Organization and Performance of US Health Systems Beaulieu, Nancy D; Chernew, Michael E; McWilliams, J Michael ...
JAMA : the journal of the American Medical Association,
01/2023, Letnik:
329, Številka:
4
Journal Article
Recenzirano
Health systems play a central role in the delivery of health care, but relatively little is known about these organizations and their performance.
To (1) identify and describe health systems in the ...United States; (2) assess differences between physicians and hospitals in and outside of health systems; and (3) compare quality and cost of care delivered by physicians and hospitals in and outside of health systems.
Health systems were defined as groups of commonly owned or managed entities that included at least 1 general acute care hospital, 10 primary care physicians, and 50 total physicians located within a single hospital referral region. They were identified using Centers for Medicare & Medicaid Services administrative data, Internal Revenue Service filings, Medicare and commercial claims, and other data. Health systems were categorized as academic, public, large for-profit, large nonprofit, or other private systems. Quality of preventive care, chronic disease management, patient experience, low-value care, mortality, hospital readmissions, and spending were assessed for Medicare beneficiaries attributed to system and nonsystem physicians. Prices for physician and hospital services and total spending were assessed in 2018 commercial claims data. Outcomes were adjusted for patient characteristics and geographic area.
A total of 580 health systems were identified and varied greatly in size. Systems accounted for 40% of physicians and 84% of general acute care hospital beds and delivered primary care to 41% of traditional Medicare beneficiaries. Academic and large nonprofit systems accounted for a majority of system physicians (80%) and system hospital beds (64%). System hospitals were larger than nonsystem hospitals (67% vs 23% with >100 beds), as were system physician practices (74% vs 12% with >100 physicians). Performance on measures of preventive care, clinical quality, and patient experience was modestly higher for health system physicians and hospitals than for nonsystem physicians and hospitals. Prices paid to health system physicians and hospitals were significantly higher than prices paid to nonsystem physicians and hospitals (12%-26% higher for physician services, 31% for hospital services). Adjusting for practice size attenuated health systems differences on quality measures, but price differences for small and medium practices remained large.
In 2018, health system physicians and hospitals delivered a large portion of medical services. Performance on clinical quality and patient experience measures was marginally better in systems but spending and prices were substantially higher. This was especially true for small practices. Small quality differentials combined with large price differentials suggests that health systems have not, on average, realized their potential for better care at equal or lower cost.
Abstract
There are now close to 17 million cancer survivors in the United States, and this number is expected to continue to grow. One decade ago the Institute of Medicine report, From Cancer Patient ...to Cancer Survivor: Lost in Transition, outlined 10 recommendations aiming to provide coordinated, comprehensive care for cancer survivors. Although there has been noteworthy progress made since the release of the report, gaps remain in research, clinical practice, and policy. Specifically, the recommendation calling for the development of quality measures in cancer survivorship care has yet to be fulfilled. In this commentary, we describe the development of a comprehensive, evidence-based cancer survivorship care quality framework and propose the next steps to systematically apply it in clinical settings, research, and policy.
Background
There is a growing interest in paying for performance as a means to align the incentives of health workers and health providers with public health goals. However, there is currently a lack ...of rigorous evidence on the effectiveness of these strategies in improving health care and health, particularly in low‐ and middle‐income countries. Moreover, paying for performance is a complex intervention with uncertain benefits and potential harms. A review of evidence on effectiveness is therefore timely, especially as this is an area of growing interest for funders and governments.
Objectives
To assess the current evidence for the effects of paying for performance on the provision of health care and health outcomes in low‐ and middle‐income countries.
