NGS first algorithm eliminated CG testing in 229/303 (75.6%) of patients, primarily by reducing repeat testing. Potential cost avoided was approximately $124 000 per annum. Hematologists overruled the triage comment in only 11/303 (3.6%) cases requesting CG testing for a specific indication.

CONCLUSIONS

Utilizing NGS as the primary genomic testing modality NGS was feasible and well accepted, reducing over three quarters of all CG requests and improving the financial case for adoption of NGS. Key factors for the success of this study were collaboration of clinical and genomic diagnostic teams in developing the algorithm, rapid turnaround time for BM interpretation for triage, and communication between laboratories.

How important is price variation between health insurers?

Prices negotiated between payers and providers affect a health insurance contract's value via enrollees' cost-sharing and self-insured employers' costs. However, price variation across payers is difficult to observe. We measure negotiated prices for hospital-payer pairs in Massachusetts and characterize price variation. Between-payer price variation is similar in magnitude to between-hospital price variation. Administrative-services-only contracts, in which insurers do not bear risk, have higher prices. We model negotiation incentives and show that contractual form and demand responsiveness to negotiated prices are important determinants of negotiated prices.

Do accountable care organizations differ according to physician-hospital integration?: A retrospective observational study

Physician-hospital integration among accountable care organizations (ACOs) has raised concern over impacts on prices and spending. However, characteristics of ACOs with greater integration between physicians and hospitals are unknown. We examined whether ACOs systematically differ by physician-hospital integration among 16 commercial ACOs operating in Massachusetts.Using claims data linked to information on physician affiliation, we measured hospital integration with primary care physicians for each ACO and categorized them into high-, medium-, and low-integrated ACOs. We conducted cross-sectional descriptive analysis to compare differences in patient population, organizational characteristics, and healthcare spending between the three groups. In addition, using multivariate generalized linear models, we compared ACO spending by integration level, adjusting for organization and patient characteristics. We identified non-elderly adults (aged 18-64) served by 16 Massachusetts ACOs over the period 2009 to 2013.High- and medium-integrated ACOs were more likely to be an integrated delivery system or an organization with a large number of providers. Compared to low-integrated ACOs, higher-integrated ACOs had larger inpatient care capacity, smaller composition of primary care physicians, and were more likely to employ physicians directly or through an affiliated hospital or physician group. A greater proportion of high-/medium-integrated ACO patients lived in affluent neighborhoods or areas with a larger minority population. Healthcare spending per enrollee in high-integrated ACOs was higher, which was mainly driven by a higher spending on outpatient facility services.This study shows that higher-integrated ACOs differ from their counterparts with low integration in many respects including higher healthcare spending, which persisted after adjusting for organizational characteristics and patient mix. Further investigation into the effects of integration on expenditures will inform the ongoing development of ACOs.

Is the evidence on the effectiveness of pay for performance schemes in healthcare changing? Evidence from a meta-regression analysis

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.

Impact of Global Budget Payments on Cardiovascular Care in Maryland: An Interrupted Time Series Analysis

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 (P_trend <0.0001). Length of stay slightly increased for patients with congestive heart failure (P_trend=0.03). Inpatient coronary artery bypass grafting surgeries decreased (P_trend <0.0001). We observed a significant decrease in casemix-adjusted 30-day readmission rate in the AMI cohort beyond the prepolicy trend (P_trend=0.0069). There were no significant changes in mortality for any of the 3 conditions. Hospitalization charges increased for ischemic stroke (P_trend <0.0001), remained constant for congestive heart failure (P_trend=0.1), and decreased for AMI (P_trend=0.0005). We observed a significant increase in electrocardiography rate charges (P_trend <0.0001), coincidentally with a reduction in volumes (P_trend=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.

Value-Based Provider Payment Initiatives Combining Global Payments With Explicit Quality Incentives: A Systematic Review

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.

Failing the metric but saving lives: The protocolization of sepsis treatment through quality measurement

Quality metrics in the healthcare sector have become a key component of ensuring improved health outcomes and care equity. Alongside the emergence of information technology in healthcare (eg. electronic health records), the primary method utilized to infer "quality" has been the development of measures for healthcare processes and outcomes. Engaging with the specific case of sepsis treatment and sepsis quality metrics, this paper traces how quality is defined, measured, and codified in a 600-bed acute-care hospital in New York City. Sepsis is a severe health condition, primarily managed in the emergency department, that is caused by infection and can result in multi-organ shutdown and mortality. Multiple government agencies have established metrics that regulate New York hospitals based on their compliance with specific sepsis treatment procedures. I draw on data from a 15-month ethnography and in-depth interviews with clinicians and administrators, to show how quality measurement is reshaping the ways healthcare is delivered and organized. I reveal how, at Borough Hospital, efforts to treat sepsis based on quality metrics have constrained clinician expertise, prioritized compliance, and reoriented workflow towards standardized treatment protocols. This reorientation leads to, what I term abstracted surveillance protocols, that increasingly regulate definitions of healthcare quality. I demonstrate that abstracted surveillance protocols enable highly complex clinical processes to be measured based on metric compliance rather than clinical pathways, therefore moving definitions of quality away from the bedside.

