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Post B. Association of a Medicare Outpatient Payment Reform With Hospital-Primary Care Integration: Heterogeneity Across Markets and Physicians. Med Care 2021; 59:1075-1081. [PMID: 34593710 DOI: 10.1097/mlr.0000000000001641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Hospital-physician integration increased rapidly in the past decade, threatening the affordability of care with minimal gains in quality. Medicare recently reformed its facility fee payments to hospitals for office consultations delivered by hospital-integrated physicians. This policy reform, affecting 200 million office visits annually, may have inadvertently encouraged hospitals to integrate with certain primary care physicians. OBJECTIVE The objective of this study was to determine whether the policy reform was associated with hospital-primary care integration. RESEARCH DESIGN I used a large sample of primary care physicians (n=98,884) drawn from Medicare claims data. I estimated cross-sectional multivariable linear probability models to measure whether the change in physicians' value-to-hospitals was associated with integration. RESULTS The reform created heterogenous results: some physicians' value-to-hospitals decreased, while others increased (first percentile to 99th percentile, -$16,000 to $47,000). This change in value had a small association with integration: for every $10,000 increase, a physician was about 0.34 percentage points (95% confidence interval: 0.16-0.52) more likely to become integrated. Among high-volume physicians, the reform had larger effects: physicians whose value-to-hospitals grew by $20,000 or more were nearly 3 percentage points more likely to become integrated. Changes in value had no effect in concentrated hospital markets and rural areas. CONCLUSIONS Effects of Medicare's site-based payments on hospital-primary care integration were concentrated among a small subset of physicians. Reforms to Medicare payment policy could influence integration among this group.
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Affiliation(s)
- Brady Post
- Department of Health Sciences, Northeastern University, Boston, MA
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Ma Q, Sridhar G, Power T, Agiro A. Assessing the downstream value of first-line cardiac positron emission tomography (PET) imaging using real world Medicare fee-for-service claims data. J Nucl Cardiol 2021; 28:2126-2137. [PMID: 31820411 DOI: 10.1007/s12350-019-01974-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/19/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Higher imaging quality makes cardiac positron emission tomography (PET) desirable for evaluation of suspected coronary artery disease (CAD). High cost of PET imaging may be offset by reduced utilization and/or improved outcomes. METHODS This retrospective observational study utilized Medicare fee-for-service dataset. Study participants had no CAD diagnosis within 1 year prior to initial imaging. The PET group (PET imaging) and propensity score matched comparison group (single photon emission computed tomography or stress echocardiography) underwent index imaging between January 2014 and December 2016. Outcomes were analyzed using generalized linear models. RESULTS Among 144,503 study subjects, 4619 (3.2%) had PET and 139,884 (96.8%) had conventional imaging. After matching, each group had 4619 patients (mean age 74 years, 59% female). The PET group had lower radiation exposure (3.8 milliSievert less per year, 95% CI - 3.96 to - 3.64, P < .0001) and unstable coronary syndrome (incidence rate ratio (IRR) 0.77, 95% CI 0.64-0.94, P = .008). The PET group experienced more hospital admissions (IRR 1.10, 95% CI 1.06-1.15, P < .0001), more use of percutaneous coronary intervention (IRR 1.24, 95% CI 1.02-1.50, P = 0.03), while similar mortality rate (hazard ratio 0.95, 95% CI 0.78-1.14, P = 0.55). The PET group had higher medical spending ($2358.2 vs $1774.3, difference = $583.9 per patient per month, P < .0001). CONCLUSIONS First-line PET imaging was not associated with reduced levels of utilization and spending. Clinical outcomes were mostly similar.
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Affiliation(s)
- Qinli Ma
- HealthCore Inc., 123 Justison Street, Suite 200, Wilmington, DE, 19801-5134, USA.
| | - Gayathri Sridhar
- HealthCore Inc., 123 Justison Street, Suite 200, Wilmington, DE, 19801-5134, USA
| | | | - Abiy Agiro
- HealthCore Inc., 123 Justison Street, Suite 200, Wilmington, DE, 19801-5134, USA
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Abstract
BACKGROUND Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services. OBJECTIVES To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification. SELECTION CRITERIA Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes. MAIN RESULTS We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies. AUTHORS' CONCLUSIONS For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.
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Affiliation(s)
- Liying Jia
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
- NHC Key Lab for Health Economics and Policy Research, Shandong University, Jinan, China
| | - Qingyue Meng
- China Center for Health Development Studies (CCHDS), Peking University, Beijing, China
| | - Anthony Scott
- Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Carlton, Melbourne, Australia
| | - Beibei Yuan
- China Center for Health Development Studies (CCHDS), Peking University, Beijing, China
| | - Lu Zhang
- Weihai Health Care Security Administration, Weihai, China
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Wadhera RK, Bhatt DL, Kind AJ, Song Y, Williams KA, Maddox TM, Yeh RW, Dong L, Doros G, Turchin A, Maddox KEJ. Association of Outpatient Practice-Level Socioeconomic Disadvantage With Quality of Care and Outcomes Among Older Adults With Coronary Artery Disease: Implications for Value-Based Payment. Circ Cardiovasc Qual Outcomes 2020; 13:e005977. [PMID: 32228065 PMCID: PMC7259485 DOI: 10.1161/circoutcomes.119.005977] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Medicare patients with coronary artery disease (CAD) have been a significant focus of value-based payment programs for outpatient practices. Physicians and policymakers, however, have voiced concern that value-based payment programs may penalize practices that serve vulnerable populations. This study evaluated whether outpatient practices that serve socioeconomically disadvantaged populations have worse CAD outcomes, and if this reflects the delivery of lower-quality care or rather, patient and community factors beyond the care provided by physician practices. METHODS AND RESULTS Retrospective cohort study of Medicare fee-for-service patients ≥65 years with CAD at outpatient practices participating in the the Practice Innovation and Clinical Excellence registry from January 1, 2010 to January 1, 2015. Outpatient practices were stratified into quintiles by the proportion of most disadvantaged patients-defined by an area deprivation score in the highest 20% nationally-served at each practice site. Prescription of guideline recommended therapies for CAD as well as clinical outcomes (emergency department presentation for chest pain, hospital admission for unstable angina or acute myocardial infarction [AMI], 30-day readmission after AMI, and 30-day mortality after AMI) were evaluated by practice-level socioeconomic disadvantage with hierarchical logistic regression models, using practices serving the fewest socioeconomically disadvantaged patients as a reference. The study included 453 783 Medicare fee-for-service patients ≥65 years of age with CAD (mean [SD] age, 75.3 [7.7] years; 39.7% female) cared for at 271 outpatient practices. At practices serving the highest proportion of socioeconomically disadvantaged patients (group 5), compared with practices serving the lowest proportion (group 1), there was no significant difference in the likelihood of prescription of antiplatelet therapy (odds ratio [OR], 0.94 [95% CI, 0.69-1.27]), β-blocker therapy if prior myocardial infarction or left ventricular ejection fraction <40% (OR, 0.97 [95% CI, 0.69-1.35]), ACE (angiotensin-converting enzyme) inhibitor or angiotensin receptor blocker if left ventricular ejection fraction <40% and/or diabetes mellitus (OR, 0.93 [95% CI, 0.74-1.19]), statin therapy (OR, 0.88 [95% CI, 0.68-1.14]), or cardiac rehabilitation (OR, 0.45 [95% CI, 0.20-1.00]). Patients cared for at the most disadvantaged-serving practices (group 5) were more likely to be admitted for unstable angina (adjusted OR, 1.46 [95% CI, 1.04-2.05]). There was no significant difference in the likelihood of emergency department presentation for chest pain or hospital admission for AMI between practices. Thirty day mortality rates after AMI were higher among patients at the most disadvantaged-serving practices (aOR, 1.31 [95% CI, 1.02-1.68]), but 30-day readmission rates did not differ. All associations were attenuated after additional adjustment for patient-level area deprivation index. CONCLUSIONS Physician outpatient practices that serve the most socioeconomically disadvantaged patients with CAD perform worse on some clinical outcomes, despite providing similar guideline-recommended care as other practices, and consequently could fare poorly under value-based payment programs. Social factors beyond care provided by outpatient practices may partly explain worse outcomes. Policymakers should consider accounting for socioeconomic disadvantage in value-based payment programs initiatives that target outpatient practices.
