American journal of accountable care最新文献

Objective: Given the increasing difficulty healthcare providers face in addressing patients' complex social circumstances and underlying health needs, organizations are considering team-based approaches including case conferences. We sought to document various perspectives on the facilitators and challenges of conducting case conferences in primary care settings.

Study design: Qualitative study using semi-structured telephone interviews.

Methods: We conducted 22 qualitative interviews with members of case conferencing teams, including physicians, nurses, and social workers from a Federally Qualified Health Clinic, as well as local county public health nurses. Interviews were recorded, transcribed, and reviewed using thematic coding to identify key themes/subthemes.

Results: Participants reported perceived benefits to patients, providers, and healthcare organizations including better care, increased inter-professional communication, and shared knowledge. Perceived challenges related to underlying organizational processes and priorities. Perceived facilitators for successful case conferences included generating and maintaining a list of patients to discuss during case conference sessions and team members being prepared to actively participate in addressing tasks and patient needs during each session. Participants offered recommendations for further improving case conferences for patients, providers, and organizations.

Conclusions: Case conferences may be a feasible approach to understanding patient's complex social needs. Participants reported that case conferences may help mitigate the effects of these social issues and that they foster better inter-professional communication and care planning in primary care. The case conference model requires administrative support and organizational resources to be successful. Future research should explore how case conferences fit into a larger population health organizational strategy so that they are resourced commensurately.

Background: Surgical care among older adults is costly. While Medicare accountable care organizations (ACOs) are designed around primary care, there are reasons to believe that participation may also affect spending on surgery. This study examines the impact that Medicare ACO alignment has on spending for inpatient and outpatient surgical care.

Study design: We conducted a retrospective cohort study using national Medicare claims (2008 through 2015). Among a 20% random sample of beneficiaries, we identified adults 65 years of age and older enrolled in fee-for-service Medicare, distinguishing between those aligned and unaligned with a Medicare ACO. We then measured payments for surgical services made on their behalf. Finally, we fit multivariable regression models to evaluate the association between ACO alignment and spending for inpatient and outpatient surgical care.

Results: We identified 37,249,845 beneficiary-year observations, of which 2,950,188 (7.9%) were aligned with a Medicare ACO. After adjustment for patient factors, ACO alignment was associated with $181 [95% confidence interval (CI), -$243 to -$118; P <0.001] lower spending per beneficiary-year. ACO alignment was associated with 2.9% fewer inpatient surgical episodes per year [incidence rate ratio (IRR), 0.97; 95% CI, 0.96 to 0.98; P <0.001] but 2.3% more outpatient episodes per year (IRR, 1.02; 95% CI, 1.02 to 1.03; P <0.001). Among inpatient surgical episodes, average payments were $956 lower for ACO aligned beneficiaries (95%CI -$1218 to -$694, P <0.001).

Conclusions and relevance: ACO alignment was associated with savings on surgical care. These savings resulted from increased outpatient surgery and reduced use of inpatient surgery as well as reduced spending per inpatient surgical episode. Greater focus on surgical care may improve the ability of ACOs to control healthcare spending.

Objectives: An increasing number of federal initiatives allow states flexibility in selecting the strategies used to achieve initiative-specific goals. Variation in the foci and intensity of implementation may explain why federal policy initiatives succeed in some states and fail in others. The CMS State Innovation Models (SIM) initiative is a complex policy intervention implemented with substantial variation across states and may have variable impacts. This paper presents a method to characterize and account for that variation in states' implementation foci and intensity in natural policy experiments.

Study design: A combination of quantitative and qualitative measures of SIM implementation was used to characterize the foci of payment and delivery system reforms across states.

Methods: A modified Delphi expert panel process was used to prioritize the features of SIM implementation that would differentiate grantee states with respect to improved health outcomes. Three researchers then reviewed summaries of published evaluations and reports to characterize and score states on each implementation feature. Expert panelists guided the researchers on developing the criteria and weights applied to the focus areas when calculating SIM implementation intensity scores for states.

Results: Over 3 years of an expert panel process, 4 dimensions of SIM implementation that would most affect health outcomes were prioritized: 1) extent and breadth of stakeholder engagement, (2) extent that SIM implementation was focused on improving behavioral health, (3) amount of SIM funding per capita, and (4) breadth and depth of value-based payment reforms. Scoring states based on the prioritized factors resulted in composite scores that differentiated states into 3 categories: high, moderate, and low implementation intensity.

