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Gaspar K, Croes R, Mikkers M, Koolman X. Length of hospital stays and financial incentives: evidence from Dutch rehabilitation centers. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024; 25:731-741. [PMID: 37556021 PMCID: PMC11192693 DOI: 10.1007/s10198-023-01615-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/26/2023] [Indexed: 08/10/2023]
Abstract
Non-linear reimbursement contracts in healthcare have been increasingly used to quantify providers' responses to financial incentives. In the present research, we utilize a large one-off increase in the reimbursement of rehabilitation care to assess to what extent providers are willing to modify their treating behavior to maximize profits. In order to disincentivize the use of short inpatient stays for rehabilitation care, Dutch policy-makers have instated a two-part stepwise tariff-schedule. A lower tariff-schedule is applied for short hospital stays (≤ 14 days), while a higher tariff-schedule is utilized for longer treatments. Switching from one schedule to the other at day 15 of inpatient care leads to a sudden and large increase in tariffs. We show that, for most care-types, patients are seldom treated in an inpatient setting for less than 15 days, while the majority of patients are discharged after the threshold. Therefore, we conclude that the financial incentive at day 15 leads to considerable distortions in treatment. However, instead of discharging all patients at the threshold point where marginal tariffs are maximized, providers tend to continue treatment indicating altruistic behavior. As healthcare payment systems move away from piecewise reimbursement (e.g., fee-for-service arrangements), and services are increasingly 'lumped' together into e.g., DRGs and bundled payments, the likelihood of such discontinuities in tariff-schedules radically increases. Our research illustrates how such discontinuities in reimbursements can lead to distortions in the amount of healthcare provided contributing to the debate on optimal healthcare contracting design.
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Affiliation(s)
- Katalin Gaspar
- School of Business and Economics, Talma Institute / VU University Amsterdam, Section Health Economics, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
| | - Ramsis Croes
- Dutch Healthcare Authority (NZa), Newtonlaan 1-41, 3584, BX, Utrecht, The Netherlands
| | - Misja Mikkers
- Dutch Healthcare Authority (NZa), Newtonlaan 1-41, 3584, BX, Utrecht, The Netherlands
- Tilburg University, Warandelaan 2, 5037, AB, Tilburg, The Netherlands
| | - Xander Koolman
- School of Business and Economics, Talma Institute / VU University Amsterdam, Section Health Economics, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
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Lin K, Li Y, Yao Y, Xiong Y, Xiang L. The impact of an innovative payment method on medical expenditure, efficiency, and quality for inpatients with different types of medical insurance: evidence from a pilot city, China. Int J Equity Health 2024; 23:115. [PMID: 38840102 PMCID: PMC11151554 DOI: 10.1186/s12939-024-02196-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 05/10/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Since 2020, China has implemented an innovative payment method called Diagnosis-Intervention Packet (DIP) in 71 cities nationwide. This study aims to assess the impact of DIP on medical expenditure, efficiency, and quality for inpatients covered by the Urban Employee Basic Medical Insurance (UEBMI) and Urban and Rural Residents Basic Medical Insurance (URRBMI). It seeks to explore whether there are differences in these effects among inpatients of the two insurance types, thereby further understanding its implications for health equity. MATERIALS AND METHODS We conducted interrupted time series analyses on outcome variables reflecting medical expenditure, efficiency, and quality for both UEBMI and URRBMI inpatients, based on a dataset comprising 621,125 inpatient reimbursement records spanning from June 2019 to June 2023 in City A. This dataset included 110,656 records for UEBMI inpatients and 510,469 records for URRBMI inpatients. RESULTS After the reform, the average expenditure per hospital admission for UEBMI inpatients did not significantly differ but continued to follow an upward pattern. In contrast, for URRBMI inpatients, the trend shifted from increasing before the reform to decreasing after the reform, with a decline of 0.5%. The average length of stay for UEBMI showed no significant changes after the reform, whereas there was a noticeable downward trend in the average length of stay for URRBMI. The out-of-pocket expenditure (OOP) per hospital admission, 7-day all-cause readmission rate and 30-day all-cause readmission rate for both UEBMI and URRBMI inpatients showed a downward trend after the reform. CONCLUSION The DIP reform implemented different upper limits on budgets based on the type of medical insurance, leading to varying post-treatment prices for UEBMI and URRBMI inpatients within the same DIP group. After the DIP reform, the average expenditure per hospital admission and the average length of stay remained unchanged for UEBMI inpatients, whereas URRBMI inpatients experienced a decrease. This trend has sparked concerns about hospitals potentially favoring UEBMI inpatients. Encouragingly, both UEBMI and URRBMI inpatients have seen positive outcomes in terms of alleviating patient financial burdens and enhancing the quality of care.
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Affiliation(s)
- Kunhe Lin
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yunfei Li
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Yifan Yao
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yingbei Xiong
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Xiang
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
- HUST Base of National Institute of Healthcare Security, Wuhan, China.
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Campinha-Bacote J. Promoting Health Equity Among Marginalized and Vulnerable Populations. Nurs Clin North Am 2024; 59:109-120. [PMID: 38272576 DOI: 10.1016/j.cnur.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
This article calls for a closer examination of health equity regarding the disparities and inequities in health care among marginalized and vulnerable populations. A review of strategies to improve culturally responsive care to these populations will be examined. This examination includes a discussion of the need for structural competence and the ongoing debate around the concepts of cultural competence and cultural humility. Cultural competemility, a new paradigm of thought regarding the relationship between cultural competence and cultural humility, will be proposed. This article culminates with downstream, midstream, and upstream approaches reducing the magnitude of inequity among marginalized and vulnerable populations.
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Spivack SB, Murray GF, Lewis VA. A Decade of ACOs in Medicare: Have They Delivered on Their Promise? JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2023; 48:63-92. [PMID: 36112955 DOI: 10.1215/03616878-10171090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
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.
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Ortiz J, Hill M, Thomas CW, Hofler R. Accountable Care Organizations and Health Disparities of Rural Latinos: A Longitudinal Analysis. Popul Health Manag 2022; 25:651-657. [PMID: 35704880 PMCID: PMC9836698 DOI: 10.1089/pop.2022.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The purpose of this study was 2-fold: (1) to analyze the change in diabetes-related hospitalization rates of rural Latino older adult patients as compared with their White counterparts and (2) to determine what factors, including rural health clinic (RHC) participation in accountable care organizations (ACOs), are related to reduced disparities in diabetes-related hospitalization rates. Data for Latino Medicare beneficiaries who were served by RHCs over an 8-year period were analyzed. First, a difference-of-means test was conducted to determine whether there was a change in disparity from the pre-ACO period (2008-2011) to the post-ACO period (2012-2015). A statistically significant decrease in disparity over time was found (t = -7.6899, df = 115, P < 0.001.) Second, multiple regression analyses of 3 separate models were conducted to determine whether ACO participation contributed to reducing disparities in diabetes-related hospitalization rates between Latinos and Whites. The analyses indicated moderate evidence that consistent ACO participation is associated with lower health disparities (t = -1.947, P = 0.0525). However, this association is not significant after balancing covariates, and no causal relationship can be established. Latinos compose one of the fastest growing groups in rural as well as urban areas of the United States. It is critical that ACOs, with their emphasis on care coordination, health care quality, and value, monitor their provision of services to Latinos, rural, and other vulnerable populations.
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Affiliation(s)
- Judith Ortiz
- College of Health Professions and Sciences, University of Central Florida, Orlando, Florida, USA
| | - Mitch Hill
- Department of Statistics, College of Sciences, University of Central Florida, Orlando, Florida, USA
| | - Chad W. Thomas
- Department of Statistics, College of Sciences, University of Central Florida, Orlando, Florida, USA
| | - Richard Hofler
- Department of Economics, College of Business, University of Central Florida, Orlando, Florida, USA
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Chen A, Ghosh A, Gwynn KB, Newby C, Henry TL, Pearce J, Fleurant M, Schmidt S, Bracey J, Jacobs EA. Society of General Internal Medicine Position Statement on Social Risk and Equity in Medicare's Mandatory Value-Based Payment Programs. J Gen Intern Med 2022; 37:3178-3187. [PMID: 35768676 PMCID: PMC9485310 DOI: 10.1007/s11606-022-07698-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/02/2022] [Indexed: 11/30/2022]
Abstract
The Affordable Care Act (2010) and Medicare Access and CHIP Reauthorization Act (2015) ushered in a new era of Medicare value-based payment programs. Five major mandatory pay-for-performance programs have been implemented since 2012 with increasing positive and negative payment adjustments over time. A growing body of evidence indicates that these programs are inequitable and financially penalize safety-net systems and systems that care for a higher proportion of racial and ethnic minority patients. Payments from penalized systems are often redistributed to those with higher performance scores, which are predominantly better-financed, large, urban systems that serve less vulnerable patient populations - a "Reverse Robin Hood" effect. This inequity may be diminished by adjusting for social risk factors in payment policy. In this position statement, we review the literature evaluating equity across Medicare value-based payment programs, major policy reports evaluating the use of social risk data, and provide recommendations on behalf of the Society of General Internal Medicine regarding how to address social risk and unmet health-related social needs in these programs. Immediate recommendations include implementing peer grouping (stratification of healthcare systems by proportion of dual eligible Medicare/Medicaid patients served, and evaluation of performance and subsequent payment adjustments within strata) until optimal methods for accounting for social risk are defined. Short-term recommendations include using census-based, area-level indices to account for neighborhood-level social risk, and developing standardized approaches to collecting individual socioeconomic data in a robust but sensitive way. Long-term recommendations include implementing a research agenda to evaluate best practices for accounting for social risk, developing validated health equity specific measures of care, and creating policies to better integrate healthcare and social services.
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Affiliation(s)
- Anders Chen
- Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Arnab Ghosh
- Department of Medicine, Weill Cornell Medical College of Columbia University, New York, NY, USA
| | - Kendrick B Gwynn
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians, Baltimore, MD, USA
| | - Celeste Newby
- Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Tracey L Henry
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Jackson Pearce
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - Stacie Schmidt
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Jennifer Bracey
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
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Nutrition programmes for individuals living with disadvantage in supported residential settings: a scoping review. Public Health Nutr 2022; 25:2625-2636. [PMID: 35470791 PMCID: PMC9991776 DOI: 10.1017/s1368980022000969] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Health inequities such as chronic disease are significantly higher among individuals living with disadvantage compared with the general population and many are reported to be attributable to preventable dietary risk factors. This study provides an overview of the current nutrition interventions for individuals living with extreme disadvantage, in supported residential settings, to develop insights into the development and implementation of policies and practices to promote long-term nutritional health and well-being. DESIGN A scoping review searched Scopus, ProQuest, CINAHL Plus, MEDLINE, and Web of Science databases using the terms 'resident', 'nutrition', 'disadvantage', 'intervention' and their synonyms, with particular emphasis on interventions in residential settings. SETTING Residential services providing nutrition provision and support. PARTICIPANTS People experiencing extreme disadvantage. RESULTS From 5262 articles, seven were included in final synthesis. Most interventions focused on building food literacy knowledge and skills. Study designs and outcome measures varied; however, all reported descriptive improvements in behaviour and motivation. In addition to food literacy, it was suggested that interventions need to address behaviour and motivations, programme sustainability, long-term social, physical and economic barriers and provide support for participants during transition into independent living. Socio-economic issues remain key barriers to long-term health and well-being. CONCLUSIONS In addition to food literacy education, future research and interventions should consider utilising an academic-community partnership, addressing nutrition-related mental health challenges, motivation and behaviour change and a phased approach to improve support for individuals transitioning into independent living.
