Effects of accountable care and payment reform on substance use disorder treatment: evidence from the initial 3 years of the alternative quality contract.

BACKGROUND AND AIMS: Global payment and accountable care reform efforts in the United States may connect more individuals with substance use disorders (SUD) to treatment. We tested whether such changes instituted under an Alternative Quality Contract (AQC) model within the Blue Cross Blue Shield of Massachusetts' (BCBSMA) insurer increased care for individuals with SUD. DESIGN: Difference-in-differences design comparing enrollees in AQC organizations with a comparison group of enrollees in organizations not participating in the AQC. SETTING: Massachusetts, USA. PARTICIPANTS: BCBSMA enrollees aged 13-64 years from 2006 to 2011 (3 years prior to and after implementation) representing 1 333 534 enrollees and 42 801 SUD service users. MEASUREMENTS: Outcomes were SUD service use and spending and SUD performance metrics. Primary exposures were enrollment into an AQC provider organization and whether the AQC organization did or did not face risk for behavioral health costs. FINDINGS: Enrollees in AQC organizations facing behavioral health risk experienced no change in the probability of using SUD services (1.64 versus 1.66%; P = 0.63), SUD spending ($2807 versus $2700; P = 0.34) or total spending ($12 631 versus $12 849; P = 0.53), or SUD performance metrics (identification: 1.73 versus 1.76%, P = 0.57; initiation: 27.86 versus 27.02%, P = 0.50; engagement: 11.19 versus 10.97%, P = 0.79). Enrollees in AQC organizations not at risk for behavioral health spending experienced a small increase in the probability of using SUD services (1.83 versus 1.66%; P = 0.003) and the identification performance metric (1.92 versus 1.76%; P = 0.007) and a reduction in SUD medication use (11.84 versus 14.03%; P = 0.03) and the initiation performance metric (23.76 versus 27.02%; P = 0.005). CONCLUSIONS: A global payment and accountable care model introduced in Massachusetts, USA (in which a health insurer provided care providers with fixed prepayments to cover most or all of their patients' care during a specified time-period, incentivizing providers to keep their patients healthy and reduce costs) did not lead to sizable changes in substance use disorder service use during the first 3 years following its implementation.

Measuring Healthcare Providers' Performances Within Managed Competition Using Multidimensional Quality and Cost Indicators.

BACKGROUND AND OBJECTIVES: The Dutch healthcare system is in transition towards managed competition. In theory, a system of managed competition involves incentives for quality and efficiency of provided care. This is mainly because health insurers contract on behalf of their clients with healthcare providers on, potentially, quality and costs. The paper develops a strategy to comprehensively analyse available multidimensional data on quality and costs to assess and report on the relative performance of healthcare providers within managed competition. DATA AND METHODS: We had access to individual information on 2409 clients of 19 Dutch diabetes care groups on a broad range of (outcome and process related) quality and cost indicators. We carried out a cost-consequences analysis and corrected for differences in case mix to reduce incentives for risk selection by healthcare providers. RESULTS AND CONCLUSION: There is substantial heterogeneity between diabetes care groups' performances as measured using multidimensional indicators on quality and costs. Better quality diabetes care can be achieved with lower or higher costs. Routine monitoring using multidimensional data on quality and costs merged at the individual level would allow a systematic and comprehensive analysis of healthcare providers' performances within managed competition.

Attribution: whose complication is it?

