Disparate Practice Patterns and Survival Outcomes: The Impact of Centralization of Cancer Care for Adrenocortical Carcinoma in the United States.

PURPOSE: Adrenocortical carcinoma is a rare but aggressive malignancy. While centralization of care to referral centers improves outcomes across common urological malignancies, there exists a paucity of data for low-incidence cancers. We sought to evaluate differences in practice patterns and overall survival in patients with adrenocortical carcinoma across types of treating facilities. MATERIALS AND METHODS: We identified all patients diagnosed with adrenocortical carcinoma from 2004-2016 in the National Cancer Database. The Kaplan-Meier method was used to evaluate overall survival and multivariable Cox regression analysis was used to investigate independent predictors of overall survival. The chi-square test was used to analyze differences in practice patterns. RESULTS: We identified 2,886 patients with adrenocortical carcinoma. Median overall survival was 21.8 months (95% CI 19.8-23.8). Academic centers had improved overall survival versus community centers on unadjusted Kaplan-Meier analysis (p <0.05) and had higher rates of adrenalectomy or radical en bloc resection (p <0.001), performed more open surgery (p <0.001), administered more systemic therapy (p <0.001) and had lower rates of positive surgical margins (p=0.03). On multivariable analysis, controlling for treatment modality, academic centers were associated with significantly decreased risk of death (HR 0.779, 95% CI 0.631-0.963, p=0.021). CONCLUSIONS: Treatment of adrenocortical carcinoma at an academic center is associated with improved overall survival compared to community programs. There are significant differences in practice patterns, including more aggressive surgical treatment at academic facilities, but the survival benefit persists on multivariable analysis controlling for treatment modality. Further studies are needed to identify the most important predictors of survival in this at-risk population.

Provider-owned insurers in the individual market.

OBJECTIVES: To describe the number and availability of individual market plans sold by provider-owned insurers and compare differences in premiums between traditional and provider-owned insurers. STUDY DESIGN: Cross-sectional analysis. METHODS: Using the Robert Wood Johnson Foundation's HIX Compare data, we identified insurers selling Affordable Care Act (ACA)-compliant policies in the individual market and identified those insurers owned by health systems by using information on their websites. We determined the number of insurers selling policies in each market and the size of the population living in areas where provider-owned insurers sold plans in 2016 and 2017. We used least squares regression to compare premiums between traditional and provider-owned insurers within markets, and we adjusted standard errors for clustering at the market and insurer level. RESULTS: There were 149 insurers that sold ACA-compliant plans in 2017, of which 51 were provider owned. Provider-owned insurers operated in 208 of the 503 exchange markets. We estimate that about 62% of US residents (more than 170 million people) live in a market in which a provider-owned insurer sells plans. Premiums did not differ significantly between traditional and provider-owned plans in 2017. CONCLUSIONS: Provider-owned insurers play a prominent role in the individual insurance market. Although health systems that sell insurance have incentives to reduce costs, provider-owned insurers and traditional insurers have similar premiums.

Assessing the Financial Condition of Provider-Sponsored Health Plans.

PURPOSE: The aim of this study was to assess the performance of health plans sponsored by provider organizations, with respect to plans generating strong positive cash flow relative to plans generating weaker cash flow. A secondary aim was to assess their capital adequacy. DESIGN: The study identified 24 provider-sponsored health plans (PSHPs) with an average positive cash flow margin from 2011 through 2013 at or above the top 75th percentile, defined as "strong cash flow PSHPs:" This group was compared with 72 PSHPs below the 75th percentile, defined as "weak cash flow PSHPs:" METHODOLOGY: Atlantic Information Services Directory of Health Plans was used to identify the PSHPs. Financial ratios were computed from 2013 National Association of Insurance Commissioners Financial Filings. The study conducted a t test mean comparison between strong and weak cash flow PSHPs across an array of financial performance and capital adequacy measures. RESULTS: In 2013, the strong cash flow PSHPs averaged a cash-flow margin ratio of 6.6%. Weak cash flow PSHPs averaged a cash-flow margin of -0.4%. The net worth capital position of both groups was more than 4.5 times authorized capital. CONCLUSION: The operational analysis shows that strong cash-flow margin PSHPs are managing their medical costs to achieve this position. Although their medical loss ratio increased by almost 300 basis points from 2011 to 2013, it was still statistically significantly lower than the weaker cash flow PSHP group (P<.001). In terms of capital adequacy, both strong and weak cash-flow margin PSHP groups possessed sufficient capital to ensure the viability of these plans.

New partnership opportunities for payers and providers.

Healthcare finance executives should consider several key factors when forming partnerships with physicians and insurers: Market expansion opportunities. Resources. Risk sharing. Capturing created value. Market response.

Why are health plans buying physician groups?

Most insurers say they have no intention of buying doc practices. Those that have done so, say it's just one tool in their accountable care strategy.

Current market trends in hospital/physician integration.