Search methods
We searched more than 15 databases in 2009, including the Cochrane Effective Practice and Organisation of Care Group Specialised Register (searched 3 March 2009), CENTRAL (2009, Issue 1) (searched 3 March 2009), MEDLINE, Ovid (1948 to present) (searched 24 June 2011), EMBASE, Ovid (1980 to 2009 Week 09) (searched 2 March 2009), EconLit, Ovid (1969 to February 2009) (searched 5 March 2009), as well as the Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 8 September 2010). We also searched the websites and online resources of numerous international agencies, organisations and universities to find relevant grey literature and contacted experts in the field. We carried out an updated search on the Results‐Based Financing website in April 2011, and re‐ran the MEDLINE search in June 2011.
Selection criteria
Pay for performance refers to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. To be included, a study had to report at least one of the following outcomes: changes in targeted measures of provider performance, such as the delivery or utilisation of healthcare services, or patient outcomes, unintended effects and/or changes in resource use. Studies also needed to use one of the following study designs: randomised trial, non‐randomised trial, controlled before‐after study or interrupted time series study, and had to have been conducted in low‐ or middle‐income countries (as defined by the World Bank).
Data collection and analysis
We aimed to present a meta‐analysis of results. However, due to the limited number of studies in each category, the diversity of intervention designs and study methods, as well as important contextual differences, we present a narrative synthesis with separate results from each study.
Main results
Nine studies were included in the review: one randomised trial, six controlled before‐after studies and two interrupted time series studies (or studies which could be re‐analysed as such). The interventions were varied: one used target payments linked to quality of care (in the Philippines). Two used target payments linked to coverage indicators (in Tanzania and Zambia). Three used conditional cash transfers, modified by quality measurements (in Rwanda, Burundi and the Democratic Republic of Congo). Two used conditional cash transfers without quality measures (in Rwanda and Vietnam). One used a mix of conditional cash transfers and target payments (China). Targeted services also varied. Most of the interventions used a wide range of targets covering inpatient, outpatient and preventive care, including a strong emphasis on services for women and children. However, one focused specifically on tuberculosis (the main outcome measure was cases detected); one on hospital revenues; and one on improved treatment of common illnesses in under‐sixes. Participants were in most cases in a mix of public and faith‐based facilities (dispensaries, health posts, health centres and hospitals), though districts were also involved and in one case payments were made direct to individual private practitioners.
One study was considered to have low risk of bias and one a moderate risk of bias. The other seven studies had a high risk of bias. Only one study included any patient health indicators. Of the four outcome measures, two showed significant improvement for the intervention group (wasting and self reported health by parents of the under‐fives), while two showed no significant difference (being C‐reactive protein (CRP)‐negative and not anaemic). The two more robust studies both found mixed results – gains for some indicators but no improvement for others. Almost all dimensions of potential impact remain under‐studied, including intended and unintended impact on health outcomes, equity, organisational change, user payments and satisfaction, resource use and staff satisfaction.
Authors' conclusions
The current evidence base is too weak to draw general conclusions; more robust and also comprehensive studies are needed. Performance‐based funding is not a uniform intervention, but rather a range of approaches. Its effects depend on the interaction of several variables, including the design of the intervention (e.g. who receives payments, the magnitude of the incentives, the targets and how they are measured), the amount of additional funding, other ancillary components such as technical support, and contextual factors, including the organisational context in which it is implemented.
The objective of this study was to critically review the empirical evidence from all relevant disciplines regarding obesity stigma in order to (i) determine the implications of obesity stigma for ...healthcare providers and their patients with obesity and (ii) identify strategies to improve care for patients with obesity. We conducted a search of Medline and PsychInfo for all peer‐reviewed papers presenting original empirical data relevant to stigma, bias, discrimination, prejudice and medical care. We then performed a narrative review of the existing empirical evidence regarding the impact of obesity stigma and weight bias for healthcare quality and outcomes. Many healthcare providers hold strong negative attitudes and stereotypes about people with obesity. There is considerable evidence that such attitudes influence person‐perceptions, judgment, interpersonal behaviour and decision‐making. These attitudes may impact the care they provide. Experiences of or expectations for poor treatment may cause stress and avoidance of care, mistrust of doctors and poor adherence among patients with obesity. Stigma can reduce the quality of care for patients with obesity despite the best intentions of healthcare providers to provide high‐quality care. There are several potential intervention strategies that may reduce the impact of obesity stigma on quality of care.
