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Scheefhals ZTM, Struijs JN, Wong A, Numans ME, Song Z, de Vries EF. Integrating Maternity Care Through Bundled Payments In The Netherlands: Early Results And Policy Lessons. Health Aff (Millwood) 2024; 43:1263-1273. [PMID: 39226512 DOI: 10.1377/hlthaff.2023.01637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
Bundled payments are increasingly used globally to move health care delivery in a value-based direction. However, evidence remains scant in key clinical areas. We evaluated bundled payments for maternity care in the Netherlands during the period 2016-18. We used a quasi-experimental difference-in-differences design to measure the association between the bundled payment model and changes in key clinical and economic outcomes. Bundled payments were associated with an increase in outpatient, midwife-led births and a reduction in in-hospital, obstetrician-led births, along with changes in the use of labor inductions and planned versus emergency cesarean deliveries. Total spending on maternity care decreased by US$328 (5 percent) per pregnancy. No changes in maternal or neonatal health outcomes were observed. Several policy lessons emerged. First, bundled payments appeared to help affect providers' behavior in the maternity care setting. Second, bundled payments seemed to exert heterogeneous effects across participating maternity care networks, as the same financial incentive translated into different changes in clinical practices and outcomes. Third, alternative payment models should be designed with clear goals and definitions of success to guide evaluation and implementation.
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Affiliation(s)
- Zoë T M Scheefhals
- Zoë T. M. Scheefhals, National Institute for Public Health and the Environment, Bilthoven, the Netherlands; and Leiden University Medical Center-Campus the Hague, the Hague, the Netherlands
| | - Jeroen N Struijs
- Jeroen N. Struijs, National Institute for Public Health and the Environment and Leiden University Medical Center
| | - Albert Wong
- Albert Wong, National Institute for Public Health and the Environment
| | | | - Zirui Song
- Zirui Song , Harvard University and Massachusetts General Hospital, Boston, Massachusetts
| | - Eline F de Vries
- Eline F. de Vries, National Institute for Public Health and the Environment
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Lin K, Xiang L. The Effects of the Multi-Hospital Global Budget Payment on Medical Expenditure and Service Volume: The Evidence from Dangyang County, China. Risk Manag Healthc Policy 2024; 17:1875-1887. [PMID: 39100547 PMCID: PMC11297547 DOI: 10.2147/rmhp.s471212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 07/23/2024] [Indexed: 08/06/2024] Open
Abstract
Background Global budget payment is currently the prevailing payment strategy internationally. In China, the concept of multi-hospital global budget payment has been proposed with the aims of achieving cost control effects while also encouraging hospital collaboration and optimising allocation of healthcare resources. This study seeks to analyse the impact of multi-hospital global budget payment in China on healthcare expenditure and service volume. Materials and Methods A retrospective comparative study was carried out in Dangyang County, China. The exposure cases were migrants who were not locally registered in the residence registration system. The study period encompassed January 1, 2017, to December 31, 2019. Including 3,246,164 outpatient medical records and 242,685 inpatient medical records. The key variables are medical expenditure and service volume indicators. Continuous variables were reported as mean and tested by t-test. We used interrupted time series analysis models to estimate the changes in the level and trend of each outcome measure after the policy. Results After the outpatient global budget payment reform, the monthly medical expenditure of the hospital alliance has transitioned from a discernible upward trajectory to a deceleration in the rate of growth. The outpatient volume in public and private high-level hospitals decreased at a rate of -419.26 person/month and -137.04 person/month, respectively. In terms of inpatient service volume, only private high-level hospitals reported a decrease, with a reduction rate of -15.38 individuals per month. Conclusion This study presents new evidence demonstrating that the multi-hospital global budget payment can effectively control costs and promote resource reallocation when implemented jointly with hospital alliance policies. However, overly lenient budget caps risk counterproductive effects.
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Affiliation(s)
- Kunhe Lin
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Li Xiang
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
- HUST Base of National Institute of Healthcare Security, Wuhan, People’s Republic of China
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3
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Simmons C, Pot M, Lorenz-Dant K, Leichsenring K. Disentangling the impact of alternative payment models and associated service delivery models on quality of chronic care: A scoping review. Health Policy 2024; 143:105034. [PMID: 38508061 DOI: 10.1016/j.healthpol.2024.105034] [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: 09/04/2023] [Revised: 02/27/2024] [Accepted: 02/29/2024] [Indexed: 03/22/2024]
Abstract
Payment reforms are frequently implemented alongside service delivery reforms, thus rendering it difficult to disentangle their impact. This scoping review aims to link alternative payment arrangements within their context of service delivery, to assess their impact on quality of chronic care, and to disentangle, where possible, the impact of payment reforms from changes to service delivery. A search of literature published between 2013 and 2022 resulted in 34 relevant articles across five types of payment models: capitation/global budget (n = 13), pay-for-coordination (n = 10), shared savings/shared risk (n = 6), blended capitation (n = 3), and bundled payments (n = 1). The certainty of evidence was generally low due to biases associated with voluntary participation in reforms. This scoping review finds that population-based payment reforms are better suited for collaborative, person-centred approaches of service delivery spanning settings and providers, but also highlights the need for a wider evidence base of studies disentangling the impact of financing from service delivery reforms. Limited evidence disentangling the two suggests that transforming service delivery to a team-based model of care alongside a purchasing reform shifting to blended capitation was more impactful in improving quality of chronic care, than the individual components of payment and service delivery. Further comparative studies employing causal inference methods, accounting for biases and quantifying aspects of service delivery, are needed to better disentangle the mechanisms impacting quality of care.
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Affiliation(s)
- Cassandra Simmons
- European Centre for Social Welfare Policy & Research, Vienna, Austria.
| | - Mirjam Pot
- European Centre for Social Welfare Policy & Research, Vienna, Austria
| | - Klara Lorenz-Dant
- General Practice, Institute of General Practice, University Hospital of Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | - Kai Leichsenring
- European Centre for Social Welfare Policy & Research, Vienna, Austria
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Lin MY, Hanchate AD, Frakt AB, Burgess JF, Carey K. Association between physician-hospital integration and inpatient care delivery in accountable care organizations: An instrumental variable analysis. Health Serv Res 2024. [PMID: 38654539 DOI: 10.1111/1475-6773.14311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVE To investigate the relationship between physician-hospital integration within accountable care organizations (ACOs) and inpatient care utilization and expenditure. DATA SOURCES The primary data were Massachusetts All-Payer Claims Database (2009-2013). STUDY SETTING Fifteen provider organizations that entered a commercial ACO contract with a major private payer in Massachusetts between 2009 and 2013. STUDY DESIGN Using an instrumental variable approach, the study compared inpatient care delivery between patients of ACOs demonstrating high versus low integration. We measured physician-hospital integration within ACOs by the proportion of primary care physicians in an ACO who billed for outpatient services with a place-of-service code indicating employment or practice ownership by a hospital. The study sample comprised non-elderly adults who had continuous insurance coverage and were attributed to one of the 15 ACOs. Outcomes of interest included total medical expenditure during an episode of inpatient care, length of stay (LOS) of the index hospitalization, and 30-day readmission. An inpatient episode was defined as 30, 45, and 60 days from the admission date. DATA COLLECTION/EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS The study examined 33,535 admissions from patients served by the 15 ACOs. Average medical expenditure within 30 days of admission was $24,601, within 45 days was $26,447, and within 60 days was $28,043. Average LOS was 3.5 days, and 5.4% of patients were readmitted within 30 days. Physician-hospital integration was associated with a 10.6% reduction in 30-day expenditure (95% CI, -15.1% to -5.9%). Corresponding estimates for 45 and 60 days were - 9.7% (95%CI, -14.2% to -4.9%) and - 9.6% (95%CI, -14.3% to -4.7%). Integration was associated with a 15.7% decrease in LOS (95%CI, -22.6% to -8.2%) but unrelated to 30-day readmission rate. CONCLUSIONS Our instrumental variable analysis shows physician-hospital integration with ACOs was associated with reduced inpatient spending and LOS, with no evidence of elevated readmission rates.
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Affiliation(s)
- Meng-Yun Lin
- Medical Center Boulevard, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Boston University School of Public Health, Boston, Massachusetts, USA
| | - Amresh D Hanchate
- Medical Center Boulevard, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Austin B Frakt
- Boston University School of Public Health, Boston, Massachusetts, USA
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Kathleen Carey
- Boston University School of Public Health, Boston, Massachusetts, USA
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Yordanov D, Oxholm AS, Prætorius T, Kristensen SR. Financial incentives for integrated care: A scoping review and lessons for evidence-based design. Health Policy 2024; 141:104995. [PMID: 38290390 DOI: 10.1016/j.healthpol.2024.104995] [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: 02/21/2023] [Revised: 01/11/2024] [Accepted: 01/14/2024] [Indexed: 02/01/2024]
Abstract
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.
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Affiliation(s)
- Dimitar Yordanov
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
| | - Anne Sophie Oxholm
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
| | - Thim Prætorius
- Research Unit for Integrated Care and Prevention, Steno Diabetes Centre Aarhus, Aarhus University Hospital, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark.
