Enabling System Functionalities of Primary Care Practices for Team Dynamics in Transformation to Team-Based Care: A Qualitative Comparative Analysis (QCA).

Team-based primary care has been shown to be an important initiative for transforming primary care to achieve whole-person care, enhance health equity, and reduce provider burnout. Organizational approaches have been explored to better implement team-based care but a thorough understanding of the role of system functions is lacking. We aimed to identify the combinations of system functionalities in primary care practices that most enable effective teamwork. We used a novel method, qualitative comparative analysis (QCA), to identify cross-case patterns in 19 primary care practices in the Harvard Academic Innovations Collaborative (AIC), an initiative for transforming primary care practices by establishing teams and implementing team-based care. QCA findings identified that primary care practices with strong team dynamics exhibited strengths in three operational care process functionalities, including management of abnormal test results, cancer screening and medication management for high-priority patients, care transitions, and in health information technology (HIT) functionality. HIT functionality alone was not sufficient to achieve the desired outcomes. System functionalities in a primary care practice that support physicians and their teams in identifying patients with urgent and complex acute illnesses requiring immediate response and care and overcoming barriers to collaboration within and across institutional settings, may be essential for sustaining strong team-based primary care.

Value-Based Purchasing Design And Effect: A Systematic Review And Analysis.

During the past two decades in the United States, all major payer types-commercial, Medicare, Medicaid, and multipayer coalitions-have introduced value-based purchasing (VBP) contracts to reward providers for improving health care quality while reducing spending. This systematic review qualitatively characterized the financial and nonfinancial features of VBP programs and examined how such features combine to create a level of program intensity that relates to desired quality and spending outcomes. Higher-intensity VBP programs are more frequently associated with desired quality processes, utilization measures, and spending reductions than lower-intensity programs. Thus, although there may be reasons for payers and providers to opt for lower-intensity programs (for example, to increase voluntary participation), these choices apparently have consequences for spending and quality outcomes.

Difficulty Obtaining Behavioral Health Services for Children: A National Survey of Multiphysician Practices.

PURPOSE: In the United States, primary care practices rely on scarce resources to deliver evidence-based care for children with behavioral health disorders such as depression, anxiety, other mental illness, or substance use disorders. We estimated the proportion of practices that have difficulty accessing these resources and whether practices owned by a health system or participating in Medicaid accountable care organizations (ACOs) report less difficulty. METHODS: This national cross-sectional study examined how difficult it is for practices to obtain pediatric (1) medication advice, (2) evidence-based psychotherapy, and (3) family-based therapy. We used the National Survey of Healthcare Organizations and Systems 2017-2018 (46.9% response rate), which sampled multiphysician primary and multispecialty care practices including 1,410 practices that care for children. We characterized practices' experience as "difficult" relative to "not at all difficult" using a 4-point ordinal scale. We used mixed-effects generalized linear models to estimate differences comparing system-owned vs independent practices and Medicaid ACO participants vs nonparticipants, adjusting for practice attributes. RESULTS: More than 85% of practices found it difficult to obtain help with evidence-based elements of pediatric behavioral health care. Adjusting for practice attributes, the percent experiencing difficulty was similar between system-owned and independent practices but was less for Medicaid ACO participants for medication advice (81% vs 89%; P = .021) and evidence-based psychotherapy (81% vs 90%; P = .006); differences were not significant for family-based treatment (85% vs 91%; P = .107). CONCLUSIONS: Most multiphysician practices struggle to obtain advice and services for child behavioral health needs, which are increasing nationally. Future studies should investigate the source of observed associations.

Patterns of Use of a Price Transparency Tool for Childbirth Among Pregnant Individuals With Commercial Insurance.

