The Complex Relationship Between Quality and Resource Use Among Medicare Fee-for-Service Beneficiaries with Diabetes.

This study examines the relationship between Healthcare Effectiveness Data and Information Set-based diabetes quality measures and resource use for evaluation and management (E&M), inpatient facility, and surgical procedure services for a national sample of Medicare fee-for-service beneficiaries in 1685 Hospital Service Areas. Using multivariate regression analyses, the study findings suggest that higher rates of beneficiaries' receipt of HbA1c, low-density lipoprotein cholesterol, and retinal eye exam tests ("composite quality") during the year is inversely related to average inpatient resource use. However, no association is found between composite quality and E&M services, suggesting that quality improvement with respect to increased rates of testing could be achieved without significant increases in resource use.

The relationships of physician practice characteristics to quality of care and costs.

BACKGROUND: Medical group practices are central to many of the proposals for health care reform, but little is known about the relationship between practice-level characteristics and the quality and cost of care. METHODS: Practice characteristics from a 2009 national survey of 211 group practices were linked to Medicare claims data for beneficiaries attributed to the practices. Multivariate regression was used to examine the relationship between practice characteristics and claims-computable measures of screening and monitoring, avoidable utilization, risk-adjusted per-beneficiary per-year (PBPY) costs, and the practice's net revenue. RESULTS: Several characteristics of group practices are predictive of screening and monitoring measures. Those measures, in turn, are predictive of lower values of avoidable utilization measures that contribute to higher PBPY costs. The effects of group practice characteristics on avoidable utilization, cost, and practice net revenue appear to work primarily through improved screening and monitoring. CONCLUSIONS: Practice characteristics influence costs indirectly through a set of statistically significant relationships among screening and monitoring measures and avoidable utilization. However, these relationships are not the only pathways connecting practice characteristics to cost and those additional pathways contain substantial "noise" adding uncertainty to the estimated direct effects. Some of the attributes thought to be important characteristics of accountable care organizations and medical homes appear to be associated with lower quality and no improvement in cost.

Value-based purchasing for physician services.

Growth in Medicare expenditures has forced legislators and policymakers to look for ways to slow spending and get more value for their money. This article reviews previous federal efforts to control Medicare costs as well as current ones required by the Patient Protection and Affordable Care Act. It also describes a proposal for value-based purchasing that the authors developed under contract to the Centers for Medicare and Medicaid Services. This approach uses two measurement systems-one for physicians who practice primarily in outpatient settings and one for physicians who practice primarily in the hospital.

Variation in diabetes care quality among medicare advantage plans: understanding the role of case mix.

This study investigates whether variation in Medicare Advantage plan performance on comprehensive diabetes care is explained by the case mix of plans. Using data on 513 Medicare Advantage plan-year observations for 2007 and 2008, the authors estimate multivariate regressions for 3 diabetes care quality measures: (1) hemoglobin screening, (2) low-density lipoprotein screening, and (3) retinal eye exam. Plan case mix is measured with the percentage of a plan's enrollees who have type 1 diabetes with and without comorbidities and the percentage of a plan's enrollees who have type 2 diabetes with and without comorbidities. Plans with a higher percentage of enrollees with type 1 diabetes with comorbidity and plans with a higher percentage of enrollees with type 2 diabetes without comorbidity have lower performance, on average. Finding evidence of a relationship between case mix and Healthcare Effectiveness Data and Information Set performance reinforces the argument for developing standardized risk adjustment or stratification methods in public reporting and pay-for-performance efforts.

Best practice implementation: lessons learned from 20 partnerships.

BACKGROUND: Partnerships can facilitate effective implementation of best practices, but literature describing effective and ineffective strategies to address barriers to implementation in partnerships is lacking. METHODS: Principal investigators (PIs) were surveyed to identify barriers to best practice implementation, rank their significance, and articulate the success and failure of solutions attempted. RESULTS: The top four categories of barriers to implementation were partnership challenges, practitioner/local organization variables, time frame challenges, and financial concerns. Ninety-eight effective and 38 ineffective solutions used to overcome these barriers were identified. The most common categories of successful solutions were flexibility of interventions to align with unique local characteristics, schedules, and budgets (36.7% of listed successful solutions); communication strategies that emphasize frequent bidirectional information exchange in person (26.5%); and thoughtful use of personnel emphasizing sites' senior leadership and centralized quality and analytic content expertise (16.3%). DISCUSSION: Despite substantial partnership diversity, consistent themes related to barriers to implementation and solutions to these barriers emerged. The successful and unsuccessful solutions provided should be proactively assessed to enhance the likelihood of future partnership success.

Physician pay-for-performance. Implementation and research issues.