Fundamentals and implementation of Microbiological Diagnostic Stewardship Programs

Microbiological diagnostic stewardship programs promote coordinated measures aimed at optimizing the use of diagnostic techniques, thus favouring the adoption of adequate and cost-effective therapeutic, clinical and preventive decisions. The implementation of microbiological diagnostic stewardship relies upon the creation of multidisciplinary committees led by clinical microbiologists for the design of diagnostic algorithms, the adequacy of the laboratory computer system to monitor the relevance of the requested diagnostic tests, the implementation of a quality control system, the design and performance of studies of cost-effectiveness, the training of the petitioner and the technical and nursing staff and the continuous evaluation of the program. The incorporation of microbiological diagnostic stewardship in routine care reports tangible benefits for the patient while strengthening the pivotal role of the clinical microbiologist in the management of infectious diseases.

Health Care Expenditures Among Adults With Diabetes After Oregon's Medicaid Expansion

OBJECTIVE

To compare trends in Medicaid expenditures among adults with diabetes who were newly eligible due to the Affordable Care Act (ACA) Medicaid expansion to trends among those previously eligible.

RESEARCH DESIGN AND METHODS

Using Oregon Medicaid administrative data from 1 January 2014 to 30 September 2016, a retrospective cohort study was conducted with propensity score-matched Medicaid eligibility groups (newly and previously eligible). Outcome measures included total per-member per-month (PMPM) Medicaid expenditures and PMPM expenditures in the following 12 categories: inpatient visits, emergency department visits, primary care physician visits, specialist visits, prescription drugs, transportation services, tests, imaging and echography, procedures, durable medical equipment, evaluation and management, and other or unknown services.

RESULTS

Total PMPM Medicaid expenditures for newly eligible enrollees with diabetes were initially considerably lower compared with PMPM expenditures for matched previously eligible enrollees during the first postexpansion quarter (mean values $561 vs. $793 PMPM, P = 0.018). Within the first three postexpansion quarters, PMPM expenditures of the newly eligible increased to a similar but slightly lower level. Afterward, PMPM expenditures of both groups continued to increase steadily. Most of the overall PMPM expenditure increase among the newly eligible was due to rapidly increasing prescription drug expenditures.

CONCLUSIONS

Newly eligible Medicaid enrollees with diabetes had slightly lower PMPM expenditures than previously eligible Medicaid enrollees. The increase in PMPM prescription drug expenditures suggests greater access to treatment over time.

Five-year Impact of a Commercial Accountable Care Organization on Health Care Spending, Utilization, and Quality of Care

BACKGROUND

Accountable Care Organizations (ACOs) have proliferated after the passage of the Affordable Care Act in 2010. Few longitudinal ACO studies with continuous enrollees exist and most are short term.

OBJECTIVE

The objective of this study was to evaluate the long-term impact of a commercial ACO on health care spending, utilization, and quality outcomes among continuously enrolled members.

RESEARCH DESIGN

Retrospective cohort study design and propensity-weighted difference-in-differences approach were applied to examine performance changes in 2 ACO cohorts relative to 1 non-ACO cohort during the commercial ACO implementation in 2010-2014.

SUBJECTS

A total of 40,483 continuously enrolled members of a commercial health maintenance organization from 2008 to 2014.

MEASURES

Cost, use, and quality metrics for various type of services in outpatient and inpatient settings.

RESULTS

The ACO cohorts had (1) increased inpatient and outpatient total spending in the first 2 years of ACO operation, but insignificant differential changes for the latter 3 years; (2) decreased outpatient spending in the latter 2 years through reduced primary care visits and lowered spending on specialists, testing, and imaging; (3) no differential changes in inpatient hospital spending, utilization, and quality measures for most of the 5 years; (4) favorable results for several quality measures in preventive and diabetes care domains in at least one of the 5 years.

CONCLUSIONS

The commercial ACO improved outpatient process quality measures modestly and slowed outpatient spending growth by the fourth year of operation, but had a negligible impact on inpatient hospital cost, use, and quality measures.

Health Care Spending, Utilization, and Quality 8 Years into Global Payment

BACKGROUND

Population-based global payment gives health care providers a spending target for the care of a defined group of patients. We examined changes in spending, utilization, and quality through 8 years of the Alternative Quality Contract (AQC) of Blue Cross Blue Shield (BCBS) of Massachusetts, a population-based payment model that includes financial rewards and penalties (two-sided risk).

METHODS

Using a difference-in-differences method to analyze data from 2006 through 2016, we compared spending among enrollees whose physician organizations entered the AQC starting in 2009 with spending among privately insured enrollees in control states. We examined quantities of sentinel services using an analogous approach. We then compared process and outcome quality measures with averages in New England and the United States.