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Affiliation(s)
- Rishi K. Wadhera
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA
| | - Amy J.H. Kind
- Geriatrics Division, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Yang Song
- Baim Institute for Clinical Research, Boston, MA
| | - Kim A. Williams
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Thomas M. Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Robert W. Yeh
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA
| | - Liyan Dong
- Baim Institute for Clinical Research, Boston, MA
| | - Gheorghe Doros
- Baim Institute for Clinical Research, Boston, MA
- Department of Biostatistics, Boston University, Boston, MA
| | - Alexander Turchin
- Baim Institute for Clinical Research, Boston, MA
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Karen E. Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
- Center for Health Economics and Policy, Institute for Public Health at Washington University, Saint Louis, MO
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McGarry BE, Grabowski DC. Managed care for long-stay nursing home residents: an evaluation of Institutional Special Needs Plans. Am J Manag Care 2019; 25:438-443. [PMID: 31518093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate the patterns of clinical service use for long-term nursing home residents enrolled in UnitedHealthcare's Medicare Advantage Institutional Special Needs Plans (I-SNPs), which provide on-site direct coordinated care for beneficiaries through the use of advanced practice clinicians. STUDY DESIGN Observational analysis of 8052 I-SNP members and 12,982 Medicare fee-for-service (FFS) long-term nursing home residents across 13 states. METHODS Multivariate analyses were performed to compare rates of emergency department (ED), inpatient, and skilled nursing facility (SNF) use between I-SNP members and Medicare FFS long-term nursing home residents. RESULTS In comparison with FFS institutionalized Medicare beneficiaries, I-SNP members had 51% lower ED use, 38% fewer hospitalizations, and 45% fewer readmissions, whereas their SNF use was 112% higher. CONCLUSIONS "At-risk" models, administered through specialized Medicare Advantage plans, that invest in clinical management in the nursing home setting have the potential to allow individuals to receive care on-site and avoid costly inpatient transfers.
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Affiliation(s)
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115-5899.
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Newman TV, Hernandez I, Keyser D, San-Juan-Rodriguez A, Swart EC, Shrank WH, Parekh N. Optimizing the Role of Community Pharmacists in Managing the Health of Populations: Barriers, Facilitators, and Policy Recommendations. J Manag Care Spec Pharm 2019; 25:995-1000. [PMID: 31456493 PMCID: PMC10397707 DOI: 10.18553/jmcp.2019.25.9.995] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The shift to a value-based health care system has incentivized providers to implement strategies that improve population health outcomes while minimizing downstream costs. Given their accessibility and expanded clinical care models, community pharmacists are well positioned to join interdisciplinary care teams to advance efforts in effectively managing the health of populations. In this Viewpoints article, we discuss the expanded role of community pharmacists and potential barriers limiting the uptake of these services. We then explore strategies to integrate, leverage, and sustain these services in a value-based economy. Although community pharmacists have great potential to improve population health outcomes because of their accessibility and clinical interventions that have demonstrated improved outcomes, pharmacists are not recognized as merit-based incentive eligible providers and, as a result, may be underutilized in this role. Additional barriers include lack of formal billing codes, which limits patient access to services such as hormonal contraception; fragmentation of Medicare, which prevents alignment of medical and pharmaceutical costs; and continued fee-for-service payment models, which do not incentivize quality. Despite these barriers, there are several opportunities for continued pharmacist involvement in new care models such as patient-centered medical homes (PCMH), accountable care organizations, and other value-based payment models. Community pharmacists integrated within PCMHs have demonstrated improved hemoglobin A1c, blood pressure control, and immunization rates. Likewise, other integrated, value-based models that used community pharmacists to provide medication therapy management services have reported a positive return on investment in overall health care costs. To uphold these efforts and effectively leverage community pharmacist services, we recommend the following: (a) recognition of pharmacists as providers to facilitate full participation in performance-based models, (b) increased integration of pharmacists in emerging delivery and payment models with rapid cycle testing to further clarify the role and value of pharmacists, and (c) enhanced collaborative relationships between pharmacists and other providers to improve interdisciplinary care. DISCLOSURES: This article was funded by the National Association of Chain Drug Stores. The authors have no potential conflicts of interest to report.
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Affiliation(s)
- Terri V. Newman
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Inmaculada Hernandez
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Donna Keyser
- UPMC Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alvaro San-Juan-Rodriguez
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Elizabeth C.S. Swart
- UPMC Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Natasha Parekh
- UPMC Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Affiliation(s)
- Yazan Duwayri
- Division of Vascular Surgery, Department of Surgery, Emory University, Atlanta, Ga
| | - Brad Johnson
- Division of Vascular Surgery, Department of Surgery, University of South Florida, Tampa, Fla
| | - Jill Rathbun
- Society for Vascular Surgery Quality and Performance Measures Committee, Chicago, Ill
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, Calif.
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Dizon MP, Linos E, Arron ST, Hills NK, Chren MM. Comparing the Quality of Ambulatory Surgical Care for Skin Cancer in a Veterans Affairs Clinic and a Fee-For-Service Practice Using Clinical and Patient-Reported Measures. PLoS One 2017; 12:e0171253. [PMID: 28141817 PMCID: PMC5283736 DOI: 10.1371/journal.pone.0171253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 01/17/2017] [Indexed: 11/18/2022] Open
Abstract
The Institute of Medicine has identified serious deficiencies in the measurement of cancer care quality, including the effects on quality of life and patient experience. Moreover, comparisons of quality in Veterans Affairs Medical Centers (VA) and other sites are timely now that many Veterans can choose where to seek care. To compare quality of ambulatory surgical care for keratinocyte carcinoma (KC) between a VA and fee-for-service (FFS) practice, we used unique clinical and patient-reported data from a comparative effectiveness study. Patients were enrolled in 1999-2000 and followed for a median of 7.2 years. The practices differed in a few process measures (e.g., median time between biopsy and treatment was 7.5 days longer at VA) but there were no substantial or consistent differences in clinical outcomes or a broad range of patient-reported outcomes. For example, 5-year tumor recurrence rates were equally low (3.6% [2.3-5.5] at VA and 3.4% [2.3-5.1] at FFS), and similar proportions of patients reported overall satisfaction at one year (78% at VA and 80% at FFS, P = 0.69). These results suggest that the quality of care for KC can be compared comprehensively in different health care systems, and suggest that quality of care for KC was similar at a VA and FFS setting.