| | - Søren Rud Kristensen
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
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Singh P, Fu N, Dale S, Orzol S, Laird J, Markovitz A, Shin E, O’Malley AS, McCall N, Day TJ. The Comprehensive Primary Care Plus Model and Health Care Spending, Service Use, and Quality. JAMA 2024; 331:132-146. [PMID: 38100460 PMCID: PMC10777250 DOI: 10.1001/jama.2023.24712] [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] [Received: 07/10/2023] [Accepted: 11/07/2023] [Indexed: 12/17/2023]
Abstract
Importance Implemented in 18 regions, Comprehensive Primary Care Plus (CPC+) was the largest US primary care delivery model ever tested. Understanding its association with health outcomes is critical in designing future transformation models. Objective To test whether CPC+ was associated with lower health care spending and utilization and improved quality of care. Design, Setting, and Participants Difference-in-differences regression models compared changes in outcomes between the year before CPC+ and 5 intervention years for Medicare fee-for-service beneficiaries attributed to CPC+ and comparison practices. Participants included 1373 track 1 (1 549 585 beneficiaries) and 1515 track 2 (5 347 499 beneficiaries) primary care practices that applied to start CPC+ in 2017 and met minimum care delivery and other eligibility requirements. Comparison groups included 5243 track 1 (5 347 499 beneficiaries) and 3783 track 2 (4 507 499 beneficiaries) practices, matched, and weighted to have similar beneficiary-, practice-, and market-level characteristics as CPC+ practices. Interventions Two-track design involving enhanced (higher for track 2) and alternative payments (track 2 only), care delivery requirements (greater for track 2), data feedback, learning, and health information technology support. Main Outcomes and Measures The prespecified primary outcome was annualized Medicare Part A and B expenditures per beneficiary per month (PBPM). Secondary outcomes included expenditure categories, utilization (eg, hospitalizations), and claims-based quality-of-care process and outcome measures (eg, recommended tests for patients with diabetes and unplanned readmissions). Results Among the CPC+ patients, 5% were Black, 3% were Hispanic, 87% were White, and 5% were of other races (including Asian/Other Pacific Islander and American Indian); 85% of CPC+ patients were older than 65 years and 58% were female. CPC+ was associated with no discernible changes in the total expenditures (track 1: $1.1 PBPM [90% CI, -$4.3 to $6.6], P = .74; track 2: $1.3 [90% CI, -$5 to $7.7], P = .73), and with increases in expenditures including enhanced payments (track 1: $13 [90% CI, $7 to $18], P < .001; track 2: $24 [90% CI, $18 to $31], P < .001). Among secondary outcomes, CPC+ was associated with decreases in emergency department visits starting in year 1, and in acute hospitalizations and acute inpatient expenditures in later years. Associations were more favorable for practices also participating in the Medicare Shared Savings Program and independent practices. CPC+ was not associated with meaningful changes in claims-based quality-of-care measures. Conclusions and Relevance Although the timing of the associations of CPC+ with reduced utilization and acute inpatient expenditures was consistent with the theory of change and early focus on episodic care management of CPC+, CPC+ was not associated with a reduction in total expenditures over 5 years. Positive interaction between CPC+ and the Shared Savings Program suggests transformation models might be more successful when provider cost-reduction incentives are aligned across specialties. Further adaptations and testing of primary care transformation models, as well as consideration of the larger context in which they operate, are needed.
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Affiliation(s)
| | - Ning Fu
- Mathematica, Princeton, New Jersey
| | | | | | | | | | | | | | | | - Timothy J. Day
- Centers for Medicare & Medicaid Innovation, Baltimore, Maryland
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Kamrani P, Flamm A. Expanding and Strengthening Your Referral Network. Dermatol Clin 2023; 41:619-626. [PMID: 37718019 DOI: 10.1016/j.det.2023.06.001] [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: 09/19/2023]
Abstract
Dermatology referral utilization is increasing, with 15% of dermatology-related visits by primary care resulting in a dermatology referral. Given this, both strengthening an expanding a referral is a key component of a successful dermatology practice. In particular, effective communication is essential for efficient patient-oriented coordinated care. Written and/or verbal communication can help build a strong communication network and, in some instances, can be applied toward Merit-based Incentive Payment System (MIPS) reporting and billing for coding families that incorporate the coordination of care. Reaching out directly to referring clinics has also been shown to increase the quantity of referrals. This can include providing clinics with patient handouts on your clinic, education on what information is prioritized within the referral, and educating staff on how to complete their referrals effectively and efficiently. Social media can play an important role in referrals, especially for patients looking for cosmetic care. There are many different platforms, and these can serve as a marketing tool for physicians looking to bring in new patients.
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Affiliation(s)
- Payvand Kamrani
- Department of Dermatology, Penn State Health, 200 Campus Drive, Suite 100, Hershey, PA 17033, USA
| | - Alexandra Flamm
- Department of Dermatology, NYU Grossman School of Medicine, 222 East 41st Street, 25th Floor, New York, NY 10017, USA.
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Sinaiko AD, Curto VE, Ianni K, Soto M, Rosenthal MB. Utilization, Steering, and Spending in Vertical Relationships Between Physicians and Health Systems. JAMA HEALTH FORUM 2023; 4:e232875. [PMID: 37656471 PMCID: PMC10474555 DOI: 10.1001/jamahealthforum.2023.2875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/06/2023] [Indexed: 09/02/2023] Open
Abstract
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.
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Affiliation(s)
- Anna D. Sinaiko
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Vilsa E. Curto
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Katherine Ianni
- Harvard PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts
| | - Mark Soto
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Meredith B. Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Ho V, Tapaneeyakul S, Russell HV. Price Increases Versus Upcoding As Drivers Of Emergency Department Spending Increases, 2012-19. Health Aff (Millwood) 2023; 42:1119-1127. [PMID: 37549336 DOI: 10.1377/hlthaff.2022.01287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Recent studies document a substantial increase in emergency department (ED) spending in the past decade, even though the number of ED visits per capita has remained relatively stable. Price increases and upcoding are sometimes cited as possible explanations, but their relative impacts are not known. We analyzed Blue Cross Blue Shield claims for patients of all ages who received care in EDs in five states in 2012 and 2019. We used estimates from spending regressions and regressions explaining coding intensity to decompose changes in spending between 2012 and 2019 into components attributable to price increases, changes in patient characteristics or treatment intensity, and upcoding. Prices accounted for at least half of the increase in ED spending per visit for four of the five states we examined. Increases in spending attributable to upcoding were notable but generally not as large. Future research should explore the associations between local market conditions, such as consolidation and ownership type, and both price increases and upcoding.
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Affiliation(s)
- Vivian Ho
- Vivian Ho , Rice University and Baylor College of Medicine, Houston, Texas
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Steenkamer B, Vaes B, Rietzschel E, Crombez J, De Geest S, Demeure F, Gielen M, Hermans MP, Teughels S, Vanacker P, van der Schueren T, Simoens S. Population health management in Belgium: a call-to-action and case study. BMC Health Serv Res 2023; 23:659. [PMID: 37340416 DOI: 10.1186/s12913-023-09626-x] [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: 09/27/2022] [Accepted: 05/31/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Although there are already success stories, population health management in Belgium is still in its infancy. A health system transformation approach such as population health management may be suited to address the public health issue of atherosclerotic cardiovascular disease, as this is one of the main causes of mortality in Belgium. This article aims to raise awareness about population health management in Belgium by: (a) eliciting barriers and recommendations for its implementation as perceived by local stakeholders; (b) developing a population health management approach to secondary prevention of atherosclerotic cardiovascular disease; and (c) providing a roadmap to introduce population health management in Belgium. METHODS Two virtual focus group discussions were organized with 11 high-level decision makers in medicine, policy and science between October and December 2021. A semi-structured guide based on a literature review was used to anchor discussions. These qualitative data were studied by means of an inductive thematic analysis. RESULTS Seven inter-related barriers and recommendations towards the development of population health management in Belgium were identified. These related to responsibilities of different layers of government, shared responsibility for the health of the population, a learning health system, payment models, data and knowledge infrastructure, collaborative relationships and community involvement. The introduction of a population health management approach to secondary prevention of atherosclerotic cardiovascular disease may act as a proof-of-concept with a view to roll out population health management in Belgium. CONCLUSIONS There is a need to instill a sense of urgency among all stakeholders to develop a joint population-oriented vision in Belgium. This call-to-action requires the support and active involvement of all Belgian stakeholders, both at the national and regional level.
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Affiliation(s)
- Betty Steenkamer
- Stichting Gezondheidscentra Eindhoven - STROOMZ NL, Eindhoven, the Netherlands
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Ernst Rietzschel
- Department of Internal Medicine & Paediatrics, Ghent University, Ghent, Belgium
- Biobanking and Cardiovascular Prevention, Ghent University Hospital, Ghent, Belgium
| | - John Crombez
- Architecture of a Qualitative, Sustainable and Inclusive Health system (AQSIH), Ghent University Hospital, Ghent, Belgium
| | - Sabina De Geest
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Department of Public Health, University of Basel, Basel, Switzerland
| | - Fabian Demeure
- Cardiology Department, CHU UCL Mont-Godinne, Namur, Belgium
| | | | - Michel P Hermans
- Endocrinology & Nutrition, Cliniques universitaires St-Luc, Brussels, Belgium
- Medical School, Catholic University of Louvain, Brussels, Belgium
| | | | - Peter Vanacker
- Department of Neurology, AZ Groeninge, Kortrijk, Belgium
- Department of Neurology, University Hospitals Antwerp, Antwerp, Belgium
- Department of Translational Neuroscience, University of Antwerp, Antwerp, Belgium
| | | | - Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
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Benson NM, Price M, Weiss M, Vogeli C, Vienneau MM, Mendu ML, Flaster A, Balentine L, Jubelt L, Meyer GS, Hsu J. Tacking upwind: reducing spending among high-risk commercially insured patients. THE AMERICAN JOURNAL OF MANAGED CARE 2023; 29:220-226. [PMID: 37229781 PMCID: PMC11056950 DOI: 10.37765/ajmc.2023.89355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
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.
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Affiliation(s)
- Nicole M Benson
- McLean Hospital, Harvard Medical School, 115 Mill St, Belmont, MA 02478.
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Benson NM, Price M, Vogeli C, Vienneau MM, Mendu ML, Flaster A, Balentine L, Jubelt L, Meyer GS, Hsu J. Population turnover and leakage in commercial ACOs. THE AMERICAN JOURNAL OF MANAGED CARE 2023; 29:e104-e110. [PMID: 37104836 PMCID: PMC10542917 DOI: 10.37765/ajmc.2023.89350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
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.
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Affiliation(s)
- Nicole M Benson
- McLean Hospital, Harvard Medical School, 115 Mill St, Belmont, MA 02478.
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Shammas RL, Coroneos CJ, Ortiz-Babilonia C, Graton M, Jain A, Offodile AC. Implementation of the Maryland Global Budget Revenue Model and Variation in the Expenditures and Outcomes of Surgical Care: A Systematic Review and Meta-analysis. Ann Surg 2023; 277:542-548. [PMID: 36314127 DOI: 10.1097/sla.0000000000005744] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Ronnie L Shammas
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University, Durham, NC
| | - Christopher J Coroneos
- Department of Surgery and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Margaret Graton
- Medical Center Library and Archives, Duke University School of Medicine, Durham, NC
| | - Amit Jain
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Anaeze C Offodile
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, TX
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Bour SS, Raaijmakers LHA, Bischoff EWMA, Goossens LMA, Rutten-van Mölken MPMH. How Can a Bundled Payment Model Incentivize the Transition from Single-Disease Management to Person-Centred and Integrated Care for Chronic Diseases in the Netherlands? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3857. [PMID: 36900870 PMCID: PMC10001506 DOI: 10.3390/ijerph20053857] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 06/18/2023]
Abstract
To stimulate the integration of chronic care across disciplines, the Netherlands has implemented single-disease management programmes (SDMPs) in primary care since 2010; for example, for COPD, type 2 diabetes mellitus, and cardiovascular diseases. These disease-specific chronic care programmes are funded by bundled payments. For chronically ill patients with multimorbidity or with problems in other domains of health, this approach was shown to be less fit for purpose. As a result, we are currently witnessing several initiatives to broaden the scope of these programmes, aiming to provide truly person-centred integrated care (PC-IC). This raises the question if it is possible to design a payment model that would support this transition. We present an alternative payment model that combines a person-centred bundled payment with a shared savings model and pay-for-performance elements. Based on theoretical reasoning and results of previous evaluation studies, we expect the proposed payment model to stimulate integration of person-centred care between primary healthcare providers, secondary healthcare providers, and the social care domain. We also expect it to incentivise cost-conscious provider-behaviour, while safeguarding the quality of care, provided that adequate risk-mitigating actions, such as case-mix adjustment and cost-capping, are taken.