RESULTS

During the 8-year post-intervention period from 2009 to 2016, the increase in the average annual medical spending on claims for the enrollees in organizations that entered the AQC in 2009 was $461 lower per enrollee than spending in the control states (P<0.001), an 11.7% relative savings on claims. Savings on claims were driven in the early years by lower prices and in the later years by lower utilization of services, including use of laboratory testing, certain imaging tests, and emergency department visits. Most quality measures of processes and outcomes improved more in the AQC cohorts than they did in New England and the nation in unadjusted analyses. Savings were generally larger among subpopulations that were enrolled longer. Enrollees of organizations that entered the AQC in 2010, 2011, and 2012 had medical claims savings of 11.9%, 6.9%, and 2.3%, respectively, by 2016. The savings for the 2012 cohort were statistically less precise than those for the other cohorts. In the later years of the initial AQC cohorts and across the years of the later-entry cohorts, the savings on claims exceeded incentive payments, which included quality bonuses and providers' share of the savings below spending targets.

CONCLUSIONS

During the first 8 years after its introduction, the BCBS population-based payment model was associated with slower growth in medical spending on claims, resulting in savings that over time began to exceed incentive payments. Unadjusted measures of quality under this model were higher than or similar to average regional and national quality measures. (Funded by the National Institutes of Health.).

Association Between the Implementation of a Population-Based Primary Care Payment System and Achievement on Quality Measures in Hawaii

Importance

Hawaii Medical Service Association (HMSA), the Blue Cross Blue Shield of Hawaii, introduced Population-based Payments for Primary Care (3PC), a new capitation-based primary care payment system, in 2016. The effect of this system on quality measures has not been evaluated.

Objective

To evaluate whether the 3PC system was associated with changes in quality, utilization, or spending in its first year.

Design, Setting, and Participants

Observational study using HMSA claims and clinical registry data from January 1, 2012, to December 31, 2016, and a propensity-weighted difference-in-differences method to compare 77 225 HMSA members in Hawaii attributed to 107 primary care physicians (PCPs) and 4 physician organizations participating in the first wave of the 3PC and 222 233 members attributed to 312 PCPs and 14 physician organizations that continued in a fee-for-service model in 2016 but had 3PC start dates thereafter.

Exposures

Participation in the 3PC system.

Main Outcomes and Measures

The primary outcome was the change in a composite measure score reflecting the probability that a member achieved an eligible measure out of 13 pooled Healthcare Effectiveness Data and Information Set quality measures. Primary care visits and total cost of care were among 15 secondary outcomes.

Results

In total, the study included 299 458 HMSA members (mean age, 42.1 years; 51.5% women) and 419 primary care physicians (mean age, 54.9 years; 34.8% women). The risk-standardized composite measure scores for 2012 to 2016 changed from 75.1% to 86.6% (+11.5 percentage points) in the 3PC group and 74.3% to 83.5% (+9.2 percentage points) in the non-3PC group (differential change, 2.3 percentage points [95% CI, 2.1 to 2.6 percentage points]; P < .001). Of 15 prespecified secondary end points for utilization and spending, 11 showed no significant difference. Compared with the non-3PC group, the 3PC system was associated with a significant reduction in the mean number of primary care visits (3.3 to 3.0 visits vs 3.3 to 3.1 visits; adjusted differential change, -3.9 percentage points [95% CI, -4.6 to -3.2 percentage points]; P < .001), but there was no significant difference in mean total cost of care ($3344 to $4087 vs $2977 to $3564; adjusted differential change, 1.0% [95% CI, -1.3% to 3.4%]; P = .39).

Conclusions and Relevance

In its first year, the 3PC population-based primary care payment system in Hawaii was associated with small improvements in quality and a reduction in PCP visits but no significant difference in the total cost of care. Additional research is needed to assess longer-term outcomes as the program is more fully implemented and to determine whether results are generalizable to other health care markets.

Design and effects of outcome-based payment models in healthcare: a systematic review

INTRODUCTION

Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects.

METHODS

We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs.

RESULTS

We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth.

DISCUSSION

Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.

Effect of Financial Bonus Size, Loss Aversion, and Increased Social Pressure on Physician Pay-for-Performance: A Randomized Clinical Trial and Cohort Study

Importance

Despite limited effectiveness of pay-for-performance (P4P), payers continue to expand P4P nationally.

Objective

To test whether increasing bonus size or adding the behavioral economic principles of increased social pressure (ISP) or loss aversion (LA) improves the effectiveness of P4P.

Design, Setting, and Participants

Parallel studies conducted from January 1 to December 31, 2016, consisted of a randomized clinical trial with patients cluster-randomized by practice site to an active control group (larger bonus size [LBS] only) or to groups with 1 of 2 behavioral economic interventions added and a cohort study comparing changes in outcomes among patients of physicians receiving an LBS with outcomes in propensity-matched physicians not receiving an LBS. A total of 8118 patients attributed to 66 physicians with 1 of 5 chronic conditions were treated at Advocate HealthCare, an integrated health system in Illinois. Data were analyzed using intention to treat and multiple imputation from February 1, 2017, through May 31, 2018.

