Financial Integration's Impact On Care Delivery And Payment Reforms: A Survey Of Hospitals And Physician Practices.
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ABSTRACT:
SUBMITTER: Fisher ES
PROVIDER: S-EPMC7849626 | biostudies-literature | 2020 Aug
REPOSITORIES: biostudies-literature
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Financial Integration's Impact On Care Delivery And Payment Reforms: A Survey Of Hospitals And Physician Practices.
Fisher Elliott S ES Shortell Stephen M SM O'Malley A James AJ Fraze Taressa K TK Wood Andrew A Palm Marisha M Colla Carrie H CH Rosenthal Meredith B MB Rodriguez Hector P HP Lewis Valerie A VA Woloshin Steven S Shah Nilay N Meara Ellen E
Health affairs (Project Hope) 20200801 8
Health systems continue to grow in size. Financial integration-the ownership of hospitals or physician practices-often has anticompetitive effects that contribute to the higher prices for health care seen in the US. To determine whether the potential harms of financial integration are counterbalanced by improvements in quality, we surveyed nationally representative samples of hospitals (<i>n</i> = 739) and physician practices (<i>n</i> = 2,189), stratified according to whether they were independ ...[more]
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Project description:ObjectivesTo investigate the impact of provider payment reforms and associated care delivery models on cost and quality in cancer care.MethodsData sources/study setting: Review of English-language literature published in PubMed, Embase and Cochrane library (2007-2019). Study design: We performed a systematic literature review (SLR) to identify the impact of cancer care reforms. Primary endpoints were resource use, cost, quality of care, and clinical outcomes. Data collection/extraction methods: For each study, we extracted and categorized comparative data on the impact of policy reforms. Given the heterogeneity in patients, interventions and outcome measures, we did a qualitative synthesis rather than a meta-analysis.ResultsOf the 26 included studies, seven evaluations were in fact qualified as quasi experimental designs in retrospect. Alternative payment models were significantly associated with reduction in resource use and cost in cancer care. Across the seventeen studies reporting data on the implicit payment reforms through care coordination, the adoption of clinical pathways was found effective in reduction of unnecessary use of low value services and associated costs. The estimates of all measures in ACO models varied considerably across participating providers, and our review found a rather mixed impact on cancer care outcomes.ConclusionThe findings suggest promising improvement in resource utilization and cost control after transition to prospective payment models, but, further primary research is needed to apply robust measures of performance and quality to better ensure that providers are delivering high-value care to their patients, while reducing the cost of care.
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Project description:ImportanceRecent health care reforms aim to increase patient access, reduce costs, and improve health care quality as payers turn to payment reform for greater value. Cardiologists need to understand emerging payment models to succeed in the evolving payment landscape. We review existing payment and delivery reforms that affect cardiologists, present 4 emerging examples, and consider their implications for clinical practice.ObservationsPublic and commercial payers have recently implemented payment reforms and new models are evolving. Most cardiology models are modified fee-for-service or address procedural or episodic care, but population models are also emerging. Although there is widespread agreement that payment reform is needed, existing programs have significant limitations and the adoption of new programs has been slow. New payment reforms address some of these problems, but many details remain undefined.Conclusions and relevanceEarly payment reforms were voluntary and cardiologists' participation is variable. However, conventional fee-for-service will become less viable, and enrollment in new payment models will be unavoidable. Early participation in new payment models will allow clinicians to develop expertise in new care pathways during a period of relatively lower risk.
