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

Medicare Payments and ACOs for Dementia Patients Across Race and Social Vulnerability

OBJECTIVES

This study investigated variations in Medicare payments for Alzheimer's disease and related dementia (ADRD) by race, ethnicity, and neighborhood social vulnerability, together with cost variations by beneficiaries' enrollment in Accountable Care Organizations (ACOs).

METHODS

We used merged datasets of longitudinal Medicare Beneficiary Summary File (2016-2020), the Social Vulnerability Index (SVI), and the Medicare Shared Savings Program (MSSP) ACO to measure beneficiary-level ACO enrollment at the diagnosis year of ADRD. We analyzed Medicare payments for patients newly diagnosed with ADRD for the year preceding the diagnosis and for the subsequent 3 years. The dataset included 742,175 Medicare fee-for-service (FFS) beneficiaries aged 65 and older with a new diagnosis of ADRD in 2017 who remained in the Medicare FFS plan from 2016 to 2020.

RESULTS

Among those newly diagnosed, Black and Hispanic patients encountered higher total costs compared to White patients, and ADRD patients living in the most vulnerable areas experienced the highest total costs compared to patients living in other regions. These cost differences persisted over 3 years postdiagnosis. Patients enrolled in ACOs incurred lower costs across all racial and ethnic groups and SVI areas. For ADRD patients living in the areas with the highest vulnerability, the cost differences by ACO enrollment of the total Medicare costs ranged from $4,403.1 to $6,922.7, and beneficiaries' savings ranged from $114.5 to $726.6 over three years post-ADRD diagnosis by patient's race and ethnicity.

CONCLUSIONS

Black and Hispanic ADRD patients and ADRD patients living in areas with higher social vulnerability would gain more from ACO enrollment compared to their counterparts.

Comparing the quality of care in physician networks to usual care for elderly patients in three German regions: a quasi-experimental cohort study

OBJECTIVES

Patients in Germany have free choice of physicians in the ambulatory care sector and can consult them as often as they wish without a referral. This can lead to inefficiencies in treatment pathways. In response, some physicians have formed networks to improve the coordination and quality of care. This study aims to investigate whether the care provided by these networks results in better health and process outcomes than usual care.

STUDY DESIGN

This was a quasi-experimental cohort study.

METHODS

We analysed claims data from 2017 to 2018 in Bavaria, Brandenburg, and Westphalia-Lippe. Our study population includes patients aged 65 years or older with heart failure (n = 267,256), back pain (n = 931,672), or depression (n = 483,068). We compared condition-specific and generic quality indicators between patients treated in physician networks and usual care. Ambulatory care-sensitive emergency department cases were used as a primary outcome measure. Imbalances between the groups were minimized using propensity score matching.

RESULTS

Rates of ambulatory care-sensitive emergency department cases yielded insignificant differences between networks and usual care in the depression and heart failure subgroups. For back pain patients, rates were 0.17 percentage points higher (P < 0.01) in network patients compared with usual care. Among network patients, generic indicators for prevention and coordination showed significantly better performance. For instance, the rate of completed vaccination against influenza is 3.03 percentage points higher (P < 0.01), and the rate of specialist visits after referral is 1.6 percentage points higher (P < 0.01) in heart failure patients, who are treated in physician networks. This is accompanied by higher rates of polypharmacy. Furthermore, the results for condition-specific indicators suggest that for most indicators, a greater proportion of the care provided by physician networks adhered to national treatment guidelines.

CONCLUSIONS

Our findings suggest that physician networks in Germany do not reduce rates of ambulatory care-sensitive emergency department cases but perform better than usual care in terms of care coordination and prevention. Further research is needed to confirm our findings and explore the implications of the potentially higher rates of polypharmacy seen in physician networks.

Floundering or Flourishing? Early Insights from the Inception of Integrated Care Systems in England

Background

In 2022, England embarked on an ambitious and innovative re-organisation to produce an integrated health and care system with a greater focus on improving population health. This study aimed to understand how nascent ICSs are developing and to identify the key challenges and enablers to integration.

Methods

Four ICSs participated in the study between November 2021 and May 2022. Semi-structured interviews with system leaders (n = 67) from health, social and voluntary care as well as representatives of local communities were held. A thematic framework approach supported by Leutz's five laws of integration framework was used to analyse the data.

Results

The benefits of ICSs include enhancing the delivery of good quality care, improving population health and providing more person-centred care in the community. However, differences between health and social care such as accountability, organisational/professional cultures, risks of duplicating efforts, tensions over funding allocation, issues of data integration and struggles in engaging local communities threaten to hamper integration.

Conclusions

Despite ICS's investing in the structural and relational components of integrated care, the unprecedented pressures on systems to reduce demand on primary and emergency care tackling elective backlogs may detract from a key goal of ICSs, improving population health and prevention.

Building alternative payment models in health care

Introduction

Global interest is growing in new value-based models of financing, delivering, and paying for health care services that could produce higher-quality and lower cost outcomes for patients and for society. However, research indicates evidence gaps in knowledge related to alternative payment models (APMs) in early experimentation phases or those contracted between private insurers and their health care provider-partners. The aim of this research was to understand and update the literature related to learning how industry experts design and implement APMs, including specific elements of their models and their choice of stakeholders to be involved in the design and contractual details.

Methods

A literature review was conducted to guide the research focus and to select themes. The sample was selected using snowball sampling to identify subject matter experts (SMEs). Researchers conducted 16 semi-structured interviews with SMEs in the US, the Netherlands, and Germany in September and October 2021. Interviews were transcribed and using Braun and Clarke's six-phase approach to thematic analysis, researchers independently read, reviewed, and coded participants' responses related to APM design and implementation and subsequently reviewed each other's codes and themes for consistency.

Results

Participants represented diverse perspectives of the payer, provider, consulting, and government areas of the health care sector. We found design considerations had five overarching themes: (1) population and scope of care and services, (2) benchmarking, metrics, data, and technology; (3) finance, APM type, risk adjustment, incentives, and influencing provider behavior, (4) provider partnerships and the role of physicians, and (5) leadership and regulatory issues.

Discussion

This study confirmed several of the core components of APM model designs and implementations found in the literature and brought insights on additional aspects not previously emphasized, particularly the role of physicians (especially in leadership) and practice transformation/care processes necessary for providers to thrive under APM models. Importantly, researchers found significant concerns relevant for policymakers about regulations relating to health data sharing, rigid price-setting, and inter-organizational data communication that greatly inhibit the ability to experiment with APMs and those models' abilities to succeed long-term.

The Impact of Structural Racism on Continuity of Care at Pediatric Academic Primary Care Clinics

OBJECTIVE

Using a structural racism framework, we assessed racial inequities in continuity of care, using the Usual Provider Continuity Index (UPC - the proportion of visits with the provider the patient saw most frequently out of all visits), in a set of large pediatric academic clinics.