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Baldwin A, Capper T, Harvey C, Willis E, Ferguson B, Browning N. PROMOTING NURSES' AND MIDWIVES' ETHICAL RESPONSIBILITIES TOWARDS VULNERABLE PEOPLE: AN ALIGNMENT OF RESEARCH AND CLINICAL PRACTICE. J Nurs Manag 2022; 30:2442-2447. [PMID: 35969415 PMCID: PMC10087887 DOI: 10.1111/jonm.13764] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/24/2022] [Accepted: 08/11/2022] [Indexed: 11/29/2022]
Abstract
AIM To stimulate discussion and debate about inclusion of vulnerable populations in primary research to inform practice change and improve health outcomes. BACKGROUND Current research practices to safeguard vulnerable people from potential harms related to power imbalances, may in fact limit the generation of evidence-based practice. EVALUATION The authors draw on their experience working and researching with a recognised group of vulnerable people, incarcerated pregnant women, to provide insight into the application of ethics in both research and clinical practice. In a novel approach, the ethical principles are presented in both contexts, articulating the synergies between them. Suggestions are presented for how individuals, managers and organisations may improve research opportunities for clinical practitioners and enhance the engagement of vulnerable people to contribute to meaningful practice and policy change. KEY ISSUES Ethical practice guidelines may limit the ability to create meaningful change for vulnerable populations, who need authentic system change to achieve good health outcomes. CONCLUSION Inclusive research and practice are essential to ensuring a strengths-based approach to healthcare and addressing health needs of the whole population. Health systems and models of care recognising the diverse lives and health needs of the broader population, demand practical, sustainable support from clinical managers. IMPLICATIONS FOR NURSING MANAGEMENT Practical suggestions for clinical managers to support point of care research is provided, embedding vulnerable voices in policy, practice development, and care provision.
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Affiliation(s)
- Adele Baldwin
- School of Nursing, Midwifery and Social Sciences, CQUniversity, Townsville, Australia
| | - Tanya Capper
- Head of Course, Midwifery, School of Nursing, Midwifery and Social Sciences, CQUniversity, Brisbane, Australia
| | - Clare Harvey
- School of Nursing, Massey University, Wellington, New Zealand
| | | | - Bridget Ferguson
- Lecturer, School of Nursing, Midwifery and Social Sciences, CQUniversity, Rockhampton, Australia
| | - Natalie Browning
- School of Nursing, Midwifery and Social Sciences, CQUniversity, Townsville, Australia
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Tee EYJ, Shah RIABRR, Ramis T, Jia-Qi LC. Bent, But Not Broken: Locus-of-Hope and Well-Being Among Malaysians Facing Economic Challenges Amidst the COVID-19 Pandemic. PSYCHOLOGICAL STUDIES 2022; 67:304-316. [PMID: 35601659 PMCID: PMC9110276 DOI: 10.1007/s12646-022-00653-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 02/17/2022] [Indexed: 11/30/2022] Open
Abstract
Hope is conceptualized as a cognitive set that has often been studied in the context of adversity. No studies, however, directly examine how locus-of-hope (LOH) influences psychological outcomes among vulnerable populations within collectivist cultural contexts. We address this gap by assessing the relationships between LOH and well-being among Malaysians facing financial struggles during the COVID-19 pandemic. We hypothesized that LOH will predict well-being but that external LOH will more strongly predict well-being than internal LOH. One-hundred and fifty-two (152) Malaysians (63 men, 89 women, average age 29.69 years old) who have (1) experienced loss of employment status (2) decrease in salary earnings or (3) earn below the lower 40% threshold of national household incomes completed a series of questionnaires assessing their LOH and well-being. Results indicate that controlling for age, perceptions of government efforts and trait optimism, LOH significantly predict well-being. Findings also show that internal LOH and LOH-family were the strongest predictors of well-being. Theoretical and practical implications are discussed in light of these findings.
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Affiliation(s)
- Eugene Y. J. Tee
- Department of Psychology, Faculty of Behavioural Sciences, Languages, and Education, HELP University, Kuala Lumpur, Malaysia
| | | | - TamilSelvan Ramis
- Centre for American Education, Sunway University, Petaling Jaya, Malaysia
| | - Lauren Chai Jia-Qi
- Department of Psychology, Faculty of Behavioural Sciences, Languages, and Education, HELP University, Kuala Lumpur, Malaysia
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Breuing J, Joisten C, Neuhaus AL, Heß S, Kusche L, Haas F, Spiller M, Pieper D. Communication strategies in the prevention of type 2 diabetes and gestational diabetes in vulnerable groups: a scoping review. Syst Rev 2021; 10:301. [PMID: 34819163 PMCID: PMC8611985 DOI: 10.1186/s13643-021-01846-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/22/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The global prevalence of diabetes is nearly 9%, with an upward trend in type 2 diabetes mellitus (T2DM) and gestational diabetes (GDM). Although evidence shows that vulnerable groups are affected disproportionally, these groups are difficult to reach in terms of preventive measures. Currently, there is no gold standard regarding communication strategies and/or public awareness campaigns. METHODS We conducted a scoping review in September 2019. Two reviewers independently screened the results of the electronic literature search in several databases, including Medline, EMBASE, and PsycINFO. Extracted data were charted, categorized, and summarized. RESULTS All of the included articles (n=24) targeted T2DM; none targeted GDM. We identified the following five different vulnerable groups within the identified studies: migrants (n=9), ethnic groups such as African Americans (n=8), people with low socioeconomic status (n=3), older people (n=1), and people in need of care (n=1). Three categories of communication strategies were identified as follows: adapted diabetes prevention programs (n=21), community health workers (n=5), and technical approaches (n=9). CONCLUSION We found different approaches for preventive interventions for T2DM. Some of these approaches were already adapted to known barriers. Communication strategies should be adapted to barriers and facilitating factors to increase participation and motivation.
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Affiliation(s)
- Jessica Breuing
- Institute for Research in Operative Medicine (IFOM), Department for Evidence Based Health Service Research, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Christine Joisten
- Institute of Movement and Neurosciences, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933 Cologne, Germany
| | - Annika Lena Neuhaus
- Institute for Research in Operative Medicine (IFOM), Department for Evidence Based Health Service Research, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Simone Heß
- Institute for Research in Operative Medicine (IFOM), Department for Evidence Based Health Service Research, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Lena Kusche
- Institute of Movement and Neurosciences, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933 Cologne, Germany
| | - Fabiola Haas
- Institute of Movement and Neurosciences, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933 Cologne, Germany
| | - Mark Spiller
- Institute of Movement and Neurosciences, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933 Cologne, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine (IFOM), Department for Evidence Based Health Service Research, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
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Drewry KM, Trivedi AN, Wilk AS. Organizational Characteristics Associated with High Performance in Medicare's Comprehensive End-Stage Renal Disease Care Initiative. Clin J Am Soc Nephrol 2021; 16:1522-1530. [PMID: 34620648 PMCID: PMC8499003 DOI: 10.2215/cjn.04020321] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 08/20/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Medicare plans to extend financial structures tested through the Comprehensive End-Stage Renal Disease Care (CEC) Initiative-an alternative payment model for maintenance dialysis providers-to promote high-value care for beneficiaries with kidney failure. The End-Stage Renal Disease Seamless Care Organizations (ESCOs) that formed under the CEC Initiative varied greatly in their ability to generate cost savings and improve patient health outcomes. This study examined whether organizational or community characteristics were associated with ESCOs' performance. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used a retrospective pooled cross-sectional analysis of all 37 ESCOs participating in the CEC Initiative during 2015-2018 (n=87 ESCO-years). Key exposures included ESCO characteristics: number of dialysis facilities, number and types of physicians, and years of CEC Initiative experience. Outcomes of interest included were above versus below median gross financial savings (2.4%) and standardized mortality ratio (0.93). We analyzed unadjusted differences between high- and low-performing ESCOs and then used multivariable logistic regression to construct average marginal effect estimates for parameters of interest. RESULTS Above-median gross savings were obtained by 23 (52%) ESCOs with no program experience, 14 (32%) organizations with 1 year of experience, and seven (16%) organizations with 2 years of experience. The adjusted likelihoods of achieving above-median gross savings were 23 (95% confidence interval, 8 to 37) and 48 (95% confidence interval, 24 to 68) percentage points higher for ESCOs with 1 or 2 years of program experience, respectively (versus none). The adjusted likelihood of achieving above-median gross savings was 1.7 (95% confidence interval, -3 to -1) percentage points lower with each additional affiliated dialysis facility. Adjusted mortality rates were lower for ESCOs located in areas with higher socioeconomic status. CONCLUSIONS Smaller ESCOs, organizations with more experience in the CEC Initiative, and those located in more affluent areas performed better under the CEC Initiative.
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MESH Headings
- Accountable Care Organizations/economics
- Accountable Care Organizations/organization & administration
- Cost Savings
- Cost-Benefit Analysis
- Cross-Sectional Studies
- Delivery of Health Care, Integrated/economics
- Delivery of Health Care, Integrated/organization & administration
- Health Care Costs
- Humans
- Kidney Failure, Chronic/diagnosis
- Kidney Failure, Chronic/economics
- Kidney Failure, Chronic/mortality
- Kidney Failure, Chronic/therapy
- Medicare/economics
- Medicare/organization & administration
- Neighborhood Characteristics
- Outcome and Process Assessment, Health Care/economics
- Outcome and Process Assessment, Health Care/organization & administration
- Quality Assurance, Health Care/organization & administration
- Quality Indicators, Health Care/organization & administration
- Renal Dialysis/adverse effects
- Renal Dialysis/economics
- Renal Dialysis/mortality
- Retrospective Studies
- Social Class
- Time Factors
- Treatment Outcome
- United States
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Affiliation(s)
- Kelsey M. Drewry
- Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Amal N. Trivedi
- Department of Health Services, Policy and Practice, Department of Medicine, Brown University, Providence, Rhode Island
- Department of Medicine, Brown University, Providence, Rhode Island
| | - Adam S. Wilk
- Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia
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Lewis VA, Spivack S, Murray GF, Rodriguez HP. FQHC Designation and Safety Net Patient Revenue Associated with Primary Care Practice Capabilities for Access and Quality. J Gen Intern Med 2021; 36:2922-2928. [PMID: 34346005 PMCID: PMC8481458 DOI: 10.1007/s11606-021-06746-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Concerns exist about the ability of safety net health care organizations to participate in US health care reform. Primary care practices are key to several efforts, but little is known about how capabilities of primary care practices serving a high share of disadvantaged patients compare to other practices. OBJECTIVE To assess capabilities around access to and quality of care among primary care practices serving a high share of Medicaid and uninsured patients compared to practices serving a low share of these patients. DESIGN We analyzed data from the National Survey of Healthcare Organizations and Systems (response rate 46.8%), conducted 2017-2018. PARTICIPANTS A total of 2190 medical practices with at least three adult primary care physicians. MAIN MEASURES Our key exposures are payer mix and federally qualified health center (FQHC) designation. We classified practices as safety net if they reported a combined total of at least 25% of annual revenue from uninsured or Medicaid patients; we then further classified safety net practices into those that identified as an FQHC and those that did not. KEY RESULTS FQHCs were more likely than other safety net practices and non-safety net practices to offer early or late appointments (79%, 55%, 62%; p=0.001) and weekend appointments (56%, 39%, 42%; p=0.03). FQHCs more often provided medication-assisted treatment for opioid use disorders (43%, 27%, 25%; p=0.004) and behavioral health services (82%, 50%, 36%; p<0.001). FQHCs were more likely to screen patients for social and financial needs. However, FQHCs and other safety net providers had more limited electronic health record (EHR) capabilities (61%, 71%, 80%; p<0.001). CONCLUSION FQHCs were more likely than other types of primary care practices (both safety net practices and other practices) to possess capabilities related to access and quality. However, safety net practices were less likely than non-safety net practices to possess health information technology capabilities.
