Experimental evidence of physician social preferences.

Physicians' professional ethics require that they put patients' interests ahead of their own and that they should allocate limited medical resources efficiently. Understanding physicians' extent of adherence to these principles requires understanding the social preferences that lie behind them. These social preferences may be divided into two qualitatively different trade-offs: the trade-off between self and other (altruism) and the trade-off between reducing differences in payoffs (equality) and increasing total payoffs (efficiency). We experimentally measure social preferences among a nationwide sample of practicing physicians in the United States. Our design allows us to distinguish empirically between altruism and equality-efficiency orientation and to accurately measure both trade-offs at the level of the individual subject. We further compare the experimentally measured social preferences of physicians with those of a representative sample of Americans, an "elite" subsample of Americans, and a nationwide sample of medical students. We find that physicians' altruism stands out. Although most physicians place a greater weight on self than on other, the share of physicians who place a greater weight on other than on self is twice as large as for all other samples-32% as compared with 15 to 17%. Subjects in the general population are the closest to physicians in terms of altruism. The higher altruism among physicians compared with the other samples cannot be explained by income or age differences. By contrast, physicians' preferences regarding equality-efficiency orientation are not meaningfully different from those of the general sample and elite subsample and are less efficiency oriented than medical students.

Association of Private Equity Firm Acquisition of Ophthalmology Practices with Medicare Spending and Use of Ophthalmology Services.

PURPOSE: Private equity (PE) firms increasingly are acquiring ophthalmology practices; little is known of their influence on care use and spending. We studied changes in use and Medicare spending after PE acquisition. DESIGN: Retrospective cohort study. PARTICIPANTS: Seven hundred sixty-two clinicians in 123 practices acquired by PE between 2017 and 2018 and 34 807 clinicians in 20 549 never-acquired practices. METHODS: We analyzed Medicare fee-for-service claims (2012-2019) combined with a novel national database of PE acquisitions of ophthalmology practices using a difference-in-differences method within an event study framework to compare changes after a practice was acquired with changes in practices that were not acquired. MAIN OUTCOME MEASURES: Numbers of beneficiaries seen; intravitreal injections and medications used for injections; and spending on ophthalmologist and optometrist services, ancillary services, and intravitreal injections. RESULTS: Comparing PE-acquired with nonacquired practices showed a 23.92% increase (n = 4.20 beneficiaries; 95% confidence interval [CI], 1.73-6.67) in beneficiaries seen per PE optometrist per quarter and no change for ophthalmologists, while spending per beneficiary increased 5.06% ($9.66; 95% CI, -2.82 to 22.14). Spending on clinician services decreased 1.62% (-$2.37; 95% CI, -5.78 to 1.04), with ophthalmologist services increasing 5.46% ($17.70; 95% CI, -2.73 to 38.15) and optometrists decreasing 4.60% (-$5.76; 95% CI, -9.17 to -2.34) per beneficiary per quarter. Ancillary services decreased 7.56% (-$2.19; 95% CI, 4.19 to -0.22). Intravitreal injection costs increased 25.0% ($20.02; 95% CI, -1.38 to 41.41) with the number increasing 5.10% (1.83; 95% CI, -0.1 to 3.80). There was a 74.09% increase (8.38 injections; 95% CI, 0.01-16.74) in ranibizumab and a 12.91% decrease (-3.40 injections; 95% CI, -6.86 to 0.07) in bevacizumab after acquisition. The event study showed consistent and often statistically significant increases in ranibizumab injections and decreases in bevacizumab injections after acquisition. CONCLUSIONS: Although not all results reached statistical significance, this study suggested that PE acquisition of practices showed little or no overall effect on use or total spending, but increased the number of unique patients seen per optometrist and the use of expensive intravitreal injections. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Ambulatory Care Fragmentation and Total Health Care Costs.