METHODS

We conducted a retrospective cohort study. Patients 12-24 months seen at three pediatric academic primary care clinics for any visit during October 1-31, 2021 were included. We then reviewed continuity for these patients in the preceding 12 months. Outcomes included each patient's UPC for all visits, and a modified UPC for well child checks only (UPC Well). Covariates included race, ethnicity, insurance, clinic site, age, sex, care management, or seeing a social worker. We evaluated for differences in outcomes using bivariate analyses and multivariable regression models.

RESULTS

Our cohort included 356 patients (74% Black, 5% Hispanic, 85% Medicaid, 52% female, median age 15.8 months). The median UPC was 0.33 and median UPC Well was 0.40. Black patients had significantly lower median values for UPC (0.33 Black vs 0.40 non-Black, P < .01) and UPC Well (0.33 Black vs 0.50 non-Black, P < .01). There were similar inequities in continuity rates by insurance and clinic site. In multivariable models, clinic site was the only variable significantly associated with continuity.

CONCLUSIONS

Clinic sites serving higher percentages of Black patients had lower rates of continuity. The main driver of racial inequities in continuity rates was at the institutional level.

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.

Disentangling the impact of alternative payment models and associated service delivery models on quality of chronic care: A scoping review

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.

Association between physician-hospital integration and inpatient care delivery in accountable care organizations: An instrumental variable analysis

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.

The Impact of Medicaid Accountable Care Organizations on Health Care Utilization, Quality Measures, Health Outcomes and Costs from 2012 to 2023: A Scoping Review

Most of the evidence regarding the success of ACOs is from the Medicare program. This review evaluates the impacts of ACOs within the Medicaid population. We identified 32 relevant studies published between 2012 and 2023 which analyzed the association of Medicaid ACOs and health care utilization (n = 21), quality measures (n = 18), health outcomes (n = 10), and cost reduction (n = 3). The results of our review regarding the effectiveness of Medicaid ACOs are mixed. Significant improvements included increased primary care visits, reduced admissions, and reduced inpatient stays. Cost reductions were reported in a few studies, and savings were largely dependent on length of attribution and years elapsed after ACO implementation. Adopting the ACO model for the Medicaid population brings some different challenges from those with the Medicare population, which may limit its success, particularly given differences in state Medicaid programs.

Measuring value in health care: lessons from accountable care organizations

Accountable care organizations (ACOs) were created to promote health care value by improving health outcomes while curbing health care expenditures. Although a decade has passed, the value of care delivered by ACOs is yet to be fully understood. We proposed a novel measure of health care value using data envelopment analysis and examined its association with ACO organizational characteristics and social determinants of health (SDOH). We observed that the value of care delivered by ACOs stagnated in recent years, which may be partially attributed to challenges in care continuity and coordination across providers. ACOs that were solely led by physicians and included more participating entities exhibited lower value, highlighting the role of coordination across ACO networks. Furthermore, SDOH factors, such as economic well-being, healthy food consumption, and access to health resources, were significant predictors of ACO value. Our findings suggest a "skinny in scale, broad in scope" approach for ACOs to improve the value of care. Health care policy should also incentivize ACOs to work with local communities and enhance care coordination of vulnerable patient populations across siloed and disparate care delivery systems.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Practice Site Heterogeneity within and between Medicaid Accountable Care Organizations

The existing literature has considered accountable care organizations (ACOs) as whole entities, neglecting potentially important variations in the characteristics and experiences of the individual practice sites that comprise them. In this observational cross-sectional study, our aim is to characterize the experience, capacity, and process heterogeneity at the practice site level within and between Medicaid ACOs, drawing on the Massachusetts Medicaid and Children's Health Insurance Program (MassHealth), which launched an ACO reform effort in 2018. We used a 2019 survey of a representative sample of administrators from practice sites participating in Medicaid ACOs in Massachusetts (n = 225). We quantified the clustering of responses by practice site within all 17 Medicaid ACOs in Massachusetts for measures of process change, previous experience with alternative payment models, and changes in the practices' ability to deliver high-quality care. Using multilevel logistic models, we calculated median odds ratios (MORs) and intraclass correlation coefficients (ICCs) to quantify the variation within and between ACOs for each measure. We found greater heterogeneity within the ACOs than between them for all measures, regardless of practice site and ACO characteristics (all ICCs ≤ 0.26). Our research indicates diverse experience with, and capacity for, implementing ACO initiatives across practice sites in Medicaid ACOs. Future research and program design should account for characteristics of practice sites within ACOs.

A flexible approach to measure care coordination based on patient-sharing networks

BACKGROUND

Effective care coordination may increase clinical efficiency, but its measurement remains difficult. The established metric "care density" (CD) measures care coordination based on patient-sharing among physicians, but it may be too rigid to generalize across disorders and countries. Therefore, we propose an extension called fragmented care density (FCD), which allows varying weights for connections between different types of providers. We compare both metrics in their ability to predict hospitalizations due to schizophrenia.

METHODS

We conducted a longitudinal cohort study based on German claims data from 2014 through 2017 to predict quarterly hospital admissions. 21,016 patients with schizophrenia from the federal state Baden-Württemberg were included. CD and FCD were calculated based on patient-sharing networks. The weights of FCD were optimized to predict hospital admissions during the first year of a 24-month follow-up. Subsequently, we employed likelihood ratio tests to assess whether adding either CD or FCD improved a baseline model with control variables for the second follow-up year.

RESULTS

The inclusion of FCD significantly improved the baseline model, Χ2(1) = 53.30, p < 0.001. We found that patients with lower percentiles in FCD had an up to 21% lower hospitalization risk than those with median or higher values, whereas CD did not affect the risk.

CONCLUSIONS

FCD is an adaptive metric that can weight provider relationships based on their relevance for predicting any outcome. We used it to better understand which medical specialties need to be involved to reduce hospitalization risk for patients with schizophrenia. As FCD can be modified for different health conditions and systems, it is broadly applicable and might help to identify barriers and promoting factors for effective collaboration.