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Affiliation(s)
- Valerie A Lewis
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, USA.
| | - Steven Spivack
- Center for Outcomes and Evaluation, Yale School of Medicine, New Haven, USA
| | - Genevra F Murray
- Department of General Internal Medicine, Boston Medical Center, Boston, USA
| | - Hector P Rodriguez
- School of Public Health, University of California, Berkeley, Berkley, USA
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Koh KA, Racine M, Gaeta JM, Goldie J, Martin DP, Bock B, Takach M, O'Connell JJ, Song Z. Health Care Spending And Use Among People Experiencing Unstable Housing In The Era Of Accountable Care Organizations. Health Aff (Millwood) 2021; 39:214-223. [PMID: 32011951 DOI: 10.1377/hlthaff.2019.00687] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Provider organizations are increasingly held accountable for health care spending in vulnerable populations. Longitudinal data on health care spending and use among people experiencing episodes of homelessness could inform the design of alternative payment models. We used Medicaid claims data to analyze spending and use among 402 people who were continuously enrolled in the Boston Health Care for the Homeless Program (BHCHP) from 2013 through 2015, compared to spending and use among 18,638 people who were continuously enrolled in Massachusetts Medicaid with no evidence of experiencing homelessness. The BHCHP population averaged $18,764 per person per year in spending-2.5 times more than spending among the comparison Medicaid population ($7,561). In unadjusted analyses this difference was explained by greater spending in the BHCHP population on outpatient care, including emergency department care, as well as on inpatient care and prescription drugs. After adjustment for covariates and multiple hypothesis testing, the difference was largely driven by outpatient spending. Differences were sensitive to adjustments for risk score, which suggests that housing instability and health risk are meaningfully correlated. This longitudinal analysis improves understanding of health care use and resource needs among people who are homeless or have unstable housing, and it could inform the design of alternative payment models for vulnerable populations.
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Affiliation(s)
- Katherine A Koh
- Katherine A. Koh ( kkoh@partners. org ) is a physician at the Boston Health Care for the Homeless Program and Massachusetts General Hospital, both in Boston, Massachusetts
| | - Melanie Racine
- Melanie Racine is the director of special projects at the Boston Health Care for the Homeless Program and a member of its Institute for Research, Quality, and Policy in Homeless Health Care
| | - Jessie M Gaeta
- Jessie M. Gaeta is chief medical officer at the Boston Health Care for the Homeless Program and a member of its Institute for Research, Quality, and Policy in Homeless Health Care. She is also an assistant professor of medicine at Boston University School of Medicine
| | - John Goldie
- John Goldie is executive director of system analytics, Boston Medical Center Health System
| | - Daniel P Martin
- Daniel P. Martin is a data scientist in the Population Health Analytics and Strategy team, Boston Medical Center Health System
| | - Barry Bock
- Barry Bock is chief executive officer of the Boston Health Care for the Homeless Program
| | - Mary Takach
- Mary Takach is a senior health policy adviser at the Boston Health Care for the Homeless Program
| | - James J O'Connell
- James J. O'Connell is president of the Boston Health Care for the Homeless Program and an assistant professor of medicine at Harvard Medical School, in Boston
| | - Zirui Song
- Zirui Song is an assistant professor of health care policy and medicine at Harvard Medical School and Massachusetts General Hospital, and a faculty member in the Center for Primary Care at Harvard Medical School
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14
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Lin SC, Yan PL, Moloci NM, Lawton EJ, Ryan AM, Adler-Milstein J, Hollingsworth JM. Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs. Health Aff (Millwood) 2021; 39:310-318. [PMID: 32011939 DOI: 10.1377/hlthaff.2019.00181] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite expectations that Medicare accountable care organizations (ACOs) would curb health care spending, their effect has been modest. One possible explanation is that ACOs' inability to prohibit out-of-network care limits their control over spending. To examine this possibility, we examined the association between out-of-network care and per beneficiary spending using national Medicare data for 2012-15. While there was no association between out-of-network specialty care and ACO spending, each percentage-point increase in receipt of out-of-network primary care was associated with an increase of $10.79 in quarterly total ACO spending per beneficiary. When we broke down total spending by place of service, we found that out-of-network primary care was associated with higher spending in outpatient, skilled nursing facility, and emergency department settings, but not inpatient settings. Our findings suggest an opportunity for the Medicare program to realize substantial savings, if policy makers developed explicit incentives for beneficiaries to seek more of their primary care within network.
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Affiliation(s)
- Sunny C Lin
- Sunny C. Lin is an assistant professor of public health at the Oregon Health & Science University-Portland State University School of Public Health, in Portland, Oregon
| | - Phyllis L Yan
- Phyllis L. Yan is a senior statistician in the Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, in Ann Arbor
| | - Nicholas M Moloci
- Nicholas M. Moloci is a statistician lead in the Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School
| | - Emily J Lawton
- Emily J. Lawton is a doctoral candidate in the Department of Health Management and Policy, University of Michigan
| | - Andrew M Ryan
- Andrew M. Ryan is the UnitedHealthcare Professor of Health Care Management, Department of Health Management and Policy, University of Michigan School of Public Health, and director of the Center for Evaluating Health Reform, University of Michigan
| | - Julia Adler-Milstein
- Julia Adler-Milstein is an associate professor of medicine and director of the Clinical Informatics and Improvement Research Center, School of Medicine, University of California San Francisco
| | - John M Hollingsworth
- John M. Hollingsworth ( kinks@med. umich. edu ) is an associate professor of urology and health management and policy at the University of Michigan Medical School and School of Public Health
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15
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Liao JM, Navathe AS, Werner RM. The Impact of Medicare's Alternative Payment Models on the Value of Care. Annu Rev Public Health 2021; 41:551-565. [PMID: 32237986 DOI: 10.1146/annurev-publhealth-040119-094327] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Over the past decade, the Centers for Medicare and Medicaid Services (CMS) have led the nationwide shift toward value-based payment. A major strategy for achieving this goal has been to implement alternative payment models (APMs) that encourage high-value care by holding providers financially accountable for both the quality and the costs of care. In particular, the CMS has implemented and scaled up two types of APMs: population-based models that emphasize accountability for overall quality and costs for defined patient populations, and episode-based payment models that emphasize accountability for quality and costs for discrete care. Both APM types have been associated with modest reductions in Medicare spending without apparent compromises in quality. However, concerns about the unintended consequences of these APMs remain, and more work is needed in several important areas. Nonetheless, both APM types represent steps to build on along the path toward a higher-value national health care system.
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Affiliation(s)
- Joshua M Liao
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington 98195, USA; .,Value and Systems Science Lab, School of Medicine, University of Washington, Seattle, Washington 98195, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Amol S Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.,Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania 19104, USA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Rachel M Werner
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.,Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania 19104, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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16
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Brewster AL, Fraze TK, Gottlieb LM, Frehn J, Murray GF, Lewis VA. The Role of Value-Based Payment in Promoting Innovation to Address Social Risks: A Cross-Sectional Study of Social Risk Screening by US Physicians. Milbank Q 2020; 98:1114-1133. [PMID: 33078875 DOI: 10.1111/1468-0009.12480] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Policy Points One of the most important possibilities of value-based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. Screening patients for social risks such as housing instability and food insecurity represents an early step physician practices can take to address social needs. At present, adoption of social risk screening by physician practices is linked with having high innovation capacity and focusing on low-income populations, but not exposure to value-based payment. Expanding social risk screening by physician practices may require standardization and technical assistance for practices that have less innovative capacity. CONTEXT One of the most important possibilities of value-based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. However, there is uncertainty about the conditions under which value-based payment will encourage health care providers to innovate to address upstream social risks. METHODS We used the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS), a nationally representative survey of physician practices (n = 2,178), to ascertain (1) the number of social risks for which practices systematically screen patients; (2) the extent of practices' participation in value-based payment models; and (3) measures of practices' capacity for innovation. We used multivariate regression models to examine predictors of social risk screening. FINDINGS On average, physician practices systematically screened for 2.4 out of 7 (34%) social risks assessed by the survey. In the fully adjusted model, implementing social risk screening was not associated with the practices' overall exposure to value-based payment. Being in the top quartile on any of three innovation capacity scales, however, was associated with screening for 0.95 to 1.00 additional social risk (p < 0.001 for all three results) relative to the bottom quartile. In subanalysis examining specific payment models, participating in a Medicaid accountable care organization was associated with screening for 0.37 more social risks (p = 0.015). Expecting more exposure to accountable care in the future was associated with greater social risk screening, but the effect size was small compared with practices' capacity for innovation. CONCLUSIONS Our results indicate that implementation of social risk screening-an initial step in enhancing awareness of social needs in health care-is not associated with overall exposure to value-based payment for physician practices. Expanding social risk screening by physician practices may require standardized approaches and implementation assistance to reduce the level of innovative capacity required.
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17
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Siracuse JJ, Farber A, Cheng TW, Levin SR, Kalesan B. Hospital-Level Medicaid Prevalence Is Associated with Increased Length of Stay after Asymptomatic Carotid Endarterectomy and Stenting Despite no Increase in Major Complications. Ann Vasc Surg 2020; 71:65-73. [PMID: 32949743 DOI: 10.1016/j.avsg.2020.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic disease is used as a quality measure and affects hospital operating margins. Patient-level Medicaid status has traditionally been associated with longer hospital LOS. Our goal was to assess the association between hospital-level Medicaid prevalence and postoperative LOS after CEA and CAS. METHODS The National Inpatient Sample was queried from 2006-2014 for CEA and CAS performed for asymptomatic carotid stenosis. Overall hospital-level Medicaid prevalence was divided into quartiles. The quartiles were further categorized into low Medicaid prevalence (LM) (lowest quartile), medium Medicaid prevalence (MM) (second and third quartiles), and high Medicaid prevalence (HM) (fourth quartile) cohorts. The primary outcome evaluated was postoperative LOS >1 day. The secondary outcomes included perioperative/in-hospital complications and mortality. RESULTS There were 984,283 patients with asymptomatic carotid stenosis who underwent CEA (88%) or CAS (12%). Mean postoperative LOS after CEA at hospitals with LM, MM, and HM prevalence was 1.4 ± 1.5, 2.1 ± 2.5, and 2.2 ± 2.8 days (P = 0.0001), respectively, and after CAS were 1.7 ± 2.6, 1.8 ± 2.1, and 2 ± 2.6 days (P < 0.0001), respectively. After CEA, relative to LM prevalence, MM (OR 1.62, 95% CI 1.17-2.24) and HM (OR 1.66, 95% CI 1.2-2.28) prevalence were associated with a higher likelihood of LOS > 1 day (P = 0.009). After CAS, relative to LM prevalence, HM prevalence was associated with a higher likelihood of LOS >1 day (OR 1.42, 95% CI 1.06-1.91) (P = 0.003). After CEA, neurologic (0.8% vs. 0.9% vs. 0.9%, P = 0.83) and cardiac complications (0.9% vs. 1.2% vs. 1.2%, P = 0.24) were similar among hospitals with LM, MM, and HM prevalence, respectively. After CAS, the prevalence of neurological (1.1% vs. 1% vs. 1.2%, P = 0.42) and cardiac complications (2% vs. 1.3% vs. 1.5%, P = 0.46) were also similar. After both CEA and CAS, mortality was similar among Medicaid prevalence cohorts. CONCLUSIONS Higher hospital-level Medicaid prevalence was associated with longer LOS after CEA and CAS for asymptomatic carotid stenosis. Value-based payment models should adjust for hospital-level Medicaid prevalence to appropriately reimburse providers and hospital with higher Medicaid prevalence as well as investigate care pathways and systems improvement to help reduce LOS.