BACKGROUND: The magnitude of the relationship between ambulatory care fragmentation and subsequent total health care costs is unclear. OBJECTIVE: To determine the association between ambulatory care fragmentation and total health care costs. RESEARCH DESIGN: Longitudinal analysis of 15 years of data (2004-2018) from the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims. SUBJECTS: A total of 13,680 Medicare beneficiaries who are 65 years and older. MEASURES: We measured ambulatory care fragmentation in each calendar year, defining high fragmentation as a reversed Bice-Boxerman Index ≥0.85 and low as <0.85. We used generalized linear models to determine the association between ambulatory care fragmentation in 1 year and total Medicare expenditures (costs) in the following year, adjusting for baseline demographic and clinical characteristics, a time-varying comorbidity index, and accounting for geographic variation in reimbursement and inflation. RESULTS: The average participant was 70.9 years old; approximately half (53%) were women. One-fourth (26%) of participants had high fragmentation in the first year of observation. Those participants had a median of 9 visits to 6 providers, with the most frequently seen provider accounting for 29% of visits. By contrast, participants with low fragmentation had a median of 8 visits to 3 providers, with the most frequently seen provider accounting for 50% of visits. High fragmentation was associated with $1085 more in total adjusted costs per person per year (95% CI $713 to $1457) than low fragmentation. CONCLUSIONS: Highly fragmented ambulatory care in 1 year is independently associated with higher total costs the following year.

Physician Turnover in the United States.

BACKGROUND: Medical groups, health systems, and professional associations are concerned about potential increases in physician turnover, which may affect patient access and quality of care. OBJECTIVE: To examine whether turnover has changed over time and whether it is higher for certain types of physicians or practice settings. DESIGN: The authors developed a novel method using 100% of traditional Medicare billing to create national estimates of turnover. Standardized turnover rates were compared by physician, practice, and patient characteristics. SETTING: Traditional Medicare, 2010 to 2020. PARTICIPANTS: Physicians billing traditional Medicare. MEASUREMENTS: Indicators of physician turnover-physicians who stopped practicing and those who moved from one practice to another-and their sum. RESULTS: The annual rate of turnover increased from 5.3% to 7.2% between 2010 and 2014, was stable through 2017, and increased modestly in 2018 to 7.6%. Most of the increase from 2010 to 2014 came from physicians who stopped practicing increasing from 1.6% to 3.1%; physicians moving increased modestly from 3.7% to 4.2%. Modest but statistically significant (P < 0.001) differences existed across rurality, physician sex, specialty, and patient characteristics. In the second and third quarters of 2020, quarterly turnover was slightly lower than in the corresponding quarters of 2019. LIMITATION: Measurement was based on traditional Medicare claims. CONCLUSION: Over the past decade, physician turnover rates have had periods of increase and stability. These early data, covering the first 3 quarters of 2020, give no indication yet of the COVID-19 pandemic increasing turnover, although continued tracking of turnover is warranted. This novel method will enable future monitoring and further investigations into turnover. PRIMARY FUNDING SOURCE: The Physicians Foundation Center for the Study of Physician Practice and Leadership.

Ambulatory Care Fragmentation, Emergency Department Visits, and Race: a Nationwide Cohort Study in the U.S.

BACKGROUND: It is unclear whether highly fragmented ambulatory care (i.e., care spread across multiple providers without a dominant provider) increases the risk of an emergency department (ED) visit. Whether any such association varies with race is unknown. OBJECTIVE: We sought to determine whether highly fragmented ambulatory care increases the risk of an ED visit, overall and by race. DESIGN AND PARTICIPANTS: We analyzed data for 14,361 participants ≥ 65 years old from the nationwide prospective REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study, linked to Medicare claims (2003-2016). MAIN MEASURES: We defined high fragmentation as a reversed Bice-Boxerman Index ≥ 0.85 (≥ 75th percentile). We used Poisson models to determine the association between fragmentation (as a time-varying exposure) and ED visits, overall and stratified by race, adjusting for demographics, medical conditions, medications, health behaviors, psychosocial variables, and physiologic variables. KEY RESULTS: The average participant was 70.5 years old; 53% were female, and 33% were Black individuals. Participants with high fragmentation had a median of 9 visits to 6 providers, with 29% of visits by the most frequently seen provider; participants with low fragmentation had a median of 7 visits to 3 providers, with 50% of visits by the most frequently seen provider. Overall, high fragmentation was associated with more ED visits than low fragmentation (adjusted risk ratio [aRR] 1.31, 95% confidence interval [CI] 1.29, 1.34). The magnitude of this association was larger among Black (aRR 1.48, 95% CI 1.44, 1.53) than White participants (aRR 1.23, 95% CI 1.20, 1.25). CONCLUSIONS: Highly fragmented ambulatory care was an independent predictor of ED visits, especially among Black individuals.