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Affiliation(s)
- Matthew P. Dizon
- Program for Clinical Research, Department of Dermatology, University of California San Francisco, San Francisco, California, United States of America
| | - Eleni Linos
- Program for Clinical Research, Department of Dermatology, University of California San Francisco, San Francisco, California, United States of America
| | - Sarah T. Arron
- Program for Clinical Research, Department of Dermatology, University of California San Francisco, San Francisco, California, United States of America
- San Francisco Veterans Affairs Medical Center, San Francisco, California, United States of America
| | - Nancy K. Hills
- Department of Biostatistics and Epidemiology, University of California San Francisco, San Francisco, California, United States of America
| | - Mary-Margaret Chren
- Program for Clinical Research, Department of Dermatology, University of California San Francisco, San Francisco, California, United States of America
- San Francisco Veterans Affairs Medical Center, San Francisco, California, United States of America
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Evans T. IHC'S COMPASS PRACTICE TRANSFORMATION NETWORK: HELPING PHYSICIANS TRANSITION TO VALUE-BASED PAYMENT. Iowa Med 2016; 106:18. [PMID: 30230279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Tempero M. At Last: Getting Paid to Think! J Natl Compr Canc Netw 2015; 13:1297. [PMID: 26553759 DOI: 10.6004/jnccn.2015.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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GAO Levels Sharp Criticism Against Physician Fee Committee. Am Fam Physician 2015; 92:11. [PMID: 27489911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Colla CH, Morden NE, Sequist TD, Schpero WL, Rosenthal MB. Choosing wisely: prevalence and correlates of low-value health care services in the United States. J Gen Intern Med 2015; 30:221-8. [PMID: 25373832 PMCID: PMC4314495 DOI: 10.1007/s11606-014-3070-z] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 08/29/2014] [Accepted: 10/04/2014] [Indexed: 01/18/2023]
Abstract
BACKGROUND Specialty societies in the United States identified low-value tests and procedures that contribute to waste and poor health care quality via implementation of the American Board of Internal Medicine Foundation's Choosing Wisely initiative. OBJECTIVE To develop claims-based algorithms, to use them to estimate the prevalence of select Choosing Wisely services and to examine the demographic, health and health care system correlates of low-value care at a regional level. DESIGN Using Medicare data from 2006 to 2011, we created claims-based algorithms to measure the prevalence of 11 Choosing Wisely-identified low-value services and examined geographic variation across hospital referral regions (HRRs). We created a composite low-value care score for each HRR and used linear regression to identify regional characteristics associated with more intense use of low-value services. PATIENTS Fee-for-service Medicare beneficiaries over age 65. MAIN MEASURES Prevalence of selected Choosing Wisely low-value services. KEY RESULTS The national average annual prevalence of the selected Choosing Wisely low-value services ranged from 1.2% (upper urinary tract imaging in men with benign prostatic hyperplasia) to 46.5% (preoperative cardiac testing for low-risk, non-cardiac procedures). Prevalence across HRRs varied significantly. Regional characteristics associated with higher use of low-value services included greater overall per capita spending, a higher specialist to primary care ratio and higher proportion of minority beneficiaries. CONCLUSIONS Identifying and measuring low-value health services is a prerequisite for improving quality and eliminating waste. Our findings suggest that the delivery of wasteful and potentially harmful services may be a fruitful area for further research and policy intervention for HRRs with higher per-capita spending. These findings should inform action by physicians, health systems, policymakers, payers and consumer educators to improve the value of health care by targeting services and areas with greater use of potentially inappropriate care.
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Affiliation(s)
- Carrie H Colla
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA,
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Bailey D, Kutscher B. Doing the right thing for asthmatic kids is penalized under fee-for-service. Mod Healthc 2015; 45:30-31. [PMID: 25671892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Goozner M. Insuring against the future. Mod Healthc 2014; 44:24. [PMID: 25134409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Miller HD. Reducing costs requires end to fee-for-service. Mod Healthc 2014; 44:25. [PMID: 25016886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Affiliation(s)
- David U Himmelstein
- The City University of New York School of Public Health, 255 West 90th Street, New York, NY, 10024, USA,
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Igaki H, Onishi H, Nakagawa K, Dokiya T, Nemoto K, Shigematsu N, Nishimura Y, Hiraoka M. A newly introduced comprehensive consultation fee in the national health insurance system in Japan: a promotive effect of multidisciplinary medical care in the field of radiation oncology--results from a questionnaire survey. Jpn J Clin Oncol 2013; 43:1233-7. [PMID: 24068710 DOI: 10.1093/jjco/hyt147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The consultation fee for outpatient radiotherapy was newly introduced in the national health insurance system in Japan in April 2012. We conducted a survey on the use of this consultation fee and its effect on clinical practices. METHODS The health insurance committee of the Japanese Society of Therapeutic Radiology and Oncology conducted a questionnaire survey. The questionnaire form was mailed to 160 councilors of the Society, the target questionees. A total of 94 answers (58% of the target questionees) sent back were used for analyses. RESULTS The analyses revealed that 75% of the hospitals charged most of the patients who receive radiotherapy in an outpatient setting a consultation fee. The introduction of the consultation fee led to some changes in radiation oncology clinics, as evidenced by the response of 'more careful observations by medical staff' in 37% of questionees and a 12% increase in the number of full-time radiation oncology nurses. It was also shown that the vast majority (92%) of radiation oncologists expected a positive influence of the consultation fee on radiation oncology clinics in Japan. CONCLUSIONS Our questionnaire survey revealed the present status of the use of a newly introduced consultation fee for outpatient radiotherapy, and the results suggested its possible effect on promoting a multidisciplinary medical care system in radiation oncology departments in Japan.
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Affiliation(s)
- Hiroshi Igaki
- *Department of Radiology, The University of Tokyo, 7-3-1, Hongo, Bunyo-ku, Tokyo 113-8655, Japan.
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Fernández Urrusuno R, Montero Balosa MC, Pérez Pérez P, Pascual de la Pisa B. Compliance with quality prescribing indicators in terms of their relationship to financial incentives. Eur J Clin Pharmacol 2013; 69:1845-53. [PMID: 23743780 DOI: 10.1007/s00228-013-1542-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Accepted: 05/21/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop quality prescribing indicators for general practitioners (GPs) who are non-monitored and not included in pay-for-performance programs, and to determine compliance with incentivized and non-incentivized indicators. STUDY DESIGN Descriptive cross sectional study. SETTING Aljarafe Primary Health Care Area (Andalusian Public Health Care Service, Spain), a rural and suburban area with a population of 323,857 inhabitants. Health assistance in this area is provided by 176 GPs in 37 health centers. Prescribing indicators were developed by a multidisciplinary group using a qualitative technique based on consensus. The members of the consensus group searched for updated recommendations focused on clinical evidence. Prescribing data were obtained from the computerised pharmacy records of reimbursed drugs and clinical data from the electronic clinical databases and hospital admission records. RESULTS Fourteen indicators based on the selection of drugs of different therapeutic groups or linked to patient´s clinical information were designed. The compliance with indicators based on the selection of drugs linked to financial incentives was higher than that of indicators not linked to financial incentives. The compliance with indicators based on clinical information varied widely. Inappropriate prescribing ranged from 7 %, in the use of long-acting beta-agonists in asthma, to 86 % in the use of drugs for the prevention of osteoporotic fractures in young women. CONCLUSIONS This study shows better compliance by GPs with indirect and incentivized quality prescribing indicators, included in pay-for-performance programs, compared with not-incentivized indicators based on the relative use of drugs and on the appropriateness prescribing.