Importance: When introduced a decade ago, patient-facing price transparency tools had low use rates and were largely not associated with changes in spending. Little is known about how such tools are used by pregnant individuals in anticipation of childbirth, a shoppable service with increasing out-of-pocket spending. Objective: To measure changes over time in the patterns and characteristics of use of a price transparency tool by pregnant individuals, and to identify the association between price transparency tool use, coinsurance, and childbirth spending. Design, Setting, and Participants: This descriptive cross-sectional study of 2 cohorts used data from a US commercial health insurance company that launched a web-based price transparency tool in 2010. Data on all price transparency tool queries for 2 periods (January 1, 2011, to December 31, 2012, and January 1, 2015, to December 31, 2016) were obtained. The sample included enrollees aged 19 to 45 years who had a delivery episode during 2 periods (November 1, 2011, to December 31, 2012, or November 1, 2015, to December 31, 2016) and were continuously enrolled for the 10 months prior to delivery (N = 253 606). Exposures: Access to a web-based price transparency tool that provided individualized out-of-pocket price estimates for vaginal and cesarean deliveries. Main Outcomes and Measures: The primary outcomes were searches on the price transparency tool by delivery mode (vaginal or cesarean), timing (first, second, or third trimester), and individual characteristics (age at childbirth, rurality, pregnancy risk status, coinsurance exposure, area educational attainment, and area median household income). Another outcome was the association of out-of-pocket childbirth spending with price transparency tool use. Results: The sample included 253 606 pregnant individuals, of whom 131 224 (51.7%) were in the 2011 to 2012 cohort and 122 382 (48.3%) were in the 2015 to 2016 cohort. In the 2015 to 2016 cohort, the mean (SD) age was 31 years (5.2 years) and most individuals had coinsurance for delivery (94 251 [77.0%]). Price searching increased from 5.9% in the 2011 to 2012 cohort to 13.0% in the 2015 to 2016 cohort. In the 2015 to 2016 cohort, 43.9% of searchers' first price query was in their first trimester. The adjusted probability of searching was lower for individuals with a high-risk pregnancy due to a previous cesarean delivery (11.5%; 95% CI, 11.0%-12.1%) vs individuals with low-risk pregnancy (13.4%; 95% CI, 12.9%-14.0%). Use increased monotonically with coinsurance, from 9.2% (95% CI, 8.7%-9.8%) among individuals with no coinsurance to 15.0% (95% CI, 14.4%-15.5%) among individuals with 11% or higher coinsurance. After adjusting for covariates, searching was positively associated with out-of-pocket delivery episode spending. Among patients with 11% coinsurance or higher, early and late searchers spent more out of pocket ($59.57 [95% CI, $33.44-$85.96] and $73.33 [95% CI, $32.04-$115.29], respectively), compared with never searchers. Conclusions and Relevance: The results of this cross-sectional study indicate that the proportion of pregnant individuals who sought price information before childbirth more than doubled within the first 6 years of availability of a price transparency tool. These findings suggest that price information may help individuals anticipate their out-of-pocket childbirth costs.

Availability of Pediatric Inpatient Services in the United States.

OBJECTIVES: We sought to evaluate trends in pediatric inpatient unit capacity and access and to measure pediatric inpatient unit closures across the United States. METHODS: We performed a retrospective study of 4720 US hospitals using the 2008-2018 American Hospital Association survey. We used linear regression to describe trends in pediatric inpatient unit and PICU capacity. We compared trends in pediatric inpatient days and bed counts by state. We examined changes in access to care by calculating distance to the nearest pediatric inpatient services by census block group. We analyzed hospital characteristics associated with pediatric inpatient unit closure in a survival model. RESULTS: Pediatric inpatient units decreased by 19.1% (34 units per year; 95% confidence interval [CI] 31 to 37), and pediatric inpatient unit beds decreased by 11.8% (407 beds per year; 95% CI 347 to 468). PICU beds increased by 16.0% (66.9 beds per year; 95% CI 53 to 81), primarily at children's hospitals. Rural areas experienced steeper proportional declines in pediatric inpatient unit beds (-26.1% vs -10.0%). Most states experienced decreases in both pediatric inpatient unit beds (median state -18.5%) and pediatric inpatient days (median state -10.0%). Nearly one-quarter of US children experienced an increase in distance to their nearest pediatric inpatient unit. Low-volume pediatric units and those without an associated PICU were at highest risk of closing. CONCLUSIONS: Pediatric inpatient unit capacity is decreasing in the United States. Access to inpatient care is declining for many children, particularly those in rural areas. PICU beds are increasing, primarily at large children's hospitals. Policy and surge planning improvements may be needed to mitigate the effects of these changes.

Pediatric Primary Care-Based Social Needs Services and Health Care Utilization.

OBJECTIVE: To evaluate the relationship between use of primary care-based social needs services and subsequent utilization of ambulatory, emergency, and inpatient services. METHODS: This retrospective 2012 to 2015 cohort study uses electronic medical record data from an academic pediatric primary care practice that screens universally for social needs and delivers services via in-house social work staff. Logistic regression (N = 7300) examines how patient characteristics relate to practice-based social service use. Negative binomial models with inverse probability of treatment weights (N = 4893) estimate adjusted incidence rate ratios for ambulatory, emergency, and inpatient service use among those who used social services compared to those who did not. RESULTS: Forty-five percent of patients used primary care-based social needs services. This use was significantly greater among those with disabling or complex medical conditions than those without (adjusted odds ratio and 95% confidence interval (CI) of 9.81 [7.39-13.01] and 2.76 [2.44-3.13], respectively); those from low-income versus high-income backgrounds (1.40 [1.21-1.61]); and Blacks and Latinos than Whites (1.33 [1.09-1.62] and 1.29 [1.05-1.59], respectively). Patients who used social services subsequently utilized ambulatory, emergency, and inpatient services at significantly higher rates than those who did not (adjusted incidence rate ratios and 95% CI of 1.54 [1.45-1.63], 1.50 [1.36-1.65], and 3.23 [2.31-4.51], respectively). CONCLUSIONS: Primary care-based social needs service use was associated with increased utilization of ambulatory services without reductions in emergency or inpatient admissions. This pattern suggests increased health care needs or access and could have payment model-dependent financial implications for practices.