The Association of Teamlets and Teams with Physician Burnout and Patient Outcomes.

BACKGROUND: Primary care "teamlets" in which a staff member and physician consistently work together might provide a simple, cost-effective way to improve care, with or without insertion within a team. OBJECTIVE: To determine the prevalence and performance of teamlets and teams. DESIGN: Cross-sectional observational study linking survey responses to Medicare claims. PARTICIPANTS: Six hundred eighty-eight general internists and family physicians. INTERVENTIONS: Based on survey responses, physicians were assigned to one of four teamlet/team categories (e.g., teamlet/no team) and, in secondary analyses, to one of eight teamlet/team categories that classified teamlets into high, medium, and low collaboration as perceived by the physician (e.g., teamlet perceived-high collaboration/no team). MAIN MEASURES: Descriptive: percentage of physicians in teamlet/team categories. OUTCOME MEASURES: physician burnout; ambulatory care sensitive emergency department and hospital admissions; Medicare spending. KEY RESULTS: 77.4% of physicians practiced in teamlets; 36.7% in teams. Of the four categories, 49.1% practiced in the teamlet/no team category; 28.3% in the teamlet/team category; 8.4% in no teamlet/team; 14.1% in no teamlet/no team. 15.7%, 47.4%, and 14.4% of physicians practiced in perceived high-, medium-, and low-collaboration teamlets. Physicians who practiced neither in a teamlet nor in a team had significantly lower rates of burnout compared to the three teamlet/team categories. There were no consistent, significant differences in outcomes or Medicare spending by teamlet/team or teamlet perceived-collaboration/team categories compared to no teamlet/no team, for Medicare beneficiaries in general or for dual-eligible beneficiaries. CONCLUSIONS: Most general internists and family physicians practice in teamlets, and some practice in teams, but neither practicing in a teamlet, in a team, or in the two together was associated with lower physician burnout, better outcomes for patients, or lower Medicare spending. Further study is indicated to investigate whether certain types of teamlet, teams, or teamlets within teams can achieve higher performance.

Association Between Individual Primary Care Physician Merit-based Incentive Payment System Score and Measures of Process and Patient Outcomes.