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Project description:ObjectivesTo evaluate whether greater experience and success with performance incentives among physician practices are related to increased participation in Medicare's voluntary value-based payment reforms.Data sources/study settingPublicly available data from Medicare's Physician Compare (n = 1,278; January 2012 to November 2013) and nationally representative physician practice data from the National Survey of Physician Organizations 3 (NSPO3; n = 907,538; 2013).Study designWe used regression analysis to examine practice-level relationships between prior exposure to performance incentives and participation in key Medicare value-based payment reforms: accountable care organization (ACO) programs, the Physician Quality Reporting System ("Physician Compare"), and the Meaningful Use of Health Information Technology program ("Meaningful Use"). Prior experience and success with financial incentives were measured as (1) the percentage of practices' revenue from financial incentives for quality or efficiency; and (2) practices' exposure to public reporting of quality measures.Data collection/extraction methodsWe linked physician participation data from Medicare's Physician Compare to the NSPO3 survey.Principal findingsThere was wide variation in practices' exposure to performance incentives, with 64 percent exposed to financial incentives, 45 percent exposed to public reporting, and 2.2 percent of practice revenue coming from financial incentives. For each percentage-point increase in financial incentives, there was a 0.9 percentage-point increase in the probability of participating in ACOs (standard error [SE], 0.1, p < .001) and a 0.8 percentage-point increase in the probability of participating in Meaningful Use (SE, 0.1, p < .001), controlling for practice characteristics. Financial incentives were not associated with participation in Physician Compare. Among ACO participants, a 1 percentage-point increase in incentives was associated with a 0.7 percentage-point increase in the probability of being "very well" prepared to utilize cost and quality data (SE, 0.1, p < .001).ConclusionsPhysicians organizations' prior experience and success with performance incentives were related to participation in Medicare ACO arrangements and participation in the meaningful use criteria but not to participation in Physician Compare. We conclude that Medicare must complement financial incentives with additional efforts to address the needs of practices with less experience with such incentives to promote value-based payment on a broader scale.
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Project description:ObjectiveTo determine the proportion of physician practices in the United States that currently meets medical home criteria.Data source/study setting2007 and 2008 National Ambulatory Medical Care Survey.Study designWe mapped survey items to the National Committee on Quality Assurance's (NCQA's) medical home standards. After awarding points for each "passed" element, we calculated a practice's infrastructure score, dividing its cumulative total by the number of available points. We identified practices that would be recognized as a medical home (Level 1 [25-49 percent], Level 2 [50-74 percent], or Level 3 [infrastructure score ≥75 percent]) and examined characteristics associated with NCQA recognition.ResultsForty-six percent (95 percent confidence interval [CI], 42.5-50.2) of all practices lack sufficient medical home infrastructure. While 72.3 percent (95 percent CI, 64.0-80.7 percent) of multi-specialty groups would achieve recognition, only 49.8 percent (95 percent CI, 45.2-54.5 percent) of solo/partnership practices meet NCQA standards. Although better prepared than specialists, 40 percent of primary care practices would not qualify as a medical home under present criteria.ConclusionAlmost half of all practices fail to meet NCQA standards for medical home recognition.
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Project description:ObjectiveTo examine changes in postacute care (PAC) use during the initial Medicare payment reforms enacted by the Balanced Budget Act of 1997.Data sourcesWe used claims data from the 5 percent Medicare beneficiary sample in 1996, 1998, and 2000. Linked data from the Denominator file, Provider of Service file, and Area Resource File provided additional patient, hospital, and market-area characteristics.Study designSix disease groups with high PAC use were selected for analysis. We used multinomial logit regression to examine how PAC use differed by year of service, controlling for patient, hospital, and market-area characteristics.Principal findingsThere were major changes in PAC use, and a portion of services shifted to settings where reimbursement remained cost-based. During the first reform, the home health agency interim payment system, home health use decreased consistently across disease groups. This decrease was accompanied by increased use in skilled nursing facilities (SNFs). Following the implementation of the prospective payment system for SNFs, the use of inpatient rehabilitation facilities increased.ConclusionsThe shift in usage among settings occurred in two stages that corresponded to the timing of payment reforms for home health agencies and SNFs. Evidence strongly suggests the substitutability between PAC settings. Financial incentives, in addition to clinical needs and individual preferences, play a major role in PAC use.