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Affiliation(s)
- Rocío Fernández Urrusuno
- Service of Pharmacy, Aljarafe-Sevilla Norte Primary Health Care Area, Distrito Sanitario Aljarafe; Avda de las Américas s/n, 41927, Mairena del Aljarafe, Seville, Spain,
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Stefanacci RG, Guerin S. Calling something an ACO does not really make it so. Manag Care 2013; 22:15-17. [PMID: 23610801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Lichtman JH, Jones SB, Leifheit-Limson EC, Wang Y, Goldstein LB. 30-day mortality and readmission after hemorrhagic stroke among Medicare beneficiaries in Joint Commission primary stroke center-certified and noncertified hospitals. Stroke 2011; 42:3387-91. [PMID: 22033986 PMCID: PMC3292255 DOI: 10.1161/strokeaha.111.622613] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke patients treated at Joint Commission Primary Stroke Center (JC-PSC)-certified hospitals have better outcomes. Data reflecting the impact of JC-PSC status on outcomes after hemorrhagic stroke are limited. We determined whether 30-day mortality and readmission rates after hemorrhagic stroke differed for patients treated at JC-PSC-certified versus noncertified hospitals. METHODS The study included all fee-for-service Medicare beneficiaries aged 65 years or older with a primary discharge diagnosis of subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH) in 2006. Covariate-adjusted logistic and Cox proportional hazards regression assessed the effect of care at a JC-PSC-certified hospital on 30-day mortality and readmission. RESULTS There were 2305 SAH and 8708 ICH discharges from JC-PSC-certified hospitals and 3892 SAH and 22 564 ICH discharges from noncertified hospitals. Unadjusted in-hospital mortality (SAH: 27.5% versus 33.2%, P<0.0001; ICH: 27.9% versus 29.6%, P=0.003) and 30-day mortality (SAH: 35.1% versus 44.0%, P<0.0001; ICH: 39.8% versus 42.4%, P<0.0001) were lower in JC-PSC hospitals, but 30-day readmission rates were similar (SAH: 17.0% versus 17.0%, P=0.97; ICH: 16.0% versus 15.5%, P=0.29). Risk-adjusted 30-day mortality was 34% lower (odds ratio, 0.66; 95% confidence interval, 0.58-0.76) after SAH and 14% lower (odds ratio, 0.86; 95% confidence interval, 0.80-0.92) after ICH for patients discharged from JC-PSC-certified hospitals. There was no difference in 30-day risk-adjusted readmission rates for SAH or ICH based on JC-PSC status. CONCLUSIONS Patients treated at JC-PSC-certified hospitals had lower risk-adjusted mortality rates for both SAH and ICH but similar 30-day readmission rates as compared with noncertified hospitals.
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Affiliation(s)
- Judith H Lichtman
- Department of Epidemiology and Public Health, Yale University School of Medicine, PO Box 208034, New Haven, CT 06520, USA.
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Dahrouge S, Hogg W, Tuna M, Russell G, Devlin RA, Tugwell P, Kristjansson E. Age equity in different models of primary care practice in Ontario. Can Fam Physician 2011; 57:1300-1309. [PMID: 22084464 PMCID: PMC3215613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To assess whether the model of service delivery affects the equity of the care provided across age groups. DESIGN Cross-sectional study. SETTING Ontario. PARTICIPANTS One hundred thirty-seven practices, including traditional fee-for-service practices, salaried community health centres (CHCs), and capitation-based family health networks and health service organizations. MAIN OUTCOME MEASURES To compare the quality of care across age groups using multilevel linear or logistic regressions. Health service delivery measures and health promotion were assessed through patient surveys (N = 5111), which were based on the Primary Care Assessment Tool, and prevention and chronic disease management were assessed, based on Canadian recommendations for care, through chart abstraction (N = 4108). RESULTS Older individuals reported better health service delivery in all models. This age effect ranged from 1.9% to 5.7%, and was larger in the 2 capitation-based models. Individuals aged younger than 30 years attending CHCs had more features of disadvantage (ie, living below the poverty line and without high school education) and were more likely than older individuals to report discussing at least 1 health promotion subject at the index visit. These differences were deemed an appropriate response to greater needs in these younger individuals. The prevention score showed an age-sex interaction in all models, with adherence to recommended care dropping with age for women. These results are largely attributable to the fact that maneuvers recommended for younger women are considerably more likely to be performed than other maneuvers. Chronic disease management scores showed an inverted U relationship with age in fee-for-service practices, family health networks, and health service organizations but not in CHCs. CONCLUSION The salaried model might have an organizational structure that is more conducive to providing appropriate care across age groups. The thrust toward adopting capitation-based payment is unlikely to have an effect on age disparities.
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Affiliation(s)
- Simone Dahrouge
- C.T. Lamont Primary Health Care Research Centre, Élisabeth Bruyère Research Institute, Ottawa, ON.
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Habermann EB, Virnig BA, Durham SB, Baxter NN. Managed care enrollment and chronically disabled women with breast cancer. Am J Manag Care 2008; 14:514-520. [PMID: 18690767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To assess whether managed care enrollment or healthcare utilization level among women enrolled in Medicare because of disability affects stage at diagnosis and treatment of breast cancer. STUDY DESIGN Retrospective study using the Surveillance, Epidemiology, and End Results-Medicare database. We compared breast cancer stage at diagnosis and treatment among women with disabilities enrolled in Medicare managed care versus fee-for-service (FFS) Medicare. Women enrolled in FFS Medicare were classified into levels of healthcare utilization during the 6 to 18 months before breast cancer diagnosis. METHODS Controlling for confounders, we used regression models to determine the effects of managed care enrollment and healthcare utilization level on earlier stage at diagnosis and treatment of breast cancer. RESULTS Disabled patients enrolled in FFS Medicare without contact with the healthcare system and those with fewer than 12 physician visits during the 6 to 18 months before breast cancer diagnosis were more likely than disabled patients enrolled in Medicare managed care to be diagnosed as having breast cancer at a late stage. There was no difference between women enrolled in Medicare managed care versus women enrolled in FFS Medicare having at least 12 physician visits during the 12-month period. Breast cancer treatment for women with disabilities did not vary across managed care enrollment or healthcare utilization level. CONCLUSION Managed care enrollment or increased contact with healthcare providers could result in earlier stage at breast cancer diagnosis.
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Affiliation(s)
- Elizabeth B Habermann
- Division of Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware St SE, MMC 729, Minneapolis, MN 55455, USA.