Importance: The Medicare Merit-based Incentive Payment System (MIPS) influences reimbursement for hundreds of thousands of US physicians, but little is known about whether program performance accurately captures the quality of care they provide. Objective: To examine whether primary care physicians' MIPS scores are associated with performance on process and outcome measures. Design, Setting, and Participants: Cross-sectional study of 80 246 US primary care physicians participating in the MIPS program in 2019. Exposures: MIPS score. Main Outcomes and Measures: The association between physician MIPS scores and performance on 5 unadjusted process measures, 6 adjusted outcome measures, and a composite outcome measure. Results: The study population included 3.4 million patients attributed to 80 246 primary care physicians, including 4773 physicians with low MIPS scores (≤30), 6151 physicians with medium MIPS scores (>30-75), and 69 322 physicians with high MIPS scores (>75). Compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly worse mean performance on 3 of 5 process measures: diabetic eye examinations (56.1% vs 63.2%; difference, -7.1 percentage points [95% CI, -8.0 to -6.2]; P < .001), diabetic HbA1c screening (84.6% vs 89.4%; difference, -4.8 percentage points [95% CI, -5.4 to -4.2]; P < .001), and mammography screening (58.2% vs 70.4%; difference, -12.2 percentage points [95% CI, -13.1 to -11.4]; P < .001) but significantly better mean performance on rates of influenza vaccination (78.0% vs 76.8%; difference, 1.2 percentage points [95% CI, 0.0 to 2.5]; P = .045] and tobacco screening (95.0% vs 94.1%; difference, 0.9 percentage points [95% CI, 0.3 to 1.5]; P = .001). MIPS scores were inconsistently associated with risk-adjusted patient outcomes: compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly better mean performance on 1 outcome (307.6 vs 316.4 emergency department visits per 1000 patients; difference, -8.9 [95% CI, -13.7 to -4.1]; P < .001), worse performance on 1 outcome (255.4 vs 225.2 all-cause hospitalizations per 1000 patients; difference, 30.2 [95% CI, 24.8 to 35.7]; P < .001), and did not have significantly different performance on 4 ambulatory care-sensitive admission outcomes. Nineteen percent of physicians with low MIPS scores had composite outcomes performance in the top quintile, while 21% of physicians with high MIPS scores had outcomes in the bottom quintile. Physicians with low MIPS scores but superior outcomes cared for more medically complex and socially vulnerable patients, compared with physicians with low MIPS scores and poor outcomes. Conclusions and Relevance: Among US primary care physicians in 2019, MIPS scores were inconsistently associated with performance on process and outcome measures. These findings suggest that the MIPS program may be ineffective at measuring and incentivizing quality improvement among US physicians.

Ambulatory Care Fragmentation and Subsequent Hospitalization: Evidence From the REGARDS Study.

BACKGROUND: Previous studies have suggested that highly fragmented ambulatory care increases the risk of subsequent hospitalization, but those studies used claims only and were not able to adjust for many clinical potential confounders. OBJECTIVE: The objective of this study was to determine the association between fragmented ambulatory care and subsequent hospitalization, adjusting for demographics, medical conditions, medications, health behaviors, psychosocial variables, and physiological variables. DESIGN: Longitudinal analysis of data (2003-2016) from the nationwide REasons for Geographic And Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims. SUBJECTS: A total of 12,693 Medicare beneficiaries 65 years and older from the REGARDS study who had at least 4 ambulatory visits in the first year of observation and did not have a hospitalization in the prior year. MEASURES: We defined high fragmentation as a reversed Bice-Boxerman score above the 75th percentile. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and incident hospitalization in the 3 months following each exposure period. RESULTS: The mean age was 70.4 years; 54% were women, and 33% were African American. During the first year of observation, participants with high fragmentation had a median of 8 ambulatory visits with 6 providers, whereas participants with low fragmentation had a median of 7 visits with 3 providers. Over 11.8 years of follow-up, 6947 participants (55%) had a hospitalization. High fragmentation was associated with an increased hazard of hospitalization (adjusted hazard ratio=1.18; 95% confidence interval: 1.12, 1.24). CONCLUSION: Highly fragmented ambulatory care is an independent risk factor for hospitalization.

Physician Practice Leaders' Perceptions of Medicare's Merit-Based Incentive Payment System (MIPS).

