Do Health Care Delivery System Reforms Improve Value? The Jury Is Still Out

Addressing Social Needs in Clinical Settings: Implementation and Impact on Health Care Utilization, Costs, and Integration of Care

In recent years, health care policy makers have focused increasingly on addressing social drivers of health as a strategy for improving health and health equity. Impacts of social, economic, and environmental conditions on health are well established. However, less is known about the implementation and impact of approaches used by health care providers and payers to address social drivers of health in clinical settings. This article reviews current efforts by US health care organizations and public payers such as Medicaid and Medicare to address social drivers of health at the individual and community levels. We summarize the limited available evidence regarding intervention impacts on health care utilization, costs, and integration of care and identify key lessons learned from current implementation efforts.

Care Management Processes Important for High-Quality Diabetes Care

OBJECTIVE

Identify the improvement in diabetes performance measures and population-based clinical outcomes resulting from changes in care management processes (CMP) in primary care practices over 3 years.

RESEARCH DESIGN AND METHODS

This repeated cross-sectional study tracked clinical performance measures for all diabetes patients seen in a cohort of 330 primary care practices in 2017 and 2019. Unit of analysis was patient-year with practice-level CMP exposures. Causal inference is based on dynamic changes in individual CMPs between years by practice. We used the Bayesian method to simultaneously estimate a five-outcome model: A1c, systolic and diastolic blood pressure, guideline-based statin use, and Optimal Diabetes Care (ODC). We control for unobserved time-invariant practice characteristics and secular change. We modeled correlation of errors across outcomes. Statistical significance was identified using 99% Bayesian credible intervals (analogous to P < 0.01).

RESULTS

Implementation of 18 of 62 CMPs was associated with statistically significant improvements in patient outcomes. Together, these resulted in 12.1% more patients meeting ODC performance measures. Different CMPs affected different outcomes. Three CMPs accounted for 47% of the total ODC improvement, 68% of A1c decrease, 21% of SBP reduction, and 55% of statin use increase: 1) systems for identifying and reminding patients due for testing, 2) after-visit follow-up by a nonclinician, and 3) guideline-based clinician reminders for preventive services during a clinic visit.

CONCLUSIONS

Effective quality improvement in primary care focuses on practice redesign that clearly improves diabetes outcomes. Tailoring CMP adoption in primary care provides effective improvement in ODC performance through focused changes in diabetes outcomes.

Diabetes care quality: do large medical groups perform better?

OBJECTIVES

To compare primary care management processes (CMPs) and outcome measures for diabetes quality among large, medium, and small medical groups.

STUDY DESIGN

Observational comparison of differences in processes and outcomes over time among 329 primary care practices that agreed to participate and returned completed surveys in both 2017 and 2019.

METHODS

We used a standardized composite measure of diabetes quality along with its 5 components and a survey measure of the presence of systematic CMPs to compare the outcomes and processes of care among clinics that were in large (≥ 12 sites), medium (4-11 sites), and small (1-3 sites) medical groups.

RESULTS

Practices from large groups had better performance than those in medium and small groups on the composite measure of diabetes outcomes in 2017 (46.5 vs 40.6 and 34.4, respectively; P < .001), as well as on each of the 5 component measures. They also had more CMPs in place (74.2% vs 66.9% and 61.4%; P < .001), including the 10 CMPs that are associated with the highest level of performance (84.2% vs 77.9% and 72.2%; P < .001). However, repeated measures in 2019 showed that the smaller groups had gained on both quality and CMP measures. There was also substantial overlap on both CMPs and performance among practices in groups of different sizes.

CONCLUSIONS

On average, primary care practices that are part of large well-established medical groups outperformed smaller-sized groups in diabetes care quality, probably because they have the resources, leadership, and infrastructure to provide more consistent care through more organized CMPs.

Factors Associated With Overuse of Health Care Within US Health Systems

Question

What features of health care systems in the US are associated with overuse of health care?

Findings

In this cross-sectional study of 676 US health care systems, those that were overusing health care had more beds, had fewer primary care physicians, had more physician practice groups, were more likely to be investor owned, and were less likely to include a major teaching hospital.

Meaning

In-depth exploration of the drivers of health care overuse is needed at the level of health systems as their incentives may not be aligned with high-value care.

Importance

Overuse of health care is a pervasive threat to patients that requires measurement to inform the development of interventions.

Objective

To measure low-value health care use within health systems in the US and explore features of the health systems associated with low-value care delivery.

Design, Setting, and Participants

In this cross-sectional analysis, we identified occurrences of 17 low-value services in 3745 hospitals and affiliated outpatient sites. Hospitals were linked to 676 health systems in the US using the Agency for Healthcare Research and Quality (AHRQ) Compendium of Health Systems. The participants were 100% of Medicare beneficiaries with claims from 2016 to 2018.

Exposures

We identified occurrences of 17 low-value services in 3839 hospitals and affiliated outpatient sites.