Interventions

Physician participants received an LBS increased by a mean of $3355 per physician (LBS-only group); prefunded incentives to elicit LA and an LBS; or increasing proportion of a P4P bonus determined by group performance from 30% to 50% (ISP) and an LBS.

Main Outcomes and Measures

The proportion of 20 evidence-based quality measures achieved at the patient level.

Results

A total of 86 physicians were eligible for the randomized trial. Of these, 32 were excluded because they did not have unique attributed patients. Fifty-four physicians were randomly assigned to 1 of 3 groups, and 33 physicians (54.5% male; mean [SD] age, 57 [10] years) and 3747 patients (63.6% female; mean [SD] age, 64 [18] years) were included in the final analysis. Nine physicians and 864 patients were randomized to the LBS-only group, 13 physicians and 1496 patients to the LBS plus ISP group, and 11 physicians and 1387 patients to the LBS plus LA group. Physician characteristics did not differ significantly by arm, such as mean (SD) physician age ranging from 56 (9) to 59 (9) years, and sex (6 [46.2%] to 6 [66.7%] male). No differences were found between the LBS-only and the intervention groups (adjusted odds ratio [aOR] for LBS plus LA vs LBS-only, 0.86 [95% CI, 0.65-1.15; P = .31]; aOR for LBS plus ISP vs LBS-only, 0.95 [95% CI, 0.64-1.42; P = .81]; and aOR for LBS plus ISP vs LBS plus LA, 1.10 [95% CI, 0.75-1.61; P = .62]). Increased bonus size was associated with a greater increase in evidence-based care relative to the comparison group (risk-standardized absolute difference-in-differences, 3.2 percentage points; 95% CI, 1.9-4.5 percentage points; P < .001).

Conclusions and Relevance

Increased bonus size was associated with significantly improved quality of care relative to a comparison group. Adding ISP and opportunities for LA did not improve quality.

Trial Registration

ClinicalTrials.gov Identifier: NCT02634879.

Hospitals Strengthened Relationships With Close Partners After Joining Accountable Care Organizations

The strategies that hospitals participating in Medicare Accountable Care Organizations (ACOs) use to achieve quality and cost containment goals are poorly understood. One possibility is that participating hospitals could try to influence where their patients receive care. To test this hypothesis, we examined whether a hospital's participation in a Medicare ACO was associated with changes in its patterns of patient sharing with other hospitals. Between 2010 and 2014, patient sharing across hospitals increased 23.3%. After controlling for hospital and regional factors, patient sharing increased 4.4% more at ACO hospitals than non-ACO hospitals (p = .001 for difference). This increase occurred disproportionately among hospitals with which ACO hospitals already shared a high proportion of their patients prior to participation, and among hospitals in ACOs characterized as physician-hospital collaborations. The increased sharing of patients among closely affiliated hospitals may serve to achieve ACO quality and cost containment goals through increased interorganizational coordination.

The Accountable Care Organization for Surgical Care

Rising health care costs superimposed on uncertainty surrounding the relationship between health care spending and quality have resulted in an urgent need to develop strategies to better align health care payment with value. Such approaches, at least in theory, work to achieve the dual aims of reducing growth in health care spending and improving population health. To date, surgery has not been prioritized in accountable care organizations (ACOs). Nonetheless, it is critically important to begin to consider strategic and impactful mechanisms through which surgery can be seamlessly woven into innovative population health models.

Practice strategies to improve primary care for chronic disease patients under a pay-for-value program

BACKGROUND

Improving primary care for patients with chronic illness is critical to advancing healthcare quality and value. Yet, little is known about what strategies are successful in helping primary care practices deliver high-quality care for this population under value-based payment models.

METHODS

Double-blind interviews in 14 primary care practices in the state of Michigan, stratified based on whether they did (n = 7) or did not (n = 7) demonstrate improvement in primary care outcomes for patients with at least one reported chronic disease between 2010 and 2013. All practices participate in a statewide pay-for-performance program run by a large commercial payer. Using an implementation science framework to identify leverage points for effecting organizational change, we sought to identify, describe and compare strategies among improving and non-improving practices across three domains: (1) organizational learning opportunities, (2) approaches to motivating staff, and (3) acquisition and use of resources.

RESULTS

We identified 10 strategies; 6 were "differentiating" - that is, more prevalent among improving practices. These differentiating strategies included: (1) participation in learning collaboratives, (2) accessing payer tools to monitor quality performance, (3) framing pay-for-performance as a practice transformation opportunity, (4) reinvesting earned incentive money in equitable, practice-centric improvement, (5) employing a care manager, and (6) using available technical support from local hospitals and provider organizations to support performance improvement. Implementation of these strategies varied based on organizational context and relative strengths.