BACKGROUND: Medicare's Merit-based Incentive Payment System (MIPS) is a major value-based purchasing program. Little is known about how physician practice leaders view the program and its benefits and challenges. OBJECTIVE: To understand practice leaders' perceptions of MIPS. DESIGN AND PARTICIPANTS: Interviews were conducted from December 12, 2019, to June 23, 2020, with leaders of 30 physician practices of various sizes and specialties across the USA. Practices were randomly selected using the Medical Group Management Association's membership database. Practices included small primary care and general surgery practices (1-9 physicians); medium primary care and general surgery practices (10-25 physicians); and large multispecialty practices (50 or more physicians). Participants were asked about their perceptions of MIPS measures; the program's effect on patient care; administrative burden; and rationale for participation. MAIN MEASURES: Major themes related to practice participation in MIPS. KEY RESULTS: Interviews were conducted with 30 practices representing all US census regions. Six major themes emerged: (1) MIPS is understood as a continuation of previous value-based payment programs and a precursor to future programs; (2) measures are more relevant to primary care practices than other specialties; (3) leaders are conflicted on whether the program improves patient care; (4) MIPS creates a substantial administrative burden, exacerbated by annual programmatic changes; (5) incentives are small relative to the effort needed to participate; and (6) external support for participation can be helpful. Many participants indicated that their practice only participated in MIPS to avoid financial penalties; some reported that physicians cared for fewer patients due to the program's administrative burden. CONCLUSIONS: Practice leaders reported several challenges related to MIPS, including irrelevant measures, administrative burden, frequent programmatic changes, and small incentives. They held mixed views on whether the program improves patient care. These findings may be useful to policymakers hoping to improve MIPS.

Healthcare Fragmentation and Incident Acute Coronary Heart Disease Events: a Cohort Study.

BACKGROUND: Highly fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with excess tests, procedures, emergency department visits, and hospitalizations. Whether fragmented care is associated with worse health outcomes, or whether any association varies with health status, is unclear. OBJECTIVE: To determine whether fragmented care is associated with the risk of incident coronary heart disease (CHD) events, overall and stratified by self-rated general health. DESIGN AND PARTICIPANTS: We conducted a secondary analysis of the nationwide prospective Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study (2003-2016). We included participants who were ≥ 65 years old, had linked Medicare fee-for-service claims, and had no history of CHD (N = 10,556). MAIN MEASURES: We measured fragmentation with the reversed Bice-Boxerman Index. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and adjudicated incident CHD events in the 3 months following each exposure period. KEY RESULTS: The mean age was 70 years; 57% were women, and 34% were African-American. Over 11.8 years of follow-up, 569 participants had CHD events. Overall, the adjusted hazard ratio (HR) for the association between high fragmentation and incident CHD events was 1.14 (95% confidence interval (CI) 0.92, 1.39). Among those with very good or good self-rated health, high fragmentation was associated with an increased hazard of CHD events (adjusted HR 1.35; 95% CI 1.06, 1.73; p = 0.01). Among those with fair or poor self-rated health, high fragmentation was associated with a trend toward a decreased hazard of CHD events (adjusted HR 0.54; 95% CI 0.29, 1.01; p = 0.052). There was no association among those with excellent self-rated health. CONCLUSION: High fragmentation was associated with an increased independent risk of incident CHD events among those with very good or good self-rated health.

Differences in ambulatory care fragmentation by race.

BACKGROUND: More fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with more subsequent healthcare utilization (such as more tests, procedures, emergency department visits, and hospitalizations) than less fragmented ambulatory care. It is not known if race and socioeconomic status are associated with fragmented ambulatory care. METHODS: We conducted a longitudinal analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, using the REGARDS baseline visit plus the first year of follow-up. We included participants ≥65 years old, who had linked fee-for-service Medicare claims, and ≥ 4 ambulatory visits in the first year of follow-up. We used Tobit regression to determine the associations between race, annual household income, and educational attainment at baseline and fragmentation score in the subsequent year (as measured with the reversed Bice-Boxerman Index). Covariates included other demographic characteristics, medical conditions, medication use, health behaviors, and psychosocial variables. Additional analyses categorized visits by the type of provider (primary care vs. specialist). RESULTS: The study participants (N = 6799) had an average age of 73.0 years, 53% were female, and 30% were black. Nearly half had low annual household income (<$35,000) and 41% had a high school education or less. Overall, participants had a median of 10 ambulatory visits to 4 providers in the 12 months following their baseline study visit. Participants in the highest quintile of fragmentation scores had a median of 11 visits to 7 providers. Black race was associated with an absolute adjusted 3% lower fragmentation score compared to white race (95% confidence interval (2% lower to 4% lower; p < 0.001). This difference was explained by blacks seeing fewer specialists than whites. Income and education were not independent predictors of fragmentation scores. CONCLUSIONS: Among Medicare beneficiaries, blacks had less fragmented ambulatory care than whites, due to lower utilization of specialty care. Future research is needed to determine the effect of fragmented care on health outcomes for blacks and whites.