ACO Clinicians Have Higher Medicare Part B Medical Services Payments Than MIPS Clinicians Under the Quality Payment Program

The Quality Payment Program (QPP) is a Medicare value-based payment program with 2 tracks: -Advanced Alternative Payment Models (A-APMs), including two-sided risk Accountable Care Organizations (ACOs), and Merit-based Incentive Payment System (MIPS). In 2020, A-APM eligible ACO clinicians received an additional 5% positive, and MIPS clinicians received up to 5% negative or 2% positive performance-based adjustments to their Medicare Part B medical services payments. It is unclear whether the different payment adjustments have differential impacts on total medical services payments for ACO and MIPS participants. We compare Medicare Part B medical services payments received by primary care clinicians participating in ACO and MIPS programs using Medicare Provider Utilization and Payment Public Use Files from 2014 to 2018 using difference-in-differences regressions. We have 254 395 observations from 50 879 unique clinicians (ACO = 37.86%; MIPS = 62.14%). Regression results suggest that ACO clinicians have significantly higher Medicare Part B medical services payments ($1003.88; 95% CI: [579.08, 1428.69]) when compared to MIPS clinicians. Our findings suggest that ACO clinicians had a greater increase in medical services payments when compared to MIPS clinicians following QPP participation. Increased payments for Medicare Part B medical services among ACO clinicians may be driven partly by higher payment adjustment rates for ACO clinicians for Part B medical services. However, increased Part B medical services payments could also reflect clinicians switching to increased outpatient services to prevent potentially costly inpatient services. Policymakers should examine both aspects when evaluating QPP effectiveness.

Do physician networks with standardized audit and feedback deliver better quality care for older patients compared to regular care?: a quasi-experimental study using claims data from Bavaria, Germany

BACKGROUND

Physician networks (PNs) are a recent development in Germany, designed to improve the coordination and quality of healthcare. We compared the performance of PNs that use a standardized system of audit and feedback to that of regular care.

METHODS

We analysed a large sample of claims data from Bavaria, Germany, using nearest-neighbour propensity score matching. Patients who had ambulatory care-sensitive conditions (ACSCs) and were enrolled in PNs were matched with control patients receiving regular care. We examined potentially avoidable hospitalizations related to the 13 most common ACSCs (primary endpoints), as well as processes-of-care indicators for disease prevention, pharmacotherapy and coordination of care.

RESULTS

There were no significant differences in rates of potentially avoidable hospitalizations between the two groups. However, the networks showed higher vaccination rates, increased participation in disease management programmes, and more frequent use of referrals when consulting specialist physicians. On average, network patients visited a greater number of specialists and had lower continuity of care compared to patients receiving regular care. Polypharmacy and PRISCUS-list prescriptions were more prevalent in the networks.

CONCLUSIONS

PNs using audit and feedback do not appear to perform better than regular care in preventing hospitalizations due to ACSCs. However, they do perform better in disease prevention measures while showing inconclusive results for care coordination and pharmacotherapy. Further research is needed to understand effective collaboration among providers and its impact on the quality of care within PNs.

Changes in Health Care Utilization During the First 2 Years of Massachusetts Medicaid Accountable Care Organizations

On March 1, 2018, the Massachusetts Medicaid and Children's Health Insurance Program (MassHealth) launched an ambitious accountable care organization (ACO) program that sought to integrate care across the physical, behavioral, functional, and social services continuum while holding ACOs accountable for cost and quality. The study objective was to describe changes in health care utilization among MassHealth members during the pre-ACO baseline (2015-2017) and post-implementation periods (2018 and 2019). Using MassHealth administrative data, the authors conducted a repeated cross-sectional study of MassHealth members enrolled in ACOs during 2015-2019. Rates of primary care visits, all-cause and primary-care sensitive emergency department (ED) visits, ED boarding, hospitalizations, acute unplanned admissions, and readmissions were reported during the baseline period (2015-2017) and year 1 (2018) and year 2 (2019). Primary care visit rates increased for adult members throughout the study period from a baseline mean of 7.2-9.2 per member per year (observed-to-expected [O:E]: 1.16) in 2019. Observed all-cause hospitalization rates fell below expected values with O:E ratios of 0.96 among adults and 0.79 among children in 2018, and 0.96 and 0.92 among adults and children, respectively, in 2019. All-cause ED visit rates increased slightly, and rates of pediatric asthma-related admissions, unplanned admissions for adults with ambulatory care sensitive conditions, and unplanned admissions and ED boarding for adults with substance use disorder and serious mental illness all declined for the study period. These findings are suggestive of utilization shifts to higher-value, lower-cost care under Massachusetts's innovative and comprehensive ACO model.

Integration on the Frontlines of Medicaid Accountable Care Organizations and Associations With Perceived Care Quality, Health Equity, and Satisfaction

Amid enthusiasm about accountable care organizations (ACOs) in Medicaid, little is known about the primary care practices engaging in them. We leverage a survey of administrators within a random sample (stratified by ACO) of 225 practices joining Massachusetts Medicaid ACOs (64% response rate; 225 responses). We measure the integration of processes with distinct entities: consulting clinicians, eye specialists for diabetes care, mental/behavioral care providers, and long-term and social services agencies. Using multivariable regression, we examine organizational correlates of integration and assess integration's relationships with care quality improvement, health equity, and satisfaction with the ACO. Integration varied across practices. Clinical integration was positively associated with perceived care quality improvement; social service integration was positively associated with addressing equity; and mental/behavioral and long-term service integration were positively associated with ACO satisfaction (all p < .05). Understanding differences in integration at the practice level is vital for sharpening policy, setting expectations, and supporting improvement in Medicaid ACOs.

Risk Selection and Care Fragmentation at Medicare Accountable Care Organizations for Patients With Dementia

BACKGROUND

Patients with dementia are a growing and vulnerable population within Medicare. Accountable care organizations (ACOs) are becoming Medicare's dominant care model, but ACO enrollment and care patterns for patients with dementia are unknown.

OBJECTIVE

The aim of this study was to compare differences in ACO enrollment for patients with versus without dementia, and in risk profiles and ambulatory care among patients with dementia by ACO enrollment status.

RESEARCH DESIGN

Cohort study assessing the relationships between patient dementia, following-year ACO enrollment, and ambulatory care patterns.

SUBJECTS

A total of 13,362 (weighted: 45, 499,049) person-years for patients [2761 (weighted: 6,312,304) for dementia patients] ages 65 years and above in the 2015-2019 Medicare Current Beneficiary Survey.

MEASURES

We assessed differences in ACO enrollment rates for patients with versus without dementia, and in dementia-relevant ambulatory care visit rates and validated care fragmentation indices among patients with dementia by ACO enrollment status.

RESULTS

Patients with versus without dementia were less likely to be enrolled in (38.3% vs. 44.6%, P<0.001), and more likely to exit (21.1% vs. 13.7%, P<0.01) ACOs. Among patients with dementia, those enrolled versus not enrolled in ACOs had a more favorable social and health risk profile on 6 of 16 measures (P<0.05). There were no differences in rates of dementia-relevant, primary, or specialty care visits. ACO enrollment was associated with 45.7% higher wellness visit rates (P<0.001), and 13.4% more fragmented primary care (P<0.01) spread across 8.7% more distinct physicians (P<0.05).

CONCLUSION

Medicare ACOs are less likely to enroll and retain patients with dementia than other patients and provide more fragmented primary care without providing additional dementia-relevant ambulatory care visits.