Conclusions: We developed a stakeholder-driven method to measure and account for variation in implementation foci and intensity in a federal policy initiative that was implemented heterogeneously across grantee states. Our method for characterizing state implementation variation may be useful for natural policy experiments examining the variable impact of policy initiatives.

Objectives: To assess the association of the transition from incident opioid use to incident chronic opioid therapy (COT) with the trajectories of healthcare utilization and expenditures.

Study design: We used a longitudinal, retrospective cohort design, including seven 120-day time periods covering preindex (t₁, t₂, and t₃), index (t₄), and postindex (t₅, t₆, and t₇) periods with data from adults aged 28 to 63 years at the index date, without cancer, and continuously enrolled in a primary commercial insurance plan (N = 20,201).

Methods: Multivariable analyses were performed on utilization (population-averaged [PA] logistic regression), expenditures (PA generalized estimating equations), and expenditure estimates (counterfactual prediction). The data used were from a commercial claims database (10% random sample from the IQVIA Real-World Data Adjudicated Claims - US database) from 2006-2015.

Results: Patients on COT were more likely to use inpatient services (adjusted odds ratio, 1.11; 95% CI, 1.01-1.21) compared with those who did not. Although expenditures peaked during the index period (t₄) for all users, differences in unadjusted average 120-day expenditures between COT and non-COT users were highest in t₄ for total ($4607) and inpatient ($2453) expenditures. COT users had significantly higher total (β = 0.183; P <.01) and inpatient (β = 0.448; P <.001) expenditures.

Conclusions: The period after incident opioid prescription but before transition to COT is an important time for payers to intervene.

Objectives: To review tools designed to evaluate and improve the extent of patient-centered medical home (PCMH) implementation.

Study design: Literature search and review of tools to evaluate PCMH "medical homeness" and track progress toward practice transformation.

Methods: We conducted a literature search to identify tools designed for evaluation and quality improvement during the PCMH change process. We identified and reviewed the content of 5 publicly available PCMH survey tools used by an administrator or clinical lead to collect data at the practice level for evaluation and/or quality improvement during PCMH implementation. We assessed each tool's coverage of PCMH content, standards, and requirements.

Results: We found that 3 tools (Patient-Centered Medical Home Assessment [PCMH-A], Primary Care Assessment Tool-Facility Edition, and Medical Home Care Coordination Survey-Healthcare Team [MHCCS-H]) are actionable for quality improvement. PCMH-A assesses the broadest array of practice capabilities and includes items pertaining to all National Committee for Quality Assurance PCMH standards. MHCCS-H was the only tool to contain items on comprehensiveness of care. There was variation in emphasis on main domains, with some content areas covered by only 1 tool.

Conclusions: There is currently little evidence on which PCMH tools are associated with improved quality outcomes, as relatively few longitudinal studies have been conducted. Of the 5 tools we reviewed, only PCMH-A and MHCCS-H impose a light administrative burden (less than 10 minutes to complete) and can identify specific actions to improve a given practice capability. Each tool is lacking in a particular content area: PCMH-A, for example, lacks items on comprehensiveness of care, whereas MHCCS-H lacks items addressing access to care.

Objectives: Institutions participating in the Medicare Bundled Payments for Care Improvement (BPCI) initiative invest significantly in efforts to reduce readmissions and costs for patients who are included in the program. Eligibility for the BPCI initiative is determined by diagnosis-related group (DRG) classification. The implications of this methodology for chronic diseases are not known. We hypothesized that patients included in a BPCI initiative for chronic obstructive pulmonary disease (COPD) would have less severe illness and decreased hospital utilization compared with those excluded from the bundled payment initiative.

Study design: Retrospective observational study.

Methods: We sought to determine the clinical characteristics and outcomes of Medicare patients admitted to the University of Alabama at Birmingham Hospital with acute exacerbations of COPD between 2012 and 2014 who were included and excluded in a BPCI initiative. Patients were included in the analysis if they were discharged with a COPD DRG or with a non-COPD DRG but with an International Classification of Diseases, Ninth Revision code for COPD exacerbation.

