Going Beyond Clinical Care to Reduce Health Care Spending: Findings From the J-CHiP Community-based Population Health Management Program Evaluation.

BACKGROUND: Addressing both clinical and nonclinical determinants of health is essential for improving population health outcomes. In 2012, the Johns Hopkins Community Health Partnership (J-CHiP) implemented innovative population health management programs across acute and community environments. The community-based program involved multidisciplinary teams [ie, physicians, care managers (CM), health behavior specialists (HBS), community health workers, neighborhood navigators] and collaboration with community-based organizations to address social determinants. OBJECTIVES: To report the impact of a community-based program on cost and utilization from 2011 to 2016. DESIGN: Difference-in-difference estimates were calculated for an inclusive cohort of J-CHiP participants and matched nonparticipants. The analysis was replicated for participants with a CM and/or HBS to estimate the differential impact with more intensive program services. SUBJECTS: A total of 3268 high-risk Medicaid and Medicare beneficiaries (1634 total J-CHiP participants, 1365 with CM and 678 with HBS). OUTCOME MEASURES: Paid costs and counts of emergency department visits, admissions, and readmissions per member per year. RESULTS: For Medicaid, costs were almost $1200 per member per year lower for participants as a whole, $2000 lower for those with an HBS, and $3000 lower for those with a CM; hospital admission and readmission rates were 9%-26% lower for those with a CM and/or HBS. For Medicare, costs were lower (-$476), but utilization was similar or higher than nonparticipants. None of the observed Medicaid or Medicare differences were statistically significant. CONCLUSIONS: Although not statistically significant, the results indicate a promising innovation for Medicaid beneficiaries. For Medicare, the impact was negligible, indicating the need for further program modification.

Key Design Considerations When Calculating Cost Savings for Population Health Management Programs in an Observational Setting.

OBJECTIVE: To illustrate the impact of key quasi-experimental design elements on cost savings measurement for population health management (PHM) programs. DATA SOURCES: Population health management program records and Medicaid claims and enrollment data from December 2011 through March 2016. STUDY DESIGN: The study uses a difference-in-difference design to compare changes in cost and utilization outcomes between program participants and propensity score-matched nonparticipants. Comparisons of measured savings are made based on (1) stable versus dynamic population enrollment and (2) all eligible versus enrolled-only participant definitions. Options for the operationalization of time are also discussed. DATA COLLECTION/EXTRACTION METHODS: Individual-level Medicaid administrative and claims data and PHM program records are used to match study groups on baseline risk factors and assess changes in costs and utilization. PRINCIPAL FINDINGS: Savings estimates are statistically similar but smaller in magnitude when eliminating variability based on duration of population enrollment and when evaluating program impact on the entire target population. Measurement in calendar time, when possible, simplifies interpretability. CONCLUSION: Program evaluation design elements, including population stability and participant definitions, can influence the estimated magnitude of program savings for the payer and should be considered carefully. Time specifications can also affect interpretability and usefulness.

Association of a Care Coordination Model With Health Care Costs and Utilization: The Johns Hopkins Community Health Partnership (J-CHiP).