CONCLUSIONS

Practices that succeeded in improving care for chronic disease patients pursued a mix of strategies that helped meet immediate care delivery needs while also creating new adaptive structures and processes to better respond to changing pressures and demands. These findings help inform payers and primary care practices seeking evidence-based strategies to foster a stronger delivery system for patients with significant healthcare needs.

Effects of episode-based payment on health care spending and utilization: Evidence from perinatal care in Arkansas

We study how physicians respond to financial incentives imposed by episode-based payment (EBP), which encourages lower spending and improved quality for an entire episode of care. Specifically, we study the impact of the Arkansas Health Care Payment Improvement Initiative, a multi-payer program that requires providers to enter into EBP arrangements for perinatal care, covering the majority of births in the state. Unlike fee-for-service reimbursement, EBP holds physicians responsible for all care within a discrete episode, rewarding physicians for efficient use of their own services and for efficient management of other health care inputs. In a difference-in-differences analysis of commercial claims, we find that perinatal spending in Arkansas decreased by 3.8% overall under EBP, compared to surrounding states. The decrease was driven by reduced spending on non-physician health care inputs, specifically the prices paid for inpatient facility care. We additionally find a limited improvement in quality of care under EBP.

The Effects of Medicare Part D on Health Outcomes of Newly Covered Medicare Beneficiaries

Objectives

To estimate the impact of Medicare Part D on cost-related prescription nonadherence and health outcomes among the newly covered medicare beneficiaries.

Method

Difference-in-differences analyses of data from a balanced panel of Medicare beneficiaries observed in each wave of the Health and Retirement Study from 2000 to 2010 were carried out. The differences in the pre- and post-Part D changes in these outcomes are calculated for previously uncovered Part D enrollees and a comparison group of previously covered Medicare beneficiaries.

Results

The results from this analysis indicate that Part D reduced cost-related nonadherence rates among the newly covered by 7 percentage points and that this decline was sustained through 2010. Part D was also associated with a 5 percentage points increase in the likelihood that a newly covered enrollee reported to be in good or better health and a 4-percentage point decline in the likelihood of being diagnosed with high blood pressure. These improvements were also sustained through 2010 but were only evident among those newly covered beneficiaries who remained enrolled in a Part D plan through 2010. However, there is insufficient evidence to conclude that Part D improved the blood pressure of newly covered, hypertensive beneficiaries.

Discussion

Part D has had a sustained impact on cost-related nonadherence rates and the health status of newly covered beneficiaries. However, the change in health status is conditional on remaining enrolled in a Part D plan over time.

Designing a Curriculum for Professionalism and Ethics Within Radiology: Identifying Challenges and Expectations

Although professionalism and ethics represent required competencies, they are more challenging than other competencies to design a curriculum for and teach. Reasons include variability in agreed definitions of professionalism within medicine and radiology. This competency is also framed differently whether as roles, duties, actions, skills, behavior, beliefs, and attitudes. Standardizing a curriculum in professionalism is difficult because each learner's (medical student/resident) professional experiences and interactions will be unique. Professionalism is intertwined throughout all (sub) specialties and areas and its teaching cannot occur in isolation as a standalone curriculum. In the past, professionalism was not emphasized enough or at all, with global (or no) assessments, with the potential effect of trainees not valuing it. Although we can teach it formally in the classroom and informally in small groups, much of professionalism is witnessed and learned as "hidden curricula". The formal, informal, and hidden curricula often contradict each other creating confusion, disillusion, and cynicism in trainees. The corporatization of medicine pressurizes us to increase efficiency (throughput) with less focus on aspects of professionalism that add value, creating a disjoint between what we do in practice and preach to trainees. Progressively, expectations for our curriculum include providing evidence for the impacts of our efforts on patient outcomes. Generational differences in the perception of professionalism and the increasingly diverse and multicultural society in which we live affects our interpretation of professionalism, which can add to confusion and misunderstanding. The objectives of this article are to outline challenges facing curriculum design in professionalism and to make suggestions to help educators avoid or overcome them.

Lower- Versus Higher-Income Populations In The Alternative Quality Contract: Improved Quality And Similar Spending

As population-based payment models become increasingly common, it is crucial to understand how such payment models affect health disparities. We evaluated health care quality and spending among enrollees in areas with lower versus higher socioeconomic status in Massachusetts before and after providers entered into the Alternative Quality Contract, a two-sided population-based payment model with substantial incentives tied to quality. We compared changes in process measures, outcome measures, and spending between enrollees in areas with lower and higher socioeconomic status from 2006 to 2012 (outcome measures were measured after the intervention only). Quality improved for all enrollees in the Alternative Quality Contract after their provider organizations entered the contract. Process measures improved 1.2 percentage points per year more among enrollees in areas with lower socioeconomic status than among those in areas with higher socioeconomic status. Outcome measure improvement was no different between the subgroups; neither were changes in spending. Larger or comparable improvements in quality among enrollees in areas with lower socioeconomic status suggest a potential narrowing of disparities. Strong pay-for-performance incentives within a population-based payment model could encourage providers to focus on improving quality for more disadvantaged populations.

