Organizational capacity among hospitals in Medicare and commercial bundled payments

OBJECTIVES

Hospitals must strategically build organizational capacities to succeed in bundled payment arrangements. Given differences between Medicare and commercial arrangements, capacities may vary between hospitals in Medicare vs both Medicare and commercial bundled payment programs. This study compared organizational capacities between these 2 hospital groups.

STUDY DESIGN

National survey of American Hospital Association (AHA) member hospitals with experience in bundled payment programs.

METHODS

We analyzed data from October 31, 2017, to April 30, 2018, collected from AHA member hospitals with bundled payment experience in only Medicare (Medicare-only hospitals) or in both Medicare and commercial insurers (multipayer hospitals). Survey questions examined capacity in 4 areas: (1) physician performance feedback, (2) care management, (3) postacute care provider utilization, and (4) health information technology.

RESULTS

Our sample included 114 hospitals reporting experience in Medicare or commercial bundled payment programs. Both Medicare-only and multipayer hospitals reported high organizational capacities in performance measurement of physician-level quality and cost feedback and in incorporation of health information technology. More multipayer hospitals reported high capacity for coordinating hospital to postacute care settings (88% vs 52%). Although nearly all hospitals in both groups reported formalized relationships with skilled nursing facilities (98%), fewer hospitals reported such relationships with long-term acute care hospitals (83%) and inpatient rehabilitation facilities (80%).

CONCLUSIONS

Although they have similar capacity in a number of areas, Medicare-only and multipayer hospitals differed with respect to other aspects of organizational capacity.

Synthesis of Novel Dna Binding Agents: Indole-Containing Analogues of Bis-Netropsin

Molecular modelling studies showed that indole dicarboxylic acids are potential linkers for the synthesis of bis-netropsin analogues with a good fit to the minor groove of DNA. To test this hypothesis, 2-carboxyindole-6-acetic acid, indole-2,6-dicarboxylic acid, 6-(2-carboxyethyl)indole-2-carboxylic acid, 6-(2-carboxy-1-ethenyl)indole-2-carboxylic acid were prepared and coupled to 3-[1-methyl-4-(1-methyl-4-aminopyrrole-2-carboxamido)pyrrole-2-carboxamido]dimethylaminopropane. Similarly indole-2,5-dicarboxylic acid was prepared and coupled to 3-[1-methyl-4-(1-methyl-4-aminopyrrple-2-carboxamido)pyrrole-2-carboxamido]propionamidine hydrochloride. The derivatives of 26–28 showed especially strong binding to AT rich regions as shown by footprinting studies.

DNA binding, solubility, and partitioning characteristics of extended lexitropsins

Four new ligands that bind to the minor groove of DNA have been designed, synthesized, and evaluated by DNA footprinting. Two of the ligands are polyamides containing central regions with five or six N-methylpyrrole units, conferring hydrophobicity and good binding affinity but without retaining the correct spacing for hydrogen bonding in the base of the minor groove. The two remaining ligands have central regions which are head-to-head-linked polyamides, in which the linker is designed to improve the phasing of hydrogen bonding of the ligand with the floor of the minor groove. The highest affinity was obtained with the two polypyrroles without headgroup spacers, indicating that H-bond phasing is secondary in determining affinity compared to the major hydrophobic driving force. With a dimethylaminoalkyl group, representing a moiety with modest base strength, at both ends, water solubility is good and pH-partition theory predicts that penetration through lipid membranes will be enhanced, compared to strongly basic amidine analogues of the alkaloid precursors. All four compounds bind to DNA, with strong selectivity for AT sequences but some tolerance of GC base pairs and subtle individual preferences. The data show that very high affinities can be anticipated for future compounds in this series, but drug design must take account of overall physicochemical properties as well as the details of hydrogen bonding between ligands and the floor of the minor groove.

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Particle size stability of intralipid and mixed total parenteral nutrition mixtures

The determination of the particle size of Intralipid fat emulsions by the non-perturbing method of photon correlation spectroscopy has been extended to include particle size determination using the Coulter counter and optical microscopy. Although little increase in particle size in 3-litre bags containing total parenteral nutrition mixtures was observed with the methods involving large dilutions, creaming was observed and optical microscopy showed aggregation and some coalescence to have taken place. The problem of re-dispersion upon dilution of aggregated (but not coalesced) fat emulsions makes direct optical observation essential in assessing the stability and safety of such fat emulsion mixtures. The effect of electrolytes (NaCl and CaCl2) on creaming, particle size and electrophoretic mobility showed both minimum stability and minimum zeta potential at 3 X 10(-3) mol dm-3 CaCl2 and at 2.5 X 10(-1) mol dm-3 NaCl. Thus, these maximum levels for electrolytes in total parenteral mixtures are indicated.