BACKGROUND: To improve quality, programs such as accountable care organizations need to determine the part of the health care system most "responsible" for a complication. This is referred to as attribution. This provides a framework to compare physicians for patients and third-party payers. Traditionally, the attribution of complications has been to the admitting physician. This may misidentify the physician "responsible" for the complication. This is especially difficult in trauma patients who have multiple providers. We hypothesized that the current mechanism for attributing complications in trauma patients is inadequate and will need to be modernized. METHODS: All trauma admissions during a 12-month period were reviewed. Patients with single-system trauma were excluded. We reviewed our trauma database for mechanism of injury, complications, and readmissions. The trauma director and the medical director of our accountable care organizations reviewed all complications and attributed them to the appropriate health care provider. These were compared with the hospital decisions using the traditional definition. RESULTS: The trauma service had 1,526 admissions. After exclusions, 1,019 patients were reviewed. One hundred twenty-five complications occurred in 73 patients. Using the traditional definition, the acute care surgery service was assigned all 125 complications. Using the trauma director and medical director method, the neurosurgical attending accounted for 36% (45 of 125) of complications. The acute care surgery attending was responsible for 34% (43 of 125) of complications, and orthopedic surgery was identified as the causative factor in 22% (27 of 125). The remaining 8% (10 of 125) were attributed to various other services. Seven patients had unexpected readmissions. Most (6 of 7) of these were related to orthopedics. CONCLUSION: Hospital complications are now being assigned to individual surgeons. Which physician is responsible for each complication will be a controversial matter. Without a critical review process with physician input, up to two thirds of complications could be attributed incorrectly. The attribution process needs to be refined. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

Mental health services in the health accounts: the Czech Republic.

BACKGROUND: Policy makers as well as health services researchers lack information on financial flows within national mental health systems. The studies that are available use different methodologies and hence it is difficult to make any comparisons. The aim of this study was to modify the existing health accounting framework and apply it to describe and analyse the financial flows within a national mental health system. METHODS: Mental health expenditures are classified by the three-dimensional methodology of OECD health accounts that is extended by two other dimensions for the purpose of the study. RESULTS: The framework of five-dimensional mental health accounts is introduced and applied to mental health expenditure in the Czech Republic, 2006. Mental health expenditure is estimated to be 4.14% of the total health expenditure. Mental health expenditure is classified based on its source of financing, provider industry, health-care function, cost category and diagnostic group. CONCLUSIONS: Health expenditure estimates present the most detailed information on resource allocation in the mental health system of the Czech Republic. The application of the standardized framework in other countries can improve the quality of international comparisons. On the national level, especially if the time series are available, mental health accounts can serve as a useful tool for strategic resource allocation decisions. This is particularly useful for the countries that plan changes in resource allocation directed from institutional to community-based care.

Measuring health care access and quality to improve health in populations.

Poor health status, rapidly escalating health care costs, and seemingly little association between investments in health care and health outcomes have prompted a call for a "pay-for-performance" system to improve population health. We suggest that both health plans and clinical service providers measure and report the rates of 5 behaviors: 1) smoking, 2) physical activity, 3) excessive drinking, 4) nutrition, and 5) condom use by sexually active youth. Because preventive services can improve population health, we suggest that health plans and clinical service providers report delivery rates of preventive services. We also suggest that an independent organization report 8 county-level indicators of health care performance: 1) health care expenditures, 2) insurance coverage, 3) rates of unmet medical, dental, and prescription drug needs, 4) preventive services delivery rates, 5) childhood vaccination rates, 6) rates of preventable hospitalizations, 7) an index of affordability, and 8) disparities in access to health care associated with race and income. To support healthy behaviors, access to work site wellness and health promotion programs should be measured. To promote coordinated care, an indicator should be developed for whether a clinical service provider is a member of an accountable care organization. To encourage clinical service providers and health plans to address the social determinants of health, organizational participation in community-benefit initiatives that address the leading social determinants of health should be assessed.

The impact of physician-owned specialty orthopaedic hospitals on surgical volume and case complexity in competing hospitals.

Published studies of physician-owned specialty hospitals have typically examined the impact of these hospitals on disparities, quality, and utilization at a national level. Our objective was to examine the impact of newly opened physician-owned specialty orthopaedic hospitals on individual competing general hospitals. We used Medicare Part A administrative data to identify all physician-owned specialty orthopaedic hospitals performing total hip arthroplasty (THA) and total knee arthroplasty (TKA) between 1991 and 2005. We identified newly opened specialty hospitals in three representative markets (Durham, NC, Kansas City, and Oklahoma City) and assessed their impact on surgical volume and patient case complexity for the five competing general hospitals located closest to each specialty hospital. The average general hospital maintained THA and TKA volume following the opening of the specialty hospitals. The average general hospital also did not experience an increase in patient case complexity. Thus, based on these three markets, we found no clear evidence that entry of physician-owned specialty orthopaedic hospitals resulted in declines in THA or TKA volume or increases in patient case complexity for the average competing general hospital.

