Many believe that fear of malpractice lawsuits drives physicians to order otherwise unnecessary care and that legal reforms could reduce such wasteful spending. Emergency physicians practice in an ...information-poor, resource-rich environment that may lend itself to costly defensive practice. Three states, Texas (in 2003), Georgia (in 2005), and South Carolina (in 2005), enacted legislation that changed the malpractice standard for emergency care to gross negligence. We investigated whether these substantial reforms changed practice.
Using a 5% random sample of Medicare fee-for-service beneficiaries, we identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. Using a quasi-experimental design, we compared patient-level outcomes, before and after legislation, in reform states and control states. We controlled for characteristics of the patients, time-invariant hospital characteristics, and temporal trends. Outcomes were policy-attributable changes in the use of computed tomography (CT) or magnetic resonance imaging (MRI), per-visit emergency department charges, and the rate of hospital admissions.
For eight of the nine state-outcome combinations tested, no policy-attributable reduction in the intensity of care was detected. We found no reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no reduction in charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction (95% confidence interval, 0.9 to 6.2) in per-visit emergency department charges.
Legislation that substantially changed the malpractice standard for emergency physicians in three states had little effect on the intensity of practice, as measured by imaging rates, average charges, or hospital admission rates. (Funded by the Veterans Affairs Office of Academic Affiliations and others.).
This pilot study was designed to identify which contextual factors facilitate/hinder the implementation of the awakening, breathing, coordination, delirium, and early mobility (ABCDE) bundle for ...guidance in future studies.
The sources of data for this study included document review, planned site visits (including interviews and observations), a brief online contextual factors survey, and self-reported process and outcome data.
All patients in the four participating SF Bay Area ICUs were eligible to be included in this pilot study.
This study took place in the four San Francisco Bay Area ICUs participating in the ICU Clinical Impact Interest Group, funded by the Gordon and Betty Moore Foundation from January 2012 through June 2013.
This was a pilot evaluation study to identify factors that facilitated/hindered the implementation of the ABCDE bundle, interventions designed to decrease the prevalence of ICU-acquired delirium and muscle weakness. The ABCDE bundle consists of spontaneous awakening trials, spontaneous breathing trials, coordination of awakening and breathing trials, choice of sedation, delirium screening and treatment, and early progressive mobility.
Process data related to bundle element compliance were collected at baseline and monthly during the intervention period. Outcome data (average ICU length of stay and average days on mechanical ventilation) were collected at baseline and quarterly during the intervention period. Hospital-specific results of the online contextual factors survey and information gathered through interviews and observations during site visits also contributed to the analysis.
Factors related to structural characteristics of the ICU, an organizational-wide patient safety culture, an ICU culture of quality improvement, implementation planning, training/support, and prompts/documentation are believed to have facilitated the rate and success of ABCDE bundle implementation. Excessive turnover (both in project and ICU leadership), staff morale issues, lack of respect among disciplines, knowledge deficits, and excessive use of registry staff are believed to have hindered implementation.
Successful implementation of the elements of the ABCDE bundle can result in significant improvements in ICU patient care. The results of this study highlight specific structural and cultural elements of ICUs and hospitals that can positively and negatively influence the implementation of complex care bundles like the ABCDE bundle. Further research is needed to assess the influence of these contextual factors across a broader variety of ICUs and hospitals.
Fee-for-service payment is blamed for many of the problems observed in the US health care system. One of the leading alternative payment models proposed in the Affordable Care Act of 2010 is bundled ...payment, which provides payment for all of the care a patient needs over the course of a defined clinical episode, instead of paying for each discrete service. We evaluated the initial "road test" of PROMETHEUS Payment, one of several bundled payment pilot projects. The project has faced substantial implementation challenges, and none of the three pilot sites had executed contracts or made bundled payments as of May 2011. The pilots have taken longer to set up than expected, primarily because of the complexity of the payment model and the fact that it builds on the existing fee-for-service payment system and other complexities of health care. Participants continue to see promise and value in the bundled payment model, but the pilot results suggest that the desired benefits of this and other payment reforms may take time and considerable effort to materialize.
To understand physician organization (PO) responses to financial incentives for quality and total cost of care among POs that were exposed to a statewide multipayer value-based payment (VBP) program, ...and to identify challenges that POs face in advancing the goals of VBP.
Semistructured qualitative interviews and survey.
We drew a stratified random sample of 40 multispecialty California POs (25% of the POs that were eligible for incentives). In-person interviews were conducted with physician leaders and a survey was administered on actions being taken to reduce costs and redesign care and to discuss the challenges to improving value. We performed a thematic analysis of interview transcripts to identify common actions taken and challenges to reducing costs.
VBP helps to promote care delivery transformation among POs, although efforts varied across organizations. Investments are occurring primarily in strategies to control hospital costs and redesign primary care, particularly for chronically ill patients; specialty care redesign is largely absent. Physician payment incentives for value remain small relative to total compensation, with continued emphasis on productivity. Challenges cited include the lack of a single enterprisewide electronic health records platform for information exchange, limited ability to influence specialists who were not exclusive to the organization, lack of payer cost and utilization data to manage costs, inability to recoup care redesign investments given the small size of VBP incentives, and lack of physician cost awareness.