Results: Six hundred and ninety-eight unique patients were discharged for an acute exacerbation of COPD; 239 (34.2%) were not classified into a COPD DRG and thus were excluded from the BPCI initiative. These patients were more likely to have intensive care unit (ICU) admissions (63.2% vs 4.4%, respectively; P <.001) and require noninvasive (46.9% vs 6.5%; P <.001) and invasive mechanical ventilation (41.4% vs 0.7%; P <.001) during their hospitalization than those in the initiative. They also had a longer ICU length of stay (5.2 vs 1.8 days; P = .011), longer hospital length of stay (10.3 days vs 3.9 days; P <.001), higher in-hospital mortality (14.6% vs 0.7%; P <.001), and greater hospitalization costs (median = $13,677 [interquartile range = $7489-$23,054] vs $4281 [$2718-$6537]; P <.001).

Conclusions: The use of DRGs to identify patients with COPD for inclusion in the BPCI initiative led to the exclusion of more than one-third of patients with acute exacerbations who had more severe illness and worse outcomes and who may benefit most from the additional interventions provided by the initiative.

Objectives: The Medicare accountable care organization (ACO) program financially rewards ACOs for providing high-quality healthcare, and also factors in the patient experience of care. This study examined whether administrative measures of wait times for specialist consults are associated with self-reported patient satisfaction.

Study design: Analyses used administrative and survey data from a clinically integrated healthcare system similar to an ACO.

Methods: Veterans Health Administration (VHA) data from 2012 was obtained. Administrative access metrics included the number of days between the creation of the consult request and: 1) first action taken on the consult, 2) scheduling of the consult, and 3) completion of the consult. The Survey of Healthcare Experiences of Patients-which is modeled after the Consumer Assessment of Healthcare Providers and Systems family of survey instruments used by ACOs to measure patient experience-provided the outcome measures. Outcomes included general VHA satisfaction measures and satisfaction with timeliness of care, including wait times for specialists and treatments. Logistic regression models predicted the likelihood of patients reporting being satisfied on each outcome. Models were risk adjusted for demographics, self-reported health, and healthcare use.

Results: Longer waits for the scheduling of consults and completed consults were found to be significantly associated with decreased patient satisfaction.

Conclusions: Because patients often report high levels of powerlessness and uncertainty while waiting for consultation, these wait times are an important patient-centered access metric for ACOs to consider. ACOs should have systems and tools in place to streamline the specialist consult referral process and increase care coordination.

Objectives: Geographic variation in the use of post-acute care (PAC - skilled nursing facility and home health care) after hospital discharge is substantial, but reasons for this remain largely unexplored. PAC use in urban hospitals compared to rural hospitals may be one key contributor. We aimed to describe PAC use, explore substitution of one type of PAC for another, and identify how PAC use varies by diagnosis in urban and rural settings.

Study design: Secondary analysis of the 2012 National Inpatient Sample including adult discharges to PAC after a hospitalization.

Methods: We adjusted for differences in patient demographics, comorbidities, hospital care provided, and hospital information, comparing use of PAC in urban and rural settings in multivariable logistic regression.

Results: Rural patients discharged from rural hospitals constituted 188,137 (12.1%) of the 1.56 million discharges in the sample. Rural discharges received less home health care (0.85; 0.80-0.90) than urban discharges, resulting in less rural PAC use overall (0.95; 0.91-0.99). Rural discharges received more overall PAC for stroke (OR 1.11; 95% CI 1.03-1.19) and less PAC for sepsis (0.92; 0.86-0.98), hip fracture (0.82; 0.70-0.96), and elective joint arthroplasty, where rural discharges had 41% lower odds of receiving PAC (0.59; 0.49-0.71).

Conclusions: The striking differences in receipt of post-acute care in urban and rural patients may constitute a disparity. Evaluation of costs and outcomes of PAC use in these settings is urgently needed as Medicare expands bundled payments for this care.

Mobile health clinics are increasingly used to deliver healthcare to urban and rural populations. An estimated 2000 vehicles in the United States are now delivering between 5 and 6 million visits annually; however, despite this growth, mobile health clinics represent an underutilized resource that could transform the way healthcare is delivered, especially in underserved areas. Preliminary research has shown that mobile health clinics have the potential to reduce costs and improve health outcomes. Their value lies primarily in their mobility, their ability to be flexibly deployed and customized to fit the evolving needs of populations and health systems, and their ability to link clinical and community settings. Few studies have identified how mobile health clinics can be sustainably utilized. We discuss the value proposition of mobile health clinics and propose 3 potential business models for them-adoption by accountable care organizations, payers, and employers.