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Affiliation(s)
- Sterre S. Bour
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands
| | - Lena H. A. Raaijmakers
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Erik W. M. A. Bischoff
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Lucas M. A. Goossens
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands
- Erasmus Choice Modelling Centre, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands
| | - Maureen P. M. H. Rutten-van Mölken
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands
- Erasmus Choice Modelling Centre, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands
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Song J, Katz AD, Dalal S, Silber J, Essig D, Qureshi S, Virk S. Comparison of Relative Value Units and 30-Day Outcomes Between Primary and Revision Pediatric Spinal Deformity Surgery. Clin Spine Surg 2023; 36:E40-E44. [PMID: 35696708 DOI: 10.1097/bsd.0000000000001352] [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] [Received: 01/01/2022] [Accepted: 05/18/2022] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to compare the relative value units (RVUs) and 30-day outcomes between primary and revision pediatric spinal deformity (PSD) surgery. SUMMARY OF BACKGROUND DATA PSD surgery is frequently complicated by the need for reoperation. However, there is limited literature on physician reimbursement rates and short-term outcomes following primary versus revision spinal deformity surgery in the pediatric population. MATERIALS AND METHODS This study utilizes data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database. Patients between 10 and 18 years of age who underwent posterior spinal deformity surgery between 2012 and 2018 were included. Univariate and multivariate regression were used to assess the independent impact of revision surgery on RVUs and postoperative outcomes, including 30-day readmission, reoperation, morbidity, and complications. RESULTS The study cohort included a total of 15,055 patients, with 358 patients who underwent revision surgery. Patients in the revision group were more likely to be younger and male sex. Revision surgery more commonly required osteotomy (13.7% vs. 8.3%, P =0.002).Univariate analysis revealed higher total RVUs (71.09 vs. 60.51, P <0.001), RVUs per minute (0.27 vs. 0.23, P <0.001), readmission rate (6.7% vs. 4.0%, P =0.012), and reoperation rate (7.5% vs. 3.3%, P <0.001) for the revision surgery group. Morbidity rates were found to be statistically similar. In addition, deep surgical site infection, pulmonary embolism, and urinary tract infection were more common in the revision group. After controlling for baseline differences in multivariate regression, the differences in total RVUs, RVUs per minute, reoperation rate, and rate of pulmonary embolism between primary and revision surgery remained statistically significant. CONCLUSIONS Revision PSD surgery was found to be assigned appropriately higher mean total RVUs and RVUs per minute corresponding to the higher operative complexity compared with primary surgery. Revision surgery was also associated with poorer 30-day outcomes, including higher frequencies of reoperation and pulmonary embolism. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Junho Song
- Northwell Health Long Island Jewish Medical Center, Queens, NY
- Hospital for Special Surgery, New York, NY
| | - Austen D Katz
- Northwell Health Long Island Jewish Medical Center, Queens, NY
| | | | - Jeff Silber
- Northwell Health Long Island Jewish Medical Center, Queens, NY
| | - David Essig
- Northwell Health Long Island Jewish Medical Center, Queens, NY
| | | | - Sohrab Virk
- Northwell Health Long Island Jewish Medical Center, Queens, NY
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Girdish C, Rossini A, Sutton BS, Parente AK, Howell BL. The Longitudinal Impact Of A Multistate Commercial Accountable Care Program On Cost, Use, And Quality. Health Aff (Millwood) 2022; 41:1795-1803. [PMID: 36469827 DOI: 10.1377/hlthaff.2022.00279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The prevalence of accountable care organizations (ACOs) has grown significantly across Medicare and commercial payers in the past decade, but there are limited insights regarding the effect of ACOs on costs in the commercial population. We used longitudinal administrative claims data over the course of nineteen calendar quarters from 2016 to 2021 to assess the ongoing incremental impact of Elevance Health's commercial ACO program on cost and use across fifteen US states. We also analyzed the program's impact on spending subcategories (inpatient, outpatient, professional, and pharmacy) and measured differences in quality performance. The program was associated with incremental savings during this period. Incremental savings were greater in the fully insured population relative to the administrative services only population and were due to outpatient and pharmacy savings. ACO providers had superior quality performance measures relative to contracted providers not participating in ACOs. Payers should be aware of the potential for diminishing marginal returns of ACO contracting on containing health care costs.
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Geurts K, Bruijnzeels M, Schokkaert E. Do we care about high-cost patients? Estimating the savings on health spending by integrated care. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:1297-1308. [PMID: 35076807 DOI: 10.1007/s10198-022-01431-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 01/07/2022] [Indexed: 06/14/2023]
Abstract
A recent integrated health care initiative in Belgium supports 12 regional pilot projects scattered across the country and representing 21% of the population. As in shared savings programs, part of the estimated savings in health spending are paid out to the projects to reinvest in new actions. Short-term savings are expected in particular from cost reductions among high-cost patients. We estimate the effect of the projects on spending using a difference-in-difference model. The sensitivity of the results to the right-skewness of spending is commonly addressed by removing or top-coding high-cost cases. However, this leads to an underestimation of realized savings at the top end of the distribution, therefore, lowering incentives for cost reduction. We show that this trade-off can be weakened by an alternative approach in which cost categories that fall out of the scope of the projects' interventions are excluded from the dependent variable. We find that this approach leads to improvements in precision and model fit that are of the same magnitude as excluding high-cost cases altogether. At the same time, it sharpens the incentives for cost reduction because the model better reflects the costs that projects can affect.
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Affiliation(s)
- Karen Geurts
- IMA Intermutualistic Agency, Brussels, Belgium.
- Department of Economics, KU Leuven, Leuven, Belgium.
| | - Marc Bruijnzeels
- Department of Public Health and Primary Care, Leiden University Medical Centre, The Hague, The Netherlands
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Remers TE, Wackers EM, van Dulmen SA, Jeurissen PP. Towards population-based payment models in a multiple-payer system: the case of the Netherlands. Health Policy 2022; 126:1151-1156. [DOI: 10.1016/j.healthpol.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 05/10/2022] [Accepted: 09/21/2022] [Indexed: 11/04/2022]
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Seyfried TN, Arismendi-Morillo G, Zuccoli G, Lee DC, Duraj T, Elsakka AM, Maroon JC, Mukherjee P, Ta L, Shelton L, D'Agostino D, Kiebish M, Chinopoulos C. Metabolic management of microenvironment acidity in glioblastoma. Front Oncol 2022; 12:968351. [PMID: 36059707 PMCID: PMC9428719 DOI: 10.3389/fonc.2022.968351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/15/2022] [Indexed: 11/24/2022] Open
Abstract
Glioblastoma (GBM), similar to most cancers, is dependent on fermentation metabolism for the synthesis of biomass and energy (ATP) regardless of the cellular or genetic heterogeneity seen within the tumor. The transition from respiration to fermentation arises from the documented defects in the number, the structure, and the function of mitochondria and mitochondrial-associated membranes in GBM tissue. Glucose and glutamine are the major fermentable fuels that drive GBM growth. The major waste products of GBM cell fermentation (lactic acid, glutamic acid, and succinic acid) will acidify the microenvironment and are largely responsible for drug resistance, enhanced invasion, immunosuppression, and metastasis. Besides surgical debulking, therapies used for GBM management (radiation, chemotherapy, and steroids) enhance microenvironment acidification and, although often providing a time-limited disease control, will thus favor tumor recurrence and complications. The simultaneous restriction of glucose and glutamine, while elevating non-fermentable, anti-inflammatory ketone bodies, can help restore the pH balance of the microenvironment while, at the same time, providing a non-toxic therapeutic strategy for killing most of the neoplastic cells.
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Affiliation(s)
- Thomas N. Seyfried
- Biology Department, Boston College, Chestnut Hill, MA, United States
- *Correspondence: Thomas N. Seyfried,
| | - Gabriel Arismendi-Morillo
- Instituto de Investigaciones Biológicas, Facultad de Medicina, Universidad del Zulia, Maracaibo, Venezuela
| | - Giulio Zuccoli
- The Program for the Study of Neurodevelopment in Rare Disorders (NDRD), University of Pittsburgh, Pittsburgh, PA, United States
| | - Derek C. Lee
- Biology Department, Boston College, Chestnut Hill, MA, United States
| | - Tomas Duraj
- Faculty of Medicine, Institute for Applied Molecular Medicine (IMMA), CEU San Pablo University, Madrid, Spain
| | - Ahmed M. Elsakka
- Neuro Metabolism, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Joseph C. Maroon
- Department of Neurosurgery, University of Pittsburgh, Medical Center, Pittsburgh, PA, United States
| | - Purna Mukherjee
- Biology Department, Boston College, Chestnut Hill, MA, United States
| | - Linh Ta
- Biology Department, Boston College, Chestnut Hill, MA, United States
| | | | - Dominic D'Agostino
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, FL, United States
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Landon SN, Padikkala J, Horwitz LI. Identifying drivers of health care value: a scoping review of the literature. BMC Health Serv Res 2022; 22:845. [PMID: 35773663 PMCID: PMC9248090 DOI: 10.1186/s12913-022-08225-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/31/2022] [Indexed: 12/03/2022] Open
Abstract
Background As health care spending reaches unsustainable levels, improving value has become an increasingly important policy priority. Relatively little research has explored factors driving value. As a first step towards filling this gap, we performed a scoping review of the literature to identify potential drivers of health care value. Methods Searches of PubMed, Embase, Google Scholar, Policy File, and SCOPUS were conducted between February and March 2020. Empirical studies that explored associations between any range of factors and value (loosely defined as quality or outcomes relative to cost) were eligible for inclusion. We created a template in Microsoft Excel for data extraction and evaluated the quality of included articles using the Critical Appraisal Skills Programme (CASP) quality appraisal tool. Data was synthesized using narrative methods. Results Twenty-two studies were included in analyses, of which 20 focused on low value service utilization. Independent variables represented a range of system-, hospital-, provider-, and patient-level characteristics. Although results were mixed, several consistent findings emerged. First, insurance incentive structures may affect value. For example, patients in Accountable Care Organizations had reduced rates of low value care utilization compared to patients in traditionally structured insurance plans. Second, higher intensity of care was associated with higher rates of low value care. Third, culture is likely to contribute to value. This was suggested by findings that recent medical school graduation and allopathic training were associated with reduced low value service utilization and that provider organizations had larger effects on value than did individual physicians. Conclusions System, hospital, provider, and community characteristics influence low value care provision. To improve health care value, strategies aiming to reduce utilization of low value services and promote high value care across various levels will be essential. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08225-6.