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Project description:ImportanceConsolidation among physician practices and between hospitals and physician practices has accelerated in the past decade, resulting in higher prices in commercial markets. The resulting integration of health care across clinicians and participation in alternative payment models (APMs), which aim to improve quality while constraining spending, are cited as reasons for consolidation, but little is known about the association between integration and APM participation.ObjectiveTo examine the association of organizational characteristics, ownership, and integration with intensity of participation in APMs among physician practices.Design, setting, and participantsA cross-sectional descriptive study, adjusted for sampling and nonresponse weights, was conducted in US physician practice respondents to the National Survey of Healthcare Organizations and Systems conducted between June 16, 2017, and August 17, 2018; of 2333 responses received (response rate, 46.9%) and after exclusion of ineligible and incomplete responses, the number of practices included in the analysis was 2061. Data analysis was performed from April 1, 2019, to August 31, 2019.ExposuresSelf-reported physician practice characteristics, including ownership, integration (clinical, cultural, financial, and functional), care delivery capabilities, activities, and environmental factors.Main outcomes and measuresParticipation in APMs: (1) bundled payments, (2) comprehensive primary care and medical home programs, (3) pay-for-performance programs, (4) capitated contracts with commercial health plans, and (5) accountable care organization contracts.ResultsA total of 49.2% of the 2061 practices included reported participating in 3 or more APMs; most participated in pay-for-performance and accountable care organization models. Covariate-adjusted analyses suggested that operating within a health care system (odds ratio [OR] for medical group: 2.35; 95% CI, 1.70-3.25; P < .001; simple health system: 1.46; 95% CI, 1.08-1.97; P = .02; and complex health system: 1.76; 95% CI, 1.25-2.47; P = .001 relative to independent practices), greater clinical (OR, 4.68; 95% CI, 2.28-9.59; P < .001) and functional (OR, 4.24; 95% CI, 2.00-8.97; P < .001) integration, and being located in the Northeast (OR for Midwest: 0.47; 95% CI, 0.34-0.65; P < .001; South: 0.47; 95% CI, 0.34-0.66; P < .001; and West: 0.64; 95% CI, 0.46-0.91; P = .01) were associated with greater APM participation.Conclusions and relevanceGreater APM participation appears to be supported by integration and system ownership.
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Project description:OBJECTIVE:To assess hospital practices in obstetric quality management activities and identify institutional characteristics associated with utilization of evidence-supported practices. METHODS:Data for this study came from a statewide survey of obstetric hospitals in California regarding their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that completed quality assurance sections of the survey to assess their practices in a broad spectrum of quality enhancement activities. The association between institutional characteristics and adoption of evidence-supported practices (ie, those supported by prior literature or recommended by professional organizations as beneficial for improving birth outcome or patient safety) was examined using bivariate analysis and appropriate statistical tests. RESULTS:Most hospitals regularly audited adherence to written protocols regarding critical areas of care; however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest and management of abnormal fetal heart rate, respectively. Private nonprofit hospitals were more likely to have a written protocol for management of abnormal fetal heart rate (P=.002). One in 10 hospitals (9.7%) did not regularly review cases with significant morbidity or mortality, and only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3%, and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia, shoulder dystocia, or postpartum hemorrhage, respectively. Teaching status was associated with more frequent simulations in these three areas (P?.04 for all), while larger volume was associated with more frequent simulations for eclampsia (P=.04). CONCLUSION:Hospitals in California engage in a wide range of practices to assure or improve quality of obstetric care, but substantial variation in practice exists among hospitals. There is opportunity for improvement in adoption of evidence-supported practices.
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Project description:ObjectiveTo examine the effect of public reporting (PR) and financial incentives tied to quality performance on the use of care management practices (CMPs) among small- and medium-sized physician groups.DataSurvey data from The National Study of Small and Medium-sized Physician Practices were used. Primary data collection was also conducted to assess community-level PR activities. The final sample included 643 practices engaged in quality reporting; about half of these practices were subject to PR.Study designWe used a treatment effects model. The instrumental variables were the community-level variables that capture the level of PR activity in each community in which the practices operate.Findings(1) PR is associated with increased use of CMPs, but the estimate is not statistically significant; (2) financial incentives are associated with greater use of CMPs; (3) practices' awareness/sensitivity to quality reports is positively related to their use of CMPs; and (4) combined PR and financial incentives jointly affect CMP use to a greater degree than either of these factors alone.ConclusionSmall- to medium-sized practices appear to respond to PR and financial incentives by greater use of CMPs. Future research needs to investigate the appropriate mix and type of incentive arrangements and quality reporting.
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