Importance: The Johns Hopkins Community Health Partnership was created to improve care coordination across the continuum in East Baltimore, Maryland. Objective: To determine whether the Johns Hopkins Community Health Partnership (J-CHiP) was associated with improved outcomes and lower spending. Design, Setting, and Participants: Nonrandomized acute care intervention (ACI) and community intervention (CI) Medicare and Medicaid participants were analyzed in a quality improvement study using difference-in-differences designs with propensity score-weighted and matched comparison groups. The study spanned 2012 to 2016 and took place in acute care hospitals, primary care clinics, skilled nursing facilities, and community-based organizations. The ACI analysis compared outcomes of participants in Medicare and Medicaid during their 90-day postacute episode with those of a propensity score-weighted preintervention group at Johns Hopkins Community Health Partnership hospitals and a concurrent comparison group drawn from similar Maryland hospitals. The CI analysis compared changes in outcomes of Medicare and Medicaid participants with those of a propensity score-matched comparison group of local residents. Interventions: The ACI bundle aimed to improve transition planning following discharge. The CI included enhanced care coordination and integrated behavioral support from local primary care sites in collaboration with community-based organizations. Main Outcomes and Measures: Utilization measures of hospital admissions, 30-day readmissions, and emergency department visits; quality of care measures of potentially avoidable hospitalizations, practitioner follow-up visits; and total cost of care (TCOC) for Medicare and Medicaid participants. Results: The CI group had 2154 Medicare beneficiaries (1320 [61.3%] female; mean age, 69.3 years) and 2532 Medicaid beneficiaries (1483 [67.3%] female; mean age, 55.1 years). For the CI group's Medicaid participants, aggregate TCOC reduction was $24.4 million, and reductions of hospitalizations, emergency department visits, 30-day readmissions, and avoidable hospitalizations were 33, 51, 36, and 7 per 1000 beneficiaries, respectively. The ACI group had 26 144 beneficiary-episodes for Medicare (13 726 [52.5%] female patients; mean patient age, 68.4 years) and 13 921 beneficiary-episodes for Medicaid (7392 [53.1%] female patients; mean patient age, 52.2 years). For the ACI group's Medicare participants, there was a significant reduction in aggregate TCOC of $29.2 million with increases in 90-day hospitalizations and 30-day readmissions of 11 and 14 per 1000 beneficiary-episodes, respectively, and reduction in practitioner follow-up visits of 41 and 29 per 1000 beneficiary-episodes for 7-day and 30-day visits, respectively. For the ACI group's Medicaid participants, there was a significant reduction in aggregate TCOC of $59.8 million and the 90-day emergency department visit rate decreased by 133 per 1000 episodes, but hospitalizations increased by 49 per 1000 episodes and practitioner follow-up visits decreased by 70 and 182 per 1000 episodes for 7-day and 30-day visits, respectively. In total, the CI and ACI were associated with $113.3 million in cost savings. Conclusions and Relevance: A care coordination model consisting of complementary bundled interventions in an urban academic environment was associated with lower spending and improved health outcomes.

Is bigger always better? The optimal size of a group practice.

The past decade saw several attempts to consolidate physician practices, but this sector remains one of the last cottage industries in the United States. This article develops a framework for analyzing the optimal size of a physician practice. The framework addresses technological factors (e.g., economies of scale and scope), behavioral factors (e.g., changing physician goals, costs of organizing and operating a practice), and market-driven factors (e.g., managed care contracting). Existing empirical research suggests three "optimal" sizes of practices: 5-10 physicians, based on economies of scale and decision-making; 20-30 physicians, based on economies of scope and initial development of a corporate structure; and 80+ (multi-specialty) physicians, which can create an system of referrals and utilization. The article concludes with observations about the challenges to physician practices as they grow.

Outcomes of a program in business education for physicians and other health care professionals.

BACKGROUND: We sought to determine the expectations that graduates of one business of medicine program had upon enrollment and to ascertain fulfillment of those expectations after completion, as well as the extent to which participating in the program improved business skills and led to advancement in office practice or career development. METHODS: A postal mail survey was conducted of graduates of The Johns Hopkins University's Business of Medicine Program, a year-long, four-course certificate program to educate midcareer academic and nonacademic physicians and other health care professionals about fundamental business practices and their application to health care. RESULTS: Surveys were sent to 285 graduates, and responses were received from 136 (48%) of them. Most respondents expected the program to expand their management skills, to enhance their knowledge of marketplace trends, and to advance their careers. These results were not correlated with respondents' age, sex, or profession (ie, physician, non-physician). More than 87% of respondents agreed that their overall expectations had been fulfilled by the time they completed the survey. Participants noted, however, that several expectations were unfulfilled upon replying to the survey. CONCLUSION: Programs designed to educate physicians and other health care professionals--in private practice, academia, or industry--about the business aspects of medicine can be effective but need to be designed carefully to integrate business theory and application to the medical setting.