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Campbell YY, McBride TD, Mueller K. Rural enrollment in Medicare Advantage continues to grow rapidly in 2008, led by private fee-for-service plans. Rural Policy Brief 2008:1-6. [PMID: 19688904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Carpenter D. Medicare. Private fee-for-service plans under scrutiny. Hosp Health Netw 2007; 81:20. [PMID: 17874810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
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Borgstede JP. The wrong fork in the road. J Am Coll Radiol 2007; 2:805-6. [PMID: 17411935 DOI: 10.1016/j.jacr.2005.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2005] [Indexed: 11/26/2022]
Affiliation(s)
- James P Borgstede
- Colorado Springs Radiologists, PC, Colorado Springs, CO 80908-3239, USA.
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Pham HH, Ginsburg PB, McKenzie K, Milstein A. Redesigning Care Delivery In Response To A High-Performance Network: The Virginia Mason Medical Center. Health Aff (Millwood) 2007; 26:w532-44. [PMID: 17623687 DOI: 10.1377/hlthaff.26.4.w532] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We examine how an integrated delivery system responded to threatened exclusion from an insurer's high-performance network by attempting to reduce costs through fundamental redesign of care processes. Some factors facilitating this transformation, such as its structure as a large salaried medical group exclusively affiliated with a hospital, might be specific to the organization and its market. Other essential elements could be replicated. But in a fee-for-service payment system, cost reduction from reducing the number of services or changing their mix can reduce profitability. Making the business case for sustaining desirable provider behavior may require that purchasers and plans make equally fundamental changes in payment policy.
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Affiliation(s)
- Hoangmai H Pham
- Center for Studying Health System Change, Washington, DC, USA.
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Loyd GE. Simulation: a strategy for success in quality and safety in pay-for-performance environments. Am Surg 2006; 72:1097-101; discussion 1126-48. [PMID: 17120954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Pay-for-Performance appears to be another step in our ever-changing healthcare environment. In most of the white papers, reports, and web pages devoted to improving the quality of healthcare in America, there is a failure to recognize or list medical simulation as a methodology to reduce the costs of implementation and to speed transition to the new order. The Agency for Healthcare Research and Quality is funding research in simulation to improve quality. This article outlines the rationales for using simulation and how simulation can benefit all involved. With a paucity of proof that simulation can deliver in terms of improving the quality of healthcare, the mass of evidence has been from observation and anecdotal tales of medical professionals that simulation is a valid tool. This article correlates the use of simulation in other nonmedical pay-for-performance professions to similar situations in medicine as some other evidence that simulation should be considered a viable option. I conclude by relating the individual strengths of simulation to the six quality initiatives of the Institute of Medicine's second report from the Committee on Quality of Health Care in America. Simulation can work to enhance the assimilation of change with each of these initiatives and help to reduce the costs of doing so. There are limitations to simulation, but used within those limitations, simulation should prove to be a powerful tool.
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Affiliation(s)
- Gary E Loyd
- Department of Anesthesiology, West Virginia University, Morgantown, West Virginia 26506-9134, USA
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DoBias M. CMS dangling carrot. Up to 50,000 dollars available in P4P plan. Mod Healthc 2006; 36:33. [PMID: 17128588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
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Affiliation(s)
- Jerome Schofferman
- SpineCare Medical Group, San Francisco Spine Institute, Daly City, California, USA
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Roohan PJ, Butch JM, Anarella JP, Gesten F, Shure K. Quality measurement in medicaid managed care and fee-for-service: the New York State experience. Am J Med Qual 2006; 21:185-91. [PMID: 16679438 DOI: 10.1177/1062860606287199] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
New York State has transitioned 1.7 million Medicaid recipients from a fee-for-service delivery system to a managed care model. To evaluate whether managed care has had a positive effect on access and quality, the New York State Department of Health compared rates of performance across standardized measures of quality (ie, childhood immunization, well-child visits, prenatal care in the first trimester, cervical cancer screening, use of appropriate medications for people with asthma, and comprehensive diabetes care) in both systems. For almost all measures, Medicaid managed care rates were statistically higher than Medicaid fee-for-service.
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Affiliation(s)
- Patrick J Roohan
- Bureau of Quality Management and Outcomes Measurement, Office of Managed Care/New York State Department of Health, Albany, New York 12237, USA.
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Hollander P, Nicewander D, Couch C, Winter D, Herrin J, Haydar Z, Ballard DJ. Quality of care of Medicare patients with diabetes in a metropolitan fee-for-service primary care integrated delivery system. Am J Med Qual 2006; 20:344-52. [PMID: 16280398 DOI: 10.1177/1062860605280205] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Diabetes care in the United States is suboptimal. Although closed-panel health maintenance organizations (HMOs) and the Department of Veterans Affairs (VA) report performance superior to national norms, fee-for-service performance is uncertain. To address this issue, 3 outcome and 5 process indicators were measured for 2010 Medicare diabetes patients across 22 sites in a large, fee-for-service primary care group practice. American Diabetes Association standards for glycemic control, low-density lipoprotein cholesterol, and blood pressure were met by 53%, 46%, and 19% of patients, respectively. Diabetes Quality Improvement Project/Alliance poor control markers for the same measures were exceeded by 9%, 20%, and 54% of patients. Chart abstraction demonstrated annual eye examination, foot examination, and nephropathy screening rates of 16%, 49%, and 38%, while Medicare claims showed an annual eye examination rate of 63%. Observed processes and outcomes in this fee-for-service setting were superior to reported national performance and similar to the best performance in staff-model HMOs and the VA.
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Affiliation(s)
- Priscilla Hollander
- Baylor-Ruth Collins Diabetes Center, Baylor University Medical Center, Baylor Health Care System, 8080 North Central Expressway, Dallas, TX 75206, USA
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Rodríguez-Vigil E, Kianes-Pérez Z. Quality of Care Provided to Patients with Diabetes Mellitus in Puerto Rico: Managed Care Versus Fee-for-Service Experience. Endocr Pract 2005; 11:376-81. [PMID: 16718949 DOI: 10.4158/ep.11.6.376] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate and compare the quality of diabetes care in a large managed care system and fee-for-service payment system in Puerto Rico. METHODS This retrospective cross-sectional study assessed the adherence to standards of diabetes care in 1,687,202 subjects--226,210 from a fee-for-service population and 1,460,992 from a managed care group. Patients with diabetes mellitus were identified from insurance claims reports. Type of health-care provider, service location, number of visits, and laboratory utilization were also assessed. RESULTS From the analysis, we identified 90,616 patients with diabetes (5.4% of the overall study group). Of these, 66,587 (73.5%) were found to have at least one encounter with a physician in a medical visit. Of the 66,586 patients with diabetes who visited a physician, only 4% were treated by an endocrinologist. General laboratory utilization was 34% for the entire population of patients with diabetes studied. In the group of patients with documented laboratory tests, 93% had a documented fasting blood glucose test; in contrast, hemoglobin A lc testing was performed in only 9% of the patients. The fee-for-service group had a higher rate of visits to medical specialists and general laboratory utilization, whereas the managed care group had a higher rate of hospital admissions and emergency department visits. CONCLUSION The quality of diabetes management and the subsequent outcomes are related to patient and health-care provider adherence to standards of care. In this analysis, we found that patients and physicians are responsible for low compliance with recognized standards of diabetes care in Puerto Rico. The lack of adequate management will lead to increased mortality, development and severity of chronic complications, and increased emergency department utilization. Therefore, health-care providers and payers should find ways to achieve more effective promotion of adherence to accepted standards of care for patients with diabetes.