Transformation could be advanced by strengthening financial incentives for value; engaging specialists in care redesign and delivering value; enhancing partnerships among POs, hospitals, and payers to align quality and cost actions; strengthening information exchange across providers; and applying other strategies to influence physician behavior.
Clinical decision support and malpractice risk Greenberg, Michael; Ridgely, M Susan
JAMA : the journal of the American Medical Association,
2011-Jul-06, Volume:
306, Issue:
1
Journal Article
EXECUTIVE SUMMARY
The article examines whether subjective performance assessments from health system executives match objective performance assessments and qualitatively explores ways to achieve high ...performance. We interviewed 138 C-suite executives of 24 health systems in California, Minnesota, Washington, and Wisconsin between 2017 and 2019. We used maximum variation sampling to select health systems to achieve diversity in performance on objective measures of clinical performance. Our interviews focused on executives’ perceptions of their own health system’s performance and factors they thought generally contributed to high performance. In our analysis, we grouped health systems based on objective performance levels (high, medium, and low) used in sampling, compared objective performance ratings with executives’ subjective performance assessments, and used thematic analysis to identify reasons for subjective assessment of health system performance and levers of high performance in general. There was poor agreement between objective and subjective performance assessments (kappa = 0.082). Subjective assessments were higher than objective assessments and captured more factors than are typically considered in performance accountability and value-based payment initiatives. Executives whose views were inconsistent with objective performance assessments did not cite clinical care quality per se as the basis for their assessment, focusing instead on market competition, financial performance, and high customer satisfaction and loyalty. Executives who cited clinical quality metrics as the basis of their assessment offered subjective ratings consistent with objective ratings. Executives identified organizational culture, organizational governance, and staff engagement as levers for achieving high performance. Future research should explore the benefits and drawbacks of considering subjective performance assessments in value-based payment initiatives.
Research on US health systems has focused on large systems with at least 50 physicians. Little is known about small systems.
Compare the characteristics, quality, and costs of care between small and ...large health systems.
Retrospective, repeated cross-sectional analysis.
Between 468 and 479 large health systems, and between 608 and 641 small systems serving fee-for-service Medicare beneficiaries, yearly between 2013 and 2017.
We compared organizational, provider and beneficiary characteristics of large and small systems, and their geographic distribution, using multiple Medicare and Internal Revenue Service administrative data sources. We used mixed-effects regression models to estimate differences between small and large systems in claims-based Healthcare Effectiveness Data and Information Set (HEDIS) quality measures and HealthPartners' Total Cost of Care measure using a 100% sample of Medicare fee-for-service claims. We fit linear spline models to examine the relationship between the number of a system's affiliated physicians and its quality and costs.
The number of both small and large systems increased from 2013 to 2017. Small systems had a larger share of practice sites (43.1% vs. 11.7% for large systems in 2017) and beneficiaries (51.4% vs. 15.5% for large systems in 2017) in rural areas or small towns. Quality performance was lower among small systems than large systems (-0.52 SDs of a composite quality measure) and increased with system size up to ∼75 physicians. There was no difference in total costs of care.
Small systems are a growing source of care for rural Medicare populations, but their quality performance lags behind large systems. Future studies should examine the mechanisms responsible for quality differences.
The Mental Health Parity and Addiction Equity Act of 2008 prohibits commercial group health plans from imposing spending and visit limitations for mental health and substance abuse services that are ...not imposed on medical-surgical services. The act also restricts the use of managed care tools that apply to behavioral health benefits in ways that differ from how they apply to medical-surgical benefits. The only precedent for this approach is Oregon's state parity law, which was implemented in 2007. The goal of this study was to estimate the effect of Oregon's parity law on expenditures for mental health and substance abuse treatment services.
The authors compared expenditures for commercially insured individuals in four Oregon health plans from 2005 through 2008 and a matched group of commercially insured individuals in Oregon who were exempt from parity. Using a difference-in-differences analysis, the authors analyzed the effect of comprehensive parity on spending for mental health and substance abuse services.
Increases in spending on mental health and substance abuse services after implementation of Oregon's parity law were almost entirely the result of a general trend observed among individuals with and without parity. Expenditures per enrollee for mental health and substance abuse services attributable to parity were positive, but they did not differ significantly from zero in any of the four plans.
Behavioral health insurance parity rules that place restrictions on how plans manage mental health and substance abuse services can improve insurance protections without substantial increases in total costs.
To determine whether bundled payment could be an effective payment model for California, the Integrated Healthcare Association convened a group of stakeholders (health plans, hospitals, ambulatory ...surgery centers, physician organizations, and vendors) to develop, through a consensus process, the methods and means of implementing bundled payment. In spite of a high level of enthusiasm and effort, the pilot did not succeed in its goal to implement bundled payment for orthopedic procedures across multiple payers and hospital-physician partners. An evaluation of the pilot documented a number of barriers, such as administrative burden, state regulatory uncertainty, and disagreements about bundle definition and assumption of risk. Ultimately, few contracts were signed, which resulted in insufficient volume to test hypotheses about the impact of bundled payment on quality and costs. Although bundled payment failed to gain a foothold in California, the evaluation provides lessons for future bundled payment initiatives.
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