Comparing Quality of Care in Veterans Affairs and Non-Veterans Affairs Settings.

BACKGROUND: Congress, veterans' groups, and the press have expressed concerns that access to care and quality of care in Department of Veterans Affairs (VA) settings are inferior to access and quality in non-VA settings. OBJECTIVE: To assess quality of outpatient and inpatient care in VA at the national level and facility level and to compare performance between VA and non-VA settings using recent performance measure data. MAIN MEASURES: We assessed Patient Safety Indicators (PSIs), 30-day risk-standardized mortality and readmission measures, and ORYX measures for inpatient safety and effectiveness; Healthcare Effectiveness Data and Information Set (HEDIS®) measures for outpatient effectiveness; and Consumer Assessment of Healthcare Providers and Systems Hospital Survey (HCAHPS) and Survey of Healthcare Experiences of Patients (SHEP) survey measures for inpatient patient-centeredness. For inpatient care, we used propensity score matching to identify a subset of non-VA hospitals that were comparable to VA hospitals. KEY RESULTS: VA hospitals performed on average the same as or significantly better than non-VA hospitals on all six measures of inpatient safety, all three inpatient mortality measures, and 12 inpatient effectiveness measures, but significantly worse than non-VA hospitals on three readmission measures and two effectiveness measures. The performance of VA facilities was significantly better than commercial HMOs and Medicaid HMOs for all 16 outpatient effectiveness measures and for Medicare HMOs, it was significantly better for 14 measures and did not differ for two measures. High variation across VA facilities in the performance of some quality measures was observed, although variation was even greater among non-VA facilities. CONCLUSIONS: The VA system performed similarly or better than the non-VA system on most of the nationally recognized measures of inpatient and outpatient care quality, but high variation across VA facilities indicates a need for targeted quality improvement.

Association Between Patient-Centered Medical Home Capabilities and Outcomes for Medicare Beneficiaries Seeking Care from Federally Qualified Health Centers.

BACKGROUND: Patient-centered medical home (PCMH) models of primary care have the potential to expand access, improve population health, and lower costs. Federally qualified health centers (FQHCs) were early adopters of PCMH models. OBJECTIVE: We measured PCMH capabilities in a diverse nationwide sample of FQHCs and assessed the relationship between PCMH capabilities and Medicare beneficiary outcomes. DESIGN: Cross-sectional, propensity score-weighted, multivariable regression analysis. PARTICIPANTS: A convenience sample of 804 FQHC sites that applied to a nationwide FQHC PCMH initiative and 231,163 Medicare fee-for-service beneficiaries who received a plurality of their primary care services from these sites. MAIN MEASURES: PCMH capabilities were self-reported using the National Committee for Quality Assurance's (NCQA's) 2011 application for PCMH recognition. Measures of utilization, continuity of care, quality, and Medicare expenditures were derived from Medicare claims covering a 1-year period ending October 2011. KEY RESULTS: Nearly 88% of sites were classified as having PCMH capabilities equivalent to NCQA Level 1, 2, or 3 PCMH recognition. These more advanced sites were associated with 228 additional FQHC visits per 1000 Medicare beneficiaries (95% CI: 176, 278), compared with less advanced sites; 0.02 points higher practice-level continuity of care (95% CI: 0.01, 0.03); and a greater likelihood of administering two of four recommended diabetes tests. However, more advanced sites were also associated with 181 additional visits to specialists per 1000 beneficiaries (95% CI: 124, 232) and 64 additional visits to emergency departments (95% CI: 35, 89)-but with no differences in inpatient utilization. More advanced sites had higher Part B expenditures ($111 per beneficiary [95% CI: $61, $158]) and total Medicare expenditures of $353 [95% CI: $65, $614]). CONCLUSIONS: Implementation of PCMH models in FQHCs may be associated with improved primary care for Medicare beneficiaries. Expanded access to care, in combination with slower development of key PCMH capabilities, may explain higher Medicare expenditures and other types of utilization.

Measuring Care Continuity: A Comparison of Claims-based Methods.