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

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

Improving the evaluation of an integrated healthcare system using entropy balancing: Population health improvements in Gesundes Kinzigtal

Background

Evidence of integrated healthcare networks' effect on population health is scarce. Moreover, current designs for evaluating such networks have shortcomings that can result in misleading conclusions. Our paper evaluates Gesundes Kinzigtal, a best-practice integrated healthcare network, using an innovative design that enlightens the discussion about health gains produced by integrated healthcare.

Research question

What is the effect of Gesundes Kinzigtal on population health?

Methods

We evaluated the effect of the integrated healthcare initiative by performing a quasi-experimental evaluation based on entropy balancing. Integrated network participants were compared to a control group and followed for five years. Claims data from 2004 to 2018 was used. Population health outcomes correspond to survival (Cox hazard ratio, Kaplan-Meier curve), mortality ratio, mean age at the time of death, and years of life lost or gained. Design validity was evaluated by assessing group balance at baseline. Finally, we compared our results to those obtained using a previously published design for evaluating integrated networks.

Results

The treatment group was composed of 9083 network participants, compared to an equivalent control group, showing, respectively, a mortality ratio of 5.4% vs 7.5% (p < 0.05), mean age at the time of death of 80.1 vs 80.3 (p > 0.05) and a gain of 0.2 years of life per person for the treatment group (p > 0.05). The Cox hazard ratio (0.72; p < 0.05) and mean survival time (1784 vs 1768 days; p < 0.05) showed better survival for treated participants. Results using the previously published design were more favorable for the treatment group; however, the design excluded participants significantly associated with greater healthcare needs.

Discussion

The integrated network had a favorable effect on participants' mortality and survival risk. Previous evaluations based on propensity score matching might overestimate the network's impact on population health by excluding participants with greater healthcare needs.

Principles of Screening for Disease and Health Risk Factors in the Emergency Department

The emergency department serves as a critical access point to the health system for many patients, especially those with limited resources. Screening for disease or risk factors for poor health outcomes can potentially improve both individual and population health. Screening initiatives should focus on evidence-based strategies and take local epidemiology and ED capacity into consideration. Initiatives should strive for community support and transparency with patients. They should also be financially sustainable for those involved. Screening can identify patients who can then be counseled, provided with prophylaxis or treatment, or referred to external resources. Through screening and intervention, the ED can serve as a vital contributor to individual and population health.

Patient-Centered Integrated Model of Home Health Care Services in South Korea (PICS-K)

Introduction

As South Korea is fast becoming an aging society, the need for integrated care of the elderly has increased. 'Community Integrated Care Initiatives' have been implemented by the Ministry of Health and Welfare. However, home healthcare is insufficient to meet this need.

Description

The National Health Insurance Service (NHIS) launched the initiative, 'Patient-Centered Integrated model of Home Health Care Services in South Korea (PICS-K)'. Its purpose is to coordinate home healthcare providers by establishing a home health care support center (HHSC) in public hospitals starting in 2021. The PICS-K has six main features: integration of primary care-hospital-personal care-social services through a consortium, HHSC in hospitals with primary care collaboration, increased accessibility, interdisciplinary team (IDT), patient-centeredness, and education.

Discussion

Integrating healthcare, personal care, and social services at multiple levels is necessary. Accordingly, platforms to share participant information and service records, and institutional payment system reforms are required.

Conclusion

In public hospitals, the HHSC supported primary care, which provides home healthcare. The model combined community healthcare and social services to accomplish the aging-in-place of the homebound population by focusing on their needs. This model will be applicable to other regions in Korea.

The Future of Public Mental Health: Challenges and Opportunities

Policy Points Social policies such as policies advancing universal childcare to expand Medicaid coverage of home- and community-based care for seniors and people with disabilities and for universal preschool are the types of policies needed to address social determinants of poor mental health. Population-based global budgeting approaches like accountable care and total cost of care models have the potential to improve population mental health by incentivizing health systems to control costs while simultaneously improving outcomes for the populations they serve. Policies expanding reimbursement for services delivered by peer support specialists are needed. People with lived experience of mental illness are uniquely well suited to helping their peers navigate treatment and other support services.

A Decade of ACOs in Medicare: Have They Delivered on Their Promise?

Accountable care organizations (ACOs) were envisioned as a way to address both health care cost growth and uneven quality in US health care. They emerged in the early 2000s, with the 2010 Affordable Care Act (ACA) establishing a Medicare ACO program. In the decade since their launch, ACOs have grown into one of Medicare's flagship payment reform programs, with millions of beneficiaries receiving care from hundreds of ACOs. While great expectations surrounded ACOs' introduction into Medicare, their impacts to date have been modest. ACOs have achieved some savings and improvements in measured quality, but disagreement persists over the meaning of those results: Do ACOs represent important, incremental steps forward on the path toward a more efficient, high-quality health care system? Or do their modest achievements signal a failure of large-scale progress despite the substantial investments of resources? ACOs have proven to be politically resilient, largely sidestepping the controversies and partisan polarization that have led to the demise of other ACA provisions. But the same features that have enabled ACOs to evade backlash have constrained their impacts and effectiveness. After a decade, ACOs' long-term influence on Medicare and the US health care system remains uncertain.

Pre-doctoral dental faculty perceptions toward value-based care: An exploratory study

OBJECTIVES

To explore pre-doctoral faculty perceptions toward implementation of value-based care (VBC) in didactic and clinical teaching.

METHODS

This project was a collaborative effort between CareQuest and the University of North Carolina at Chapel Hill, Adams School of Dentistry introducing VBC to pre-doctoral dental faculty as part of a new curriculum. Following a faculty development session on VBC in June 2021, faculty and subject matter experts were invited to participate in qualitative interviews. Subject matter experts were interviewed to establish a baseline for VBC knowledge and understanding. Interviews were recorded and transcribed verbatim. Analysis was conducted by two analysts using ATLAS.ti and a thematic analysis approach.

RESULTS

Six faculty and two subject matter experts participated in interviews. Although dental faculty demonstrated some understanding of VBC, they recognized that more training is required to build in-depth knowledge and implementation strategies for teaching dental students. Faculty discussed value-based concepts such as prevention-focused teaching, person-centered care, and disease management over invasive restoration of teeth, and how VBC is bringing about a paradigm shift in dentistry that needs to be reflected in dental education. They acknowledged a disconnect between VBC in didactic teaching versus clinical instruction. Those interviewed believed it would take time to shift faculty mindset and readiness to teach VBC, and continued efforts are needed at the leadership and faculty level for acceptance and implementation.

CONCLUSIONS

Although dental faculty recognize that VBC can bring a shift in dental practice, more training and guidance to implement it in didactic and clinical teaching is needed.