The Role of Mental Health Disease in Potentially Preventable Hospitalizations: Findings From a Large State

BACKGROUND

Preventable hospitalizations are markers of potentially low-value care. Addressing the problem requires understanding their contributing factors.

OBJECTIVE

The objective of this study is to determine the correlation between specific mental health diseases and each potentially preventable hospitalization as defined by the Agency for Healthcare Research and Quality.

DESIGN/SUBJECTS

The Texas Inpatient Public Use Data File, an administrative database of all Texas hospital admissions, identified 7,351,476 adult acute care hospitalizations between 2005 and 2008.

MEASURES

A hierarchical multivariable logistic regression model clustered by admitting hospital adjusted for patient and hospital factors and admission date.

RESULTS

A total of 945,280 (12.9%) hospitalizations were potentially preventable, generating $6.3 billion in charges and 1.2 million hospital days per year. Mental health diseases [odds ratio (OR), 1.25; 95% confidence interval (CI), 1.22-1.27] and substance use disorders (OR, 1.13; 95% CI, 1.12-1.13) both increased odds that a hospitalization was potentially preventable. However, each mental health disease varied from increasing or decreasing the odds of potentially preventable hospitalization depending on which of the 12 preventable hospitalization diagnoses were examined. Older age (OR, 3.69; 95% CI, 3.66-3.72 for age above 75 years compared with 18-44 y), black race (OR 1.44; 95% CI, 1.43-1.45 compared to white), being uninsured (OR 1.52; 95% CI, 1.51-1.54) or dual-eligible for both Medicare and Medicaid (OR, 1.23; 95% CI, 1.22-1.24) compared with privately insured, and living in a low-income area (OR, 1.20; 95% CI, 1.17-1.23 for lowest income quartile compared with highest) were other patient factors associated with potentially preventable hospitalizations.

CONCLUSIONS

Better coordination of preventative care for mental health disease may decrease potentially preventable hospitalizations.

Impact of Accountable Care Organizations on Utilization, Care, and Outcomes: A Systematic Review

Since 2010, more than 900 accountable care organizations (ACOs) have formed payment contracts with public and private insurers in the United States; however, there has not been a systematic evaluation of the evidence studying impacts of ACOs on care and outcomes across payer types. This review evaluates the quality of evidence regarding the association of public and private ACOs with health service use, processes, and outcomes of care. The 42 articles identified studied ACO contracts with Medicare ( N = 24 articles), Medicaid ( N = 5), commercial ( N = 11), and all payers ( N = 2). The most consistent associations between ACO implementation and outcomes across payer types were reduced inpatient use, reduced emergency department visits, and improved measures of preventive care and chronic disease management. The seven studies evaluating patient experience or clinical outcomes of care showed no evidence that ACOs worsen outcomes of care; however, the impact on patient care and outcomes should continue to be monitored.

The Alternative Quality Contract: Impact on Service Use and Spending for Children With ADHD

In 2009, Blue Cross-Blue Shield of Massachusetts (BCBSMA) implemented the alternative quality contract (AQC), which pays provider organizations a global payment for all services used by enrollees. BCBSMA claims for 2006-2011 were used to compare youths enrolled in provider organizations participating in the AQC (7,407 person-years [PYs]) with those not participating (45,398 PYs). Difference-in-differences models estimated changes in mental health and substance abuse treatment service utilization and spending attributable to the AQC. The AQC was associated with small increases in the probability of any outpatient visits and in the probability and number of medication management visits among children with attention-deficit hyperactivity disorder (ADHD). Spending did not change, and there was no evidence of reductions in service utilization or spending for children with ADHD in the first three years of AQC implementation.

Advancing Value-Based Population Health Management Through Payer-Provider Partnerships: Improving Outcomes for Children With Complex Conditions

Population health management (PHM) approaches to improve cost and quality remain limited. To address this gap, stakeholders within an integrated delivery and financing system in Western Pennsylvania designed, implemented, and tested a value-based care model for children with medically complex conditions that could be scaled across the broader pediatric population. The model included: (1) a multilevel, interdisciplinary infrastructure; (2) actionable analytics reports to guide continuous quality improvement; (3) alternative provider payments; (4) consumer-directed spending accounts; and (5) shared savings with practices. Four practices caring for 215 children (<age 21) with medically complex conditions participated in the demonstration. Quality and cost outcomes were compared between the intervention group and a comparison group using propensity scores. The program generated cost savings over a 2-year performance period, although the difference between the intervention and comparison groups was not significant, likely because of the small N. Quality of care was maintained or improved for the intervention group from baseline to the end of the performance period. This model is an example of how real-world laboratories that leverage strong payer-provider partnerships can be a useful platform for testing value-based PHM models with the potential to reduce healthcare costs while maintaining or improving care quality.