Use of board certification and recertification of pediatricians in health plan credentialing policies.

CONTEXT: Health plans conduct credentialing processes to select and retain qualified physicians who will provide high-quality care to their subscribers. One of the tools available to health plans to help ensure physician competence is assessment of board certification status. OBJECTIVE: To determine the credentialing policies of health plans regarding the use of board certification and recertification for general pediatricians and pediatric subspecialists. DESIGN, SETTING, AND PARTICIPANTS: Telephone survey conducted February through July 2005 of credentialing personnel from a US national sample of 244 health plans stratified by enrollment size, Medicaid proportion, and for-profit or not-for-profit status. MAIN OUTCOME MEASURES: Proportion of health plans that require general or subspecialty board certification at initial contract or at any time during association with the plan and recertification to maintain credentialing or to bill as a specialist or subspecialist; percentage of physicians credentialed in each health plan and credentialing goals for each plan regarding the proportion of physicians to be board certified. RESULTS: Response rate was 193 of 244 (79%). Overall, 174 (90%) of the plans do not require general pediatricians to be board certified at the time of initial credentialing, and only 41% ever require a general pediatrician to become board certified. Similarly, only 80 (40%) ever require subspecialists to become board certified in their subspecialty. Although 80 of 192 (41%) report requiring recertification of general pediatricians, almost half do not have a time frame in which recertification must occur. Seventy-seven percent of plans allow physicians to bill as subspecialists with expired certificates. CONCLUSIONS: These findings, although specific to pediatrics, likely apply to other primary care disciplines and raise questions regarding the ability of plans to ensure initial or continued competence of their credentialed physicians. Growing public concern regarding patient safety, as well as demonstrated patient preferences for certified physicians, will likely result in greater emphasis on quality assessments in physician credentialing.

Innovation and risk selection in deregulated social health insurance.

One important motive for deregulating social health insurance is to encourage product innovation. For the first time, the cost savings achieved by non-US managed care plans that are attributable to product innovation are estimated, using a novel approach. Panel data from a major Swiss health insurer permits to infer health status, which can be used to predict health care expenditure. The econometric evidence suggests that the managed care plans benefit from risk selection effects. In the case of the health maintenance organization (HMO) plan, however, the pure innovation effect may account for as much as two-thirds of the cost advantage.

Risk adjustment in Switzerland.

In Switzerland the new law on Health Insurance, effective since 1996, introduced pro competitive changes in the market of sickness funds. The legislator expected high mobility between sickness funds of both healthy and sick insured as open enrolment was introduced with the new law. That is why the risk adjustment scheme, that was already introduced 1993, was limited until 2005. However, consumer mobility remained low and risk selection strategies are still profitable, since risk-adjustment is based only on demographic variables. This paper describes risk adjustment, consumer mobility, risk selection activities of sickness funds and the impact of imperfect risk adjustment on the development of HMO and PPO models. The paper concludes with a description of the current political and scientific discussion in Switzerland.

Managed competition and consumer price sensitivity in social health insurance.

This paper examines whether the introduction of managed competition in Dutch social health insurance has resulted in effective price competition among insurance funds. We find evidence of limited price competition, which may be caused by low consumer price sensitivity. Using aggregate panel data from all insurance funds over the period 1996-1998, estimated premium elasticities of market share are -0.3 for compulsory coverage and -0.8 for supplementary coverage. These elasticities are much smaller than in managed competition settings in US group insurance. This may be explained by differences in switching experience and higher search costs associated with individual insurance.

Managed competition versus industrial purchasing of health care among the Fortune 500.