Health Care Spending on Respiratory Diseases in the United States, 1996-2016

Rationale: Respiratory conditions account for a large proportion of health care spending in the United States. A full characterization of spending across multiple conditions and over time has not been performed. Objectives: To estimate health care spending in the United States for 11 respiratory conditions from 1996 to 2016, providing detailed trends and an evaluation of factors associated with spending growth. Methods: We extracted data from the Institute of Health Metrics and Evaluation's Disease Expenditure Project Database, producing annual estimates in spending for 38 age and sex groups, 7 types of care, and 3 payer types. We performed a decomposition analysis to estimate the change in spending associated with changes in each of five factors (population growth, population aging, disease prevalence, service usage, and service price and intensity). Measurements and Main Results: Total spending across all respiratory conditions in 2016 was $170.8 billion (95% confidence interval [CI], $164.2-179.2 billion), increasing by $71.7 billion (95% CI, $63.2-80.8 billion) from 1996. The respiratory conditions with the highest spending in 2016 were asthma and chronic obstructive pulmonary disease, contributing $35.5 billion (95% CI, $32.4-38.2 billion) and $34.3 billion (95% CI, $31.5-37.3 billion), respectively. Increasing service price and intensity were associated with 81.4% (95% CI, 70.3-93.0%) growth from 1996 to 2016. Conclusions: U.S. spending on respiratory conditions is high, particularly for chronic conditions like asthma and chronic obstructive pulmonary disease. Our findings suggest that service price and intensity, particularly for pharmaceuticals, should be a key focus of attention for policymakers seeking to reduce health care spending growth.

Pay-for-Performance in the Massachusetts Medicaid Delivery System Transformation Initiative

ABSTRACT

Pay-for-performance (P4P) is among the alternative payment models (APMs) that are designed to incentivize enhancements to healthcare efficiency and quality. Massachusetts' Office of Medicaid implemented a delivery system transformation initiative (DSTI) through an 1115(a) Demonstration Waiver to support and incentivize seven safety net hospitals to implement clinical care changes and transition to risk-based APMs. Comparative case study design was used to describe achievement of hospital-specific clinical and operational measures. Qualifying hospitals implemented 47 projects across three categories: (1) development of a fully integrated delivery system, (2) health outcomes and quality, and (3) ability to respond to statewide transformation to value-based purchasing and to accept alternatives to fee-for-service payments that promote system sustainability. Projects commonly focused on care transitions improvements, physical and behavioral healthcare integration, and chronic disease care management interventions. Collectively, the hospitals met all or most of 60 population-focused improvement measures and 10 common measures' targets, indicative of the progress. Some hospitals achieved substantial positive gains; however, missed targets suggest substantial organizational and workflow changes over a longer timeframe as well as consistent patient engagement may be necessary. Overall, the P4P structure of DSTI was effective in encouraging organizational change and supporting the transition of these hospitals towards APMs.

Maternity care clinician inclusion in Medicaid Accountable Care Organizations

BACKGROUND

Medicaid Accountable Care Organizations (ACO) are increasingly common, but the network breadth for maternity care is not well described. The inclusion of maternity care clinicians in Medicaid ACOs has significant implications for access to care for pregnant people, who are disproportionately insured by Medicaid.

PURPOSE

To address this, we evaluate obstetrician-gynecologists (OB/GYN), maternal-fetal medicine specialists (MFM), certified nurse midwives (CNM), and acute care hospital inclusion in Massachusetts Medicaid ACOs.

METHODOLOGY/APPROACH

Using publicly available provider directories for Massachusetts Medicaid ACOs (n = 16) from December 2020 -January 2021, we quantify obstetrician-gynecologists, maternal-fetal medicine specialists, CNMs, and acute care hospital with obstetric department inclusion in each Medicaid ACO. We compare maternity care provider and acute care hospital inclusion across and within ACO type. For Accountable Care Partnership Plans, we compare maternity care clinician and acute care hospital inclusion to ACO enrollment.

RESULTS

Primary Care ACO plans include 1185 OB/GYNs, 51 MFMs, and 100% of Massachusetts acute care hospitals, but CNMs were not easily identifiable in the directories. Across Accountable Care Partnership Plans, a mean of 305 OB/GYNs (median: 97; range: 15-812), 15 MFMs (Median: 8; range: 0-50), 85 CNMs (median: 29; range: 0-197), and half of Massachusetts acute care hospitals (median: 23.81%; range: 10%-100%) were included.

CONCLUSION AND PRACTICE IMPLICATIONS

Substantial differences exist in maternity care clinician inclusion across and within ACO types. Characterizing the quality of included maternity care clinicians and hospitals across ACOs is an important target of future research. Highlighting maternal healthcare as a key area of focus for Medicaid ACOs-including equitable access to high-quality obstetric providers-will be important to improving maternal health outcomes.

Multicomponent, high-intensity, and patient-centered care intervention for complex patients in transitional care: SPICA program

Multimorbidity is increasingly present in our environment. Besides, this is accompanied by a deterioration of social and environmental conditions and affects the self-care ability and access to health resources, worsening health outcomes and determining a greater complexity of care. Different multidisciplinary and multicomponent programs have been proposed for the care of complex patients around hospital discharge, and patient-centered coordination models may lead to better results than the traditional ones for this type of patient. However, programs with these characteristics have not been systematically implemented in our country, despite the positive results obtained. Hospital Universitario de Canarias cares for patients from the northern area of Tenerife and La Palma, Spain. In this hospital, a multicomponent and high-intensity care program is carried out by a multidisciplinary team (made up of family doctors and nurses together with social workers) with complex patients in the transition of care (SPICA program). The aim of this program is to guarantee social and family reintegration and improve the continuity of primary healthcare for discharged patients, following the patient-centered clinical method. Implementing multidisciplinary and high-intensity programs would improve clinical outcomes and would be cost-effective. This kind of program is directly related to the current clinical governance directions. In addition, as the SPICA program is integrated into a Family and Community Care Teaching Unit for the training of both specialist doctors and specialist nurses, it becomes a place where the specific methodology of those specialties can be carried out in transitional care. During these 22 years of implementation, its continuous quality management system has allowed it to generate an important learning curve and incorporate constant improvements in its work processes and procedures. Currently, research projects are planned to reevaluate the effectiveness of individualized care plans and the cost-effectiveness of the program.

Digital health: The next evolution of healthcare delivery

Healthcare delivery models have evolved from fee-for-service to incentivized care like patient-centered medical homes and accountable care organizations. This article discusses the evolution of healthcare delivery models and presents a vision for digital health.