An Out-of-Pocket Cost Removal Intervention on Fecal Occult Blood Test Attendance

INTRODUCTION

To date, no comparative study has assessed the impact of a cost-removal intervention on fecal occult blood testing (FOBT). In 2012, the Japanese government introduced a nationwide project to remove out-of-pocket costs for FOBT. The study objective was to evaluate the differential impact of the intervention on FOBT attendance in the total population and various subgroups.

METHODS

This study analyzed 309,103 people in national, repeated cross-sectional studies, observed pre- and post-intervention (2010 and 2013), using covariate-adjusted difference-in-differences estimates to compare intervention and no-intervention groups. The outcome measure was uptake of FOBT attendance resulting from the intervention. Stratified analyses were conducted according to sociodemographic and health-related characteristics.

RESULTS

The intervention was associated with significantly positive uptake of FOBT in both genders, but the impact was greater in women than men: 6.7% (95% CI=5.2, 8.1) for women and 2.7% (95% CI=1.1, 4.3) for men in the covariate-adjusted models. Post-intervention, attendance increased in almost all subgroups in women. However, among men, some socially advantaged subgroups, such as high expenditure, high education, and public officers, showed no effect. Some subgroups such as current smokers and less than high school education were identified as hard-to-reach populations that may be less sensitive to the intervention, irrespective of gender.

CONCLUSIONS

This is the first comparative study of cost-removal intervention for uptake of FOBT. The intervention may increase FOBT attendance. However, the size of the effect is not great, especially in men, and differential effects occurred across subgroups including gender and socioeconomic differences.

An educational intervention to increase awareness reduces unnecessary laboratory testing in an internal medicine resident-run clinic

At our resident-run clinic in an underserved community, laboratory test costs in 2013 exceeded the government subsidy by $400 000. To optimize limited resources and improve patient care, an education program to reduce testing was implemented.

Between November 2014 and January 2015, residents attended lectures on utilization of laboratory testing, focusing on standard practice guidelines, and analyses of unnecessary tests. Multivariate nonparametric statistical methods and subgroup analysis were used to evaluate cost reduction.

There were 453 clinic visits during the intervention period and 471 visits during the control period. Lectures were independently associated with a significant laboratory cost reduction. Median laboratory cost per visit decreased from $106.00 to $74.00. Total cost in the study period decreased from $79 403 to $51 463. There were similar reductions of laboratory costs in two subgroups: age groups of <50 years and ≥50 years, new encounters, and follow-up visits . In the analysis of individual tests, the cost of TSH and Vitamin D tests had the greatest reduction ($8176 and $5088 respectively).

An appropriate physician education program can reduce laboratory tests and costs. Screening tests with inadequate evidence support were reduced most, whereas those with proven benefits did not decrease significantly.

Evaluating the Effects of Pioneer Accountable Care Organizations on Medicare Part D Drug Spending and Utilization

BACKGROUND

The improvement of medication use is a critical mechanism that accountable care organization (ACO) could use to save overall costs. Currently pharmaceutical spending is not part of the calculation for ACO-shared savings and risks. Thus, ACO providers may have strong incentives to prescribe more medications hoping to avoid expensive downstream medical costs.

METHODS

We designed a quasinatural experiment study to evaluate the effects of Pioneer ACOs on Medicare Part D spending and utilization. Medicare fee-for-service beneficiaries with Part D drug coverage who were aligned to a Pioneer ACO were compared with a random 5% sample of non-ACO beneficiaries. Outcomes included changes in Part D spending, number of prescription fills, percent of brand medications, and total Part A and B medical spending. We utilized a generalized linear model with a difference-in-differences approach to estimate 2011-2012 changes in these outcomes among beneficiaries aligned with Pioneer ACOs, adjusting for all beneficiary-level demographics, income and insurance status, clinical characteristics, and regional fixed effects.

RESULTS

Being in an ACO did not significantly affect Part D spending (-$23.52; P=0.19), total prescriptions filled (-0.12; P=0.27), and the percent of claims for brand-name drugs (0.06%; P=0.23). The ACO group was associated with savings in Parts A and B spending of $345 (P<0.0001) per person per year.

CONCLUSIONS

We found that beneficiaries aligned to Pioneer ACOs were not associated with changes in pharmaceutical spending and use, but were associated with savings in Parts A and B spending in 2012.

Analysis of Healthcare Cost and Utilization in the First Two Years of the Medicare Shared Savings Program Using Big Data from the CMS Enclave

The Medicare Shared Savings Program (MSSP) is the larger of the first two Accountable Care Organization (ACO) programs by the Centers for Medicare and Medicaid Services (CMS). In this study we assessed healthcare cost and utilization of 1.71 million Medicare beneficiaries assigned to the 333 MSSP ACOs in the calendar years of 2013 and 2014, in comparison to years 2010 and 2011, using the official CMS data. We employed doubly robust estimation (propensity score weighting followed by generalized linear regression) to adjust the analyses to beneficiary personal traits, history of chronic conditions, previous healthcare utilization, ACO administrative region, and ZIP code socioeconomic factors. In comparison to the care delivered to the control cohort of 17.7 million non-ACO beneficiaries, we found that the care patterns for ACO beneficiaries shifted away from some costly types of care, but at the expense of increased utilization of other types, increased imaging and testing expenditures, and increased medication use, with overall net greater increase in cost instead of smaller increase.