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Affiliation(s)
- Susan N Landon
- Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, 227 E 30th St, Room 633, New York, NY, 10016, USA
| | - Jane Padikkala
- Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, 227 E 30th St, Room 633, New York, NY, 10016, USA
| | - Leora I Horwitz
- Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, 227 E 30th St, Room 633, New York, NY, 10016, USA. .,Center for Healthcare Innovation and Delivery Science, NYU Langone Health, New York, NY, USA. .,Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA.
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Milad MA, Murray RC, Navathe AS, Ryan AM. Value-Based Payment Models In The Commercial Insurance Sector: A Systematic Review. Health Aff (Millwood) 2022; 41:540-548. [PMID: 35377757 DOI: 10.1377/hlthaff.2021.01020] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
| | - Roslyn C Murray
- Roslyn C. Murray, University of Michigan, Ann Arbor, Michigan
| | - Amol S Navathe
- Amol S. Navathe, Corporal Michael J. Cresencz Veterans Affairs Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania
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Reindersma T, Sülz S, Ahaus K, Fabbricotti I. The Effect of Network-Level Payment Models on Care Network Performance: A Scoping Review of the Empirical Literature. Int J Integr Care 2022; 22:3. [PMID: 35431706 PMCID: PMC8973838 DOI: 10.5334/ijic.6002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 03/16/2022] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Thomas Reindersma
- Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Sandra Sülz
- Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Kees Ahaus
- Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Isabelle Fabbricotti
- Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Weinmeyer RM, McHugh M, Coates E, Bassett S, O'Dwyer LC. Employer-Led Strategies to Improve the Value of Health Spending: A Systematic Review. J Occup Environ Med 2022; 64:218-225. [PMID: 35244086 PMCID: PMC8887846 DOI: 10.1097/jom.0000000000002395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To systematically review studies that evaluated the impact of employer-led efforts in the United States to improve the value of health spending, where employers have implemented changes to their health benefits to reduce costs while improving or maintaining quality. METHODS We included all studies of employer-led health benefit strategies that reported outcomes for both employer health spending and employee health outcomes. RESULTS Our search returned 44 studies of employer health benefit changes that included measures of both health spending and quality. The most promising efforts were those that lowered or eliminated cost sharing for primary care or medications for chronic illnesses. High deductible health plans with a savings option appeared less promising. CONCLUSIONS More research is needed on the characteristics and contexts in which these benefit changes were implemented, and on actions that address employers' current concerns.
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Affiliation(s)
- Richard M Weinmeyer
- Northwestern University, Chicago, Illinois (Dr Weinmeyer, Dr McHugh, Dr Basset, and Ms O'Dwyer); UnitedHealth Group, Minneapolis, Minnesota (Ms Coates)
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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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Gudiksen KL, Murray RB. Options for states to constrain pricing power of health care providers. FRONTIERS IN HEALTH SERVICES 2022; 2:1020920. [PMID: 36925859 PMCID: PMC10012805 DOI: 10.3389/frhs.2022.1020920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
Health care is becoming increasingly unaffordable for both individuals and employers and prices vary in nearly incomprehensible ways that do not correlate with quality. In many areas, consolidation of insurers and providers resulted in market failure that needs policy interventions. With federal gridlock, state policymakers are seeking options for controlling health care costs in markets where competition has failed. In this article, we discuss a spectrum of options that policymakers have to more directly control healthcare prices: (1) establishing a cost-growth benchmark, (2) creating a public option, (3) capping or establishing a default out-of-network payment rate for health care services, (4) creating affordability standards that authorize the insurance commissioner to reject contracts with excessive rate increases, (5) creating global budgets for hospital-based care, (6) capping excessive prices and/or tiering allowed rate updates, and (7) creating a population-based payment model. We provide a roadmap for state policymakers to consider these options, review the experiences with states who have tried these models, and discuss additional design considerations that policymakers should consider with any of these models. In the 1970's and 1980's, during a time of rapid growth in health care prices and spending, states took a decisive leadership role in developing regulatory models to curb the growth in health care costs and improve affordability for their citizens. It is time for states to lead the nation once again in addressing the current health care cost and affordability crisis in the U.S.
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Affiliation(s)
- Katherine L Gudiksen
- The Source on Healthcare Price and Competition, University of Hastings College of the Law, San Francisco, CA, United States
| | - Robert B Murray
- The Source on Healthcare Price and Competition, University of Hastings College of the Law, San Francisco, CA, United States.,Global Health Payment LLC, Towson, MD, United States
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Zhou W, Jian W, Wang Z, Pan J, Hu M, Yip W. Impact of global budget combined with pay-for-performance on the quality of care in county hospitals: a difference-in-differences study design with a propaensity-score-matched control group using data from Guizhou province, China. BMC Health Serv Res 2021; 21:1296. [PMID: 34856985 PMCID: PMC8641159 DOI: 10.1186/s12913-021-07338-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Provider payment system has a profound impact on health system performance. In 2016, a number of counties in rural Guizhou, China, implemented global budget (GB) for county hospitals with quality control measures. The aim of this study is to measure the impact of GB combined with pay-for-performance on the quality of care of inpatients in county-level hospitals in China. METHODS Inpatient cases of four diseases, including pneumonia, chronic asthma, acute myocardial infarction and stroke, from 16 county-level hospitals in Guizhou province that implemented GB in 2016 were selected as the intervention group, and similar inpatient cases from 10 county-level hospitals that still implemented fee-for-services were used as the control group. Propensity matching score (PSM) was used for data matching to control for age factors, and difference-in-differences (DID) models were constructed using the matched samples to perform regression analysis on quality of care for the four diseases. RESULTS After the implementation of GB, rate of sputum culture in patients with pneumonia, rate of aspirin at discharge, rate of discharge with β-blocker and rate of smoking cessation advice in patients with acute myocardial infarction increased. Rate of oxygenation index assessment in patient with chronic asthma decreased 20.3%. There are no significant changes in other indicators of process quality. CONCLUSIONS The inclusion of pay-for-performance in the global budget payment system will help to reduce the quality risks associated with the reform of the payment system and improve the quality of care. Future reform should also consider the inclusion of the pay-for-performance mechanism.
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Affiliation(s)
- Wuping Zhou
- Department of Health Policy and Management, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Weiyan Jian
- Department of Health Policy and Management, School of Public Health, Peking University Health Science Center, Beijing, China.
| | - Zhifan Wang
- Department of Health Policy and Management, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Jay Pan
- West China Research Center for Rural Health Development, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Min Hu
- School of Public Health, Fudan University, Shanghai, China
| | - Winnie Yip
- Harvard School of Public Health, Boston, MA, USA
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Lin MY, Hanchate AD, Frakt AB, Burgess JF, Carey K. Do accountable care organizations differ according to physician-hospital integration?: A retrospective observational study. Medicine (Baltimore) 2021; 100:e25231. [PMID: 33761713 PMCID: PMC9281958 DOI: 10.1097/md.0000000000025231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 02/26/2021] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Meng-Yun Lin
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC
- Boston University School of Public Health, 715 Albany Street, Boston
| | - Amresh D. Hanchate
- Boston University School of Public Health, 715 Albany Street, Boston
- Boston University School of Medicine, 801 Massachusetts Avenue
| | - Austin B. Frakt
- Boston University School of Public Health, 715 Albany Street, Boston
- Partnered Evidence-based Policy Resource Center
| | - James F. Burgess
- Boston University School of Public Health, 715 Albany Street, Boston
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA
| | - Kathleen Carey
- Boston University School of Public Health, 715 Albany Street, Boston
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Viganego F, Um EK, Ruffin J, Fradley MG, Prida X, Friebel R. Impact of Global Budget Payments on Cardiovascular Care in Maryland: An Interrupted Time Series Analysis. Circ Cardiovasc Qual Outcomes 2021; 14:e007110. [PMID: 33622052 DOI: 10.1161/circoutcomes.120.007110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Global budget payments (GBP) are considered effective in containing health care expenditures; however, information on their impact on quality of cardiovascular care is limited. We aimed to evaluate the effects of GBP on utilization, outcomes, and costs for 3 major cardiovascular conditions. Methods We analyzed claims data of hospital admissions in Maryland from fiscal year 2013 to 2018. Using segmented regression, we evaluated temporal trends in hospitalizations, length of stay, percutaneous coronary intervention and coronary artery bypass grafting volumes, case mix-adjusted 30-day readmission rates, risk-standardized mortality rates, and hospitalization charges in patients with principal diagnosis of heart failure, acute ischemic stroke, and acute myocardial infarction (AMI) in relation to GBP implementation. Trends in global cardiovascular procedure charges/volumes were also studied. Results Hospitalization rates for congestive heart failure and AMI remained unaffected by GBP, while the gradient of ischemic stroke admissions decreased (Ptrend <0.0001). Length of stay slightly increased for patients with congestive heart failure (Ptrend=0.03). Inpatient coronary artery bypass grafting surgeries decreased (Ptrend <0.0001). We observed a significant decrease in casemix-adjusted 30-day readmission rate in the AMI cohort beyond the prepolicy trend (Ptrend=0.0069). There were no significant changes in mortality for any of the 3 conditions. Hospitalization charges increased for ischemic stroke (Ptrend <0.0001), remained constant for congestive heart failure (Ptrend=0.1), and decreased for AMI (Ptrend=0.0005). We observed a significant increase in electrocardiography rate charges (Ptrend <0.0001), coincidentally with a reduction in volumes (Ptrend=0.0003). Conclusions Introducing GBP in Maryland had no perceivable adverse effects on inpatient outcomes and quality indicators for 3 major cardiovascular conditions. Savings were observed in the AMI cohort, possibly due to reduced unnecessary readmissions, efficiency improvements, or shifts to outpatient care. Reduced cardiovascular procedure volumes were counterbalanced by a proportional rise in charges. State-level adoption of GBP with pay-for-performance incentives may be effective for cost containment without adversely impacting quality of cardiovascular care.