To What Extent Are ACO and PCMH Models Advancing the Triple Aim Objective? Implications and Considerations for Primary Care Medical Practices

Accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) have emerged to advance the health care system by achieving the Triple Aim of improving population health, reducing costs, and enhancing the patient experience. This review examines evidence regarding the relationship between these innovative care models and care outcomes, costs, and patient experiences. The 28 articles summarized in this review show that ACO and PCMH models play an important role in achieving the Triple Aim, when compared with conventional care models. However, there can be drawbacks associated with model implementation. The long-term success of these models still merits further investigation.

Diabetes And The Fragmented State Of US Health Care And Policy

Progress in the prevention and treatment of type 2 diabetes-the dominant form of diabetes-appears to have stalled in the US over the past decade, and diabetes-related morbidity has increased nationally. The most geographically and socioeconomically disadvantaged segments of the population have been especially hard hit, and interventions that reduce the risk for diabetes have not reached these populations. In this overview article we lay out how fragmentation in health policy and governance, payers and reimbursement design, and service delivery in the US has contributed to low accountability and coordination, and thus stagnation and persistent inequities. We also review the evidence regarding past, ongoing, and new reforms that may help address fragmentation, lower diabetes burdens, and narrow disparities.

Using a mixed-effect model with a parameter-space of heterogenous dimension to evaluate whether accountable care organizations are associated with greater uniformity across constituent practices

Accountable care organization (ACO) legislation was designed to improve patient outcomes by inducing greater coordination of care and adoption of best practices. Therefore, it is of interest to assess whether greater uniformity occurs among practices comprising an ACO post ACO formation. We develop a mixed-effect model with a difference-in-difference design to evaluate the effect of a patient receiving care from an ACO on patient outcomes and adapt this model to examine whether an ACO is associated with increased uniformity across its constituent practices. The task is complicated by the organizations within an ACO forming an additional layer in the multilevel model, due to medical practices and hospitals that form an ACOs being nested within the ACO, making the number of levels of the model variable and the dimension of the parameter space time-varying. We develop the model and a procedure for testing the hypothesis that ACO formation was associated with increased uniformity among its constituent practices. We apply our procedure to a cohort of medicare beneficiaries followed over 2009-2014. Although there is extensive heterogeneity of becoming an ACOs across practices, we find that the formation of an ACO appears to be associated with greater uniformity of patient outcomes among its constituent practices.

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

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

Assessing the effect of a regional integrated care model over ten years using quality indicators based on claims data - the basic statistical methodology of the INTEGRAL project

BACKGROUND

The regional integrated health care model "Healthy Kinzigtal" started in 2006 with the goal of optimizing health care and economic efficiency. The INTEGRAL project aimed at evaluating the effect of this model on the quality of care over the first 10 years.

METHODS

This methodological protocol supplements the study protocol and the main publication of the project. Comparing quality indicators based on claims data between the intervention region and 13 structurally similar control regions constitutes the basic scientific approach. Methodological key issues in performing such a comparison are identified and solutions are presented.

RESULTS

A key step in the analysis is the assessment of a potential trend in prevalence for a single quality indicator over time in the intervention region compared to the corresponding trends in the control regions. This step has to take into account that there may be a common - not necessarily linear - trend in the indicator over time and that trends can also appear by chance. Conceptual and statistical approaches were developed to handle this key step and to assess in addition the overall evidence for an intervention effect across all indicators. The methodology can be extended in several directions of interest.

CONCLUSIONS

We believe that our approach can handle the major statistical challenges: population differences are addressed by standardization; we offer transparency with respect to the derivation of the key figures; global time trends and structural changes do not invalidate the analyses; the regional variation in time trends is taken into account. Overall, the project demanded substantial efforts to ensure adequateness, validity and transparency.

Association of Hospital Interoperable Data Sharing With Alternative Payment Model Participation

Importance

Interoperable patient data exchange across hospitals remains an important policy goal for reducing costs and improving the quality of care. Congress designated 2018 as the goal for nationwide interoperability, and policy makers hoped that aligning financial incentives via alternative payment models (APMs) would help achieve that goal.

Objective

To measure interoperability progress since 2014, assess the association between alternative payment model participation and hospital engagement in interoperable data sharing from 2014 to 2018, and evaluate hospital-reported barriers to interoperability in 2018.

Design Setting and Participants

This cohort study included nonfederal acute care hospitals in the US from January 2014 to December 2018 that responded to the American Hospital Association Annual Survey. Data were analyzed from October 2019 through March 2021.

Exposures

Participation in an APM, including accountable care organizations, bundled payments, or patient-centered medical homes.

Main Outcomes and Measures

Hospital engagement in all 4 domains of interoperability: finding/querying for data, sending data electronically, receiving data electronically, and integrating electronic patient data from external care delivery organizations.

Results

The sample included 3928 hospitals in the US from January 2014 to December 2018. Progress across interoperability domains was uneven, 2430 (88.3%) hospitals sending and 2115 (76.9%) receiving patient data electronically in 2018. However, only 1249 (45.4%) hospitals engaged in all 4 domains of interoperability in 2018, and growth between 2014 and 2018 was slow. There was no evidence that participation in APMs was associated with interoperability, with multivariate models suggesting that participation in an APM was associated with only a non-statistically significant 1-percentage point increase in interoperability engagement (β = 0.01; 95% CI, -0.01 to 0.03). The most commonly cited barrier to interoperability was challenges associated with sharing data across different electronic health record vendors.

Conclusions and Relevance

In this cohort study of hospital interoperability, fewer than half of US hospitals were engaged in interoperable data exchange in 2018. There was no observable evidence that hospital APM participation was associated with interoperability engagement. Many hospitals report technical and governance challenges to data sharing that are unlikely to be addressed by the alignment of financial incentives alone.

[10 Years Accountable Care Organizations in the USA: Impulses for Health Care Reform in Germany?]

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.

Accountable care organizations and physician antibiotic prescribing behavior

BACKGROUND

Physician accountable care organization (ACO) affiliation has been found to reduce cost and improve quality across metrics that are directly measured by the Medicare ACO programs. However, little is known about potential spillover effects from this program onto non-measured physician behavior such as antibiotic prescribing.

METHODS

Using a two-part structural selection model that accounts for selection into treatment (ACO group), and non-treatment (control group), we compare physician antibiotic prescribing across these groups with adjustment for volume, patient, physician and institutional characteristics. We also estimate heterogeneous treatment responses across specialties, focusing on physicians with a primary specialty of internal medicine, family or general practice, nurse practitioners, as well as general and orthopedic surgeons.