The Early Impact Of The 'Alternative Quality Contract' On Mental Health Service Use And Spending In Massachusetts

Accountable care using global payment with performance bonuses has shown promise in controlling spending growth and improving care. This study examined how an early model, the Alternative Quality Contract (AQC) established in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA), has affected care for mental illness. We compared spending and use for enrollees in AQC organizations that did and did not accept financial risk for mental health with enrollees not participating in the contract. Compared with BCBSMA enrollees in organizations not participating in the AQC, we found that enrollees in participating organizations were slightly less likely to use mental health services and, among mental health services users, small declines were detected in total health care spending, but no change was found in mental health spending. The declines in probability of use of mental health services and in total health spending among mental health service users attributable to the AQC were concentrated among enrollees in organizations that accepted financial risk for behavioral health. Interviews with AQC organization leaders suggested that the contractual arrangements did not meaningfully affect mental health care delivery in the program's initial years, but organizations are now at varying stages of efforts to improve mental health integration.

The impact of secure messaging on workflow in primary care: Results of a multiple-case, multiple-method study

INTRODUCTION

Secure messaging is a relatively new addition to health information technology (IT). Several studies have examined the impact of secure messaging on (clinical) outcomes but very few studies have examined the impact on workflow in primary care clinics. In this study we examined the impact of secure messaging on workflow of clinicians, staff and patients.

METHODS

We used a multiple case study design with multiple data collections methods (observation, interviews and survey).

RESULTS

Results show that secure messaging has the potential to improve communication and information flow and the organization of work in primary care clinics, partly due to the possibility of asynchronous communication. However, secure messaging can also have a negative effect on communication and increase workload, especially if patients send messages that are not appropriate for the secure messaging medium (for example, messages that are too long, complex, ambiguous, or inappropriate). Results show that clinicians are ambivalent about secure messaging. Secure messaging can add to their workload, especially if there is high message volume, and currently they are not compensated for these activities. Staff is -especially compared to clinicians- relatively positive about secure messaging and patients are overall very satisfied with secure messaging. Finally, clinicians, staff and patients think that secure messaging can have a positive effect on quality of care and patient safety.

CONCLUSION

Secure messaging is a tool that has the potential to improve communication and information flow. However, the potential of secure messaging to improve workflow is dependent on the way it is implemented and used.

Effects of accountable care and payment reform on substance use disorder treatment: evidence from the initial 3 years of the alternative quality contract

BACKGROUND AND AIMS

Global payment and accountable care reform efforts in the United States may connect more individuals with substance use disorders (SUD) to treatment. We tested whether such changes instituted under an Alternative Quality Contract (AQC) model within the Blue Cross Blue Shield of Massachusetts' (BCBSMA) insurer increased care for individuals with SUD.

DESIGN

Difference-in-differences design comparing enrollees in AQC organizations with a comparison group of enrollees in organizations not participating in the AQC.

SETTING

Massachusetts, USA.

PARTICIPANTS

BCBSMA enrollees aged 13-64 years from 2006 to 2011 (3 years prior to and after implementation) representing 1 333 534 enrollees and 42 801 SUD service users.

MEASUREMENTS

Outcomes were SUD service use and spending and SUD performance metrics. Primary exposures were enrollment into an AQC provider organization and whether the AQC organization did or did not face risk for behavioral health costs.

FINDINGS

Enrollees in AQC organizations facing behavioral health risk experienced no change in the probability of using SUD services (1.64 versus 1.66%; P = 0.63), SUD spending ($2807 versus $2700; P = 0.34) or total spending ($12 631 versus $12 849; P = 0.53), or SUD performance metrics (identification: 1.73 versus 1.76%, P = 0.57; initiation: 27.86 versus 27.02%, P = 0.50; engagement: 11.19 versus 10.97%, P = 0.79). Enrollees in AQC organizations not at risk for behavioral health spending experienced a small increase in the probability of using SUD services (1.83 versus 1.66%; P = 0.003) and the identification performance metric (1.92 versus 1.76%; P = 0.007) and a reduction in SUD medication use (11.84 versus 14.03%; P = 0.03) and the initiation performance metric (23.76 versus 27.02%; P = 0.005).

CONCLUSIONS

A global payment and accountable care model introduced in Massachusetts, USA (in which a health insurer provided care providers with fixed prepayments to cover most or all of their patients' care during a specified time-period, incentivizing providers to keep their patients healthy and reduce costs) did not lead to sizable changes in substance use disorder service use during the first 3 years following its implementation.