Background
The use of blended payment schemes in primary care, including the use of financial incentives to directly reward ‘performance’ and ‘quality’ is increasing in a number of countries. There ...are many examples in the US, and the Quality and Outcomes Framework (QoF) for general practitioners (GPs) in the UK is an example of a major system‐wide reform. Despite the popularity of these schemes, there is currently little rigorous evidence of their success in improving the quality of primary health care, or of whether such an approach is cost‐effective relative to other ways to improve the quality of care.
Objectives
The aim of this review is to examine the effect of changes in the method and level of payment on the quality of care provided by primary care physicians (PCPs) and to identify:
i) the different types of financial incentives that have improved quality;
ii) the characteristics of patient populations for whom quality of care has been improved by financial incentives; and
iii) the characteristics of PCPs who have responded to financial incentives.
Search methods
We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library), MEDLINE, HealthSTAR, EMBASE, CINAHL, PsychLIT, and ECONLIT. Searches of Internet‐based economics and health economics working paper collections were also conducted. Finally, studies were identified through the reference lists of retrieved articles, websites of key organisations, and from direct contact with key authors in the field. Articles were included if they were published from 2000 to August 2009.
Selection criteria
Randomised controlled trials (RCT), controlled before and after studies (CBA), and interrupted time series analyses (ITS) evaluating the impact of different financial interventions on the quality of care delivered by primary healthcare physicians (PCPs). Quality of care was defined as patient reported outcome measures, clinical behaviours, and intermediate clinical and physiological measures.
Data collection and analysis
Two review authors independently extracted data and assessed study quality, in consultation with two other review authors where there was disagreement. For each included study, we reported the estimated effect sizes and confidence intervals.
Main results
Seven studies were included in this review. Three of the studies evaluated single‐threshold target payments, one examined a fixed fee per patient achieving a specified outcome, one study evaluated payments based on the relative ranking of medical groups’ performance (tournament‐based pay), one study examined a mix of tournament‐based pay and threshold payments, and one study evaluated changing from a blended payments scheme to salaried payment. Three cluster RCTs examined smoking cessation; one CBA examined patients' assessment of the quality of care; one CBA examined cervical screening, mammography screening, and HbA1c; one ITS focused on four outcomes in diabetes; and one controlled ITS (a difference‐in‐difference design) examined cervical screening, mammography screening, HbA1c, childhood immunisation, chlamydia screening, and appropriate asthma medication. Six of the seven studies showed positive but modest effects on quality of care for some primary outcome measures, but not all. One study found no effect on quality of care. Poor study design led to substantial risk of bias in most studies. In particular, none of the studies addressed issues of selection bias as a result of the ability of primary care physicians to select into or out of the incentive scheme or health plan.
Authors' conclusions
The use of financial incentives to reward PCPs for improving the quality of primary healthcare services is growing. However, there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Implementation should proceed with caution and incentive schemes should be more carefully designed before implementation. In addition to basing incentive design more on theory, there is a large literature discussing experiences with these schemes that can be used to draw out a number of lessons that can be learned and that could be used to influence or modify the design of incentive schemes. More rigorous study designs need to be used to account for the selection of physicians into incentive schemes. The use of instrumental variable techniques should be considered to assist with the identification of treatment effects in the presence of selection bias and other sources of unobserved heterogeneity. In randomised trials, care must be taken in using the correct unit of analysis and more attention should be paid to blinding. Studies should also examine the potential unintended consequences of incentive schemes by having a stronger theoretical basis, including a broader range of outcomes, and conducting more extensive subgroup analysis. Studies should more consistently describe i) the type of payment scheme at baseline or in the control group, ii) how payments to medical groups were used and distributed within the groups, and iii) the size of the new payments as a percentage of total revenue. Further research comparing the relative costs and effects of financial incentives with other behaviour change interventions is also required.