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Affiliation(s)
| | - Eun K Um
- AMSTAT Consulting, LLC, Bethesda, MD (A.E.K.U., J.R.)
| | | | - Michael G Fradley
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, Philadelphia (M.G.F.)
| | - Xavier Prida
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa (X.P.)
| | - Rocco Friebel
- Department of Health Policy, London School of Economics and Political Science, United Kingdom (R.F.)
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Ouayogodé MH, Meara E, Ho K, Snyder CM, Colla CH. Estimates of ACO savings in the presence of provider and beneficiary selection. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 9:100460. [PMID: 33412439 DOI: 10.1016/j.hjdsi.2020.100460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/24/2020] [Accepted: 08/03/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Medicare's accountable care organizations (ACOs)-designed to improve quality and lower spending-were associated with growing savings in previous studies. However, savings estimates may be biased by beneficiary sorting among providers based on healthcare needs and by providers opting into the program based on anticipated gains. METHODS Using Medicare administrative claims (2009-2014), we compared annual spending changes after provider organizations joined ACOs to changes in non-ACOs (controls). To address provider selection, using novel data to identify non-ACO organizations, we restricted controls to comparably large provider organizations. To address beneficiary selection, we (a) estimated within-organization (including non-ACO comparison organizations) spending changes, (b) estimated within-beneficiary spending changes, (c) incorporated beneficiaries without qualifying healthcare expenses, and (d) used a fixed beneficiary ACO assignment using the pre-ACO period. RESULTS Each year, 19% of Medicare beneficiaries switched provider organizations. Spending was higher for switchers than stayers ($3163, p < .001) and grew more the next year ($2004; p < .001). Starting from a baseline regression modeled on previous ACO evaluations, estimated savings varied widely as we sequentially introduced methods to address selection. Combining methods, however, generated more stable estimated ACO savings of $46 (p = .022), averaged across cohorts. CONCLUSIONS When implementing a comprehensive suite of methods to adjust for provider and beneficiary selection, we estimated ACO savings that grew over time. Our estimates are in line with, but smaller than, previous estimates in the literature. Implementing piecemeal adjustments produced misleading results. IMPLICATIONS Our results confirm the importance of selection for savings estimates and for provider organizations managing costs and quality. Attribution rules that consider multiple years may help mitigate the impact of beneficiary churn for providers and payers. Implementing payment reform by randomizing early participants, or implementing fully across selected markets, may better serve efforts to evaluate and improve payment models. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Mariétou H Ouayogodé
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, 610 Walnut Street, Madison, WI, 53726, USA.
| | - Ellen Meara
- Harvard University, T.H. Chan School of Public Health, 677 Huntington Avenue Kresge, 4th Floor, Boston, Massachussetts, 02115, USA.
| | - Kate Ho
- Princeton University, Department of Economics, 285 Julis Romo Rabinowitz Building, Princeton, NJ, 08544, USA.
| | - Christopher M Snyder
- Dartmouth College, Department of Economics, 301 Rockefeller Hall, Hanover, NH, 03755, USA.
| | - Carrie H Colla
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Research Building, Level 5, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
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Pronovost PJ, Urwin JW, Beck E, Coran JJ, Sundaramoorthy A, Schario ME, Muisyo JM, Sague J, Shea S, Runnels P, Zeiger T, Topalsky G, Wilhelm A, Palakodeti S, Navathe AS. Making a Dent in the Trillion-Dollar Problem: Toward Zero Defects. ACTA ACUST UNITED AC 2021. [DOI: 10.1056/cat.19.1064] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Peter J. Pronovost
- Chief Clinical Transformation and Quality Officer, University Hospitals, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, USA
- Weatherhead School of Management, Case Western Reserve University, Cleveland, Ohio, USA
| | - John W. Urwin
- Clinical Fellow in Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Beck
- Chief Operating Officer, University Hospitals, Cleveland, Ohio, USA
| | - Justin J. Coran
- Senior Data Scientist, University Hospitals, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | | | - Mark E. Schario
- Vice President, Population Health, and President of University Hospitals Quality Care Network, University Hospitals, Cleveland, Ohio, USA
| | - James M. Muisyo
- Data Scientist, Analytics, University Hospitals, Cleveland, Ohio, USA
| | - Jonathan Sague
- Vice President, UH Ventures Clinical Operations, University Hospitals, Cleveland, Ohio, USA
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, USA
| | - Susan Shea
- Senior Actuarial Analyst, University Hospitals, Cleveland, Ohio, USA
| | - Patrick Runnels
- Chief Medical Officer, Population Health-Behavioral Health, and Director of Population Health Education, University Hospitals, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Todd Zeiger
- Vice President, UH Primary Care Institute, University Hospitals, Cleveland, Ohio, USA
| | - George Topalsky
- Vice President, UH Primary Care Institute, University Hospitals, Cleveland, Ohio, USA
| | | | - Sandeep Palakodeti
- Chief Medical Officer, Population Health, University Hospitals, Cleveland, Ohio, USA
| | - Amol S. Navathe
- Assistant Professor of Health Policy and Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Cattel D, Eijkenaar F. Value-Based Provider Payment Initiatives Combining Global Payments With Explicit Quality Incentives: A Systematic Review. Med Care Res Rev 2020; 77:511-537. [PMID: 31216945 PMCID: PMC7536531 DOI: 10.1177/1077558719856775] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 05/20/2019] [Indexed: 01/17/2023]
Abstract
An essential element in the pursuit of value-based health care is provider payment reform. This article aims to identify and analyze payment initiatives comprising a specific manifestation of value-based payment reform that can be expected to contribute to value in a broad sense: (a) global base payments combined with (b) explicit quality incentives. We conducted a systematic review of the literature, consulting four scientific bibliographic databases, reference lists, the Internet, and experts. We included and compared 18 initiatives described in 111 articles/documents on key design features and impact on value. The initiatives are heterogeneous regarding the operationalization of the two payment components and associated design features. Main commonalities between initiatives are a strong emphasis on primary care, the use of "virtual" spending targets, and the application of risk adjustment and other risk-mitigating measures. Evaluated initiatives generally show promising results in terms of lower spending growth with equal or improved quality.
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Paredes-Fernández D, Lenz-Alcayaga R, Hernández-Sánchez K, Quiroz-Carreño J. Characterization and analysis of the basic elements of health payment mechanisms and their most frequent types. Medwave 2020; 20:e8041. [DOI: 10.5867/medwave.2020.09.8041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/07/2020] [Indexed: 11/27/2022] Open
Abstract
Introduction Healthcare systems are developed in imperfect scenarios, in which there are constant failures (uncertainty, information asymmetry, agency relationship problem, and supply-induced demand). These failures, based on the imperfection of the sector, determine the relationships and incentives between the actors. It is within this context that payment mechanisms regulate aspects of the system behavior and incentives, acting as instruments for the purchasing of health care from providers, mediated by health insurance on behalf of users. Objective To characterize the basic elements of most frequent payment mechanisms to help providers in their relationship with payers. Methods A review of the evidence was conducted in PubMed, Google, Google Scholar, and strategic snowball selection. Payment mechanisms consist of three classical microeconomics variables, fixed or variable: price, quantity, and expense. Time dimensions are used to analyze their attributes and effects. Different mechanisms emerge from the combination of these variables. Results Among the most used are: Fee-For-Service, Global Budget, Bundled Payments, Diagnosis-Related Groups, Per-capita, Performance Pay, and Risk-Sharing Agreements. A fourth has also gained importance: Financial Risk. Conclusions Payment mechanisms are essential to link health efforts with clinical practice. They make it possible to regulate relationships between insurers, providers, and users, which, depending on the architecture of the mechanism, can become beneficial or hinder the fulfillment of the objectives of the health system.
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Speer M, McCullough JM, Fielding JE, Faustino E, Teutsch SM. Excess Medical Care Spending: The Categories, Magnitude, and Opportunity Costs of Wasteful Spending in the United States. Am J Public Health 2020; 110:1743-1748. [PMID: 33058700 DOI: 10.2105/ajph.2020.305865] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Landmark reports from reputable sources have concluded that the United States wastes hundreds of billions of dollars every year on medical care that does not improve health outcomes. While there is widespread agreement over how wasteful medical care spending is defined, there is no consensus on its magnitude or categories. A shared understanding of the magnitude and components of the issue may aid in systematically reducing wasteful spending and creating opportunities for these funds to improve public health.To this end, we performed a review and crosswalk analysis of the literature to retrieve comprehensive estimates of wasteful medical care spending. We abstracted each source's definitions, categories of waste, and associated dollar amounts. We synthesized and reclassified waste into 6 categories: clinical inefficiencies, missed prevention opportunities, overuse, administrative waste, excessive prices, and fraud and abuse.Aggregate estimates of waste varied from $600 billion to more than $1.9 trillion per year, or roughly $1800 to $5700 per person per year. Wider recognition by public health stakeholders of the human and economic costs of medical waste has the potential to catalyze health system transformation.
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Affiliation(s)
- Matthew Speer
- Matthew Speer and J. Mac McCullough are with the College of Health Solutions, Arizona State University, Phoenix. Jonathan E. Fielding, Elinore Faustino, and Steven M. Teutsch are with the Center for Health Advancement, University of California, Los Angeles Fielding School of Public Health
| | - J Mac McCullough
- Matthew Speer and J. Mac McCullough are with the College of Health Solutions, Arizona State University, Phoenix. Jonathan E. Fielding, Elinore Faustino, and Steven M. Teutsch are with the Center for Health Advancement, University of California, Los Angeles Fielding School of Public Health
| | - Jonathan E Fielding
- Matthew Speer and J. Mac McCullough are with the College of Health Solutions, Arizona State University, Phoenix. Jonathan E. Fielding, Elinore Faustino, and Steven M. Teutsch are with the Center for Health Advancement, University of California, Los Angeles Fielding School of Public Health
| | - Elinore Faustino
- Matthew Speer and J. Mac McCullough are with the College of Health Solutions, Arizona State University, Phoenix. Jonathan E. Fielding, Elinore Faustino, and Steven M. Teutsch are with the Center for Health Advancement, University of California, Los Angeles Fielding School of Public Health
| | - Steven M Teutsch
- Matthew Speer and J. Mac McCullough are with the College of Health Solutions, Arizona State University, Phoenix. Jonathan E. Fielding, Elinore Faustino, and Steven M. Teutsch are with the Center for Health Advancement, University of California, Los Angeles Fielding School of Public Health
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Abstract
Background: Accountable care organizations (ACOs) are becoming a common payment and delivery model. Despite widespread interest, little empirical research has examined what efforts or strategies ACOs are using to change care and reduce costs. Knowledge of ACOs' clinical efforts can provide important context for understanding ACO performance, particularly to distinguish arenas where ACOs have and have not attempted care transformation. Purpose: The aim of the study was to understand ACOs' efforts to change clinical care during the first 18 months of ACO contracts. Methods: We conducted semistructured interviews between July and December 2013. Our sample includes ACOs that began performance contracts in 2012, including Medicare Shared Savings Program and Pioneer participants, stratified across key factors. In total, we conducted interviews with executives from 30 ACOs. Iterative qualitative analysis identified common patterns and themes. Results: ACOs in the first year of performance contracts are commonly focusing on four areas: first, transforming primary care through increased access and team-based care; second, reducing avoidable emergency department use; third, strengthening practice-based care management; and fourth, developing new boundary spanner roles and activities. ACOs were doing little around transforming specialty care, acute and postacute care, or standardizing care across practices during the first 18 months of ACO performance contracts. Practice Implications: Results suggest that cost reductions associated with ACOs in the first years of contracts may be related to primary care. Although in the long term many hope ACOs will achieve coordination across a wide array of care settings and providers, in the short term providers under ACO contracts are focused largely on primary care-related strategies. Our work provides a template of the common areas of clinical activity in the first years of ACO contracts, which may be informative to providers considering becoming an ACO. Further research will be needed to understand how these strategies are associated with performance.