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Affiliation(s)
- Efraín Rodríguez-Vigil
- Center for Diabetes Control Inc., Sánchez Osorio Avenue #5A3, Villa Fontana, Carolina, Puerto Rico 00983
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Abstract
Keeping up with the technical and academic advances in medicine of the past 2 decades has made studying the US government's physician reimbursement system a low priority for most physicians. However, in the current environment of declining physician reimbursement and increasing frequency of compliance audits by Medicare, it is important for all physicians to have a basic understanding of the Medicare payment process. A major component of the physician payment system occurs at the local level. Through local coverage determinations, state Medicare contractors make more than 90% of all Medicare coverage decisions. Federal law requires Medicare contractors to seek physician input into their coverage decision process through contractor advisory committees, and through these committees, physicians can have significant influence over the coverage decision process. Once local contractors have made their coverage decisions, the covered indications for a procedure or treatment are published for the provider community. At that point, it becomes the responsibility of physicians to know the covered indications for certain services, because contractors will deny claims for services that are not linked to covered indications. This review focuses on the basics of the local Medicare payment process, with emphasis on the development of local coverage decisions by contractors. This understanding will allow physicians to positively influence the local reimbursement process.
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Affiliation(s)
- Bibb Allen
- American College of Radiology, Reston, VA 20191, USA
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Abstract
BACKGROUND Stroke affects more than 500,000 older persons each year in the United States, but no studies have compared older stroke patients in Medicare health maintenance organizations (HMOs) and fee-for-service (FFS) after recent changes in FFS reimbursement. OBJECTIVES We sought to compare utilization and outcomes after stroke in Medicare HMO and FFS. DESIGN We reviewed administrative data in 11 regions from Medicare and a large national health plan. SUBJECTS We studied Medicare beneficiaries 65 years and older discharged with ischemic stroke during 1998-2000, ie, 4816 HMO patients and a random sample of 4187 FFS patients from 422 hospitals. MEASURES We measured survival, rehospitalization, length of stay, discharge destination, and warfarin use. RESULTS Overall, HMO patients were younger, male, non-Caucasian, and had fewer comorbid conditions. When compared with FFS patients, HMO patients were more likely to be rehospitalized within 30 days for a primary diagnosis of ischemic stroke (Adjusted Hazard Ratio = 1.45, 95% Confidence Interval [CI] 1.14-1.83) or ill-defined conditions (eg, rehabilitation services) (2.87, 95% CI 1.85-4.46) and less likely to be rehospitalized for fluid and electrolyte disorders (0.54, 95% CI 0.34-0.87) or circulatory/respiratory problems (0.77, 95% CI 0.60-0.98). There were no consistent differences in 30-day mortality or in 1-year rehospitalization or mortality for 30-day survivors. HMO patients also were much less likely to be discharged to rehabilitation facilities, slightly less likely to be discharged to skilled nursing facilities and to have a shorter length of stay, and did not differ in the use of home care services or warfarin use when compared with FFS patients. CONCLUSIONS Traditional measures of quality such as 30-day rehospitalization may not be valid when comparing HMO and FFS patients if differences might reflect an alternative service mix. Utilization of post-acute care for FFS patients appears similar to HMO patients except for discharge to rehabilitation facilities.
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Affiliation(s)
- Maureen A Smith
- Department of Population Health Sciences, University of Wisconsin-Madison Medical School, Madison, Wisconsin 53705-2397, USA.
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Duszak R. When Expert Coding Advice Isn’t. J Am Coll Radiol 2005; 2:634-5. [PMID: 17411891 DOI: 10.1016/j.jacr.2005.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Richard Duszak
- West Reading Radiology Associates, Reading, PA 19612-6052, USA.
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Trisolini MG, Smith KW, McCall NT, Pope GC, Klosterman M. Evaluating the performance of medicare fee-for-service providers using the health outcomes survey: a comparison of two methods. Med Care 2005; 43:699-704. [PMID: 15970785 DOI: 10.1097/01.mlr.0000167178.86325.b6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Health status measures are now being used for evaluating the performance of health care organizations. Trends in SF-36 component scores have previously been examined for Medicare-managed care plans but not for providers serving Medicare fee-for-service (FFS) beneficiaries. We compared 2 methods for evaluating the performance of Medicare FFS providers, the Research Triangle Institute (RTI) and Health Assessment Laboratory (HAL) methods. METHODS Data were collected from 6547 Medicare FFS beneficiaries in 10 cohorts. SF-36 Physical Health (PCS) and Mental Health (MCS) component scores were computed at baseline and after a 2-year follow-up. The RTI approach predicts follow-up scores based on a standard care regression model. The HAL approach determines the percentage of beneficiaries whose status is the "same or better" at follow-up. Both approaches then compare observed to expected scores for each cohort. RESULTS The HAL method did not detect any statistically significant differences for the PCS; the RTI method detected a small PCS difference for one cohort. The HAL method identified 4 cohorts that had significantly higher MCS scores; the RTI approach identified one cohort with significantly lower scores. CONCLUSIONS The 2 approaches provided consistent assessments of provider performance for the PCS but not for the MCS. The differences in the MCS results may have been affected by differing treatment of deaths during follow-up. The HAL approach disregards deaths for the MCS, whereas the RTI method imputes values for death. Implications of using self-reported health status for monitoring provider performance are discussed.
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Keating NL, Landrum MB, Meara E, Ganz PA, Guadagnoli E. Do Increases in the Market Share of Managed Care Influence Quality of Cancer Care in the Fee-For-Service Sector? J Natl Cancer Inst 2005; 97:257-64. [PMID: 15713960 DOI: 10.1093/jnci/dji044] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Increases in the market share of managed care in an area are associated with decreases in expenditures in the fee-for-service sector (i.e., a spillover effect). Given concerns that these decreases in expenditures result from reductions in necessary care, we examined associations between increases in managed care market share and changes in the quality of care delivered to cancer patients in the fee-for-service sector. METHODS We studied a population-based sample of fee-for-service Medicare beneficiaries aged 66 years or older who were diagnosed with breast (N = 41,394) or colorectal (N = 48,027) cancer during 1993-1999. We used fixed effects regression analysis of SEER cancer registry and Medicare claims data to assess whether county-level increases in the market share of managed care over time were associated with the quality of cancer care. All statistical tests were two-sided. RESULTS Increases in the market share of managed care were not associated with most quality indicators, including receipt of surveillance mammography after diagnosis for patients with breast cancer (P = .83), receipt of radiation after breast-conserving surgery among women who underwent breast-conserving surgery (P = .16), receipt of adjuvant chemotherapy for patients with stage III colorectal cancer (P = .94), or surveillance colonoscopy after treatment for colorectal cancer (P = .39). Increases in the market share of managed care were associated with increased rates of surveillance carcinoembryonic antigen testing for colorectal cancer patients (P = .001). CONCLUSIONS Increases in managed care market share had limited or no effect on the quality of care for cancer patients. Concerns that increases in managed care would have large negative spillover effects on the quality of cancer care appear to be unfounded; however, the potential for managed care to stimulate improved quality throughout the medical care system have not yet been realized.
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Affiliation(s)
- Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA.