Identifying Patients with Persistent Preventable Utilization Offers an Opportunity to Reduce Unnecessary Spending.

BACKGROUND: Improving care for high-cost patients is increasingly important for improving the value of healthcare. Most prior research has focused on identifying patients with high costs, but the extent to which these costs are potentially preventable remains unclear. OBJECTIVE: To identify patients with persistent preventable utilization and compare their characteristics with high-cost patients. DESIGN: Descriptive analysis using Medicare claims data from 2013 to 2014. PARTICIPANTS: Medicare fee-for-service and dual-eligible beneficiaries (N = 515,689) from the New York metropolitan area who were continuously enrolled in Medicare Parts A and B in 2013 and 2014. MAIN MEASURES: The primary analysis focuses on patients with persistent preventable utilization (at least one preventable emergency department visit, hospitalization, or 30-day readmission in both 2013 and 2014) and high-cost patients in 2014 (top 10% of total annual spending). We compared demographic, medical, behavioral, and social characteristics and total and preventable healthcare utilization between these two groups. KEY RESULTS: Patients with persistent preventable utilization accounted for 4.8% of the overall patient population, 13.4% of overall costs, but 46.2% of preventable costs among all Medicare patients. Compared with high-cost patients, patients with persistent preventable utilization had lower median healthcare costs ($33,383 vs. $56,552), but their median potentially preventable costs were seven times higher ($7151 vs. $928). We also found that 1.9% of patients could be categorized in both the persistent preventable utilization group and the high-cost group. This subset of patients had the highest median Medicare costs and preventable costs and represented over 30% of total preventable spending and 9.4% of overall costs among all Medicare patients. CONCLUSION: Designing and targeting interventions for patients with persistent preventable utilization may offer an important opportunity to reduce unnecessary utilization and promote high-value care.

How Physicians Spend Their Work Time: an Ecological Momentary Assessment.

BACKGROUND: Little is known about how physicians spend their work time. OBJECTIVE: To determine how physicians in outpatient care spend their time at work, using an innovative method: ecological momentary assessment (EMA). DESIGN: Physician activity was measured via EMA, using a smartphone app. PARTICIPANTS: Twenty-eight practices across 16 US states. Sixty-one physicians: general internal medicine, family medicine, non-interventional cardiology, orthopedics. MAIN MEASURES: Proportions of time spent on 14 activities within 6 broad categories of work: direct patient care (including both face-to-face care and other patient care-related activities), electronic health record (EHR) input, administration, teaching/supervising, personal time, and other. KEY RESULTS: After excluding personal time, physicians spent 66.5% of their time on direct patient care (23.6% multitasking with use of the EHR and 42.9% without the EHR), 20.7% on EHR input alone, 7.7% on administrative activities, and 5.0% on other activities (0.6% using the EHR). In total, physicians spent 44.9% of their time on the EHR. LIMITATIONS: Unable to measure time spent at home on the EHR or other work tasks; participating physicians were not a random sample of US physicians. CONCLUSIONS: The efficiency of highly trained professionals spending only two-thirds of their time on direct patient care may be questioned. EHR use continues to account for a large proportion of physician time. Further attempts should be made to redesign both EHRs and physician work processes.

Association Between Patients' Self-Reported Gaps in Care Coordination and Preventable Adverse Outcomes: a Cross-Sectional Survey.