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Yaqoob M, Wang J, Sweeney AT, Wells C, Rego V, Jaber BL. Trends in Avoidable Hospitalizations for Diabetes: Experience of a Large Clinically Integrated Health Care System. J Healthc Qual 2020; 41:125-133. [PMID: 31094945 DOI: 10.1097/jhq.0000000000000145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Prevention quality indicators (PQIs) are used in hospital discharge data sets to identify quality of care for ambulatory care-sensitive conditions, such as diabetes. We examined the impact of clinical integration efforts on diabetes-related PQIs in a large community-based health care organization. Inpatient and observation hospitalizations from nine acute care hospitals were trended over 5 years (2012-2016). Using established technical specifications, annual hospitalizations rates were calculated for four diabetes-related PQIs: uncontrolled diabetes, short-term complications, long-term complications, and lower extremity amputations. The mean (±standard error of the mean) annual hospitalization rate for uncontrolled diabetes and short-term complications gradually increased from 1.3 ± 1.1 and 3.2 ± 2.5 per 1,000 discharges to 2.4 ± 1.7 (p < .001) and 7.1 ± 3.2 (p < .001) per 1,000 discharges, respectively. Conversely, the annual hospitalization rate for long-term complications and lower extremity amputations gradually decreased from 12.6 ± 1.1 and 88.6 ± 1.0 per 1,000 discharges to 6.5 ± 1.0 (p = .004) and 82.2 ± 1.0 per 1,000 discharges (p < .001). Trends generally persisted across payers, age, sex, and race. There was an inverse correlation between county income-per-capita and hospitalization rate for short-term complications (p = .04), long-term complications (p = .03), and lower extremity amputations (p < .001). Study limitations included use of administrative data, evolving coding practices, and ecological fallacy. Ambulatory-based efforts to optimize diabetes care can prevent long-term complications and reduce avoidable hospitalizations.
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Lee JT, Polsky D, Fitzsimmons R, Werner RM. Proportion of Racial Minority Patients and Patients With Low Socioeconomic Status Cared for by Physician Groups After Joining Accountable Care Organizations. JAMA Netw Open 2020; 3:e204439. [PMID: 32383749 PMCID: PMC7210481 DOI: 10.1001/jamanetworkopen.2020.4439] [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: 11/20/2019] [Accepted: 03/05/2020] [Indexed: 11/14/2022] Open
Abstract
Importance The incentive structure of accountable care organizations (ACOs) may lead to participating physician groups selecting fewer vulnerable patients. Objective To test for changes in the percentage of racial minority patients and patients with low socioeconomic status cared for by physician groups after joining the ACO. Design, Setting, and Participants This retrospective cohort consisted of a 15% random sample of Medicare fee-for-service beneficiaries attributed to physician groups from 2010 to 2016. Medicare Shared Savings Program (MSSP) participation was determined using ACO files. Analyses were conducted between January 1, 2019, and February 25, 2020. Exposures Using linear probability models, we conducted difference-in-differences analyses based on the year a physician group joined an ACO to estimate changes in vulnerable patients within ACO-participating groups compared with nonparticipating groups. Main Outcomes and Measures Whether the patient was black, was dually enrolled in Medicare and Medicaid, and poverty and unemployment rates of the patient's zip code. Results In a cohort of 76 717 physician groups caring for 7 307 130 patients, 16.1% of groups caring for 27.8% of patients participated in an MSSP ACO. Using 2010 characteristics, patients attributed to ACOs from 2012 to 2016, compared with those who were not, were less likely to be black (8.0% [n = 81 698] vs 9.3% [n = 270 924]) or dually enrolled in Medicare and Medicaid (12.8% [n = 130 957] vs 18.2% [n = 528 685]), and lived in zip codes with lower poverty rates (13.8% vs 15.5%); unemployment rates were similar (8.0% vs 8.5%). In the difference-in-differences analysis, there was no statistically significant change associated with ACO participation in the proportions of vulnerable patients attributed to ACO-participating groups compared with nonparticipating groups. After joining an ACO, ACO-participating groups had 0.0 percentage points change (95% CI, -0.1 to 0.1 percentage points; P = .59) for black patients, -0.1 percentage points (95% CI, -0.2 to 0.1 percentage points; P = .32) for patients dually enrolled in Medicare and Medicaid, 0.2 percentage points (95% CI, -3.5 to 4.0 percentage points; P = .91) in poverty rates, and -0.4 percentage points (95% CI, -2.0 to 1.2 percentage points; P = .62) in unemployment rates. Conclusions and Relevance In this cohort study, there were no changes in the proportions of vulnerable patients cared for by ACO-participating physician groups after joining an ACO compared with changes among nonparticipating groups.
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Affiliation(s)
- Jessica T. Lee
- Perelman School of Medicine, Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Daniel Polsky
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland
| | - Robert Fitzsimmons
- Perelman School of Medicine, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel M. Werner
- Perelman School of Medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Guan X, Zhang C, Hu H, Shi L. The impact of global budget on expenditure, service volume, and quality of care among patients with pneumonia in a secondary hospital in China: a retrospective study. BMC Public Health 2020. [PMID: 32306932 DOI: 10.1186/s12889‐020‐08619‐3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Chinese government has begun to dampen the growth of health expenditure by implementing Global Budgets (GB). Concerns were raised about whether reductions in expenditure would lead to a deterioration of quality of care. This paper aims to evaluate the impact of GB on health expenditure, service volume and quality of care among Chinese pneumonia patients. METHODS A secondary hospital that replaced Fee-For-Service (FFS) with GB in China in 2016 was sampled. We used daily expenditure to assess health expenditure; monthly admission, length of stay (LOS), number of drugs per record and record containing antibiotics to evaluate service volume; record with multiple antibiotics and readmission to assess quality of care. Descriptive analyses were adopted to evaluate changes after the reform, logistic regression and multivariable linear regressions were used to analyze changes associated with the reform. RESULTS In 2015 and 2016, 3400 admissions from 3173 inpatients and 2342 admissions from 2246 inpatients were admitted, respectively. According to regression analyses, daily expenditure, LOS, readmission, and records with multiple antibiotic usages significantly declined after the reform. However, no significant relation was observed between GB and the number of drugs per record or record containing antibiotics. CONCLUSIONS When compared with FFS, GB can curtail health expenditure and improve quality of care. As far as service volume was concerned, LOS and monthly admission declined, while number of drugs per record and record containing antibiotics were not affected.
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Affiliation(s)
- Xiaodong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China.,International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Chi Zhang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
| | - Huajie Hu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China. .,International Research Center for Medicinal Administration, Peking University, Beijing, China.
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Guan X, Zhang C, Hu H, Shi L. The impact of global budget on expenditure, service volume, and quality of care among patients with pneumonia in a secondary hospital in China: a retrospective study. BMC Public Health 2020; 20:522. [PMID: 32306932 PMCID: PMC7168859 DOI: 10.1186/s12889-020-08619-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 03/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Chinese government has begun to dampen the growth of health expenditure by implementing Global Budgets (GB). Concerns were raised about whether reductions in expenditure would lead to a deterioration of quality of care. This paper aims to evaluate the impact of GB on health expenditure, service volume and quality of care among Chinese pneumonia patients. METHODS A secondary hospital that replaced Fee-For-Service (FFS) with GB in China in 2016 was sampled. We used daily expenditure to assess health expenditure; monthly admission, length of stay (LOS), number of drugs per record and record containing antibiotics to evaluate service volume; record with multiple antibiotics and readmission to assess quality of care. Descriptive analyses were adopted to evaluate changes after the reform, logistic regression and multivariable linear regressions were used to analyze changes associated with the reform. RESULTS In 2015 and 2016, 3400 admissions from 3173 inpatients and 2342 admissions from 2246 inpatients were admitted, respectively. According to regression analyses, daily expenditure, LOS, readmission, and records with multiple antibiotic usages significantly declined after the reform. However, no significant relation was observed between GB and the number of drugs per record or record containing antibiotics. CONCLUSIONS When compared with FFS, GB can curtail health expenditure and improve quality of care. As far as service volume was concerned, LOS and monthly admission declined, while number of drugs per record and record containing antibiotics were not affected.
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Affiliation(s)
- Xiaodong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191 China
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Chi Zhang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191 China
| | - Huajie Hu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191 China
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191 China
- International Research Center for Medicinal Administration, Peking University, Beijing, China
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Giacoma T, Ayvaci MU, Gaston RS, Mejia A, Tanriover B. Transplant physician and surgeon compensation: A sample framework accounting for nonbillable and value-based work. Am J Transplant 2020; 20:641-652. [PMID: 31566885 PMCID: PMC7042066 DOI: 10.1111/ajt.15625] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 09/20/2019] [Accepted: 09/24/2019] [Indexed: 01/25/2023]
Abstract
Work relative value unit (wRVU)-based fee schedules are predominantly used by both the Centers for Medicare & Medicaid Services (CMS) and private payers to determine the payments for physicians' clinical productivity. However, under the Affordable Care Act, CMS is transitioning into a value-based payment structure that rewards patient-oriented outcomes and cost savings. Moreover, in the context of solid organ transplantation, physicians and surgeons conduct many activities that are neither billable nor accounted for in the wRVU models. New compensation models for transplant professionals must (1) justify payments for nonbillable work related to transplant activity/procedures; (2) capture the entire academic, clinical, and relationship-building work effort as part of RVU determination; and (3) move toward a value-based compensation scheme that aligns the incentives for physicians, surgeons, transplant center, payers, and patients. In this review, we provide an example of redesigning RVUs to address these challenges in compensating transplant physicians and surgeons. We define a customized RVU (cRVU) for activities that typically do not generate wRVUs and create an outcome value unit (OVU) measure that incorporates outcomes and cost savings into RVUs to include value-based compensation.