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Affiliation(s)
- Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Bindu Kalesan
- Center for Clinical Translational Epidemiology and Comparative Effectiveness Research, Preventative Medicine & Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA
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18
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Comfort LN, Fulton BD, Shortell SM. Assessing the Short-Term Association Between Rural Hospitals' Participation in Accountable Care Organizations and Changes in Utilization and Financial Performance. J Rural Health 2020; 37:334-346. [PMID: 32657481 DOI: 10.1111/jrh.12494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Although much research has been done on accountable care organizations (ACOs), little is known about their impact on rural hospitals. We examine the association between rural hospitals' participation in an ACO and their performance on utilization and financial measures. METHODS This quasi-experimental study estimates the relationship between voluntary ACO participation and hospital metrics using propensity score-matched, longitudinal regression models with year and hospital fixed effects. Regression models controlled for secular trends and time-varying hospital and county characteristics. Hospital measures were from the American Hospital Association, RAND Hospital Data, and Leavitt Partners. The initial population comprises 643 rural hospitals that participated in an ACO for at least one year during the 2011 to 2018 study period and 1,541 rural hospitals that did not participate in an ACO. From this population we created a sample of propensity score-matched hospitals consisting of 525 ACO-participating and 525 comparable non-ACO hospitals. RESULTS Rural hospitals' participation in an ACO is not associated with changes in hospital utilization or financial measures, nor is there an association between these performance metrics and whether another within-county hospital participated in an ACO. A secondary analysis limited to Critical Access Hospitals provides some evidence that inpatient utilization increases in the second year of ACO participation, though the increases are not significant in year 3 and beyond. CONCLUSION We find no evidence that rural hospitals experience substantive changes in outpatient visits, inpatient utilization, or operating margin in the years immediately after joining an ACO.
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Affiliation(s)
- Leeann N Comfort
- Department of Health Policy and Management, University of California, Berkeley, Berkeley, California.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Brent D Fulton
- Department of Health Policy and Management, University of California, Berkeley, Berkeley, California
| | - Stephen M Shortell
- Department of Health Policy and Management, University of California, Berkeley, Berkeley, California
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19
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Abstract
PURPOSE OF REVIEW Diabetes mellitus is a leading chronic disease worldwide. Access to diabetes care varies widely and is influenced by multiple factors including social, geographic, and economic conditions. The use of technology to expand healthcare may bridge these barriers and improve access. Our aim was to review the evidence for the role of telehealth to expand access to quality diabetes care. RECENT FINDINGS There is evidence that application of technology-based programs to deliver healthcare are both feasible and effective. These programs are accepted by both patients and providers, can reduce healthcare costs, and may redress inequalities in healthcare access. Technology-based care models can improve disease management, enhance efficiency and clinical decision-making, promote patient self-management skills, and promote patient centered care. Future research should focus on implementation of technology-based healthcare delivery programs on a larger scale.
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Affiliation(s)
- Anusha Verravanallur Appuswamy
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY, 13210, USA
| | - Marisa E Desimone
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY, 13210, USA.
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20
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Barriers and facilitating factors in the prevention of diabetes type 2 and gestational diabetes in vulnerable groups: A scoping review. PLoS One 2020; 15:e0232250. [PMID: 32401778 PMCID: PMC7219729 DOI: 10.1371/journal.pone.0232250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 04/12/2020] [Indexed: 11/27/2022] Open
Abstract
Aims Type 2 diabetes mellitus (T2DM) and gestational diabetes (GDM) are globally on the rise, accompanied by comorbidities and associated health costs. Increased physical activity, healthy nutrition, and weight loss have shown the potential to prevent T2DM/GDM. Despite this, reaching vulnerable groups remains a key challenge. The aim of this scoping review was to identify barriers and facilitating factors in the prevention of T2DM/GDM in vulnerable groups. Methods We conducted a systematic literature search in May 2018, updated in September 2019, in several databases (e.g. PubMed, Embase) to identify barriers and facilitating factors in the prevention of T2DM/GDM in vulnerable groups. Two reviewers independently screened the results. Extracted data was charted, categorized, and summarized. Results We included 125 articles. Ninety-eight studies were extracted, and eight categories of barriers and facilitating factors were formed. The most common categories of barriers were limited knowledge, family/friends, and economic factors, and the most common categories of facilitating factors were family/friends, social support, and knowledge. Conclusion This scoping review identified various barriers and facilitating factors in vulnerable groups. Preventive interventions should consider these barriers and facilitating factors in developing preventive interventions or in adapting existing ones.
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21
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Vickery KD, Ford BR, Harwood EM, Guthrie KF, Linzer M. Awareness of Payment Reform: a Survey of Patients, Staff, and Providers in Safety Net Primary Care Clinics. J Gen Intern Med 2020; 35:1597-1599. [PMID: 31625036 PMCID: PMC7210349 DOI: 10.1007/s11606-019-05451-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Affiliation(s)
| | - Becky R Ford
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Eileen M Harwood
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
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22
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Lee JT, Polsky D, Fitzsimmons R, Werner RM. Proportion of Racial Minority Patients and Patients With Low Socioeconomic Status Cared for by Physician Groups After Joining Accountable Care Organizations. JAMA Netw Open 2020; 3:e204439. [PMID: 32383749 PMCID: PMC7210481 DOI: 10.1001/jamanetworkopen.2020.4439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/05/2020] [Indexed: 11/14/2022] Open
Abstract
Importance The incentive structure of accountable care organizations (ACOs) may lead to participating physician groups selecting fewer vulnerable patients. Objective To test for changes in the percentage of racial minority patients and patients with low socioeconomic status cared for by physician groups after joining the ACO. Design, Setting, and Participants This retrospective cohort consisted of a 15% random sample of Medicare fee-for-service beneficiaries attributed to physician groups from 2010 to 2016. Medicare Shared Savings Program (MSSP) participation was determined using ACO files. Analyses were conducted between January 1, 2019, and February 25, 2020. Exposures Using linear probability models, we conducted difference-in-differences analyses based on the year a physician group joined an ACO to estimate changes in vulnerable patients within ACO-participating groups compared with nonparticipating groups. Main Outcomes and Measures Whether the patient was black, was dually enrolled in Medicare and Medicaid, and poverty and unemployment rates of the patient's zip code. Results In a cohort of 76 717 physician groups caring for 7 307 130 patients, 16.1% of groups caring for 27.8% of patients participated in an MSSP ACO. Using 2010 characteristics, patients attributed to ACOs from 2012 to 2016, compared with those who were not, were less likely to be black (8.0% [n = 81 698] vs 9.3% [n = 270 924]) or dually enrolled in Medicare and Medicaid (12.8% [n = 130 957] vs 18.2% [n = 528 685]), and lived in zip codes with lower poverty rates (13.8% vs 15.5%); unemployment rates were similar (8.0% vs 8.5%). In the difference-in-differences analysis, there was no statistically significant change associated with ACO participation in the proportions of vulnerable patients attributed to ACO-participating groups compared with nonparticipating groups. After joining an ACO, ACO-participating groups had 0.0 percentage points change (95% CI, -0.1 to 0.1 percentage points; P = .59) for black patients, -0.1 percentage points (95% CI, -0.2 to 0.1 percentage points; P = .32) for patients dually enrolled in Medicare and Medicaid, 0.2 percentage points (95% CI, -3.5 to 4.0 percentage points; P = .91) in poverty rates, and -0.4 percentage points (95% CI, -2.0 to 1.2 percentage points; P = .62) in unemployment rates. Conclusions and Relevance In this cohort study, there were no changes in the proportions of vulnerable patients cared for by ACO-participating physician groups after joining an ACO compared with changes among nonparticipating groups.
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Affiliation(s)
- Jessica T. Lee
- Perelman School of Medicine, Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Daniel Polsky
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland
| | - Robert Fitzsimmons
- Perelman School of Medicine, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel M. Werner
- Perelman School of Medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Ouayogodé MH, Fraze T, Rich EC, Colla CH. Association of Organizational Factors and Physician Practices' Participation in Alternative Payment Models. JAMA Netw Open 2020; 3:e202019. [PMID: 32239223 PMCID: PMC7118519 DOI: 10.1001/jamanetworkopen.2020.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/07/2020] [Indexed: 11/14/2022] Open
Abstract
Importance Consolidation among physician practices and between hospitals and physician practices has accelerated in the past decade, resulting in higher prices in commercial markets. The resulting integration of health care across clinicians and participation in alternative payment models (APMs), which aim to improve quality while constraining spending, are cited as reasons for consolidation, but little is known about the association between integration and APM participation. Objective To examine the association of organizational characteristics, ownership, and integration with intensity of participation in APMs among physician practices. Design, Setting, and Participants A cross-sectional descriptive study, adjusted for sampling and nonresponse weights, was conducted in US physician practice respondents to the National Survey of Healthcare Organizations and Systems conducted between June 16, 2017, and August 17, 2018; of 2333 responses received (response rate, 46.9%) and after exclusion of ineligible and incomplete responses, the number of practices included in the analysis was 2061. Data analysis was performed from April 1, 2019, to August 31, 2019. Exposures Self-reported physician practice characteristics, including ownership, integration (clinical, cultural, financial, and functional), care delivery capabilities, activities, and environmental factors. Main Outcomes and Measures Participation in APMs: (1) bundled payments, (2) comprehensive primary care and medical home programs, (3) pay-for-performance programs, (4) capitated contracts with commercial health plans, and (5) accountable care organization contracts. Results A total of 49.2% of the 2061 practices included reported participating in 3 or more APMs; most participated in pay-for-performance and accountable care organization models. Covariate-adjusted analyses suggested that operating within a health care system (odds ratio [OR] for medical group: 2.35; 95% CI, 1.70-3.25; P < .001; simple health system: 1.46; 95% CI, 1.08-1.97; P = .02; and complex health system: 1.76; 95% CI, 1.25-2.47; P = .001 relative to independent practices), greater clinical (OR, 4.68; 95% CI, 2.28-9.59; P < .001) and functional (OR, 4.24; 95% CI, 2.00-8.97; P < .001) integration, and being located in the Northeast (OR for Midwest: 0.47; 95% CI, 0.34-0.65; P < .001; South: 0.47; 95% CI, 0.34-0.66; P < .001; and West: 0.64; 95% CI, 0.46-0.91; P = .01) were associated with greater APM participation. Conclusions and Relevance Greater APM participation appears to be supported by integration and system ownership.
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Affiliation(s)
- Mariétou H. Ouayogodé
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison
| | - Taressa Fraze
- Department of Family and Community Medicine, School of Medicine, University of California, San Francisco
| | | | - Carrie H. Colla
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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24
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Rochefort DA. Making Single-Payer Reform Work for Behavioral Health Care: Lessons From Canada and the United States. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2020; 50:334-349. [PMID: 32089054 DOI: 10.1177/0020731420906746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The claim is often made that the adoption of single-payer health care in the United States would result in dramatic improvement of services for people with mental health and substance use disorders. Evidence from this sector in countries with such frameworks is mixed, however, presenting both positive and negative lessons for an American audience. Focusing on Canada as an example, this article sheds light on this topic by drawing on sources in the professional and academic literature, government reports, news stories and features, and research on-site by the author. A concluding section highlights key policy issues that American single-payer advocates will need to address for meaningful reform of the behavioral health care sector.
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Affiliation(s)
- David A Rochefort
- Department of Political Science, Northeastern University, Boston, Massachusetts, USA
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25
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How Do Accountable Care Organizations Deliver Preventive Care Services? A Mixed-Methods Study. J Gen Intern Med 2019; 34:2451-2459. [PMID: 31432439 PMCID: PMC6848496 DOI: 10.1007/s11606-019-05271-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 03/29/2019] [Accepted: 05/15/2019] [Indexed: 11/02/2022]
Abstract
BACKGROUND The Affordable Care Act and the introduction of accountable care organizations (ACOs) have increased the incentives for patients and providers to engage in preventive care, for example, through quality metrics linked to disease prevention. However, little is known about how ACOs deliver preventive care services. OBJECTIVE To understand how Medicare ACOs provide preventive care services to their attributed patients. DESIGN Mixed-methods study using survey data reporting Medicare ACO capabilities in patient care management and interviews with high-performing ACOs. PARTICIPANTS ACO executives completed survey data on 283 Medicare ACOs. These data were supplemented with 39 interviews conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff. MAIN MEASURES Survey measures included ACO performance, organizational characteristics, collaboration experience, and capabilities in care management and quality improvement. Telephone interviews followed a semi-structured interview guide and explored the mechanisms used, and motivations of, ACOs to deliver preventive care services. KEY RESULTS Medicare ACOs that reported being comprehensively engaged in the planning and management of patient care - including conducting reminders for preventive care services - had more beneficiaries and had a history of collaboration experience, but were not more likely to receive shared savings or achieve high-quality scores compared to other surveyed ACOs. Interviews revealed that offering annual wellness visits and having a system-wide approach to closing preventive care gaps are key mechanisms used by high-performing ACOs to address patients' preventive care needs. Few programs or initiatives were identified that specifically target clinically complex patients. Aside from meeting patient needs, motivations for ACOs included increasing patient attribution and meeting performance targets. CONCLUSIONS ACOs are increasingly motivated to deliver preventive care services. Understanding the mechanisms and motivations used by high-performing ACOs may help both providers and payers to increase the use of preventive care.