BACKGROUND: Whether patients' reports of gaps in care coordination reflect clinically significant problems is unclear. OBJECTIVE: To determine any association between patient-reported gaps in care coordination and patient-reported preventable adverse outcomes. DESIGN AND PARTICIPANTS: We administered a cross-sectional survey on experiences with healthcare to participants in the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who were ≥ 65 years old. Of the 15,817 participants in REGARDS at the time of our survey (August 2017-November 2018), 11,138 completed the survey. We restricted the sample to participants who reported ≥ 2 ambulatory visits and ≥ 2 ambulatory providers in the past year (N = 7568). MAIN MEASURES: We considered 7 gaps in ambulatory care coordination, elicited with previously validated questions. We considered 4 outcomes: (1) a test that was repeated because the doctor did not have the result of the first test, (2) a drug-drug interaction that occurred due to multiple prescribers, (3) an emergency department visit that could have been prevented by better communication among providers, and (4) a hospital admission that could have been prevented by better communication among providers. We used logistic regression to determine the association between ≥ 1 gap in care coordination and ≥ 1 preventable outcome, adjusting for potential confounders. KEY RESULTS: The average age of the sample was 77.0 years; 55% were female, and 34% were African-American. More than one-third of participants (38.1%) reported ≥ 1 gap in care coordination and nearly one-tenth (9.8%) reported ≥ 1 preventable outcome. Having ≥ 1 gap in care coordination was associated with an increased odds of ≥ 1 preventable outcome (adjusted odds ratio 1.55; 95% confidence interval 1.33, 1.81). CONCLUSIONS: Participants' reports of gaps in care coordination were associated with an increased odds of preventable adverse outcomes. Future interventions should leverage patients' observations to detect and resolve gaps in care coordination.

Association Between Patient Social Risk and Physician Performance Scores in the First Year of the Merit-based Incentive Payment System.

Importance: The US Merit-based Incentive Payment System (MIPS) is a major Medicare value-based payment program aimed at improving quality and reducing costs. Little is known about how physicians' performance varies by social risk of their patients. Objective: To determine the relationship between patient social risk and physicians' scores in the first year of MIPS. Design, Setting, and Participants: Cross-sectional study of physicians participating in MIPS in 2017. Exposures: Physicians in the highest quintile of proportion of dually eligible patients served; physicians in the 3 middle quintiles; and physicians in the lowest quintile. Main Outcomes and Measures: The primary outcome was the 2017 composite MIPS score (range, 0-100; higher scores indicate better performance). Payment rates were adjusted -4% to 4% based on scores. Results: The final sample included 284 544 physicians (76.1% men, 60.1% with ≥20 years in practice, 11.9% in rural location, 26.8% hospital-based, and 24.6% in primary care). The mean composite MIPS score was 73.3. Physicians in the highest risk quintile cared for 52.0% of dually eligible patients; those in the 3 middle risk quintiles, 21.8%; and those in the lowest risk quintile, 6.6%. After adjusting for medical complexity, the mean MIPS score for physicians in the highest risk quintile (64.7) was lower relative to scores for physicians in the middle 3 (75.4) and lowest (75.9) risk quintiles (difference for highest vs middle 3, -10.7 [95% CI, -11.0 to -10.4]; highest vs lowest, -11.2 [95% CI, -11.6 to -10.8]; P < .001). This relationship was found across specialties except psychiatry. Compared with physicians in the lowest risk quintile, physicians in the highest risk quintile were more likely to work in rural areas (12.7% vs 6.4%; difference, 6.3 percentage points [95% CI, 6.0 to 6.7]; P < .001) but less likely to care for more than 1000 Medicare beneficiaries (9.4% vs 17.8%; difference, -8.3 percentage points [95% CI, -8.7 to -8.0]; P < .001) or to have more than 20 years in practice (56.7% vs 70.6%; difference, -13.9 percentage points [95% CI, -14.4 to -13.3]; P < .001). For physicians in the highest risk quintile, several characteristics were associated with higher MIPS scores, including practicing in a larger group (mean score, 82.4 for more than 50 physicians vs 46.1 for 1-5 physicians; difference, 36.2 [95% CI, 35.3 to 37.2]; P < .001) and reporting through an alternative payment model (mean score, 79.5 for alternative payment model vs 59.9 for reporting as individual; difference, 19.7 [95% CI, 18.9 to 20.4]; P < .001). Conclusions and Relevance: In this cross-sectional analysis of physicians who participated in the first year of the Medicare MIPS program, physicians with the highest proportion of patients dually eligible for Medicare and Medicaid had significantly lower MIPS scores compared with other physicians. Further research is needed to understand the reasons underlying the differences in physician MIPS scores by levels of patient social risk.