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Tseng CL, Greenberg JD, Helmer D, Rajan M, Tiwari A, Miller D, Crystal S, Hawley G, Pogach L. Dual-system utilization affects regional variation in prevention quality indicators: the case of amputations among veterans with diabetes. Am J Manag Care 2004; 10:886-92. [PMID: 15609743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
OBJECTIVE To determine the impact of dual-system utilization by veterans on regional variation in lower-extremity amputation rates. STUDY DESIGN Retrospective longitudinal cohort analysis. PATIENTS AND METHODS Subjects were veterans with diabetes who used Veterans Health Administration (VHA) care and were dually enrolled in Medicare fee for service in fiscal years (FY) 1997--1999. We evaluated the impact of Centers for Medicare and Medicaid Services (CMS) data on prevalence of baseline foot risk factors, medical comorbidities, and amputations in FY 1997--1998, and ranking of 22 regions using risk-adjusted major and minor amputation rates in FY 1999. RESULTS The addition of CMS data significantly increased the prevalence of amputations and risk factors for the 218,528 dually eligible veterans (all Pvalues <.001). In FY 1999, we identified 3.1 minor and 4.5 major amputations per 1000 patients (VHA data) versus 5.5 minor and 8.6 major amputations per 1000 patients (VHA/CMS data); the prevalence of any peripheral vascular condition in FY 1997--1998 was 5.7% (VHA) versus 13.0% (VHA/CMS). The impact of including CMS data varied across regions for amputation outcomes, ranging from an additional 34.3% to 150.7%. Using observed-to-expected amputation ratios and 99% confidence intervals, the addition of CMS data changed the outlier status for 8 of 22 regions for both major and minor amputations. CONCLUSION Risk covariates and amputation outcomes were substantially underestimated using VHA data only. Our findings demonstrate the importance of evaluating dual-system utilization when conducting program evaluations for healthcare systems with a substantial number of dual enrollees.
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Affiliation(s)
- Chin-Lin Tseng
- Center for Healthcare Knowledge Management, Veterans Affairs-New Jersey Healthcare System, East Orange, NJ 07018, USA
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Benedetti R, Flock B, Pedersen S, Ahern M. Improved clinical outcomes for fee-for-service physician practices participating in a diabetes care collaborative. ACTA ACUST UNITED AC 2004; 30:187-94. [PMID: 15085784 DOI: 10.1016/s1549-3741(04)30020-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The Rockwood Clinic in Spokane, Washington, participated in the Washington State Diabetes Collaborative, which promoted spread of the Chronic Care Model. Eleven participating providers managed care for 698 patients with diabetes, while 19 non-participating providers had 1,300 patients. IMPLEMENTING THE CHRONIC CARE MODEL: Rockwood upgraded its clinical information system to allow for creation of a patient registry to track clinical measures and generate performance reports. Components included a referral mechanism to facilitate more frequent use of diabetes educators, monthly reports, and sharing of results and updated clinical information from consulting specialists. Rockwood created a self-management tool kit and implemented patient goal setting and group visits. OUTCOME MEASURES Seven of the 12 patient outcomes were significantly better for participating providers (p < .05). Two favorable outcomes, eye examinations and blood pressure < 130/85 mm Hg, were significantly associated with greater participation levels at p < .05. DISCUSSION Implementing the Chronic Care Model to improve care, using quality improvement staff and administrative support, required fundamental changes in the system of care delivery. These changes were designed to refocus diabetes care efforts at Rockwood on prevention rather than acute care episodes.
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Blue Cross Blue Shield to restructure reimbursement. Tenn Med 2004; 97:266. [PMID: 15230060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
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Abstract
CONTEXT Since 2000, the Centers for Medicare & Medicaid Services (CMS) has been collecting information on beneficiaries' experiences with health care for Medicare managed care (MMC) and traditional fee-for-service (FFS) Medicare. OBJECTIVES To compare beneficiary experiences with managed care and FFS arrangements throughout the country and to assess the stability of those differences over time. DESIGN, SETTING, AND PARTICIPANTS CMS administered managed care and FFS versions of the Consumer Assessment of Health Plans Study (CAHPS) survey to samples of beneficiaries (aged > or =65 years) from Medicare + Choice MMC organizations and from geographic strata within the traditional FFS Medicare program. We analyzed responses collected in 2000 and 2001 from 497,869 respondents: 299,058 beneficiaries enrolled in MMC plans (response rate, 82%) and 198,811 enrolled in FFS Medicare (response rate, 68%). Differences between MMC and FFS within states were assessed after adjustment for case mix and nonresponse. For estimates at the regional and national level, state estimates were combined after weighting by the MMC enrollment in the state. MAIN OUTCOME MEASURES Four overall ratings (of the plan, personal physician, care received overall, and care received from specialists), 5 measures summarizing beneficiaries' experiences with care (getting care needed; getting care quickly; communication with clinicians; courtesy and respect of physician's office staff; and paperwork, information, and customer service), and reports of receipt of 3 preventive services (flu shots, pneumococcal vaccinations, and being advised to quit smoking) were assessed. RESULTS Respondents in MMC and FFS plans were similar to each other and to the Medicare population as a whole. Nationally, FFS Medicare beneficiaries rated experiences with care measured by the CAHPS survey higher than did MMC beneficiaries; for instance, in ratings of care received overall (scale of 1-10) (8.91 FFS vs 8.86 MMC, P<.001, in 2000; and 8.88 FFS vs 8.78 MMC, P<.001, in 2001). Differences between FFS and MMC varied across states, however. Managed care enrollees reported significantly fewer problems with paperwork, information, and customer service (2.62 FFS vs 2.55 MMC, P<.001, in 2000; and 2.59 FFS vs 2.51 MMC, P<.001, in 2001). Enrollees in MMC were also more likely to report having received immunizations for influenza and pneumococcus (from any source) (in 2000, 77% of MMC vs 63% of FFS respondents; P<.001), and smokers were more likely to report having received counseling to quit smoking. CONCLUSIONS Our data suggest that managed care was better at delivering preventive services, whereas traditional Medicare was better in other aspects of care related to access and beneficiary experiences. These relative strengths should be considered when policy decisions are made that affect the availability of choice or influence beneficiaries to choose one model of care over another.
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Affiliation(s)
- Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Mass 02115, USA.
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Stuart B, Singhal PK, Magder LS, Zuckerman IH. How robust are health plan quality indicators to data loss? A Monte Carlo simulation study of pediatric asthma treatment. Health Serv Res 2004; 38:1547-61. [PMID: 14727787 PMCID: PMC1360963 DOI: 10.1111/j.1475-6773.2003.00192.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES (1) To test the robustness of a health plan quality indicator (QI) for persistent asthma to various forms of data loss and (2) to assess the implications of the findings for other health plan quality measures. DATA SOURCES/STUDY SETTINGS Maryland Medicaid fee-for-service (FFS) claims. Children with asthma (n = 5,804) were selected from Medicaid enrollment records and medical and pharmacy FFS claims filed between June 1996 and December 1997. STUDY DESIGN A variant of a HEDIS measure for treatment of persistent asthma (the percent of asthma patients filling two or more rescue medications who also filled a controller medication) was selected to test the robustness of proportion-based QIs to loss of data. Data loss was simulated through a series of Monte Carlo experiments. DATA COLLECTION/EXTRACTION METHODS Merged FFS medical and prescription claims. PRINCIPAL FINDINGS The asthma QI measure was highly robust to systematic and random data loss. The measure declined by less than 2 percent in the presence of up to a 35 percent data loss. Redundancy in the numerator of the QI significantly increased the robustness of the measure to data loss. CONCLUSIONS A HEDIS-related QI measure for persistent asthma is robust to data loss. The findings suggest that other proportion-based quality indicators, particularly those in which plan members have multiple opportunities to meet the numerator criterion, are likely to reflect true levels of health plan quality in the face of incomplete data capture.