BACKGROUND: Assessing care continuity is important in evaluating the impact of health care reform and changes to health care delivery. Multiple measures of care continuity have been developed for use with claims data. OBJECTIVE: This study examined whether alternative continuity measures provide distinct assessments of coordination within predefined episodes of care. RESEARCH DESIGN AND SUBJECTS: This was a retrospective cohort study using 2008-2009 claims files for a national 5% sample of beneficiaries with congestive heart failure, chronic obstructive pulmonary disease, and diabetes mellitus. MEASURES: Correlations among 4 measures of care continuity-the Bice-Boxerman Continuity of Care Index, Herfindahl Index, usual provider of care, and Sequential Continuity of Care Index-were derived at the provider- and practice-levels. RESULTS: Across the 3 conditions, results on 4 claims-based care coordination measures were highly correlated at the provider-level (Pearson correlation coefficient r=0.87-0.98) and practice-level (r=0.75-0.98). Correlation of the results was also high for the same measures between the provider- and practice-levels (r=0.65-0.92). CONCLUSIONS: Claims-based care continuity measures are all highly correlated with one another within episodes of care.

JOURNAL CLUB: Radiologists' Perceptions of Computerized Decision Support: A Focus Group Study From the Medicare Imaging Demonstration Project.

OBJECTIVE: The purpose of this study was to discern radiologists' perceptions regarding the implementation of a decision support system intervention as part of the Medicare Imaging Demonstration project and the effect of decision support on radiologists' interactions with ordering clinicians, their radiology work flow, and appropriateness of advanced imaging. SUBJECTS AND METHODS: A focus group study was conducted with a diverse sample of radiologists involved in interpreting advanced imaging studies at Medicare Imaging Demonstration project sites. A semistructured moderator guide was used, and all focus group discussions were recorded and transcribed verbatim. Qualitative data analysis software was used to code thematic content and identify representative segments of text. Participating radiologists also completed an accompanying survey designed to supplement focus group discussions. RESULTS: Twenty-six radiologists participated in four focus group discussions. The following major themes related to the radiologists' perceptions after decision support implementation were identified: no substantial change in radiologists' interactions with referring clinicians; no substantial change in radiologist work flow, including protocol-writing time; and no perceived increase in imaging appropriateness. Radiologists provided suggestions for improvements in the decision support system, including increasing the usability of clinical data captured, and expressed a desire to have greater involvement in future development and implementation efforts. CONCLUSION: Overall, radiologists from health care systems involved in the Medicare Imaging Demonstration did not perceive that decision support had a substantial effect, either positive or negative, on their professional roles and responsibilities. Radiologists expressed a desire to improve efficiencies and quality of care by having greater involvement in future efforts.

The association between health care quality and cost: a systematic review.

BACKGROUND: Although there is broad policy consensus that both cost containment and quality improvement are critical, the association between costs and quality is poorly understood. PURPOSE: To systematically review evidence of the association between health care quality and cost. DATA SOURCES: Electronic literature search of PubMed, EconLit, and EMBASE databases for U.S.-based studies published between 1990 and 2012. STUDY SELECTION: Title, abstract, and full-text review to identify relevant studies. DATA EXTRACTION: Two reviewers independently abstracted data with differences reconciled by consensus. Studies were categorized by level of analysis, type of quality measure, type of cost measure, and method of addressing confounders. DATA SYNTHESIS: Of 61 included studies, 21 (34%) reported a positive or mixed-positive association (higher cost associated with higher quality); 18 (30%) reported a negative or mixed-negative association; and 22 (36%) reported no difference, an imprecise or indeterminate association, or a mixed association. The associations were of low to moderate clinical significance in many studies. Of 9 studies using instrumental variables analysis to address confounding by unobserved patient health status, 7 (78%) reported a positive association, but other characteristics of these studies may have affected their findings. LIMITATIONS: Studies used widely heterogeneous methods and measures. The review is limited by the quality of underlying studies. CONCLUSION: Evidence of the direction of association between health care cost and quality is inconsistent. Most studies have found that the association between cost and quality is small to moderate, regardless of whether the direction is positive or negative. Future studies should focus on what types of spending are most effective in improving quality and what types of spending represent waste. PRIMARY FUNDING SOURCE: Robert Wood Johnson Foundation.

Impact of socioeconomic adjustment on physicians' relative cost of care.