To conduct a systematic review of randomized controlled trials (RCTs) of the safety and effectiveness of primary care provided by advanced practice nurses (APNs) and evaluate the potential of their ...deployment to help alleviate primary care shortages.
PubMed, Medline and the Cumulative Index to Nursing and Allied Health Literature.
RCTs and their follow-up reports that compared outcomes of care provided to adults by APNs and physicians in equivalent primary care provider roles were selected for inclusion.
Ten articles (seven RCTs, plus two economic evaluations and one 2-year follow-up study of included RCTs) met inclusion criteria. Data were extracted regarding study design, setting and outcomes across four common categories.
The seven RCTs include data for 10 911 patients who presented for ongoing primary care (four RCTs) or same-day consultations for acute conditions (three RCTs) in the primary care setting. Study follow-up ranged from 1 day to 2 years. APN groups demonstrated equal or better outcomes than physician groups for physiologic measures, patient satisfaction and cost. APNs generally had longer consultations compared with physicians; however, two studies reported that APN patients required fewer consultations over time.
There were few differences in primary care provided by APNs and physicians; for some measures APN care was superior. While studies are needed to assess longer term outcomes, these data suggest that the APN workforce is well-positioned to provide safe and effective primary care.
Tuberculosis can be treated, prevented, and cured. Rapid, sustained declines in tuberculosis deaths in many countries during the past 50 years provide compelling evidence that ending the pandemic is ...feasible. Yet this disease—which has plagued humanity since before recorded history and has killed hundreds of millions of people over the past two centuries—remains a relentless scourge. In 2017, 1·6 million people died from tuberculosis, including 300 000 people with HIV, representing more deaths than any other infectious disease. Moreover, in many parts of the world, drugresistant forms of tuberculosis threaten struggling control efforts. The world can no longer ignore the enormous pall cast by the tuberculosis epidemic. Going forward, the global tuberculosis response must be an inclusive, comprehensive response within the broader sustainable development agenda. No one-size-fits-all approach can succeed.
Summary To improve maternal health requires action to ensure quality maternal health care for all women and girls, and to guarantee access to care for those outside the system. In this paper, we ...highlight some of the most pressing issues in maternal health and ask: what steps can be taken in the next 5 years to catalyse action toward achieving the Sustainable Development Goal target of less than 70 maternal deaths per 100 000 livebirths by 2030, with no single country exceeding 140? What steps can be taken to ensure that high-quality maternal health care is prioritised for every woman and girl everywhere? We call on all stakeholders to work together in securing a healthy, prosperous future for all women. National and local governments must be supported by development partners, civil society, and the private sector in leading efforts to improve maternal–perinatal health. This effort means dedicating needed policies and resources, and sustaining implementation to address the many factors influencing maternal health-care provision and use. Five priority actions emerge for all partners: prioritise quality maternal health services that respond to the local specificities of need, and meet emerging challenges; promote equity through universal coverage of quality maternal health services, including for the most vulnerable women; increase the resilience and strength of health systems by optimising the health workforce, and improve facility capability; guarantee sustainable finances for maternal–perinatal health; and accelerate progress through evidence, advocacy, and accountability.
In a landmark article published 50 years ago, Avedis Donabedian proposed using the triad of structure, process, and outcome to evaluate the quality of health care. That triad, along with his eventual ...seven pillars of quality, continues to inform efforts to improve care.
Though historians are often hesitant to declare any event a “first,” one might safely claim that the contemporary health care quality movement had its “founding moment” in October 1965. Less than 3 months after the Medicare and Medicaid programs were enacted, the newly created Health Services Research Section of the U.S. Public Health Service convened a meeting in Chicago of leaders from many health-related fields. These leaders considered the influence of social and economic research on public health, the organization of community health agencies, and the quality of health services.
One of these experts, Avedis Donabedian, a professor of medical . . .
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