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Gupta R, Steers N, Moriates C, Wali S, Braddock CH, Ong M. High-Value Care Culture Among the Future Physician Workforce in Internal Medicine. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:1347-1354. [PMID: 31460932 DOI: 10.1097/acm.0000000000002619] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Training in high-spending regions correlates with higher spending patterns among practicing physicians. This study aimed to evaluate whether trainees' exposure to a high-value care culture differed based on type of health system in which they trained. METHOD In 2016, 517 internal medicine residents at 12 California graduate medical education programs (university, community, and safety-net medical centers) completed a cross-sectional survey assessing perceptions of high-value care culture within their respective training program. The authors used multilevel linear regression to assess the relationship between type of medical center and High-Value Care Culture Survey (HVCCS) scores. The correlation between mean institutional HVCCS and Centers for Medicare and Medicaid Services' Value-Based Purchasing (VBP) scores was calculated using Spearman rank coefficients. RESULTS Of 517 residents, 306 (59.2%), 83 (16.1%), and 128 (24.8%) trained in university, community, and safety-net programs, respectively. Across all sites, the mean HVCCS score was 51.2 (standard deviation [SD] 11.8) on a 0-100 scale. Residents reported lower mean HVCCS scores if they were from safety-net-based training programs (β = -4.4; 95% confidence interval: -8.2, -0.6) with lower performance in the leadership and health system messaging domain (P < .001). Mean institutional HVCCS scores among university and community sites positively correlated with institutional VBP scores (Spearman r = 0.71; P < .05). CONCLUSIONS Safety-net trainees reported less exposure to aspects of high-value care culture within their training environments. Tactics to improve the training environment to foster high-value care culture include training, increasing access to data, and improving open communication about value.
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Affiliation(s)
- Reshma Gupta
- R. Gupta is interim chief value director, UCLA-Olive View Medical Center, assistant professor, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, and director, Evaluation and Outreach, Costs of Care, Boston, Massachusetts. N. Steers is biostatistician, VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, and adjunct associate professor of medicine and sociology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California. C. Moriates is assistant dean for healthcare value, associate chair of quality, safety and value, and associate professor, Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas, and director of implementation, Costs of Care, Boston, Massachusetts. S. Wali is chair, Department of Medicine at Olive View-UCLA Medical Center, and professor and executive vice chair of medicine for affiliated University of California, Los Angeles hospitals, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California. C.H. Braddock III is vice dean for education, David Geffen School of Medicine, and professor, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California. M. Ong is professor, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, and chief, Hospitalist Division, Greater Los Angeles VA Health Care System, Los Angeles, California
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Aikin KJ, Boudewyns V, Betts KR, Southwell BG, Williams P. Individual- and Ad-Level Predictors of Perceptions of Serious and Actionable Risks in Direct-to-Consumer Prescription Drug TV Advertising. JOURNAL OF HEALTH COMMUNICATION 2019; 24:536-546. [PMID: 31253071 DOI: 10.1080/10810730.2019.1632396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Prescription drug broadcast advertisements in the United States are required to present the product's major risks in at least the audio portion of the ad (21 CFR 202.1(e)(1)). This can result in a lengthy list of risks and side effects. The U.S. Food and Drug Administration has been studying the effects of limiting the major statement to those risks that are serious and actionable. We explore the level of agreement between consumers and experts regarding what risks and side effects are serious and actionable, and how variations in the content of major risk statement as well as other factors such as demographic variables, perceived accuracy of direct-to-consumer advertising, illness knowledge, and knowledge of prescription drug regulations, predict perceptions of risk and actionability. Participants (N = 1,000) self-diagnosed with depression or insomnia were randomly assigned to view a television ad for their respective condition that presented the full major statement or an edited version that included only serious and actionable risks. Results indicated consumers' perceptions of risk severity generally matched experts' assessment, but there was relatively less agreement about risk actionability. Results also varied as a function of income and gender.
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Affiliation(s)
- Kathryn J Aikin
- a US Food and Drug Administration, Office of Prescription Drug Promotion , Silver Spring , Maryland , USA
| | - Vanessa Boudewyns
- b Science in the Public Sphere, Center for Communication Science, RTI International , Research Triangle Park , North Carolina , USA
| | - Kevin R Betts
- a US Food and Drug Administration, Office of Prescription Drug Promotion , Silver Spring , Maryland , USA
| | - Brian G Southwell
- b Science in the Public Sphere, Center for Communication Science, RTI International , Research Triangle Park , North Carolina , USA
| | - Peyton Williams
- b Science in the Public Sphere, Center for Communication Science, RTI International , Research Triangle Park , North Carolina , USA
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McCullough JM, Speer M, Teutsch SM, Fielding JE. Non-clinical Prevention Opportunities and Waste in the U.S. Healthcare System. Am J Prev Med 2019; 56:904-907. [PMID: 30879909 DOI: 10.1016/j.amepre.2018.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 10/27/2022]
Affiliation(s)
- J Mac McCullough
- College of Health Solutions, Arizona State University, Phoenix, Arizona.
| | - Matthew Speer
- College of Health Solutions, Arizona State University, Phoenix, Arizona
| | - Steven M Teutsch
- Center for Health Advancement, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California
| | - Jonathan E Fielding
- Center for Health Advancement, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California
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Breuing J, Graf C, Neuhaus AL, Heß S, Lütkemeier L, Haas F, Spiller M, Pieper D. Communication strategies in the prevention of type 2 and gestational diabetes in vulnerable groups: protocol for a scoping review. Syst Rev 2019; 8:98. [PMID: 30999955 PMCID: PMC6474039 DOI: 10.1186/s13643-019-1021-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 04/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The global prevalence of diabetes mellitus is nearly 9%, with an upward trend in type 2 and gestational diabetes mellitus (T2DM/GDM). Evidence shows that vulnerable groups are affected disproportionally. Therefore, there is an increasing need to implement policies to prevent risk factors for T2DM/GDM and to promote a healthy lifestyle. However, up to now, no gold standard in terms of communication strategies and/or public awareness campaigns is known. METHODS/DESIGN We will conduct a systematic scoping review to evaluate communication strategies in the prevention of T2DM/GDM in vulnerable groups. Two reviewers will independently screen the results of the electronic literature search in PubMed, EMBASE, PsycINFO, PSYNDEX, Social Science Citation Index, and CINAHL. Extracted data will be charted, categorized, and summarized. DISCUSSION The results will be used to inform the National education and communication strategy on diabetes mellitus in Germany. In particular, the results will be discussed in focus groups of experts to develop recommendations for communication strategies. SYSTEMATIC REVIEW REGISTRATION PROSPERO does not register scoping reviews.
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Affiliation(s)
- Jessica Breuing
- Institute for Research in Operative Medicine (IFOM), Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109 Cologne, Germany
| | - Christine Graf
- Institute of Movement and Neurosciences, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933 Cologne, Germany
| | - Annika Lena Neuhaus
- Institute for Research in Operative Medicine (IFOM), Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109 Cologne, Germany
| | - Simone Heß
- Institute for Research in Operative Medicine (IFOM), Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109 Cologne, Germany
| | - Lena Lütkemeier
- Institute of Movement and Neurosciences, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933 Cologne, Germany
| | - Fabiola Haas
- Institute of Movement and Neurosciences, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933 Cologne, Germany
| | - Mark Spiller
- Institute of Movement and Neurosciences, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933 Cologne, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine (IFOM), Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109 Cologne, Germany
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Nguyen CA, Gilstrap LG, Chernew ME, McWilliams JM, Landon BE, Landrum MB. Social Risk Adjustment of Quality Measures for Diabetes and Cardiovascular Disease in a Commercially Insured US Population. JAMA Netw Open 2019; 2:e190838. [PMID: 30924891 PMCID: PMC6450315 DOI: 10.1001/jamanetworkopen.2019.0838] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Patients' social risk factors may be associated with physician group performance on quality measures. OBJECTIVE To examine the association of social risk with change in physician group performance on diabetes and cardiovascular disease (CVD) quality measures in a commercially insured population. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study using claims data from 2010 to 2014 from a US national health insurance plan, the performance of 1400 physician groups (physicians billing under the same tax identification number) was estimated. After base adjustments for age and sex, changes in variation across groups and reordering of rankings resulting from additional adjustments for clinical, social, or both clinical and social risk factors were analyzed. In all models, only within-group associations were adjusted to distinguish the association of patients' social risk factors with outcomes while excluding physician groups' distinct characteristics that could also change observed performance. Data analysis was conducted between April and July 2018. MAIN OUTCOMES AND MEASURES Process measures (hemoglobin A1c [HbA1c] testing, low-density lipoprotein cholesterol [LDL-C] testing, and statin use), disease control measures (HbA1c and LDL-C level control), and use-based outcome measures (hospitalizations for ambulatory-sensitive conditions) were calculated with base adjustment (age and sex), clinical adjustment, social risk factor adjustment, and both clinical and social adjustments. Quality variance in physician group performance and changes in rankings following these adjustments were measured. RESULTS This study identified 1 684 167 enrollees (859 618 [51%] men) aged 18 to 65 years (mean [SD] age, 50 [10.7] years) with diabetes or CVD. Performance rates were high for HbA1c and LDL-C level testing (mean ranged from 79.5% to 87.2%) but lower for statin use (54.7% for diabetes cohort and 44.2% for CVD cohort) and disease control measures (57.9% on LDL-C control for diabetes cohort and 40.0% for CVD cohort). On average, only 8.8% of enrollees with diabetes and 1.0% of enrollees with CVD in a group were hospitalized. The addition of clinical and social risk factors to base adjustment reduced variance across physician groups for most measures (percentage change in SD ranged from -13.9% to 1.6%). Although overall agreement between performance scores with base vs full adjustment was high, there was still substantial reordering for some measures. For example, social risk adjustment resulted in reordering for disease control in the diabetes cohort. Of the 1400 physician groups, 330 (23.6%) had performance rankings for HbA1c control that increased or decreased by at least 10 percentile points after adding social risk factors to age and sex. Both clinical and social risk adjustment affected rankings on hospital admissions. CONCLUSIONS AND RELEVANCE Accounting for social risk may be important to mitigate adverse consequences of performance-based payments for physician groups serving socially vulnerable populations.
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Affiliation(s)
- Christina A. Nguyen
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lauren G. Gilstrap
- Division of Cardiovascular Medicine, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
- Department of Health Care Policy, The Dartmouth Institute, Dartmouth Medical School, Hanover, New Hampshire
| | - Michael E. Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - J. Michael McWilliams
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Oregon's Coordinated Care Organization Experiment: Are Members' Experiences of Care Actually Changing? J Healthc Qual 2019; 41:e38-e46. [PMID: 30664535 DOI: 10.1097/jhq.0000000000000178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In 2012, Oregon embarked on an ambitious plan to redesign financing and care delivery for Medicaid. Oregon's Coordinated Care Organizations (CCOs) are the first statewide effort to use accountable care principles to pay for Medicaid benefits. We surveyed 8,864 Medicaid-eligible participants approximately 1 year before and 12 months after CCO implementation to assess the impact of CCOs on member-reported outcomes. We compared changes in outcomes over time between Medicaid CCO members, Medicaid fee-for-service (FFS) members, and those who were uninsured. After 1 year, Medicaid beneficiaries enrolled in CCOs reported better access to care, better quality care, and better connections to primary care than Medicaid FFS or uninsured persons. We did not find early evidence of improvements in preventive care and screenings or in ED utilization. Although these are early indicators, results suggest that Oregon's delivery system transformation is having a positive impact on patient experience outcomes.