The theory of managed competition has found favor with many health policy analysts and academic economists alike. Three characteristics--consumer choice, defined contribution, and dissemination of information--signal managed competition strategy. By requiring private employers to provide their employees with a choice of health carriers, a fixed-dollar strategy (defined contribution), and quality information to make appropriate choices among carriers, managed competition offers to remedy imperfections in both the consumer and provider sides of the market for health insurance. In an extensive survey of health care purchasing practices among Fortune 500 companies we found that major companies are not using the managed competition approach to health care purchasing. Instead, most of the companies surveyed are purchasing health care in the same way as they do other inputs to production--a pattern we call industrial purchasing.

Performance of diagnosis-based risk adjustment measures in a population of sick Australians.

OBJECTIVE: Australia is beginning to explore 'managed competition' as an organising framework for the health care system. This requires setting fair capitation rates, i.e. rates that adjust for the risk profile of covered lives. This paper tests two US-developed risk adjustment approaches using Australian data. METHODS: Data from the 'co-ordinated care' dataset (which incorporates all service costs of 16,538 participants in a large health service research project conducted in 1996-99) were grouped into homogenous risk categories using risk adjustment 'grouper software'. The grouper products yielded three sets of homogenous categories: Diagnostic Groups and Diagnostic cost Groups. A two-stage analysis of predictive power was used: probability of any service use in the concurrent year, next year and the year after (logistic regression) and, for service users, a regression of logged cost of service use. The independent variables were diagnosis gender, a SES variable and the RESULTS: Age, gender and diagnosis-based risk adjustment measures explain around 40-45% of variation in costs of service use in the current year for untrimmed data (compared with around 15% for age and gender alone). Prediction of subsequent use is much poorer (around 20%). Using more information to assign people to risk categories generally improves prediction. CONCLUSIONS: Predictive power of diagnosis-base risk adjusters on this Australian dataset is similar to that found in IMPLICATIONS: Low predictive power carries policy risks of cream skimming rather than managing population health and care. Competitive funding models with risk adjustment on prior year experience could reduce system efficiency if implemented with current risk adjustment technology.

Impact of HMO market structure on physician-hospital strategic alliances.

OBJECTIVE: To assess the impact of HMO market structure on the formation of physician-hospital strategic alliances from 1993 through 1995. The two trends, managed care and physician-hospital integration have been prominent in reshaping insurance and provider markets over the past decade. STUDY DESIGN: Pooled cross-sectional data from the InterStudy HMO Census and the Annual Survey conducted by the American Hospital Association (AHA) between 1993 and the end of 1995 to examine the effects of HMO penetration and HMO numbers in a market on the formation of hospital-sponsored alliances with physicians. Because prior research has found nonlinear effects of HMOs on a variety of dependent variables, we operationalized HMO market structure two ways: using a Taylor series expansion and cross-classifying quartile distributions of HMO penetration and numbers into 16 dummy indicators. Alliance formation was operationalized using the presence of any alliance model (IPA, PHO, MSO, and foundation) and the sum of the four models present in the hospital. Because managed care and physician-hospital integration are endogenous (e.g., some hospitals also sponsor HMOs), we used an instrumental variables approach to model the determinants of HMO penetration and HMO numbers. These instruments were then used with other predictors of alliance formation: physician supply characteristics, the extent of hospital competition, hospital-level descriptors, population size and demographic characteristics, and indicators for each year. All equations were estimated at the MSA level using mixed linear models and first-difference models. PRINCIPAL FINDINGS: Contrary to conventional wisdom, alliance formation is shaped by the number of HMOs in the market rather than by HMO penetration. This confirms a growing perception that hospital-sponsored alliances with physicians are contracting vehicles for managed care: the greater the number of HMOs to contract with, the greater the development of alliances. The models also show that alliance formation is low in markets where a small number of HMOs have deeply penetrated the market. First-difference models further show that alliance formation is linked to HMO consolidation (drop in the number of HMOs in a market) and hospital downsizing. Alliance formation is not linked to changes in hospital costs, profitability, or market competition with other hospitals. CONCLUSIONS: Hospitals appear to form alliances with physicians for several reasons. Alliances serve to contract with the growing number of HMOs, to pose a countervailing bargaining force of providers in the face of HMO consolidation, and to accompany hospital downsizing and restructuring efforts. IMPLICATIONS FOR POLICY, DELIVERY, OR PRACTICE: Physician-hospital integration is often mentioned as a provider response to increasing cost-containment pressures due to rising managed care penetration. Our findings do not support this view. Alliances appear to serve the hospital's interest in bargaining with managed care plans on a more even basis.