RESULTS

We find that ACO affiliation helps reduce antibiotic prescribing by 20.4 (95%CI = -26.65 to -14.16, p-value<0.001) prescriptions (about 19.5%) per year. We show that each additional hospital and practice affiliation increases prescriptions by 1.6 (95%CI = 1.27 to 1.95, p-value<0.001) and 1.7 (95%CI = 1.00 to 2.47, p-value<0.001), respectively. However, the use of electronic health records and high-quality medical training is associated with a decrease in antibiotic use of 7.9 (95%CI = -8.79 to -7.07, p-value<0.001) and 3.6 (95%CI = -4.47 to -2.73, p-value<0.001) claims, respectively. The treatment effects are found to vary with specialty, where internal medicine physicians experience an average decrease of 23.6 (95%CI = -29.98 to -17.20, p-value<0.001), family and general practice physicians a decrease of 22.1 (95%CI = -28.37 to -15.77, p-value<0.001), nurse practitioners a decrease of 7.1 (95%CI = -13.99 to -0.77, p-value = 0.028), general surgeons a decrease of 9.6 (95%CI = -16.02 to -3.25, p-value = 0.003), and orthopedic surgeons a reduction of 8.1 (95%CI = -14.84 to -1.42, p-value = 0.018) in their antibiotic prescribing per year.

CONCLUSIONS

In assessing the impact of Medicare ACO programs it is important to account for spillover effects. Our study finds that ACO affiliation has had a measurable impact on physician antibiotic prescribing.

Rural and urban disparities in quality of home health care: A longitudinal cohort study (2014-2018)

PURPOSE

Home health care is one of the fastest growing health care sectors in the United States. However, little is known of differences in trends in quality performance between rural and urban home health agencies over time. This study aimed to examine disparities in quality performance between rural and urban home health agencies between 2014 and 2018.

METHODS

This is a cohort study using 2014-2018 national Home Health Compare data and Providers of Service Profile data, including 7,908 home health agencies, of which 1,537 were rural agencies. Quality performance measures included timely initiation of care, hospitalization, and emergency department (ED) visits. Two-level hierarchical regression models were used to identify rural-urban differences in these quality indicators over time when controlling organizational characteristics.

FINDINGS

Rural agencies were less likely to be for-profit and accredited, and more likely to be hospital-based, serve both Medicare and Medicaid beneficiaries, and have hospice programs. Rural agencies consistently outperformed on timely initiation of care over time, and urban agencies consistently outperformed on hospitalization and ED visits over time. These gaps between rural and urban agencies were steady over time except the gap in hospitalization, which slightly narrowed over time (Coef. = 0.11, P = .001 for urban and year interaction term).

CONCLUSIONS

Significant differences exist in quality of care between rural and urban home health agencies and such differences have not been significantly narrowed over time. To reduce rural-urban disparities, policy makers should take into account unique challenges faced by urban and rural agencies when making policy decisions.

Effectiveness of a care transitions intervention for older adults discharged home from the emergency department: A randomized controlled trial

BACKGROUND

Improving care transitions following emergency department (ED) visits may reduce post-ED adverse events among older adults (e.g., ED revisits, decreased function). The Care Transitions Intervention (CTI) improves hospital-to-home transitions; however, its effectiveness at improving post-ED outcomes is unknown. We tested the effectiveness of the CTI with community-dwelling older adult ED patients, hypothesizing that it would reduce revisits and increase performance of self-management behaviors during the 30 days following discharge.

METHODS

We conducted a randomized controlled trial among patients age ≥ 60 discharged home from one of three EDs in two states. Intervention participants received a minimally modified CTI, with a home visit 24 to 72 h postdischarge and one to three phone calls over 28 days. We collected demographic, health status, and psychosocial data at the initial ED visit. Medication adherence and knowledge of red flag symptoms were assessed via phone survey. Care use and comorbidities were abstracted from medical records. We performed multivariate regressions for intention-to-treat and per-protocol (PP) analyses.

RESULTS

Participant characteristics (N = 1,756) were similar across groups: mean age 72.4 ± 8.6 years and 53% female. Of those randomized to the intervention, 84% completed the home visit. Overall, 12.4% of participants returned to the ED within 30 days. The CTI did not significantly affect odds of 30-day ED revisits (adjusted odds ratio [AOR] = 0.97, 95% confidence interval [CI] = 0.72 to 1.30) or medication adherence (AOR = 0.89, 95% CI = 0.60 to 1.32). Participants receiving the CTI (PP) had increased odds of in-person follow-up with outpatient clinicians during the week following discharge (AOR = 1.24, 95% CI = 1.01 to 1.51) and recalling at least one red flag from ED discharge instructions (AOR = 1.34 95% CI = 1.05 to 1.71).

CONCLUSIONS

The CTI did not reduce 30-day ED revisits but did significantly increase key care transition behaviors (outpatient follow-up, red flag knowledge). Additional research is needed to explore if patients with different conditions benefit more from the CTI and whether decreasing ED revisits is the most appropriate outcome for all older adults.

Defining Pooled' Place-Based' Budgets for Health and Social Care: A Scoping Review

Introduction

Current descriptions of pooled budgets in the literature pose challenges to good quality evaluation of their contribution to integrated care. Addressing this gap is increasingly important given the shift from early models of integrated care targeting segments of the population, to more recent approaches that aim to target 'places', broader geographically defined populations. This review draws on the current international evidence to describe practical examples of pooled health and social care budgets, highlighting specific place-based approaches.

Methods

We initially conducted a scoping review, a systematic database search ('Medline', 'Embase', 'Econ Lit' and 'Google Scholar') complemented by further snowballing for academic and 'grey literature' publications (1995 - 2020). Results were analysed thematically according to budget characteristics and macro-environment, with additional specific case studies.

Results

Thirty-six primary studies were included, describing ten broad models of pooled budgets across seven countries. Most budgets targeted specific sub-populations rather than an entire geographically defined population. Specific budget structures varied and were generally under-described. The closest place-based models were for small populations and implemented in a national health system, or insurance-based with natural geographical boundaries.

Conclusion

Despite their increasing relevance in the current political debate, pooled place-based budgets are still at an early stage of implementation and research. Adequate description is required for future meta-analysis of effectiveness on outcomes.

Economic Aspects of Delivering Primary Care Services: An Evidence Synthesis to Inform Policy and Research Priorities

Policy Points The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. While there is a large amount of literature on the economic aspects of delivering primary care services, there is a need for more comprehensive overviews of this evidence. In this article, we offer such an overview. Evidence suggests that there are several strategies involving coverage, financing, service delivery, and governance arrangements which can, if implemented, have positive economic impacts on the delivery of primary care services. These include arrangements such as worker task-shifting and telemedicine. The implementation of any such arrangements, based on positive economic evidence, should carefully account for potential impacts on overall health care access and quality. There are many opportunities for further research, with notable gaps in evidence on the impacts of increasing primary care funding or the overall supply of primary care services.

CONTEXT

The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. To strengthen primary health care, policymakers need guidance on how to allocate resources in a manner that maximizes its economic benefits.

METHODS

We collated and synthesized published systematic reviews of evidence on the economic aspects of different models of delivering primary care services. Building on previous efforts, we adapted existing taxonomies of primary care components to classify our results according to four categories: coverage, financing, service delivery, and governance.