Recent research underscores the gaps that exist between evidence-based medical practices and the care that many patients actually receive. Recognizing this, large purchasers are experimenting with new reimbursement arrangements called pay-for-performance (P4P) that tie a portion of payments for physician services to measures of quality. Agency theory, from the discipline of economics, provides a perspective on the challenges P4P is likely to encounter. The focus of most P4P initiatives on medical group performance raises additional questions about its potential effectiveness as a catalyst for change.

Physician use of disease management programs.

This paper examines differences in availability, use, and perceived usefulness of disease management programs as reported by generalist and specialist physicians functioning as primary care providers in health plans. Implications of these differences are discussed in terms of the three types of purchasers: private insurers, Medicare, and Medicaid. The design is a cross-sectional mail and telephone mixed-mode survey. The data come from 23 health plans in five states (Florida, New York, Colorado, Pennsylvania, and Washington), including six metropolitan areas: Seattle, New York City, Miami, Pittsburgh, Philadelphia, and Denver. The study participants are 1,244 generalist and specialist physicians who contracted with health plans as primary care providers. They were drawn from a 2001 mail and telephone survey of 2,105 generalist and 1,693 specialist physicians serving commercial, Medicaid, and Medicare patients. Physician responses about use of disease management for their patients in the health plan and how useful they thought it was were regressed on physician, physician organization, and physician-health plan relationship characteristics. While generalist physicians are likely to report having disease management programs available and using them, specialists vary greatly in their response to the disease management programs. In contrast to physicians associated with commercial plans, implementation of disease management programs among physicians associated with Medicaid plans varied across states. Primary care providers trained in generalist areas of practice are more likely than specialists functioning as primary care providers to report that disease management programs are available and to use them. They also find them more useful than do specialists.

Health-Based Capitation Risk Adjustment in Minnesota Public Health Care Programs.

This article documents the history and implementation of health-based capitation risk adjustment in Minnesota public health care programs, and identifies key implementation issues. Capitation payments in these programs are risk adjusted using an historical, health plan risk score, based on concurrent risk assessment. Phased implementation of capitation risk adjustment for these programs began January 1, 2000. Minnesota's experience with capitation risk adjustment suggests that: (1) implementation can accelerate encounter data submission, (2) administrative decisions made during implementation can create issues that impact payment model performance, and (3) changes in diagnosis data management during implementation may require changes to the payment model.

Evaluating health plan quality 1: a conceptual model.

OBJECTIVE: To develop a theoretical foundation for measuring health plan quality from a physician's perspective. STUDY DESIGN: Literature review and theory development. METHODS: We defined health plan quality as the degree to which health plan management practices increase the likelihood of high-quality care for individuals and populations and addressed the ways in which health plan quality is similar to, and different from, other commonly used quality measures. Based on an assessment of the literature, we proposed a conceptual model that organizes health plan care management practices into a coherent structure for measuring health plan quality. RESULTS: A conceptual model of health plan operation that organizes managerial practices into a structure for measuring health plan quality from a physician's perspective was developed. CONCLUSION: Health plan quality is distinct from quality of care, and physicians can provide unique, timely, and reliable information about aspects of health plan quality.

Evaluating health plan quality 2: survey design principles for measuring health plan quality.

OBJECTIVE: To develop principles for measuring the quality of specific health plans from a physician's perspective. STUDY DESIGN: Literature review, expert review, cognitive interviews. METHODS: We did a literature review on the use of physician surveys about managed care to determine the contributions and weaknesses of those surveys. Then, an expert review of prior survey efforts to measure health plan quality from the physician's perspective was performed. RESULTS: A survey instrument based on a conceptual model of health plan quality was developed. Its purpose was to measure health plan quality from the physician's perspective. Principles for surveying physicians guided the structure of the survey. CONCLUSION: Survey instruments can be designed to take into account a physician's unique perspective on health plan quality and can include measures that control for potential biases such as anti-managed care bias.

Evaluating health plan quality 3: survey measurement properties.

OBJECTIVE: To assess the measurement and scaling properties of survey items designed to measure health plan quality from a physician's perspective. STUDY DESIGN: Prospective survey design with multivariate regression analysis. METHODS: Data were from 3798 physicians representing 23 health plans in 5 regions: Florida, New York, Colorado, Pennsylvania, and Washington. Scale reliability was assessed by using the Cronbach alpha. Generalist and specialist scales were compared with structural equation modeling. Multivariate analysis was used to examine internal validity by testing theoretically based hypotheses. RESULTS: Scales constructed from the data were reliable, were stable across both generalist and specialist physicians, and demonstrated construct validity. Hypotheses about the relationship between physician experiences with a health plan and physician recommendations of the plan were confirmed, supporting construct validity. CONCLUSION: The items on the survey instrument can be used with confidence to measure health plan quality from a physician perspective.