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Werner RM, Kanter GP, Polsky D. Association of Physician Group Participation in Accountable Care Organizations With Patient Social and Clinical Characteristics. JAMA Netw Open 2019; 2:e187220. [PMID: 30657535 PMCID: PMC6400068 DOI: 10.1001/jamanetworkopen.2018.7220] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Accountable care organizations (ACOs) may increase health care disparities by excluding physician groups that care for socially and clinically vulnerable patients. OBJECTIVE To estimate the association between the patient characteristics of a physician group and the group's participation in a newly formed ACO. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study investigated a 20% random sample of US Medicare fee-for-service beneficiaries attributed to physician groups identified in Medicare claims before ACO participation from January 1, 2010, through December 31, 2011. Physician groups that participated and did not participate in the Medicare Shared Savings Program (MSSP) from January 1, 2012, through December 31, 2014, were identified in the Medicare MSSP 2014 provider file. Data analyses were conducted from September 1, 2017, to March 30, 2018. EXPOSURES Using multivariable regression, the association between physician group participation in the MSSP and the group's patients' characteristics before ACO formation was estimated focusing on measures of the vulnerability of the group's patients. All ACO-participating physician groups were compared with ACO-nonparticipating physician groups for reference, and estimates were made at the physician and patient level. MAIN OUTCOMES AND MEASURES Percentage of a physician group's patient panel that was socially vulnerable (based on race, dual Medicare and Medicaid enrollment, or living in high-poverty zip code) or clinically high risk. RESULTS Among 67 891 physician groups caring for 5 394 181 patients, 7215 physician groups (10.6%) participated in an MSSP ACO by 2014. Comparing mean percentages across practices, the patients of non-ACO-participating physician groups, more patients of ACO-participating physician groups were black (mean percentage across practices, 12.1% vs 10.6%), dually enrolled in Medicare and Medicaid (23.0% vs 19.3%), living in poverty (10.7% vs 11.1%), and high risk (34.2% vs 30.2%). After adjustment, physician groups that participated in an ACO had 5.1 percentage points (95% CI, 0.1-10.0 percentage points; P = .05) more dually enrolled patients and 4.0 percentage points (95% CI, 1.9-6.1 percentage points; P < .001) more high-risk patients. At the patient level, patients who were at high risk were more likely to be attributed to a group that became part of an ACO, with 4.5 percentage points (95% CI, 0.5-8.5 percentage points; P = .03) more high-risk patients being attributed to an ACO, but other associations were not statistically different from zero. CONCLUSIONS AND RELEVANCE Accountable care organizations may be an effective approach to target care among high-risk patients. In this study, physician groups that participated in the MSSP ACO program cared for more clinically vulnerable patients than did nonparticipating groups, and ACO-participating physician groups cared for an equally large number of socially vulnerable patients compared with nonparticipating physician groups.
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Affiliation(s)
- Rachel M. Werner
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Genevieve P. Kanter
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Daniel Polsky
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Breuing J, Pieper D, Neuhaus AL, Heß S, Lütkemeier L, Haas F, Spiller M, Graf C. Barriers and facilitating factors in the prevention of diabetes type II and gestational diabetes in vulnerable groups: protocol for a scoping review. Syst Rev 2018; 7:245. [PMID: 30580761 PMCID: PMC6304233 DOI: 10.1186/s13643-018-0919-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a significant worldwide increase in type 2 diabetes mellitus and gestational diabetes (T2DM/GDM) linked to a range of associated comorbidities and rising healthcare costs. It has been shown that an increase in physical activity, healthy nutrition, and weight loss may prevent or delay T2DM/GDM manifestation. Despite this, it remains a key challenge to reach various populations, in particular so-called vulnerable groups, mostly with a migration background and/or low socio-economic status. METHODS/DESIGN We will conduct a scoping review to identify barriers and facilitating factors in the prevention of T2DM/GDM in vulnerable groups. An electronic literature search will be performed in MEDLINE, EMBASE, PsycINFO, PSYNDEX, Social Science Citation Index, and CINAHL. Two reviewers will independently select studies for inclusion. Extracted data will be charted, categorized, and summarized. DISCUSSION The results will be used to inform the National education and communication strategy on diabetes mellitus in Germany. In particular, the results will be discussed in focus groups of experts to develop recommendations for developing preventive measures targeting vulnerable groups. SYSTEMATIC REVIEW REGISTRATION PROSPERO does not register scoping reviews.
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Affiliation(s)
- Jessica Breuing
- Institute for Research in Operative Medicine (IFOM), Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109 Cologne, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine (IFOM), Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109 Cologne, Germany
| | - Annika Lena Neuhaus
- Institute for Research in Operative Medicine (IFOM), Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109 Cologne, Germany
| | - Simone Heß
- Institute for Research in Operative Medicine (IFOM), Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109 Cologne, Germany
| | - Lena Lütkemeier
- Institute of Movement and Neurosciences, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933 Cologne, Germany
| | - Fabiola Haas
- Institute of Movement and Neurosciences, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933 Cologne, Germany
| | - Mark Spiller
- Institute of Movement and Neurosciences, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933 Cologne, Germany
| | - Christine Graf
- Institute of Movement and Neurosciences, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933 Cologne, Germany
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Zhou S, Ciarametaro M, Wu B, Singer J, Dubois RW. Utilization of High-Cost Interventions for Targeted Clinical Conditions During the Early Stages of ACO Development in a Commercially Insured Population. Popul Health Manag 2018; 22:377-384. [PMID: 30513071 DOI: 10.1089/pop.2018.0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study compared utilization patterns of high-cost services and medications for patients receiving care from Accountable Care Organization (ACO)-participating physicians and those receiving care from non-ACO physicians during the initial phases of ACO development in a commercially insured environment. Patients ≥18 years (≥40 years for chronic obstructive pulmonary disease [COPD]) with prevalent rheumatoid arthritis, inflammatory bowel disease, multiple sclerosis, type 2 diabetes, COPD, or chronic low back pain between January 1, 2012, and August 31, 2014 were identified in the HealthCore Integrated Research DatabaseSM. Patients were assigned to the ACO cohort if their primary treating physician was contracted to the health plan through an ACO agreement. Each clinical condition was stratified for severity of illness. Cohort utilization patterns were compared for the 12-month period following the index encounter. The primary outcome measures show that there was no statistically significant utilization difference between the ACO and non-ACO cohorts for 90% of the 82 comparisons made. It is expected that some measures will achieve significant difference simply because of having this many comparisons, but no clear pattern was identified. This study did not observe statistically significant differences in utilization of high-cost services and medications between ACO and non-ACO cohorts with limited experience in the ACO model. Future analyses with longer study durations, at later stages of ACO development, tracking a more granular level of physician organizational structure, and with designs that integrate clinical and administrative data are essential to better understand the impact of payment innovation strategies using an ACO structure.
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Affiliation(s)
| | | | | | | | - Robert W Dubois
- National Pharmaceutical Council, Washington, District of Columbia
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Cross-Barnet C, Benatar S, Courtot B, Hill I, Johnston E, Cheeks M. Inequality and Innovation: Barriers and Facilitators to 17P Administration to Prevent Preterm Birth among Medicaid Participants. Matern Child Health J 2018; 22:1607-1616. [PMID: 29956128 DOI: 10.1007/s10995-018-2556-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objectives Strategies to prevent preterm birth are limited. 17 Alpha-Hydroxyprogesterone Caproate (17P) injections have been shown to be effective, but the intervention is under-used. This mixed methods study investigates barriers and facilitators to 17P administration among Medicaid and CHIP participants enrolled in Strong Start for Mothers and Newborns, a federal preterm birth prevention program. Methods Twenty-seven awardees with more than 200 sites in 30 states, the District of Columbia, and Puerto Rico enrolled approximately 46,000 women in Strong Start from 2013 to 2016. Participant data, including data on preterm birth and 17P, was collected for each woman. Intensive interviews (n = 211) conducted with Strong Start program staff and providers (n = 314) included questions about 17P provision. Results Of women whose data included a valid response regarding 17P initiation, 3919 had a prior preterm birth and current singleton pregnancy; 14.95% received 17P. Barriers to 17P administration include late entry to prenatal care, administrative burden of preauthorization, cost risks to providers, limits in scope of practice for non-physician providers, and social barriers among participants. Facilitators for provision include streamlined work flows and the option of home administration. Conclusions for Practice A universal insurance authorization process could mitigate many barriers to 17P use. Providers need continuing education regarding the effectiveness of 17P, and expanding scope of practice for non-physician prenatal care providers would increase access. Targeted program interventions can help to overcome social barriers Medicaid participants face in accessing care. Streamlined work processes and the option of home health services are two effective program-based facilitators for providing 17P to a Medicaid population.
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Affiliation(s)
- Caitlin Cross-Barnet
- Center for Medicare and Medicaid Innovation (CMMI), 7500 Security Boulevard, WB-19-72, Baltimore, MD, 21244, USA.
| | - Sarah Benatar
- Urban Institute, 2100 M St NW, Washington, DC, 20037, USA
| | | | - Ian Hill
- Urban Institute, 2100 M St NW, Washington, DC, 20037, USA
| | - Emily Johnston
- Urban Institute, 2100 M St NW, Washington, DC, 20037, USA
| | - Morgan Cheeks
- Urban Institute, 2100 M St NW, Washington, DC, 20037, USA
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Fisher AM, Mtonga TM, Espino JU, Jonkman LJ, Connor SE, Cappella NK, Douglas GP. User-centered design and usability testing of RxMAGIC: a prescription management and general inventory control system for free clinic dispensaries. BMC Health Serv Res 2018; 18:703. [PMID: 30200939 PMCID: PMC6131751 DOI: 10.1186/s12913-018-3517-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 08/30/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To address challenges related to medication management in underserved settings, we developed a system for Prescription Management And General Inventory Control, or RxMAGIC, in collaboration with the Birmingham Free Clinic in Pittsburgh, Pennsylvania. RxMAGIC is an interoperable, web-based medication management system designed to standardize and streamline the dispensing practice and improve inventory control in a free clinic setting. This manuscript describes the processes used to design, develop, and deploy RxMAGIC. METHODS We transformed data from previously performed mixed-methods needs assessment studies into functional user requirements using agile development methods. Requirements took the form of user stories that were prioritized to drive implementation of RxMAGIC as a web-application. A functional prototype was developed and tested to understand its perceived usefulness before developing a production system. Prior to deployment, we evaluated the usability of RxMAGIC with six users to diagnose potential interaction challenges that may be avoided through redesign. The results from this study were similarly prioritized and informed the final features of the production system. RESULTS We developed 45 user stories that acted as functional requirements to incrementally build RxMAGIC. Integrating with the electronic health record at the clinic was a requirement for deployment. We utilized health data standards to communicate with the existing order entry system; an outgoing electronic prescribing framework was leveraged to send prescription data to RxMAGIC. The results of the usability study were positive, with all tested features receiving a mean score of four or five (i.e. somewhat easy or easy, respectively) on a five-point Likert scale assessing ease of completion, thus demonstrating the system's simplicity and high learnability. RxMAGIC was deployed at the clinic in October 2016 over a two-week period. CONCLUSIONS We built RxMAGIC, an open-source, pharmacist-facing dispensary management information system that augments the pharmacist's ability to efficiently deliver medication services in a free clinic setting. RxMAGIC provides electronic dispensing and automated inventory management and alerting capabilities. We deployed RxMAGIC at the Birmingham Free Clinic and measured its usability with potential users. In future work, we plan to continue to measure the impact of RxMAGIC on pharmacist efficiency and satisfaction.