BACKGROUND: Ongoing efforts to profile physicians on their relative cost of care have been criticized because they do not account for differences in patients' socioeconomic status (SES). The importance of SES adjustment has not been explored in cost-profiling applications that measure costs using an episode of care framework. OBJECTIVES: We assessed the relationship between SES and episode costs and the impact of adjusting for SES on physicians' relative cost rankings. RESEARCH DESIGN: We analyzed claims submitted to 3 Massachusetts commercial health plans during calendar years 2004 and 2005. We grouped patients' care into episodes, attributed episodes to individual physicians, and standardized costs for price differences across plans. We accounted for differences in physicians' case mix using indicators for episode type and a patient's severity of illness. A patient's SES was measured using an index of 6 indicators based on the zip code in which the patient lived. We estimated each physician's case mix-adjusted average episode cost and percentile rankings with and without adjustment for SES. RESULTS: Patients in the lowest SES quintile had $80 higher unadjusted episode costs, on average, than patients in the highest quintile. Nearly 70% of the variation in a physician's average episode cost was explained by case mix of their patients, whereas the contribution of SES was negligible. After adjustment for SES, only 1.1% of physicians changed relative cost rankings >2 percentiles. CONCLUSIONS: Accounting for patients' SES has little impact on physicians' relative cost rankings within an episode cost framework.

Evaluation of a center of excellence program for spine surgery.

BACKGROUND: The Centers for Medicare and Medicaid Services and many private health plans are encouraging patients to seek orthopedic care at hospitals designated as centers of excellence. No evaluations have been conducted to compare patient outcomes and costs at centers of excellence versus other hospitals. The objective of our study was to assess whether hospitals designated as spine surgery centers of excellence by a group of over 25 health plans provided higher quality care. METHODS: Claims representing approximately 54 million commercially insured individuals were used to identify individuals aged 18-64 years with 1 of 3 types of spine surgery in 2007-2009: 1-level or 2-level cervical fusion (referred to as cervical simple fusion), 1-level or 2-level lumbar fusion (referred to as lumbar simple fusion), or lumbar discectomy and/or decompression without fusion. The primary outcomes were any complication (7 complications were captured) and 30-day readmission. The multivariate models controlled for differences in age, sex, and comorbidities between the 2 sets of hospitals. RESULTS: A total of 29,295 cervical simple fusions, 27,214 lumbar simple fusions, and 28,911 lumbar discectomy/decompressions were identified, of which 42%, 42%, and 47%, respectively, were performed at a hospital designated as a spine surgery center of excellence. Designated hospitals had a larger number of beds and were more likely to be an academic center. Across the 3 types of spine surgery (cervical fusions, lumbar fusions, or lumbar discectomies/decompressions), there was no difference in the composite complication rate [OR 0.90 (95% CI, 0.72-1.12); OR 0.98 (95% CI, 0.85-1.13); OR 0.95 (95% CI, 0.82-1.07), respectively] or readmission rate [OR 1.03 (95% CI, 0.87-1.21); OR 1.01 (95% CI, 0.89-1.13); OR 0.91 (95%, CI 0.79-1.04), respectively] at designated hospitals compared with other hospitals. CONCLUSIONS: On average, spine surgery centers of excellence had similar complication rates and readmission rates compared with other hospitals. These results highlight the importance of empirical evaluations of centers of excellence programs.

Evaluation of centers of excellence program for knee and hip replacement.

BACKGROUND: Medicare and private plans are encouraging individuals to seek care at hospitals that are designated as centers of excellence. Few evaluations of such programs have been conducted. This study examines a large national initiative that designated hospitals as centers of excellence for knee and hip replacement. OBJECTIVE: Comparison of outcomes and costs associated with knee and hip replacement at designated hospitals and other hospitals. RESEARCH DESIGN: Retrospective claims analysis of approximately 54 million enrollees. STUDY POPULATION: Individuals with insurance from one of the sponsors of this centers of excellence program who underwent a primary knee or hip replacement in 2007-2009. OUTCOMES: Primary outcomes were any complication within 30 days of discharge and costs within 90 days after the procedure. RESULTS: A total of 80,931 patients had a knee replacement and 39,532 patients had a hip replacement of which 52.2% and 56.5%, respectively, were performed at a designated hospital. Designated hospitals had a larger number of beds and were more likely to be an academic center. Patients with a knee replacement at designated hospitals did not have a statistically significantly lower overall complication rate with an odds ratio of 0.90 (P=0.08). Patients with hip replacement treated at designated hospitals had a statistically significant lower risk of complications with an odds ratio of 0.80 (P=0.002). There was no significant difference in 90-day costs for either procedure. CONCLUSIONS: Hospitals designated as joint replacement centers of excellence had lower rates of complications for hip replacement, but there was no statistically significant difference for knee replacement. It is important to validate the criteria used to designate centers of excellence.

Patient sharing among physicians and costs of care: a network analytic approach to care coordination using claims data.