Meaningful Use of Electronic Health Records by Outpatient Physicians and Readmissions of Medicare Fee-for-Service Beneficiaries.

BACKGROUND: Nearly one-fifth of hospitalized Medicare fee-for-service beneficiaries are readmitted within 30 days. Participation in the Meaningful Use initiative among outpatient physicians may reduce readmissions. OBJECTIVE: To evaluate the impact of outpatient physicians' participation in Meaningful Use on readmissions. SUBJECTS AND RESEARCH DESIGN: The study population included 90,774 Medicare fee-for-service beneficiaries from New York State (2010-2012). We compared changes in the adjusted odds of readmission for patients of physicians who participated in Meaningful Use-stage 1, before and after attestation as meaningful users, with concurrent patients of matched control physicians who used paper records or electronic health records without Meaningful Use participation. Three secondary analyses were conducted: (1) limited to patients with 3+ Elixhauser comorbidities; (2) limited to patients with conditions used by Medicare to penalize hospitals with high readmission rates (acute myocardial infarction, congestive heart failure, and pneumonia); and (3) using only patients of physicians with electronic health records who were not meaningful users as the controls. MAIN OUTCOME: Thirty-day readmission. RESULTS: Patients of Meaningful Use physicians had 6% lower odds of readmission compared with patients of physicians who were not meaningful users, but the estimate was not statistically significant (odds ratio: 0.94, 95% confidence interval, 0.88-1.01). Estimated odds ratios from secondary analyses were broadly consistent with our primary analysis. CONCLUSIONS: Physician participation in Meaningful Use was not associated with reduced readmissions. Additional studies are warranted to see if readmissions decline in future stages of Meaningful Use where more emphasis is placed on health information exchange and outcomes.

Healthcare Fragmentation and the Frequency of Radiology and Other Diagnostic Tests: A Cross-Sectional Study.

BACKGROUND: Fragmented ambulatory care has been associated with high rates of emergency department visits and hospitalizations, but effects on other types of utilization are unclear. OBJECTIVE: To determine whether more fragmented care is associated with more radiology and other diagnostic tests, compared to less fragmented care. DESIGN: We conducted a cross-sectional study using claims from five commercial payers for 2010. The study took place in the Hudson Valley, a seven-county region in New York State. PARTICIPANTS: We included adult patients who were insured through the participating payers and were attributed to a primary care physician in the region. We restricted the cohort to those with ≥4 ambulatory visits, as measures of fragmentation are not reliable if based on ≤3 visits (N = 126,801). MAIN MEASURES: For each patient, we calculated fragmentation using a reversed Bice-Boxerman Index, which we divided into seven categories. We used negative binomial regression to determine the association between fragmentation category and rates of radiology and other diagnostic tests, stratified by number of chronic conditions and adjusting for patient age, gender, and number of visits. KEY RESULTS: Patients with the most fragmented care had approximately twice as many radiology and other diagnostic tests as patients with the least fragmented care, across all groups stratified by number of chronic conditions (each adjusted p < 0.0001). For example, among patients with ≥5 chronic conditions, those with the least fragmented care had 258 tests per 100 patients, and those with the most fragmented care had 542 tests per 100 patients (+284 tests per 100 patients, or +110 %, adjusted p < 0.0001). CONCLUSION: More fragmented care was independently associated with higher rates of radiology and other diagnostic tests than less fragmented care.