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Affiliation(s)
- Bruce Stuart
- The Peter Lamy Center on Drug Therapy and Aging, University of Maryland School of Pharmacy, Baltimore 21201, USA
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Blewett LA, Parente ST, Finch MD, Peterson E. National health data warehouse: issues to consider. J Healthc Inf Manag 2004; 18:52-8. [PMID: 14971080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
A national data warehouse that links public and private data could be used to monitor trends in healthcare costs, utilization, quality of care, and adherence to quality guidelines and changes in treatment protocols. The development of the data warehouse, however, would require overcoming a number of political and technical challenges to gain access to private insurance data. This article outlines recommendations from a national conference sponsored by the Agency for Healthcare Research and Quality (AHRQ) on the private sector's role in quality monitoring and provides an operational outline for the development of a national private sector health data warehouse.
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Affiliation(s)
- Lynn A Blewett
- Division of Health Services Research and Policy, School of Public Health, University of Minnesota, Minneapolis, USA
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Cook JA, Fitzgibbon G, Burke-Miller J, Mulkern V, Grey DD, Heflinger CA, Paulson R, Hoven CW, Stein-Seroussi A, Kelleher K. Medicaid behavioral health care plan satisfaction and children's service utilization. Health Care Financ Rev 2004; 26:43-55. [PMID: 15776699 PMCID: PMC4194880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study examines associations between caregivers' satisfaction with children's Medicaid-funded behavioral health care plans and the likelihood that children with severe emotional disturbance receive mental health services. Data are from a multisite study of managed care versus fee-for-service (FFS) settings. In multivariate logistic regression analyses controlling for demographic, environmental, site, and clinical characteristics, plan satisfaction was associated with greater likelihood of subsequent service use regardless of managed care versus FFS setting. Children in managed care plans were less likely to use intensive residential and non-traditional outpatient services. Efforts to increase plan satisfaction may encourage service use, consequently, improving children's behavioral health outcomes.
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Silcox PD. Quality of care by insurance plan. A fee-for-service versus health maintenance organization comparison. Outcomes Manag 2003; 7:170-3. [PMID: 14618775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
This study sought to determine if differences in quality of care existed between fee-for-service and health maintenance organization insurance plans (N = 154) for patients with congestive heart failure. There were no statistically significant differences in outcomes between the insurance plans.
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Sommers AR, Wholey DR. The effect of HMO competition on gatekeeping, usual source of care, and evaluations of physician thoroughness. Am J Manag Care 2003; 9:618-27. [PMID: 14527107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
OBJECTIVES To examine the effects of HMO enrollment and HMO competition on evaluations of physician thoroughness through their effects on gatekeeping and having a usual source of care and to determine whether the effects of HMO competition spill over to individuals not enrolled in HMOs and whether these effects differ in those enrolled vs not enrolled in HMOs. STUDY SAMPLE A nationally representative sample of 27 441 adults from the household component of the Community Tracking Study-Round 1 (July, 1996, through July, 1997). STUDY DESIGN A retrospective econometric analysis of Community Tracking Study data merged with measures of HMO competition. METHODS Gatekeeping was regressed on HMO enrollment, HMO competition, and control variables using ordered logistic regression. Usual source of care was regressed on gatekeeping, HMO enrollment, HMO competition, and control variables using logistic regression. Evaluation of physician thoroughness was regressed on gatekeeping, usual source of care, HMO enrollment, HMO competition, and control variables using multivariate regression. RESULTS HMO competition increases use of gatekeeping and gatekeeping increases having a usual source of care for all individuals. For HMO enrollees, HMO competition increases having a usual source of care, whereas for those not in HMOs, it decreases having a usual source of care. For all individuals, having a usual source of care increases evaluation of physician thoroughness. For those in HMOs, gatekeeping decreases evaluation of physician thoroughness. CONCLUSIONS For HMO enrollees, the overall effect of HMO competition is to increase evaluations of physician thoroughness. For those not in HMOs, although there are HMO competition spillover effects, they are offsetting, resulting in no overall effect of HMO competition on evaluations of physician thoroughness.
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Affiliation(s)
- Andrew R Sommers
- Center for Outcome and Effectiveness Research, Agency for Healthcare Research and Quality, Rockville, MD, USA.
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Luft HS. Variations in patterns of care and outcomes after acute myocardial infarction for Medicare beneficiaries in fee-for-service and HMO settings. Health Serv Res 2003; 38:1065-79. [PMID: 12968817 PMCID: PMC1360933 DOI: 10.1111/1475-6773.00163] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To assess revascularization and mortality after acute myocardial infarction (AMI) for all Medicare patients in fee-for-service (FFS) and health maintenance organization (HMO) settings in California. DATA SOURCES/STUDY SETTING Hospital discharge abstract and death certificate data linked with Medicare enrollment files for patients aged 65 and over with Medicare coverage (69,040) discharged from a California-licensed hospital in 1994-1996. STUDY DESIGN Risk-adjusted results were assessed for HMOs and FFS, as well as for FFS beneficiaries from areas served by each plan. DATA COLLECTION/EXTRACTION METHODS Risk models were based on all sampled patients. The HMO patients were aggregated into 17 pseudoplans: 5 individual plans, 4 large plans split geographically (10 observations), and 2 "pseudoplans" of small HMOs. Observed versus expected 30-day mortality rates, lengths-of-stay (LOS) during the index hospitalization and any transfers, revascularization (coronary artery bypass graft [CABG] surgery and/or percutaneous transluminal coronary angioplasty [PTCA]) during the index hospitalization or 30 days after admission, were calculated for each pseudoplan. PRINCIPAL FINDINGS Risk-adjusted death rate was slightly higher in FFS than in HMO settings (p < .01 with one risk adjustment model, n.s. with another). Three pseudoplans had significantly (p < .01) better than expected mortality rates. One pseudoplan was significantly worse (p < .05) with one risk adjustment model but not the other. The LOS and revascularization rates varied widely, but were not associated with outcomes. Plans with among the best results had the lowest LOS and revascularization rates. These pseudoplans were less likely to have their patients initially admitted to a hospital with revascularization capability, but the hospitals they used had higher CABG volumes. Even if CABG facilities were available during the index admission, in these plans with better than expected mortality rates, revascularization was often postponed or carried out elsewhere. CONCLUSIONS For Medicare patients having an AMI in the mid-1990s in California, risk-adjusted outcomes were no different, or slightly better on average, for those in HMOs than in FFS. Not all plans performed equally well, so understanding what leads to differences in quality is more important than simple comparisons of HMOs versus FFS.
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Affiliation(s)
- Harold S Luft
- Institute for Health Policy Studies, University of California, San Francisco 94118, USA
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