BACKGROUND: Improving care coordination is a national priority and a key focus of health care reforms. However, its measurement and ultimate achievement is challenging. OBJECTIVE: To test whether patients whose providers frequently share patients with one another-what we term 'care density'-tend to have lower costs of care and likelihood of hospitalization. DESIGN: Cohort study PARTICIPANTS: 9,596 patients with congestive heart failure (CHF) and 52,688 with diabetes who received care during 2009. Patients were enrolled in five large, private insurance plans across the US covering employer-sponsored and Medicare Advantage enrollees MAIN MEASURES: Costs of care, rates of hospitalizations KEY RESULTS: The average total annual health care cost for patients with CHF was $29,456, and $14,921 for those with diabetes. In risk adjusted analyses, patients with the highest tertile of care density, indicating the highest level of overlap among a patient's providers, had lower total costs compared to patients in the lowest tertile ($3,310 lower for CHF and $1,502 lower for diabetes, p < 0.001). Lower inpatient costs and rates of hospitalization were found for patients with CHF and diabetes with the highest care density. Additionally, lower outpatient costs and higher pharmacy costs were found for patients with diabetes with the highest care density. CONCLUSION: Patients treated by sets of physicians who share high numbers of patients tend to have lower costs. Future work is necessary to validate care density as a tool to evaluate care coordination and track the performance of health care systems.

Perspectives of Physicians in Small Rural Practices on the Medicare Quality Payment Program.

The Centers for Medicare & Medicaid Services (CMS) recently launched its Quality Payment Program (QPP), which considerably changes the way physicians are paid under Medicare. There has been significant concern about the ability of small rural practices to successfully participate in the program. To address these concerns, RAND researchers conducted interviews with physicians in small rural practices on the initial implementation of the QPP in order to understand the flexibility provisions for small rural practices and to inform future federal rulemaking for the QPP. The findings suggest that small rural practices are struggling to participate in the QPP. Interviewees reported frustration with a lack of clarity of program details, requirements that appeared to be determined late and were subject to change, and the amount of effort needed to participate. Interviewees suggested several changes to the QPP and Medicare policy to improve the ability of small rural practices to participate in the program. These changes included clarifying and specifying program requirements, reducing the frequency of program policy changes, delaying program implementation for small practices, avoiding penalizing small practices that serve vulnerable populations, developing less obtrusive methods for assessing the quality of care of small practices, providing additional information technology support for small rural practices, and enabling greater engagement of rural physicians by policymakers.

Practice Expenses Associated with Comprehensive Primary Care Capabilities.

Through the Comprehensive Primary Care (CPC) and Comprehensive Primary Care Plus (CPC+) programs, the Centers for Medicare & Medicaid Services (CMS) has encouraged primary care practices to invest in "comprehensive primary care" capabilities. Empirical evidence suggests these capabilities are under-reimbursed or not reimbursed under prevailing fee-for-service payment models. To help CMS design alternative payment models (APMs) that reimburse the costs of these capabilities, the authors developed a method for estimating related practice expenses. Fifty practices, sampled for diversity across CPC+ participation status, geographic region, rural status, size, and parent-organization affiliation, completed the study. Researchers developed a mixed-methods strategy, beginning with interviews of practice leaders to identify their capabilities and the types of costs incurred. This was followed by researcher-assisted completion of a workbook tailored to each practice, which gathered related labor and nonlabor costs. In a final interview, practice leaders reviewed cost estimates and made any needed corrections before approval. A main goal was to address a persistent question faced by CMS: When practices reported widely divergent costs for a given capability, was that divergence due to practices having different prices for the same capability or from their having substantially different capabilities? The cost estimation method developed in this project collected detailed data on practice capabilities and their costs. However, the small sample did not allow quantitative estimation of the contributions of service level and pricing to the variation in overall costs. This cost estimation method, deployed on a larger scale, could generate robust data to inform new payment models aimed at incentivizing and sustaining comprehensive primary care.

Estimating the Costs of Implementing Comprehensive Primary Care: A Narrative Review.

The performance of the any health-care system relies on a high-functioning primary care system. Increasing primary care practices' adoption of "comprehensive primary care" capabilities might yield meaningful improvements in the quality and efficiency of primary care. However, many comprehensive primary care capabilities, such as care management and coordination, are not compensated via traditional fee-for-service payment. To calculate new payments for these capabilities, policymakers would need estimates of the costs that practices incur when adopting, maintaining, and using the capabilities. We performed a narrative review of the existing literature on the costs of adopting and implementing comprehensive primary care capabilities. These studies have found that practices incur significant costs when adopting and implementing comprehensive primary care capabilities. However, the studies had significant limitations that prevent extensive use of their estimates for payment policy. Particularly, the strongest studies focused on a small numbers of practices in specific geographic areas and the concepts and methods used to assess costs varied greatly across the studies. Furthermore, none of the studies in our review attempted to estimate differences in costs across practices with patients at varying levels of complexity and illness burden which is important for risk-adjusting payments to practices. Therefore, due to the heterogeneous designs and limited generalizability of published studies highlight the need for additional research, especially if payers wish to link their financial support for comprehensive primary care capabilities to the costs of these capabilities for primary care practices.