This article explores recent trends that are dramatically changing the landscape of typical hospital/physician integration models and provides the reader with useful insights to better evaluate this dynamically changing marketplace.

A physicians' agenda for partnering with employers and insurers: fresh ideas.

We report the results of the second phase of a multiphase qualitative investigation of the ways physicians, employers, and insurers can work together more effectively to provide better ambulatory care to employees and their dependents. This article focuses on ways physicians can develop more useful relationships among these groups. We used a grounded theory approach to conduct 71 interviews from August 12, 2004, to December 27, 2005, with 25 practicing physicians in large and small groups, urban and rural areas, private and academic settings, and primary care and specialty practices; 33 hospital administrators, medical association executives, health insurance medical officers, and health policy analysts; and 13 senior executives of large and small companies. The study identifies 2 approaches to the structuring of ambulatory care that can lead to improved health care outcomes and value. In the first approach, direct contracting between physicians and employers transfers tasks previously performed by insurers to employers or other intermediaries who may be able to provide better service or lower cost. In the second approach, insurer-mediated relationships between physicians and employers are restructured, particularly in ways that improve information flow. Such relationships may strengthen physicians' ability to provide quality services while enabling patients to make more informed decisions about physician selection, treatments, and spending. We believe that broader use of these approaches may improve the quality and efficiency of ambulatory care for the large proportion of the population that has work-related health insurance. Although the findings are promising, our intent is not to claim broad external validity but rather to encourage greater experience with these approaches and more formal studies of their effectiveness.

Brief report: The prevalence and use of chronic disease registries in physician organizations. A national survey.

OBJECTIVE: Disease registries are lists of patients with a particular chronic illness, including clinical information, to improve the care of individuals and populations. The objective of this study was to determine the prevalence of disease registries in physician organizations and the extent to which they are used to improve care. DESIGN: A cross-sectional national telephone survey with a response rate of 70%. SETTING: All physician organizations in the United States with 20 physicians or more. PARTICIPANTS: Chief executive officers, presidents, or medical directors of 1040 physician organizations. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Forty-seven percent of organizations reported having a registry for at least 1 chronic illness, with diabetes registries being the most common. Half (51%) of the registries were not linked to clinical data. Organizations with at least 1 registry were more likely to have implemented other chronic care improvements (P < .0001). Factors associated with the presence of registries in physician organizations include external incentives for quality and extent of information technology capabilities. CONCLUSIONS: Disease registries are not utilized by half of physician organizations. This finding is disturbing because registries have the potential to catalyze needed improvement in chronic care management.

Why provider-sponsored plans' admin cost are lower than commercial, Blue Cross plans.

Why do provider-sponsored health plans have 20% lower administrative expenses than Blue Cross commercial plans? Here's some detailed data that you can use to benchmark your own administrative costs.

Health promotion in physician organizations: results from a national study.

BACKGROUND: Health promotion programs can be effective in improving the delivery of clinical preventive services and in improving population health; however, the availability of health promotion programs offered through physician organizations, such as medical groups and independent practice associations, are largely unknown. METHODS: This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California, Berkeley, to document the extent to which physician organizations offer health promotion programs. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%. RESULTS: Overall, 60% of physician organizations offer at least one health promotion program targeting one or more of eight areas: prenatal education (42%), smoking cessation (39%), nutrition (39%), weight loss (34%), health risk assessments (25%), stress management (25%), substance abuse (20%), and sexually transmitted disease prevention (16%). Factors positively associated with offering health promotion programs include the following: outside reporting of quality measures, public recognition for quality measures, clinical information technology systems, being a medical group, and ownership by a hospital or health plan. CONCLUSIONS: Physician organizations in the United States have a long way to go in offering these important programs to their patients. However, our findings also suggest that health plans, purchasers, and policymakers can play a positive role in increasing the use of these programs. By offering recognition and incentives for quality improvement, and by funding the expansion of information technology, the healthcare community can encourage and enable physician organizations to increase the availability of health promotion programs nationally.

Managed care arrangements of health networks and systems. A review of the 1999 experience.

The 1990s witnessed various health provider efforts to integrate health care delivery with financing functions. Physician and hospital-led organizations developed their own insurance products and also contracted on a capitated or shared-risk basis with health maintenance organizations (HMOs). Several studies exist on the efforts of physician-led health organizations in these areas, but few studies exist on hospital-led organizations. We examined unique data on hospital-led health networks and systems for 1999 and found that about 60% had provider-owned insurance products and 50% held capitated contracts for their affiliates. In addition, these hospital-led organizations--especially health systems--had comparable levels of capitated contracting when compared to physician-led organizations. Although interest in capitation has waned, current economic realities may reignite interest in these arrangements given their potential for containing health expenditures without increasing consumer risk. In light of this, it is now a good time for physicians and medical group managers to reflect on their experiences in the 1990s and to assess the merits and shortcomings of different intermediary organizations with which they may align.