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Affiliation(s)
- Tracy Giacoma
- Transplant Institute at Methodist Dallas, Dallas, TX
| | - Mehmet U.S. Ayvaci
- Information Systems & Operations Management, the University of Texas at Dallas, Richardson, TX
| | - Robert S. Gaston
- Division of Nephrology, the University of Alabama at Birmingham, Birmingham, AL
| | - Alejandro Mejia
- Department of Surgery, Methodist Dallas Transplant Institute, Dallas, TX
| | - Bekir Tanriover
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX
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Ho V, Metcalfe L, Vu L, Short M, Morrow R. Annual Spending per Patient and Quality in Hospital-Owned Versus Physician-Owned Organizations: an Observational Study. J Gen Intern Med 2020; 35:649-655. [PMID: 31482340 PMCID: PMC7080686 DOI: 10.1007/s11606-019-05312-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 04/23/2019] [Accepted: 07/30/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recent studies that compared patient spending in hospital-owned physician practices versus physician-owned groups did not compare quality of care. Past studies had incomplete measures of physician-hospital integration, or lacked patient-level data. OBJECTIVE To measure the association between physician-hospital integration and both spending and quality using patient-level data and explicit physician-hospital contracting information. DESIGN Retrospective review of claims data from 2014 through 2016. Adjustments were made for patient, physician, and regional characteristics. PATIENTS Patients aged 19 to 64 enrolled in a Blue Cross Blue Shield Texas Preferred Provider Organization in the four largest metropolitan areas in Texas who could be attributed to a physician practice based on claims. MAIN OUTCOMES AND MEASURES Annual spending per patient was compared for patients treated by a physician practice that is billing through a hospital, versus billing through an independent physician practice; spending was also subdivided by BETOS category, by site and type of care, and percent of patients with positive spending by subcategory. Quality measures included readmission within 30 days of discharge for hospitalized patients, appropriate care for diabetic patients, and screening mammography for women ages 50-64. RESULTS Estimates suggest that patients in a preferred provider organization incur spending which is 5.8 percentage points higher when treated by doctors in hospital-owned versus physician-owned practices (95% CI 1.7 to 9.9; p = 0.006). Spending is significantly higher for durable medical equipment, imaging, unclassified services, and outpatient care. The spending difference appears attributable to greater service utilization rather than higher prices. There was no consistent difference in care quality for hospital-owned versus physician-owned practices. CONCLUSIONS AND RELEVANCE We find that financial integration between physicians and hospitals raises patient spending, but not care quality. Given that higher spending raises the price of health insurance, policy makers should carefully consider policies that limit consolidation of hospitals and physicians.
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Affiliation(s)
- Vivian Ho
- Baker Institute for Public Policy at Rice University, Houston, TX, USA. .,Department of Economics, Rice University, MS 22, 6100 Main Street, Houston, TX, 77005, USA. .,Department of Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA.
| | | | - Lan Vu
- Blue Cross Blue Shield of Texas, Chicago, IL, USA
| | - Marah Short
- Baker Institute for Public Policy at Rice University, Houston, TX, USA
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Five-year Impact of a Commercial Accountable Care Organization on Health Care Spending, Utilization, and Quality of Care. Med Care 2020; 57:845-854. [PMID: 31348124 DOI: 10.1097/mlr.0000000000001179] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
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.
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Liu X, Zhang Q, Xu Y, Wu X, Wang X. Trend analysis of medical expenses in Shenzhen after China's new health-care reforms. Int J Health Plann Manage 2019; 35:760-772. [PMID: 31802556 DOI: 10.1002/hpm.2951] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/19/2019] [Accepted: 10/22/2019] [Indexed: 02/03/2023] Open
Abstract
Since China initiated new health-care reforms in early 2009, a variety of measures have been implemented to slow the growth of medical expenses. This study was conducted to investigate the effect of controlling medical expenses. Based on inpatients' medical expenses at the largest tertiary hospital in Shenzhen, China, from 2009 to 2017, this study analyzed the changes in medical expenses and expense structures according to payment sources (insured or self-financed), stratifying the medical expenses according to the ICD-10 classification chapters of the principal diagnoses of the inpatients in two years (2009 and 2017) in order to control for confounding diseases. The results showed that mean inpatient expenses continued to rise from 2009 to 2017, and the expenses of the self-financed group began to exceed those of the insured group after 2011. Drug and consumable expenses were still the main factors that affected inpatient expenses, and consumable expenses remarkably increased, becoming the highest proportion of expenses. New health-care reforms were effective in controlling growing medical expenses for insured patients but did not make a significant difference in the expenses of self-financed patients. The excessive use of consumables has become a new driver of growing medical expenses.
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Affiliation(s)
- Xueyan Liu
- Center for Social Security Studies, Wuhan University, Wuhan, China
- Shenzhen People's Hospital, Shenzhen, China
| | - Qilin Zhang
- Center for Social Security Studies, Wuhan University, Wuhan, China
| | - Yong Xu
- Shenzhen People's Hospital, Shenzhen, China
| | - Xiaoyun Wu
- Shenzhen People's Hospital, Shenzhen, China
| | - Xiaofeng Wang
- College of Communication, Shenzhen University, Shenzhen, China
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Newhouse JP, Price M, Hsu J, Landon B, McWilliams JM. Delivery system performance as financial risk varies. THE AMERICAN JOURNAL OF MANAGED CARE 2019; 25:e388-e394. [PMID: 31860233 PMCID: PMC7412600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Banner Health, a large delivery system in Maricopa County, Arizona, entered into both Medicare and commercial insurance contracts that varied the amount of financial risk that Banner assumed. Rates of utilization and spending under these various contracts were investigated. STUDY DESIGN Prior to 2012, Banner held Medicare Advantage (MA) contracts, and in 2012 it began as a Medicare Pioneer accountable care organization (ACO). Banner also introduced a commercial ACO contract in that year. We compared risk-adjusted healthcare utilization and spending in the MA plan, the ACO, and a local traditional Medicare (TM) comparison group. We also compared risk-adjusted utilization and spending in Banner's commercial ACO with that of a comparison group drawn from the same employment groups who were not attributed to Banner providers. METHODS We used claims and encounter data to measure utilization and spending. We risk adjusted using CMS and HHS Hierarchical Condition Categories. RESULTS Within Medicare, MA enrollees had lower risk-adjusted utilization and total spending than either the Pioneer ACO participants or a local TM comparison group. Participation in the Pioneer ACO program was associated with a greater reduction in hospitalization rates for ACO patients relative to local TM patients served by non-ACO providers, but the effect on total medical spending was ambiguous. Risk-adjusted differences between the commercial ACO group and the fee-for-service comparison group were generally small. CONCLUSIONS The results are consistent with CMS' efforts to shift reimbursement away from pure fee-for-service reimbursement.
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Kanter GP, Polsky D, Werner RM. Changes In Physician Consolidation With The Spread Of Accountable Care Organizations. Health Aff (Millwood) 2019; 38:1936-1943. [DOI: 10.1377/hlthaff.2018.05415] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Genevieve P. Kanter
- Genevieve P. Kanter is an assistant professor in the Division of General Internal Medicine and the Department of Medical Ethics and Health Policy, both at the University of Pennsylvania Perelman School of Medicine, in Philadelphia
| | - Daniel Polsky
- Daniel Polsky is the Bloomberg Distinguished Professor of Health Policy and Economics at Johns Hopkins University, jointly appointed in the Bloomberg School of Public Health and the Carey Business School, in Baltimore, Maryland
| | - Rachel M. Werner
- Rachel M. Werner is the Robert D. Eilers Professor of Health Care Management at the Wharton School, a professor of Medicine at the Perelman School of Medicine, and executive director of the Leonard Davis Institute of Health Economics, all at the University of Pennsylvania, and core faculty at the Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, in Philadelphia
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Steenkamer BM, Drewes HW, van Vooren N, Baan CA, van Oers H, Putters K. How executives' expectations and experiences shape population health management strategies. BMC Health Serv Res 2019; 19:757. [PMID: 31655602 PMCID: PMC6815420 DOI: 10.1186/s12913-019-4513-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 09/04/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Within Population Health Management (PHM) initiatives, stakeholders from various sectors apply PHM strategies, via which services are reorganised and integrated in order to improve population health and quality of care while reducing cost growth. This study unravelled how stakeholders' expectations and prior experiences influenced stakeholders intended PHM strategies. METHODS This study used realist principles. Nine Dutch PHM initiatives participated. Seventy stakeholders (mainly executive level) from seven different stakeholder groups (healthcare insurers, hospitals, primary care groups, municipalities, patient representative organisations, regional businesses and program managers of the PHM initiatives) were interviewed. Associations between expectations, prior experiences and intended strategies of the various stakeholder groups were identified through analyses of the interviews. RESULTS Stakeholders' expectations, their underlying explanations and intended strategies could be categorized into four themes: 1. Regional collaboration; 2. Governance structures and stakeholder roles; 3. Regional learning environments, and 4. Financial and regulative conditions. Stakeholders agreed on the long-term expectations of PHM development. Differences in short- and middle-term expectations, and prior experiences were identified between stakeholder groups and within the stakeholder group healthcare insurers. These differences influenced stakeholders' intended strategies. For instance, healthcare insurers that intended to stay close to the business of care had encountered barriers in pushing PHM e.g. lack of data insight, and expected that staying in control of the purchasing process was the best way to achieve value for money. Healthcare insurers that were more keen to invest in experiments with data-technology, new forms of payment and accountability had encountered positive experiences in establishing regional responsibility and expected this to be a strong driver for establishing improvements in regional health and a vital and economic competitive region. CONCLUSION This is the first study that revealed insight into the differences and similarities between stakeholder groups' expectations, experiences and intended strategies. These insights can be used to improve the pivotal cooperation within and between stakeholder groups for PHM.