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Affiliation(s)
- Arielle M. Fisher
- Center for Health Informatics for the Underserved, Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Timothy M. Mtonga
- Center for Health Informatics for the Underserved, Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Jeremy U. Espino
- Center for Health Informatics for the Underserved, Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | | | | | - Nickie K. Cappella
- Center for Health Informatics for the Underserved, Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Gerald P. Douglas
- Center for Health Informatics for the Underserved, Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA USA
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Fraze TK, Fisher ES, Tomaino MR, Peck KA, Meara E. Comparison of Populations Served in Hospital Service Areas With and Without Comprehensive Primary Care Plus Medical Homes. JAMA Netw Open 2018; 1:e182169. [PMID: 30646177 PMCID: PMC6324508 DOI: 10.1001/jamanetworkopen.2018.2169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Little is known about the types of primary care practices that have chosen to participate in the Comprehensive Primary Care Plus (CPC+) program or about how participation could affect disparities. OBJECTIVE To describe practices that joined the CPC+ model and compare hospital service areas with and without CPC+ practices. DESIGN, SETTING, AND PARTICIPANTS This comparative cross-sectional study identified 2647 CPC+ practices in round 1 (from January 1, 2017; round 1 is ongoing through 2021). Using IMS Health Care Organization Services data, ownership and characteristics of health systems and practices were extracted. Practices participating in the CPC+ program were compared with practices with similar proportions of primary care physicians (>85%) within the 14 regions designated as eligible to participate by the Centers for Medicare & Medicaid Services. Within eligible regions, hospital service areas with (n = 434) and without (n = 322) 1 or more CPC+ practice were compared. Characteristics compared included area-level population demographics (from the US Census Bureau), health system characteristics (from the IMS Health Care Organization Services), and use of health services by Medicare fee-for-service enrollees (Dartmouth Atlas). MAIN OUTCOMES AND MEASURES Area-level characteristics of all eligible CPC+ regions, areas without a CPC+ practice, and areas with 1 or more CPC+ practices. RESULTS Of 756 eligible service areas, 322 had no CPC+ practices and 434 had at least 1 CPC+ practice. Of 2647 CPC+ practices, 579 (21.9%) had 1 physician and 1791 (67.7%) had 2 to 10 physicians. In areas without CPC+ practices, the population had a lower median income ($43 197 [interquartile range, $42 170-$44 224] vs $57 206 [interquartile range, $55 470-$58 941]), higher mean share of households living in poverty (17.8% [95% CI, 17.2%-18.4%] vs 14.4% [95% CI, 13.9%-15.0%]), higher mean educational attainment of high school or less (52.7% [95% CI, 51.7%-53.6%] vs 43.1% [95% CI, 42.1%-44.2%]), higher mean proportion of disabled residents (17.7% [95% CI, 17.3%-18.2%] vs 14.2% [13.8%-14.6%]), higher mean participation in Medicare (21.9% [95% CI, 21.3%-22.4%] vs 18.8% [95% CI, 18.3%-19.1%]) and Medicaid (22.2% [95% CI, 21.5%-22.9%]) vs 18.5% [95% CI, 17.8%-19.2%]), and higher mean proportion of uninsured residents (12.4% [95% CI, 11.9%-12.9%] vs 10.3% [95% CI, 9.9%-10.7%]) (P < .001 for all) compared with areas that had a CPC+ practice. CONCLUSIONS AND RELEVANCE According to this study, although a diverse set of practices joined the CPC+ program, practices in areas characterized by patient populations with greater advantage were more likely to join, which may affect access to advanced primary care medical home models such as CPC+, by vulnerable populations.
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Affiliation(s)
- Taressa K. Fraze
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Elliott S. Fisher
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Marisa R. Tomaino
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Kristen A. Peck
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Ellen Meara
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
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Vickery KD, Shippee ND, Menk J, Owen R, Vock DM, Bodurtha P, Soderlund D, Hayward RA, Davis MM, Connett J, Linzer M. Integrated, Accountable Care For Medicaid Expansion Enrollees: A Comparative Evaluation of Hennepin Health. Med Care Res Rev 2018; 77:46-59. [DOI: 10.1177/1077558718769481] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hennepin Health, a Medicaid accountable care organization, began serving early expansion enrollees (very low-income childless adults) in 2012. It uses an integrated care model to address social and behavioral needs. We compared health care utilization in Hennepin Health with other Medicaid managed care in the same area from 2012 to 2014, controlling for demographics, chronic conditions, and enrollment patterns. Homelessness and substance use were higher in Hennepin Health. Overall adjusted results showed Hennepin Health had 52% more emergency department visits and 11% more primary care visits than comparators. Over time, modeling a 6-month exposure to Hennepin Health, emergency department and primary care visits decreased and dental visits increased; hospitalizations decreased nonsignificantly but increased among comparators. Subgroup analysis of high utilizers showed lower hospitalizations in Hennepin Health. Integrated, accountable care under Medicaid expansion showed some desirable trends and subgroup benefits, but overall did not reduce acute health care utilization versus other managed care.
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Affiliation(s)
| | | | | | - Ross Owen
- Health Strategy Director, Hennepin County, Minneapolis, MN, USA
| | | | - Peter Bodurtha
- Hennepin County Center of Innovation and Excellence, Minneapolis, MN, USA
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Vickery KD, Shippee ND, Guzman-Corrales LM, Cain C, Turcotte Manser S, Walton T, Richards J, Linzer M. Changes in Quality of Life Among Enrollees in Hennepin Health: A Medicaid Expansion ACO. Med Care Res Rev 2018; 77:60-73. [PMID: 29749288 DOI: 10.1177/1077558718769457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite limited program evaluations of Medicaid accountable care organizations (ACOs), no studies have examined if cost-saving goals negatively affect quality of life and health care experiences of low-income enrollees. The Hennepin Health ACO uses an integrated care model to address the physical, behavioral, and social needs of Medicaid expansion enrollees. As part of a larger evaluation, we conducted semistructured interviews with 35 primary care using Hennepin Health members enrolled for 2 or more years. Using fuzzy set qualitative comparative analysis, we assessed enrollee complexity and use of the care model and improvements in quality of life. We found improved quality of life was consistently associated with strong bonds to primary care, consistent mental health care, and support from extended care team members. Comprehensive, integrated care models within ACOs may improve quality of life for low-income Medicaid enrollees through coordinated primary and mental health care.
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Affiliation(s)
| | | | | | - Cindy Cain
- University of California, Los Angeles, CA, USA
| | | | - Tom Walton
- Integrated Planning and Analysis, Hennepin County, Minneapolis, MN, USA
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Lewis VA, Fraze T, Fisher ES, Shortell SM, Colla CH. ACOs Serving High Proportions Of Racial And Ethnic Minorities Lag In Quality Performance. Health Aff (Millwood) 2018; 36:57-66. [PMID: 28069847 DOI: 10.1377/hlthaff.2016.0626] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Accountable care organizations (ACOs) are intended, in part, to improve health care quality. However, little is known about how ACOs may affect disparities or how providers serving disadvantaged patients perform under Medicare ACO contracts. We analyzed racial and ethnic disparities in health care outcomes among ACOs to investigate the association between the share of an ACO's patients who are members of racial or ethnic minority groups and the ACO's performance on quality measures. Using data from Medicare and a national survey of ACOs, we found that having a higher proportion of minority patients was associated with worse scores on twenty-five of thirty-three Medicare quality performance measures, two disease composite measures, and an overall quality composite measure. However, ACOs serving a high share of minority patients were similar to other ACOs in most observable characteristics and capabilities, including provider composition, services, and clinical capabilities. Our findings suggest that ACOs with a high share of minority patients may struggle with quality performance under ACO contracts, especially during their early years of participation-maintaining or potentially exacerbating current inequities. Policy makers must consider how to refine ACO programs to encourage the participation of providers that serve minority patients and to reward performance appropriately.
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Affiliation(s)
- Valerie A Lewis
- Valerie A. Lewis is an assistant professor of health policy at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, in Lebanon, New Hampshire
| | - Taressa Fraze
- Taressa Fraze is a research scientist at the Dartmouth Institute for Health Policy and Clinical Practice
| | - Elliott S Fisher
- Elliott S. Fisher is director of the Dartmouth Institute for Health Policy and Clinical Practice and the John E. Wennberg Distinguished Professor of Health Policy, Medicine, and Community and Family Medicine, Geisel School of Medicine at Dartmouth
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor of Health Policy and Management, a professor of organization behavior, director of the Center for Healthcare Organizational and Innovation Research, and dean emeritus, all at the School of Public Health, University of California, Berkeley
| | - Carrie H Colla
- Carrie H. Colla is an associate professor of health policy at the Dartmouth Institute for Health Policy and Clinical Practice
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Fraze T, Lewis VA, Rodriguez HP, Fisher ES. Housing, Transportation, And Food: How ACOs Seek To Improve Population Health By Addressing Nonmedical Needs Of Patients. Health Aff (Millwood) 2018; 35:2109-2115. [PMID: 27834253 DOI: 10.1377/hlthaff.2016.0727] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Addressing nonmedical needs-such as the need for housing-is critical to advancing population health, improving the quality of care, and lowering the costs of care. Accountable care organizations (ACOs) are well positioned to address these needs. We used qualitative interviews with ACO leaders and site visits to examine how these organizations addressed the nonmedical needs of their patients, and the extent to which they did so. We developed a typology of medical and social services integration among ACOs that disentangles service and organizational integration. We found that the nonmedical needs most commonly addressed by ACOs were the need for transportation and housing and food insecurity. ACOs identified nonmedical needs through processes that were part of the primary care visit or care transformation programs. Approaches to meeting patients' nonmedical needs were either individualized solutions (developed patient by patient) or targeted approaches (programs developed to address specific needs). As policy makers continue to provide incentives for health care organizations to meet a broader spectrum of patients' needs, these findings offer insights into how health care organizations such as ACOs integrate themselves with nonmedical organizations.
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Affiliation(s)
- Taressa Fraze
- Taressa Fraze is a research scientist at the Dartmouth Institute for Health Policy and Clinical Practice, in Lebanon, New Hampshire
| | - Valerie A Lewis
- Valerie A. Lewis is an assistant professor at the Dartmouth Institute for Health Policy and Clinical Practice
| | - Hector P Rodriguez
- Hector P. Rodriguez is a professor of health policy and management and codirector of the Center for Healthcare Organizational and Innovation Research, both at the School of Public Health, University of California, Berkeley
| | - Elliott S Fisher
- Elliott S. Fisher is director of the Dartmouth Institute for Health Policy and Clinical Practice
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Yasaitis LC, Pajerowski W, Polsky D, Werner RM. Physicians' Participation In ACOs Is Lower In Places With Vulnerable Populations Than In More Affluent Communities. Health Aff (Millwood) 2018; 35:1382-90. [PMID: 27503961 DOI: 10.1377/hlthaff.2015.1635] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Early evidence suggested that accountable care organizations (ACOs) could improve health care quality while constraining costs, and ACOs are expanding throughout the United States. However, if disadvantaged patients have unequal access to physicians who participate in ACOs, that expansion may exacerbate health care disparities. We examined the relationship between physicians' participation in both Medicare and commercial ACOs across the country and the sociodemographic characteristics of their likely patient populations. Physicians' participation in ACOs varied widely across hospital referral regions, from nearly 0 percent to over 85 percent. After we adjusted for individual physician and practice characteristics, we found that physicians who practiced in ZIP Code Tabulation Areas where a higher percentage of the population was black, living in poverty, uninsured, or disabled or had less than a high school education-compared to other areas-had significantly lower rates of ACO participation than other physicians. Our findings suggest that vulnerable populations' access to physicians participating in ACOs may not be as great as access for other groups, which could exacerbate existing disparities in health care quality.