Main Outcomes and Measures

Hospitals were linked to health systems using AHRQ’s Compendium of Health Systems. Between March and August 2021, we modeled overuse occurrences with a negative binomial regression model including the year-quarter, procedure indicator, and a health system indicator. The model included random effects for hospital and beneficiary age, sex, and comorbidity count specific to each indicator, hospital, and quarter. The beta coefficients associated with the health system term, normalized, reflect the tendency of that system to use low-value services relative to all other systems. With ordinary least squares regression, we explored health system characteristics associated with the Overuse Index (OI), expressed as a standard deviation where the mean across all health systems is 0.

Results

There were 676 unique health systems assessed in our study that included from 1 to 163 hospitals (median of 2). The mean age of eligible beneficiaries was 75.5 years and 76% were women. Relative to the lowest tertile, health systems in the upper tertile of medical groups count and bed count had an OI that was higher by 0.38 standard deviations (SD) and 0.44 SD, respectively. Health systems that were primarily investor owned had an OI that was 0.56 SD higher than those that were not investor owned. Relative to the lowest tertile, health systems in the upper tertile of primary care physicians, upper tertile of teaching intensity, and upper quartile of uncompensated care had an OI that was lower by 0.59 SD, 0.45 SD, and 0.47 SD, respectively.

Conclusions and Relevance

In this cross-sectional study of US health systems, higher amounts of overuse among health systems were associated with investor ownership and fewer primary care physicians. The OI is a valuable tool for identifying potentially modifiable drivers of overuse and is adaptable to other levels of investigation, such as the state or region, which might be affected by local policies affecting payment or system consolidation.

Comparative Effectiveness of a Complex Care Program for High-Cost/High-Need Patients: a Retrospective Cohort Study

BACKGROUND

High-cost/high-need (HCHN) adults and the healthcare systems that provide their care may benefit from a new patient-centered model of care involving a dedicated physician and nurse team who coordinate both clinical and social services for a small patient panel.

OBJECTIVE

Evaluate the impact of a Complex Care Program (CCP) on likelihood of patient survival and hospital admission in 180 days following empanelment to the CCP.

DESIGN

Retrospective cohort study using a quasi-experimental design with CCP patients propensity score matched to a concurrent control group of eligible but unempaneled patients.

SETTING

Kaiser Permanente Mid-Atlantic States (KPMAS) during 2017-2018.

PARTICIPANTS

Nine hundred twenty-nine CCP patients empaneled January 2017-June 2018, 929 matched control patients for the same period.

INTERVENTIONS

The KPMAS CCP is a new program consisting of 8 teams each staffed by a physician and nurse who coordinate care across a continuum of specialty care, tertiary care, and community services for a panel of 200 patients with advanced clinical disease and recent hospitalizations.

MAIN OUTCOMES

Time to death and time to first hospital admission in the 180 days following empanelment or eligibility.

RESULTS

Compared to matched control patients, CCP patients had prolonged time to death (hazard ratio [HR]: 0.577, 95% CI: 0.474, 0.704), and CCP decedents had longer survival (median days 69.5 vs. 53.0, p=0.03). CCP patients had similar time to hospital admission (HR: 1.081, 95% CI: 0.930, 1.258), with similar results when adjusting for competing risk of death (HR: 1.062, 95% CI: 0.914, 1.084).

LIMITATIONS

Non-randomized intervention; single healthcare system; patient eligibility limited to specific conditions.

CONCLUSION

The KPMAS CCP was associated with significantly reduced short-term mortality risk for eligible patients who volunteered to participate in this intervention.

Impact of Patient-Centered Medical Home Transformation on Providers, Staff, and Quality

The Patient-Centered Medical Home (PCMH) has become a widely implemented model to transform the delivery of care, but little evidence exists regarding the model's impact on providers, nurses, and staff. This study examined the impact of the PCMH model on (1) provider and staff satisfaction, (2) work-life balance, (3) teamwork, (4) professional experience, (5) patient care factors, and (6) quality outcomes. The authors confidentially surveyed physicians, advanced practice providers (APPs), nurses, care managers, and office staff in 2011 prior to implementation of the PCMH model and in 2016 after implementation at 34 primary care offices providing care to 171,045 patients. A total of 349 pre-PCMH implementation surveys (84% response rate) and 549 follow-up surveys (92% response rate) were received. Implementation of the PCMH model did not result in changes in provider, nurse, and staff responses to composite measures of satisfaction (P = 0.45), work-life balance (P = 0.68), teamwork (P = 0.26), patient care (P = 0.62), or professional experience (P = 0.14). Physicians and APPs experienced a negative, but mostly nonsignificant, change in all composite measures with implementation of the PCMH model. Quality markers improved for diabetes control HbA1c <8 (62.6% to 67.9%; P < 0.001), hypertension control (60.9% to 75.0%; P < 0.001), breast cancer screening (53.9% to 77.4%; P < 0.001), and colorectal cancer screening (43.9% to 70.3%; P < 0.001). Across a large primary care network, implementation of the PCMH model failed to improve overall satisfaction, work-life balance, teamwork, patient care, or professional experience. The model, combined with financial incentives, did result in improvements across multiple patient quality domains.