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Affiliation(s)
- Betty M. Steenkamer
- Tilburg School of Social and Behavioural Sciences, Tilburg University, Tranzo, PO Box 90153, 5000 LE Tilburg, The Netherlands
| | - Hanneke W. Drewes
- National Institute for Public Health and the Environment (RIVM), PO Box 1, 3720 BA Bilthoven, The Netherlands
| | - Natascha van Vooren
- National Institute for Public Health and the Environment (RIVM), PO Box 1, 3720 BA Bilthoven, The Netherlands
| | - Caroline A. Baan
- Tilburg School of Social and Behavioural Sciences, Tilburg University, Tranzo, PO Box 90153, 5000 LE Tilburg, The Netherlands
- National Institute for Public Health and the Environment (RIVM), PO Box 1, 3720 BA Bilthoven, The Netherlands
| | - Hans van Oers
- Tilburg School of Social and Behavioural Sciences, Tilburg University, Tranzo, PO Box 90153, 5000 LE Tilburg, The Netherlands
- National Institute for Public Health and the Environment (RIVM), PO Box 1, 3720 BA Bilthoven, The Netherlands
| | - Kim Putters
- Erasmus School of Health Policy & Management (ESHPM), P.O. Box 1738, 3000 DR Rotterdam, The Netherlands
- The Netherlands Institute for Social Research, PO Box 16164, 2500 BD The Hague, The Netherlands
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Barriers to payment reform: Experiences from nine Dutch population health management sites. Health Policy 2019; 123:1100-1107. [PMID: 31578167 DOI: 10.1016/j.healthpol.2019.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 06/06/2019] [Accepted: 09/16/2019] [Indexed: 11/23/2022]
Abstract
Population health management (PHM) initiatives aim for better population health, quality of care and reduction of expenditure growth by integrating and optimizing services across domains. Reforms shifting payment of providers from traditional fee-for-service towards value-based payment models may support PHM. We aimed to gain insight into payment reform in nine Dutch PHM sites. Specifically, we investigated 1) the type of payment models implemented, and 2) the experienced barriers towards payment reform. Between October 2016 and February 2017, we conducted 36 (semi-)structured interviews with program managers, hospitals, insurers and primary care representatives of the sites. We addressed the structure of payment models and barriers to payment reform in general. After three years of PHM, we found that four shared savings models for pharmaceutical care and five extensions of existing (bundled) payment models adding providers into the model were implemented. Interviewees stated that reluctance to shift financial accountability to providers was partly due to information asymmetry, a lack of trust and conflicting incentives between providers and insurers, and last but not least a lack of a sense of urgency. Small steps to payment reform have been taken in the Dutch PHM sites, which is in line with other international PHM initiatives. While acknowledging the autonomy of PHM sites, governmental stewardship (e.g. long-term vision, supporting knowledge development) can further stimulate value-based payment reforms.
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Roos A, Croes RR, Shestalova V, Varkevisser M, Schut FT. Price effects of a hospital merger: Heterogeneity across health insurers, hospital products, and hospital locations. HEALTH ECONOMICS 2019; 28:1130-1145. [PMID: 31264329 PMCID: PMC6772112 DOI: 10.1002/hec.3920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 03/26/2019] [Accepted: 05/19/2019] [Indexed: 06/09/2023]
Abstract
In most studies on hospital merger effects, the unit of observation is the merged hospital, whereas the observed price is the weighted average across hospital products and across payers. However, little is known about whether price effects vary between hospital locations, products, and payers. We expand existing bargaining models to allow for heterogeneous price effects and use a difference-in-differences model in which price changes at the merging hospitals are compared with price changes at comparison hospitals. We find evidence of heterogeneous price effects across health insurers, hospital products and hospital locations. These findings have implications for ex ante merger scrutiny.
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Affiliation(s)
- Anne‐Fleur Roos
- Erasmus School of Health Policy & ManagementErasmus University RotterdamRotterdamNetherlands
| | - Ramsis R. Croes
- Erasmus School of Health Policy & ManagementErasmus University Rotterdam & Dutch Healthcare AuthorityUtrechtNetherlands
- Dutch Healthcare AuthorityUtrechtNetherlands
| | | | - Marco Varkevisser
- Erasmus School of Health Policy & ManagementErasmus University RotterdamRotterdamNetherlands
| | - Frederik T. Schut
- Erasmus School of Health Policy & ManagementErasmus University RotterdamRotterdamNetherlands
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Menendez ME, Parrish RC, Ring D, Chen NC. Variation in Physician Charges and Medicare Payments for Hand Surgery. J Hand Microsurg 2019; 11:61-70. [PMID: 31413488 PMCID: PMC6692153 DOI: 10.1055/s-0038-1660772] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 04/26/2018] [Indexed: 12/23/2022] Open
Abstract
Purpose To assess national and state-level variation in physician charges (full amounts requested before payments are negotiated) and Medicare payments for common hand procedures. Materials and Methods Using the Medicare Provider Utilization and Payment Data Public Use File for 2012, we evaluated national and state variations in physician charges and Medicare payments for carpal tunnel release, trigger finger release, trigger finger injection, closed treatment of distal radius fracture, and interposition arthroplasty, intercarpal or carpometacarpal joints. We assessed variation, using the coefficient of variation. We also determined the correlation between charges and payments, as well as the association of patient volume with charges and payments. Results There was wide state-level variation in physician charges for carpal tunnel release (11-fold), trigger finger release (9.6-fold), and trigger finger injection (5.5-fold). On a national level, physician charges varied substantially for carpal tunnel release, trigger finger release, trigger finger injection, closed treatment of distal radius fracture, and interposition arthroplasty, intercarpal or carpometacarpal joints. Medicare payments varied to a lesser extent. The correlations between physician charges and Medicare reimbursements were not strong. Weak to no correlations were noted between patient volume and both charges and payments. Conclusion Physician charges for hand surgery vary substantially across states and nationally, and they do not correlate well with Medicare payments and surgeon volume. As the health care market transitions toward more restrictive physician networks and high-deductible plans, protecting uninsured and out-of-network patients from unexpected, high medical bills should be a policy priority. Type of Study/Level of Evidence Economic/Decision Analysis, Level III study.
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Affiliation(s)
- Mariano E. Menendez
- Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, United States
| | - Raymond C. Parrish
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Texas, United States
| | - David Ring
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Neal C. Chen
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
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Seibert K, Stiefler S, Domhoff D, Wolf-Ostermann K, Peschke D. [A systematic review on population-based indicators of the quality of care in formal and informal provider networks and their application in health economic evaluations]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2019; 144-145:7-23. [PMID: 31327735 DOI: 10.1016/j.zefq.2019.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 06/19/2019] [Accepted: 06/28/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Provider networks in healthcare can emerge as either formal or informal networks. For sector-encompassing population-based quality measurement in informal networks, which allows for conclusions about the cost-effectiveness of care for home-dwelling persons in need of care, a comprehensive review on suitable quality indicators that can be derived from German social health insurance claims data is still lacking. OBJECTIVE Primary review questions: Which population-based indicators of quality of care in formal and informal provider networks are described in the international literature? Which of these indicators are used as outcome parameters in health economic evaluations, and what are the methodological approaches in these evaluations? Rating approaches and methods for establishing thresholds as well as the validity and suitability of quality indicators to predict quality of care as well as the potential for the calculation of quality indicators based on German social health insurance claims data are included in the secondary review questions. SEARCH METHODS Databases searched in May 2017 and July 2018 included PubMed, The Cochrane Library und NHS EED, CINAHL, GeroLit and EconLit. In addition, we hand-searched references of the studies identified and screened the project database Health Services Research Germany. SELECTION CRITERIA Quantitative design, German or English language. Any kind of formal or informal network for which distinct members regarding single providers are named and population-based quality indicators for adults (18 years or older) are described. DATA COLLECTION AND ANALYSIS Two authors (Cohen's Kappa = 0.64) independently screened titles, abstracts and full texts. A third independent reviewer was consulted in cases of uncertainty regarding the inclusion of studies. Critical appraisal was conducted using AMSTAR, the Cochrane Risk-of-Bias Tool, the Newcastle-Ottawa Scale (NOS), the Appraisal Tool for Cross-Sectional Studies (AXIS) and the criteria of the Drummond Checklist. MAIN RESULTS 137 studies were included, five of which evaluated informal provider networks and applied indicators for medical conditions such as diabetes mellitus or heart failure or events like ambulatory care-sensitive hospitalisations, which were also utilized for formal networks. Five out of 14 health economic evaluations also assessed associations between costs and quality of care. The majority of studies did not include evidence on rating approaches and/or thresholds. Even though the validity and reliability of the used data in single studies is frequently discussed, only one in four of the included studies undertook a discussion of the suitability of the applied indicators. 121 studies explored indicators that can, in whole or in part, potentially be calculated on the basis of German social health insurance claims data and that target medical conditions such as osteoarthritis, asthma, chronic pain, chronic obstructive pulmonary disease, cardiovascular disease, dementia, diabetes mellitus, osteoporosis or mental health disorders as well as ambulatory care-sensitive events, appropriate medication of the elderly and polypharmacy, preventive care and continuity of care. AUTHORS' CONCLUSIONS This systematic review identified quality indicators that were predominantly used in formal provider networks and, with sufficient testing and further development, include the possibility of being used for measuring the quality of care in informal networks. The need for further research on suitable approaches to measure the interactions of quality of care and costs and on the validity, reliability and predictive suitability of single indicators as well as the finding that quality indicators especially developed for the German ambulatory sector were rarely used in the included studies constitute promising starting points for both an intensified methodological debate and the critical discussion of issues concerning population-based, sector-encompassing measurement of quality of care in health services research.
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Affiliation(s)
- Kathrin Seibert
- Universität Bremen, Fachbereich 11: Human- und Gesundheitswissenschaften, Institut für Public Health und Pflegeforschung, Bremen, Deutschland; Universität Bremen, Wissenschaftsschwerpunkt Gesundheitswissenschaften, Bremen, Germany.
| | - Susanne Stiefler
- Universität Bremen, Fachbereich 11: Human- und Gesundheitswissenschaften, Institut für Public Health und Pflegeforschung, Bremen, Deutschland; Universität Bremen, Wissenschaftsschwerpunkt Gesundheitswissenschaften, Bremen, Germany
| | - Dominik Domhoff
- Universität Bremen, Fachbereich 11: Human- und Gesundheitswissenschaften, Institut für Public Health und Pflegeforschung, Bremen, Deutschland; Universität Bremen, Wissenschaftsschwerpunkt Gesundheitswissenschaften, Bremen, Germany
| | - Karin Wolf-Ostermann
- Universität Bremen, Fachbereich 11: Human- und Gesundheitswissenschaften, Institut für Public Health und Pflegeforschung, Bremen, Deutschland; Universität Bremen, Wissenschaftsschwerpunkt Gesundheitswissenschaften, Bremen, Germany
| | - Dirk Peschke
- Universität Bremen, Fachbereich 11: Human- und Gesundheitswissenschaften, Institut für Public Health und Pflegeforschung, Bremen, Deutschland; Universität Bremen, Wissenschaftsschwerpunkt Gesundheitswissenschaften, Bremen, Germany
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