FINDINGS

We identified and classified 109 reviews that met our inclusion criteria according to our taxonomy of primary care components: coverage, financing, service delivery, and governance arrangements. A significant body of evidence suggests that several specific primary care arrangements, such as health workers' task shifting and telemedicine, can have positive economic impacts (such as lower overall health care costs). Notably absent were reviews on the impact of increasing primary care funding or the overall supply of primary care services.

CONCLUSIONS

There is a great opportunity for further research to systematically examine the broader economic impacts of investing in primary care services. Despite progress over the last decade, significant evidence gaps on the economic implications of different models of primary care services remain, which could help inform the basis of future research efforts.

New Horizons-Addressing Healthcare Disparities in Endocrine Disease: Bias, Science, and Patient Care

Unacceptable healthcare disparities in endocrine disease have persisted for decades, and 2021 presents a difficult evolving environment. The COVID-19 pandemic has highlighted the gross structural inequities that drive health disparities, and antiracism demonstrations remind us that the struggle for human rights continues. Increased public awareness and discussion of disparities present an urgent opportunity to advance health equity. However, it is more complicated to change the behavior of individuals and reform systems because societies are polarized into different factions that increasingly believe, accept, and live different realities. To reduce health disparities, clinicians must (1) truly commit to advancing health equity and intentionally act to reduce health disparities; (2) create a culture of equity by looking inwards for personal bias and outwards for the systemic biases built into their everyday work processes; (3) implement practical individual, organizational, and community interventions that address the root causes of the disparities; and (4) consider their roles in addressing social determinants of health and influencing healthcare payment policy to advance health equity. To care for diverse populations in 2021, clinicians must have self-insight and true understanding of heterogeneous patients, knowledge of evidence-based interventions, ability to adapt messaging and approaches, and facility with systems change and advocacy. Advancing health equity requires both science and art; evidence-based roadmaps and stories that guide the journey to better outcomes, judgment that informs how to change the behavior of patients, providers, communities, organizations, and policymakers, and passion and a moral mission to serve humanity.

Orchestration versus bookkeeping: How stakeholder pressures drive a healthcare purchaser's institutional logics

Background

Healthcare purchasers such as health insurers and governmental bodies are expected to strategically manage chronic care chains. In doing so, purchasers can contribute to the goal of improving task division and collaboration between chronic care providers as has been recommended by numerous studies. However, healthcare purchasing research indicates that, in most countries, purchasers still struggle to fulfil a proactive, strategic approach. Consequently, a typical pattern occurs in which care improvement initiatives are instigated, but not transformed into regular care. By acknowledging that healthcare purchasers are embedded in a care chain of stakeholders who have different, sometimes conflicting, interests and, by taking an institutional logics lens, we seek to explain why achieving strategic purchasing and sustainable improvement is so elusive.

Method and findings

We present a longitudinal case study in which we follow a health insurer and care providers aiming to improve the care of patients with Chronic Obstructive Pulmonary Disease (COPD) in a region of the Netherlands. Taking a theoretical lens of institutional logics, our aim was to answer ‘how stakeholder pressures influence a purchaser’s use of institutional logics when pursuing the right care at the right place’. The insurer by default predominantly expressed a bookkeeper’s logic, reflecting a focus on controlling short-term care costs by managing individual providers. Over time, a contrasting orchestrator’s logic emerged in an attempt to achieve chain-wide improvement, striving for better health outcomes and lower long-term costs. We established five types of stakeholder pressure to explain the shift in logic adoption: relationship pressures, cost pressures, medical demands, public health demands and uncertainty. Linking the changes in logic over time with stakeholder pressures showed that, firstly, the different pressures interact in influencing the purchaser. Secondly, we saw that the lack of intra-organisational alignment affects how the purchaser deals with the different stakeholder pressures.

Conclusions

By highlighting the purchaser’s difficult position in the care chain and the consequences of their own internal responses, we now better understand why the intended orchestrator’s logic and thereby a strategic approach to purchasing chronic care proves unsustainable within the Dutch healthcare system of managed competition.

The one-year impact of accountable care networks among Washington State employees

OBJECTIVE

To estimate the impact of a new, two-sided risk model accountable care network (ACN) on Washington State employees and their families.

DATA SOURCES/STUDY SETTING

Administrative data (January 2013-December 2016) on Washington State employees.

STUDY DESIGN

We compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0-5, 6-18, 19-26, 18-64).

DATA COLLECTION/EXTRACTION METHODS

We used difference-in-difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children.

PRINCIPAL FINDINGS

We estimate a 1-2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: -1.8, P < .01; age 0-5: -1.2, P = .07; age 6-18: -1.2, P = .06; age 19-26; -1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19-26 were also responsive with inpatient admissions declines (-0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures.

CONCLUSIONS

Washington's state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality.

Ten-Year Evaluation of the Population-Based Integrated Health Care System "Gesundes Kinzigtal"

BACKGROUND

The population-based integrated health care system called "Gesundes Kinzigtal" (Integrierte Versorgung Gesundes Kinzigtal, IVGK) was initiated more than 10 years ago in the Kinzig River Valley region, which is located in the Black Forest in the German state of Baden-Württemberg. IVGK is intended to optimize health care while maximizing cost-effectiveness. It consists of programs for promoting health and for enabling cooperation among service providers, as well as of a shared-savings contract that has enabled resources to be saved every year. The goal of the present study was to investigate trends in the quality of care provided by IVGK over the past ten years in comparison to conventional care.

METHODS

This is a non-randomized observational study with a control-group design (Kinzig River Valley versus 13 structurally comparable control regions), employing data collected by AOK, a large statutory health-insurance provider in Germany, over the period 2006-2015. Quality assessment was conducted with the aid of a set of indicators, developed by the authors, that was based exclusively on claims data. The statistical analysis of the trends in these indicators over time was conducted with preset criteria for the relevance of any observed changes, as well as preset mechanisms of controlling for confounding factors.

RESULTS

For 88 of the 101 evaluable indicators, no relevant difference was seen between the trend over time in the region of the intervention and the average trend in the control regions. Relevant differences in favor of the IVGK were observed for six indicators, and negatively divergent trends compared to the controls were observed for seven indicators. In the main summarizing statistical analysis, no positive or negative difference was found between the Kinzig River Valley and the other regions with respect to trends in the health-care indicators over time.

CONCLUSION

An evaluation based on 101 indicators derived from health-insurance data did not reveal any improvement of the quality of care by IVGK and the totality of the programs that were implemented under it. However, under the conditions of the shared-savings contract, no relevant diminution in the quality of care was observed over a period of 10 years either, compared with structurally similar control regions without an integrated care model.

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.