We examine family physicians' responses to financial incentives for medical services in Ontario, Canada. We use administrative data covering 2003–2008, a period during which family physicians could ...choose between the traditional fee for service (FFS) and blended FFS known as the Family Health Group (FHG) model. Under FHG, FFS physicians are incentivized to provide comprehensive care and after‐hours services. A two‐stage estimation strategy teases out the impact of switching from FFS to FHG on service production. We account for the selection into FHG using a propensity score matching model, and then we use panel‐data regression models to account for observed and unobserved heterogeneity. Our results reveal that switching from FFS to FHG increases comprehensive care, after‐hours, and nonincentivized services by 3%, 15%, and 4% per annum. We also find that blended FFS physicians provide more services by working additional total days as well as the number of days during holidays and weekends. Our results are robust to a variety of specifications and alternative matching methods. We conclude that switching from FFS to blended FFS improves patients' access to after‐hours care, but the incentive to nudge service production at the intensive margin is somewhat limited.
Highlights • Several studies have been performed to estimate the value of comprehensive care for multimorbid/frail patients. • Evidence for the effectiveness of these comprehensive care programs ...remains insufficient. • It remains unclear which target groups will benefit most from comprehensive care. • Evaluation studies could improve by using more appropriate outcome measures.
Total joint arthroplasty (TJA) has been a recent target of reimbursement reform. As such, the purpose of this study was to evaluate trends in Medicare reimbursement to hospitals for TJA patients from ...2011 to 2017.
The Inpatient Utilization and Payment Public Use File was queried for all primary total hip and knee arthroplasty episodes. This file includes all services billed to Medicare via the Inpatient Prospective Payment System. Extracted data included hospital charges and amount paid by Medicare. All data were adjusted for inflation to 2017 US dollars. Multiple linear mixed-model regression analyses were conducted to assess change over time, and geo-modelling was used to represent reimbursement by location.
A total of 3,368,924 primary TJA procedures were billed to Medicare by hospitals from 2011 to 2017 and included in the study. The mean inflation-adjusted Medicare payment to hospitals for DRG 469 decreased from $22,783.66 to $19,604.62 per procedure (−$3179.04; −14.0%; P < .001) and decreased from $13,290.79 to $11,771.54 for DRG 470 (−$1519.25; −11.4%, P = .011) from 2011 to 2017. Meanwhile, the mean charge submitted by hospitals increased by $6483.39 and $5115.60 for DRGs 469 and 470, respectively (+7.4% for 469, +9.3% for 470; P < .001). Medicare reimbursement to hospitals varied by state.
During the study period, the mean Medicare reimbursement to hospitals decreased for TJA from 2011 to 2017. Meanwhile, the average charge submitted by hospitals increased. As alternative payment models continue to undergo evaluation and development, these data are important for the advancement of more agreeable reimbursement models in arthroplasty care.
Hidradenitis suppurativa (HS) can have devastating impacts on quality of life (QoL), especially during adolescence when patients face unique challenges related to self-esteem, body-image, and sexual ...maturation. Many teenage HS patients also experience social challenges related to school, relationships, and employment that may require physician intervention. Strategies for comprehensive management of this special group include addressing low medication adherence, screening for comorbidities, and recommending practical lifestyle modifications to reduce disease flares. Herein, we review the impact of HS on adolescent patients and provide practical recommendations to minimize effects on the adolescent life course.
Objective: This study aimed to clarify the meaning of reorganizing the lives of elderly people living alone discharged from a community comprehensive care unit.Methods: We conducted semi-structured ...interviews with 14 elderly people living alone discharged from a community comprehensive care unit after being hospitalized in an acute care unit and conducted a qualitative descriptive analysis of their lives.Results: Six categories were extracted as meanings of reorganizing the lives of elderly people living alone after discharge from the community comprehensive care unit,switching lives, affirming the past, enjoying life, regaining life, living with determination, and living with caution.Conclusion: In reorganizing the lives of elderly people living alone discharged from the community comprehensive care unit , they reconsidered their original lifestyle and way of living after being in and out of the hospital. Moreover, they looked back on their lives to that point and, through affirmation and acceptance, lived with determination and simultaneously confronted their mortality.
The Risk Assessment and Prediction Tool (RAPT) is used to predict patient discharge disposition after total joint arthroplasty. Following a comprehensive, multidisciplinary redesign, our institution ...noticed a trend toward home discharge in patients with RAPT scores that historically predicted discharge to acute care facilities, presenting an opportunity to redefine the predictive ranges for RAPT.
Retrospectively collected data were analyzed from a single institution in patients undergoing elective primary total joint arthroplasty from January 2016 to April 2017. Predictive accuracy (PA) was calculated for each RAPT score (1-12), RAPT score risk ranges (low, intermediate, and high), as well as overall. Other factors evaluated included patient-reported discharge expectation, body mass index, and American Society of Anesthesiologists scores as related to discharge disposition and the PA of RAPT.
Overall PA of RAPT was 88% (n = 1024 patients). Patients were high risk for acute care facility with a RAPT score of 1 to 3 (PA ≥ 83%), intermediate risk 4 to 7 (PA, 52%-79%), and low risk 8 to 12 (PA ≥ 89%). In multivariable analysis, RAPT score and patient-reported discharge expectation had the strongest correlation with actual discharge disposition.
Our multidisciplinary redesign has impacted the PA of RAPT. The original predictive ranges should be modified to reflect the increasing proportion of patients being discharged home following elective arthroplasty procedures. We have identified patient-expected discharge destination as a powerful modulator of the RAPT score and suggest that it be taken into consideration for discharge planning.
Abstract The number of people in their last years of life with advanced chronic conditions, palliative care needs, and limited life prognosis due to different causes including multi-morbidity, organ ...failure, frailty, dementia, and cancer is rising. Such people represent more than 1% of the population. They are present in all care settings, cause around 75% of mortality, and may account for up to one-third of total national health system spend. The response to their needs is usually late and largely based around institutional palliative care focused on cancer. There is a great need to identify these patients and integrate an early palliative approach according to their individual needs in all settings, as suggested by the World Health Organization. Several tools have recently been developed in different European regions to identify patients with chronic conditions who might benefit from palliative care. Similarly, several models of integrated palliative care have been developed, some with a public health approach to promote access to all in need. We describe the characteristics of these initiatives and suggest how to develop a comprehensive and integrated palliative approach in primary and hospital care and to design public health and community-oriented practices to assess and respond to the needs in the whole population. Additionally, we report ethical challenges and prognostic issues raised and emphasize the need for research to test the various tools and models to generate evidence about the benefits of these approaches to patients, their families, and to the health system.
Sickle cell disease (SCD) requires coordinated, specialized medical care for optimal outcomes. There are no United States (US) guidelines that define a pediatric comprehensive SCD program. We report ...a modified Delphi consensus‐seeking process to determine essential, optimal, and suggested elements of a comprehensive pediatric SCD center. Nineteen pediatric SCD specialists participated from the US. Consensus was predefined as 2/3 agreement on each element's categorization. Twenty‐six elements were considered essential (required for guideline‐based SCD care), 10 were optimal (recommended but not required), and five were suggested. This work lays the foundation for a formal recognition process of pediatric comprehensive SCD centers.
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