No exit? The effect of health status on dissatisfaction and disenrollment from health plans.

OBJECTIVE: To examine the implications of serious and chronic health problems on the willingness of enrollees to switch health plans if they are dissatisfied with their current arrangements. DATA SOURCE: A large (20,283 respondents) survey of employees of three national corporations committed to the model of managed competition, with substantial enrollment in four types of health plans: fee-for-service, prepaid group practice, independent practice associations, and point-of-service plans. STUDY DESIGN: A set of logistic regression models are estimated to determine the probability of disenrollment, if dissatisfied, controlling for the influence on satisfaction and disenrollment of age, race, education, family income and size, gender, marital status, mental health status, pregnancy, duration of employment and enrollment in the plan, number of alternative plans, and HMO penetration in the local market. Separate coefficients are estimated for enrollees with and without significant physical health problems. Additional models are estimated to test for the influence of selection effects as well as alternative measures of dissatisfaction and health problems. DATA COLLECTION: Data were collected through a mailed survey with a response rate of 63.5 percent; comparisons to a subsample administered by telephone showed few differences. PRINCIPAL FINDINGS: In group/staff model HMOs and point-of-service plans, only 12-17 percent of the chronically ill enrollees who were so dissatisfied when surveyed that they intended to disenroll actually left their plan in the next open enrollment period. This compared to 25-29 percent of the healthy enrollees in these same plans, who reported this level of dissatisfaction and 58-63 percent of the enrollees under fee-for-service insurance. CONCLUSIONS: Switching plans appears to be significantly limited for enrollees with serious health problems, the very enrollees who will be best informed about the ability of their health plan to provide adequate medical care. These effects are most pronounced in plans that have exclusive contracts with providers. We conclude that disenrollment provides only weak safeguards on quality for the sickest enrollees and that reported levels of dissatisfaction and disenrollment represent inaccurate signals of plan performance.

A model of the impact of reimbursement schemes on health plan choice.

Flat capitation (uniform prospective payments) makes enrolling healthy enrollees profitable to health plans. Plans with relatively generous benefits may attract the sick and fail through a premium spiral. We simulate a model of idealized managed competition to explore the effect on market performance of alternatives to flat capitation such as severity-adjusted capitation and reduced supply-side cost-sharing. In our model flat capitation causes severe market problems. Severity adjustment and to a lesser extent reduced supply-side cost-sharing improve market performance, but outcomes are efficient only in cases in which people bear the marginal costs of their choices.

Accountability for health outcomes and the proper unit of analysis: what do the experts think?

BACKGROUND: An invitational conference was held in Dearborn, MI, in April of 1998 to discuss technical and conceptual issues related to the general topic of using outcomes data to compare plans, networks, and providers. Approximately 150 researchers, clinicians, purchasers, and representatives of accreditation bodies and government agencies attended. SURVEY OF PARTICIPANTS: At the opening session, attendees participated in an electronic survey exercise designed to identify areas of agreement or disagreement on controversial issues related to the main conference topic. MAIN FINDINGS: There was general agreement about the basic concept of health plan and provider accountability for health outcomes, and about the need for further development of data sources and case-mix adjustment models. There was disagreement about other issues, including questions of who should bear the cost of collecting outcomes data and whether results should be analyzed at health plan, network, or individual clinician level. CONCLUSION: A group of experts agreed on the importance of reporting comparative outcomes data, but disagreed on many of the technical details of how that could best be done.