What are the appropriate methodological standards for international comparisons of health data?

International comparisons of health systems are frequently used to inform national health policy debates. These comparisons can be used to gauge areas of strength and weakness in a health system, and to find potential solutions from abroad that can be applied locally. But such comparisons are methodologically fraught and, if not carefully performed and used, can be misleading.In a recent IJHPR article, Baruch Levi has raised concerns about the use of international comparisons of self-reported health data in health policy debates in Israel. Self-reported health is one of the most robust and frequently used measures of health, and the OECD uses a commonly accepted measure specification, which has five response categories. Israel's survey question, unlike the OECD measure specification, includes only four response categories. While this may be a valid method when applied over time as a scale within Israel, it creates problems for international comparison.To improve comparability, Israel's Central Bureau of Statistics could revise the survey question. However, revising the question would introduce a "break" in the data series that interrupts comparisons within Israel over time. Israeli policymakers therefore face a decision about priorities: is it more important to them to be able to track health status within Israel over time, or to be able to make meaningful comparisons to other countries? If the priority were international comparisons and the Israel survey was revised, a small study could be conducted among a sample of Israeli respondents to enable crosswalking of self-reported health responses from the four-point scale to the five-point scale. If the Central Bureau of Statistics does not revise its survey, the OECD should examine whether a stronger caveat is possible for its comparisons.

International migration patterns of physicians to the United States: a cross-national panel analysis.

OBJECTIVES: To analyze the dynamics of physician international migration patterns and identify the countries deviating most from expected migration rates. METHODS: A negative binomial log-linear model of physician migration to the United States from every other country was constructed using a panel of country-level data for years 1994-2000. The model was used to identify factors associated with physician migration and to identify countries with higher or lower rates of physician migration than expected. RESULTS: Physician migration varied with a country's GDP per capita in an inverse-U pattern, with highest migration rates from middle-income countries. The absence of medical schools, immigrant networks in the United States, medical instruction in English, proximity to the United States, and the lack of political and civil liberties were also associated with higher migration rates. Countries with higher-than-predicted migration rates included Iceland, Albania, Armenia, Dominica, Lebanon, Syria, the United Arab Emirates, and Bulgaria. Countries with lower-than-predicted migration rates included Mexico, Japan, Brazil, Zimbabwe, Mauritania, Portugal, Senegal, and France. CONCLUSIONS: This analysis shows that many of the most powerful factors associated with physician migration are difficult or impossible for countries to change through public policy. GDP per capita and proximity to the U.S. are two of the most powerful predictors of physician migration. Networks of immigrants in the U.S. and fewer political and civil liberties also put countries at higher risk for physician emigration. Several other factors that were associated with physician migration might be more easily amenable to policy intervention. These factors include the absence of a medical school and medical instruction in English. Policies addressing these factors would involve making several difficult tradeoffs, however. Other examples of policies that are effective in minimizing physician migration might be found by examining countries with lower-than-expected migration rates.

The Medicare Access And CHIP Reauthorization Act: Effects On Medicare Payment Policy And Spending.

In 2015, Congress repealed the Sustainable Growth Rate formula for Medicare physician payment, eliminating mandatory payment cuts when spending exceeded what was budgeted. In its place, Congress enacted the Medicare Access and CHIP Reauthorization Act (MACRA), which established a two-track performance-based payment system that encourages physicians to participate in alternative payment models. MACRA could have huge effects on health care delivery, but the nature of those effects is highly uncertain. Using the RAND Corporation's Health Care Payment and Delivery Simulation Model, we estimated the effects of MACRA on Medicare spending and utilization and examined how effects would differ under various scenarios. We estimate that MACRA will decrease Medicare spending on physician services by -$35 to -$106 billion (-2.3 percent to -7.1 percent) and change spending on hospital services by $32 to -$250 billion (0.7 percent to -5.1 percent) in 2015-30. The spending effects are critically dependent on the strength of incentives in the alternative payment models, particularly the incentives for physicians to reduce hospital spending and physician responses to MACRA payment rates.