An Assessment of the Impact of Just Culture on Quality and Safety in US Hospitals

In pursuit of high reliability, numerous organizations have promoted Just Culture, but its impact has never been assessed. This report combines data from a longitudinal survey–based study of clinical peer review practices in a cohort of 457 acute care hospitals with 43 measures from the Hospital Compare database and interprets them in relation to the long-term trends of Agency for Healthcare Research and Quality (AHRQ) data on the Hospital Survey of Patient Safety Culture. In all, 211 of 270 respondents (79%) indicated that their hospital has adopted Just Culture. More than half believe that it has had a positive impact. Just Culture implementation and its degree of impact are associated with somewhat better peer review process, but not with objective measures of hospital performance. Non-Punitive Response to Error has consistently been the lowest scoring category (45% positive) in the AHRQ database. Widespread adoption of Just Culture has not reduced reluctance to report or the culture of blame it targets.

Endorsing performance measures is a matter of trust

Healthcare agencies should ensure that performance measures for accreditation or reimbursement are supported by sound scientific evidence and safeguarded from potential commercial influences, argue Peter Eichacker and colleagues

Payment and Care for Hematopoietic Cell Transplantation Patients: Toward a Specialized Medical Home for Complex Care Patients

Patient-centered medical home models are fundamental to the advanced alternative payment models defined in the Medicare Access and Children's Health Insurance Plan Reauthorization Act (MACRA). The patient-centered medical home is a model of healthcare delivery supported by alternative payment mechanisms and designed to promote coordinated medical care that is simultaneously patient-centric and population-oriented. This transformative care model requires shifting reimbursement to include a per-patient payment intended to cover services not previously reimbursed such as disease management over time. Payment is linked to quality measures, including proportion of care delivered according to predefined pathways and demonstrated impact on outcomes. Some medical homes also include opportunities for shared savings by reducing overall costs of care. Recent proposals have suggested expanding the medical home model to specialized populations with complex needs because primary care teams may not have the facilities or the requisite expertise for their unique needs. An example of a successful care model that may provide valuable lessons for those creating specialty medical home models already exists in many hematopoietic cell transplantation (HCT) centers that deliver multidisciplinary, coordinated, and highly specialized care. The integration of care delivery in HCT centers has been driven by the specialty care their patients require and by the payment methodology preferred by the commercial payers, which has included bundling of both inpatient and outpatient care in the peritransplant interval. Commercial payers identify qualified HCT centers based on accreditation status and comparative performance, enabled in part by center-level comparative performance data available within a national outcomes database mandated by the Stem Cell Therapeutic and Research Act of 2005. Standardization across centers has been facilitated via voluntary accreditation implemented by Foundation for the Accreditation of Cell Therapy. Payers have built on these community-established programs and use public outcomes and program accreditation as standards necessary for inclusion in specialty care networks and contracts. Although HCT centers have not been described as medical homes, most HCT providers have already developed the structures that address critical requirements of MACRA for medical homes.

Partnering with Insurers in Caring for the Most Vulnerable Youth with Diabetes: NICH as an Integrator

PURPOSE OF REVIEW

In this review, we outline barriers to appropriately caring for high-risk youth with diabetes and discuss efforts in partnering with insurers through Alternative Payment Models to achieve the Triple Aim (improved health, improved care, and reduced costs) for this population.

RECENT FINDINGS

Current approaches in caring for youth with diabetes who evidence a high degree of social complexity are woefully ineffective. These youth are vulnerable to repeat diabetic ketoacidosis episodes, poor glycemic control, and excessive utilization of healthcare resources. To effectively pursue the Triple Aim, an "integrator" (i.e., an entity that accepts responsibility for all components of the Triple Aim for a specified population) must be identified; however, this does not fit into current fee-for-service models. Integrators for youth with diabetes are limited, but early examples of integrator efforts are promising. We present one successful "integrator," Novel Interventions in Children's Healthcare (NICH), and detail this program's efforts in partnering with insurers to serve high-risk youth with diabetes.

Achieving moral, high quality, affordable medical care in America through a true free market

The basis of a just and moral economic model for health care is examined in the context of Catholic social teaching. The performance of the current model of "central economic planning" in medicine is evaluated in terms of the core principles of the social doctrine of the Catholic Church and compared to freedom-based economic models. It is clear that the best way to respect and serve human dignity, the common good, subsidiarity, and solidarity in medicine is through the establishment of a true, free-market health economy. Lay Summary : This article reviews the impact of recent healthcare reforms as well as traditional "third party payment" models for healthcare financing in America (insurance). Impact on patients and doctors are evaluated in the context of Catholic social doctrine and the Catechism. The many shortcomings and negative consequences of an economy planned centrally by government are compared to the benefits of a true free-market medical economy with empowered individuals. The analysis shows that interference in the patient-physician relationship and the centrally planned medical economy itself violates Catholic teachings, harms patients and doctors, and create morally evil outcomes and economic structures.