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Affiliation(s)
- Laura C Yasaitis
- Laura C. Yasaitis is a postdoctoral research fellow at the Perelman School of Medicine and a fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, in Philadelphia
| | - William Pajerowski
- William Pajerowski is a doctoral candidate at the Wharton School and a fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Daniel Polsky
- Daniel Polsky is executive director of and the Robert D. Eilers Professor in Health Care Management and Economics at the Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Rachel M Werner
- Rachel M. Werner is a professor of medicine and health care management at the University of Pennsylvania and a staff physician at the Crescenz Veterans Affairs Medical Center, in Philadelphia
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Fraze TK, Lewis VA, Tierney E, Colla CH. Quality of Care Improves for Patients with Diabetes in Medicare Shared Savings Accountable Care Organizations: Organizational Characteristics Associated with Performance. Popul Health Manag 2017; 21:401-408. [PMID: 29211623 DOI: 10.1089/pop.2017.0102] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Accountable care organizations (ACOs), a primary care-centric delivery and payment model, aim to promote integrated population health, which may improve care for those with chronic conditions such as diabetes. Research has shown that, overall, the ACO model is effective at reducing costs, but there is substantial variation in how effective different types of ACOs are at impacting costs and improving care delivery. This study examines how ACO organizational characteristics - such as composition, staffing, care management, and experiences with health reform - were associated with quality of care delivered to patients with diabetes. Secondary data were analyzed retrospectively to examine Medicare Shared Savings Program (MSSP) ACOs' performance on diabetes metrics in the first 2 years of ACO contracts. Ordinary least squares was used to analyze 162 MSSP ACOs with publicly available performance data and the National Survey of ACOs. ACOs improved performance significantly for patients with diabetes between contract years 1 and 2. In year 1, also having a private payer contract and an increased number of services within the ACO were positively associated with performance, while having a community health center or a hospital were negatively associated with performance. Better performance in year 1 was negatively associated with improved performance in year 2. This study found that ACOs substantively improved diabetes management within initial contract years. ACOs may need different types of support throughout their contracts to ensure continued improvements in performance.
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Affiliation(s)
- Taressa K Fraze
- The Dartmouth Institute for Health Policy and Clinical Practice , Geisel School of Medicine at Dartmouth, Lebanon , New Hampshire
| | - Valerie A Lewis
- The Dartmouth Institute for Health Policy and Clinical Practice , Geisel School of Medicine at Dartmouth, Lebanon , New Hampshire
| | - Emily Tierney
- The Dartmouth Institute for Health Policy and Clinical Practice , Geisel School of Medicine at Dartmouth, Lebanon , New Hampshire
| | - Carrie H Colla
- The Dartmouth Institute for Health Policy and Clinical Practice , Geisel School of Medicine at Dartmouth, Lebanon , New Hampshire
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Goldstein E, Athale N, Sciolla AF, Catz SL. Patient Preferences for Discussing Childhood Trauma in Primary Care. Perm J 2017; 21:16-055. [PMID: 28333604 DOI: 10.7812/tpp/16-055] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Exposure to traumatic events is common in primary care patients, yet health care professionals may be hesitant to assess and address the impact of childhood trauma in their patients. OBJECTIVE To assess patient preferences for discussing traumatic experiences and posttraumatic stress disorder (PTSD) with clinicians in underserved, predominantly Latino primary care patients. DESIGN Cross-sectional study. MAIN OUTCOME MEASURE We evaluated patients with a questionnaire assessing comfort to discuss trauma exposure and symptoms using the Adverse Childhood Experiences (ACE) Study questionnaire and the Primary Care-PTSD screen. The questionnaire also assessed patients' confidence in their clinicians' ability to help with trauma-related issues. Surveys were collected at an integrated medical and behavioral health care clinic. RESULTS Of 178 adult patients asked, 152 (83%) agreed to participate. Among participants, 37% screened positive for PTSD, 42% reported 4 or more ACEs, and 26% had elevated scores on both measures. Primary Care-PTSD and ACE scores were strongly positively correlated (r = 0.57, p < 0.001). Most patients agreed they were comfortable being asked about trauma directly or through screening questionnaires and did not oppose the inclusion of trauma-related information in their medical record. In addition, most patients perceived their clinician as comfortable asking questions about childhood trauma and able to address trauma-related problems. CONCLUSION Screening is acceptable to most primary care patients regardless of trauma exposure or positive PTSD screening. Findings may aid primary care clinicians to consider screening regularly for ACEs and PTSD to better serve the health care needs of trauma-exposed patients.
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Affiliation(s)
- Ellen Goldstein
- Doctoral Graduate from the Betty Irene Moore School of Nursing at the University of California, Davis.
| | - Ninad Athale
- Family Physician at OLE Health, an Associate Medical Director of County Campus, the Medical Director of Napa County Alcohol and Drug Services, and a Volunteer Clinical Instructor at the University of California, Davis School of Medicine.
| | - Andrés F Sciolla
- Associate Professor at the Department of Psychiatry and Behavioral Sciences at the University of California, Davis.
| | - Sheryl L Catz
- Professor of Nursing Science from the Betty Irene Moore School of Nursing at the University of California, Davis.
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Tanenbaum SJ. Can Payment Reform Be Social Reform? The Lure and Liabilities of the "Triple Aim". JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2017; 42:53-71. [PMID: 27729444 DOI: 10.1215/03616878-3702770] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The formulation of the triple aim responds to three problems facing the US health care system: high cost, low quality, and poor health status. The purpose of this article is to analyze the potential of the health care system to achieve the triple aim and, specifically, the attempt to improve population health by rewarding providers who contain costs. The first section of the article will consider the task of improving population health through the health care system. The second section of the article will discuss CMS's efforts to pay providers to achieve the triple aim, that is, to improve health care and population health while containing cost. These include Maryland's Global Revenue Budget model, bundled payments, and ACOs, and they highlight the extent to which this version of integration is underwritten by savings achieved by providers for the Medicare program. The conclusion section of the article will consider the politics of payment reform as social reform. It will address proposals that health care payers and providers lead in addressing the social contributors to ill health and urge payment reformers to appreciate more fully the politics and policies of other sectors and the dynamics of their inclusion in population health improvement.
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Wiley JA, Rittenhouse DR, Shortell SM, Casalino LP, Ramsay PP, Bibi S, Ryan AM, Copeland KR, Alexander JA. Managing chronic illness: physician practices increased the use of care management and medical home processes. Health Aff (Millwood) 2017; 34:78-86. [PMID: 25561647 DOI: 10.1377/hlthaff.2014.0404] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The effective management of patients with chronic illnesses is critical to bending the curve of health care spending in the United States and is a crucial test for health care reform. In this article we used data from three national surveys of physician practices between 2006 and 2013 to determine the extent to which practices of all sizes have increased their use of evidence-based care management processes associated with patient-centered medical homes for patients with asthma, congestive heart failure, depression, and diabetes. We found relatively large increases over time in the overall use of these processes for small and medium-size practices as well as for large practices. However, the large practices used fewer than half of the recommended processes, on average. We also identified the individual processes whose use increased the most and show that greater use of care management processes is positively associated with public reporting of patient experience and clinical quality and with pay-for-performance.
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Affiliation(s)
- James A Wiley
- James A. Wiley is a professor at the Institute for Health Policy Studies, University of California, San Francisco (UCSF)
| | - Diane R Rittenhouse
- Diane R. Rittenhouse is an associate professor in the Department of Family and Community Medicine, UCSF
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor of Health Policy and Management and faculty director of the Center for Healthcare Organizational and Innovation Research (CHOIR), School of Public Health; and a professor of organizational behavior, Haas School of Business, all at the University of California, Berkeley
| | - Lawrence P Casalino
- Lawrence P. Casalino is the Livingston Farrand Professor in the Department of Public Health, Weill Cornell Medical College, in New York City
| | - Patricia P Ramsay
- Patricia P. Ramsay is a research specialist and administrative director in CHOIR, School of Public Health, UC Berkeley
| | - Salma Bibi
- Salma Bibi is a research analyst in the School of Public Health, UC Berkeley
| | - Andrew M Ryan
- Andrew M. Ryan is an associate professor of public health at the University of Michigan, in Ann Arbor
| | - Kennon R Copeland
- Kennon R. Copeland is senior vice president and director of statistics and methodology at NORC at the University of Chicago, in Bethesda, Maryland
| | - Jeffrey A Alexander
- Jeffrey A. Alexander is a professor emeritus at the University of Michigan, in Ann Arbor
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Bharel M. Emergency Care for Homeless Patients: A Window Into the Health Needs of Vulnerable Populations. Am J Public Health 2016; 106:784-5. [PMID: 27049413 DOI: 10.2105/ajph.2016.303161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Monica Bharel
- Monica Bharel is the Commissioner of the Massachusetts Department of Public Health, Boston
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Alegría M, Alvarez K, Ishikawa RZ, DiMarzio K, McPeck S. Removing Obstacles To Eliminating Racial And Ethnic Disparities In Behavioral Health Care. Health Aff (Millwood) 2016; 35:991-9. [PMID: 27269014 PMCID: PMC5027758 DOI: 10.1377/hlthaff.2016.0029] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite decades of research, racial and ethnic disparities in behavioral health care persist. The Affordable Care Act expanded access to behavioral health care, but many reform initiatives fail to consider research about racial/ethnic minorities. Mistaken assumptions that underlie the expansion of behavioral health care run the risk of replicating existing service disparities. Based on a review of relevant literature and numerous observational and field studies with minority populations, we identified the following three mistaken assumptions: Improvement in health care access alone will reduce disparities, current service planning addresses minority patients' preferences, and evidence-based interventions are readily available for diverse populations. We propose tailoring the provision of care to remove obstacles that minority patients face in accessing treatment, promoting innovative services that respond to patients' needs and preferences, and allowing flexibility in evidence-based practice and the expansion of the behavioral health workforce. These proposals should help meet the health care needs of a growing racial/ethnic minority population.
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Affiliation(s)
- Margarita Alegría
- Margarita Alegría is a professor of psychology in the Department of Psychiatry at Harvard Medical School and chief of the Disparities Research Unit, Department of Medicine, at Massachusetts General Hospital (MGH), both in Boston
| | - Kiara Alvarez
- Kiara Alvarez is a postdoctoral research fellow in the Disparities Research Unit, Department of Medicine, at MGH
| | - Rachel Zack Ishikawa
- Rachel Zack Ishikawa is project director in the Disparities Research Unit, Department of Medicine, at MGH
| | - Karissa DiMarzio
- Karissa DiMarzio is a research assistant in the Disparities Research Unit, Department of Medicine, at MGH
| | - Samantha McPeck
- Samantha McPeck is a research assistant in the Disparities Research Unit, Department of Medicine, at MGH
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Early Complications in Hip and Knee Arthroplasties in a Safety Net Hospital vs a University Center. J Arthroplasty 2016; 31:754-8. [PMID: 26654489 DOI: 10.1016/j.arth.2015.10.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 09/30/2015] [Accepted: 10/23/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Indigent populations face unique challenges that may increase surgical risk and adversely affect the outcomes of hip and knee arthroplasties. This study examines whether there is a difference in early postoperative complications in patients treated in a safety net hospital and in a nearby university center. METHODS A retrospective review was undertaken of 533 consecutive hip and knee arthroplasties performed by a single experienced surgeon in a safety net hospital and in a university medical center from 2008 to 2012. Patients were followed for a minimum of 2 years. The primary outcomes evaluated were total complications, deep infections, and reoperations. Statistical comparison of the data from the 2 patient groups was carried out using Fisher exact test. RESULTS Despite the lower percentage of index revision procedures in the safety net group (8% vs 20.5%; P = .0003), the incidence of adverse outcomes was higher in this group than in the university group: for total complications, 12.3% vs 4.9% (P = .003); for deep infections, 3.2% vs 0.6% (P = .025); and for reoperations, 7.5% vs 2.6% (P = .009). For primary procedures in particular, differences in the incidences of these outcomes were even more significant. CONCLUSIONS In this study, early complications were more frequent in patients who underwent hip and knee arthroplasties in a safety net hospital compared with those who underwent the same procedures in a nearby university center. Future prospective studies are warranted to determine which patient-related or care process-related factors should be optimized to improve arthroplasty outcomes in vulnerable, safety net populations.
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Characteristics of Hospital and Emergency Care Super-utilizers with Multiple Chronic Conditions. J Emerg Med 2016; 50:e203-14. [DOI: 10.1016/j.jemermed.2015.09.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 08/07/2015] [Accepted: 09/04/2015] [Indexed: 11/19/2022]
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