Suitability of elderly adult hospital readmission rates for profiling readmissions in younger adult and pediatric populations.

OBJECTIVE: To determine the correlation between hospital 30-day risk-standardized readmission rates (RSRRs) in elderly adults and those in nonelderly adults and children. DATA SOURCES/STUDY SETTING: US hospitals (n = 1760 hospitals admitting adult patients and 235 hospitals admitting both adult and pediatric patients) in the 2013-2014 Nationwide Readmissions Database. STUDY DESIGN: Cross-sectional analysis comparing 30-day RSRRs for elderly adult (≥65 years), middle-aged adult (40-64 years), young adult (18-39 years), and pediatric (1-17 years) patients. PRINCIPAL FINDINGS: Hospital elderly adult RSRRs were strongly correlated with middle-aged adult RSRRs (Pearson R2 .69 [95% confidence interval (CI) 0.66-0.71]), moderately correlated with young adult RSRRs (Pearson R2 .44 [95% CI 0.40-0.47]), and weakly correlated with pediatric RSRRs (Pearson R2 .28 [95% CI 0.17-0.38]). Nearly identical findings were observed with measures of interquartile agreement and Kappa statistics. This stepwise relationship between age and strength of correlation was consistent across every hospital characteristic. CONCLUSIONS: Hospital readmission rates in elderly adults, which are currently used for public reporting and hospital comparisons, may reflect broader hospital readmission performance in middle-aged and young adult populations; however, they are not reflective of hospital performance in pediatric populations.

Physician and facility drivers of spending variation in locoregional prostate cancer.

BACKGROUND: Prostate cancer is the most common male cancer, with a wide range of treatment options. Payment reform to reduce unnecessary spending variation is an important strategy for reducing waste, but its magnitude and drivers within prostate cancer are unknown. METHODS: In total, 38,971 men aged ≥66 years with localized prostate cancer who were enrolled in Medicare fee-for-service and were included in the Surveillance, Epidemiology, and End Results-Medicare database from 2009 to 2014 were included. Multilevel linear regression with physician and facility random effects was used to examine the contributions of urologists, radiation oncologists, and their affiliated facilities to variation in total patient spending in the year after diagnosis within geographic region. The authors assessed whether spending variation was driven by patient characteristics, disease risk, or treatments. Physicians and facilities were sorted into quintiles of adjusted patient-level spending, and differences between those that were high-spending and low-spending were examined. RESULTS: Substantial variation in spending was driven by physician and facility factors. Differences in cancer treatment modalities drove more variation across physicians than differences in patient and disease characteristics (72% vs 2% for urologists, 20% vs 18% for radiation oncologists). The highest spending physicians spent 46% more than the lowest and had more imaging tests, inpatient care, and radiotherapy spending. There were no differences across spending quintiles in the use of robotic surgery by urologists or the use of brachytherapy by radiation oncologists. CONCLUSIONS: Significant differences were observed for patients with similar demographics and disease characteristics. This variation across both physicians and facilities suggests that efforts to reduce unnecessary spending must address decision making at both levels.

Adult-Oriented Health Reform and Children's Insurance and Access to Care: Evidence from Massachusetts Health Reform.

Objective A national debate is underway about the value of key provisions within the adult-oriented Affordable Care Act (ACA)-the individual mandate, expansion of Medicaid eligibility, and essential benefits. How these provisions affect child health insurance and access to care may help us anticipate how children may be affected if the ACA is repealed. We study Massachusetts health reform because it enacted these key provisions statewide in 2006. Methods We used a difference-in-differences (DD) approach to assess the impact of Massachusetts health reform on uninsurance and access to care among children 0-17 years in Massachusetts compared to children in other New England states. The National Survey of Children's Health provided the pre-reform year and two post-reform years (1 and 5 years post-reform). We analyzed outcomes for children overall and children previously and newly-eligible for Medicaid under Massachusetts health reform, adjusting for age, sex, race/ethnicity, non-English language, and having special health care needs. Results Compared to other New England states, Massachusetts's enactment of the individual mandate, Medicaid expansion, and essential benefits was associated with trends at 5 years post-reform toward lower uninsurance for children overall (DD = - 1.1, p-for-DD = 0.05), increased access to specialty care (DD = 7.7, p-for-DD = 0.06), but also with a decrease in access to preventive care (DD=-3.4, p-for-DD = 0.004). At 1 year post-reform, access to specialty care improved for children newly-Medicaid-eligible (DD = 18.3, p-for-DD = 0.03). Conclusions for Practice Adult-oriented health reforms may have reduced uninsurance and improved access to some types of care for children in Massachusetts. Repealing the ACA may produce modest detriments for children.

Care Quality and Spending Among Commercially Insured Children With Disabilities.

OBJECTIVE: To identify opportunities to improve care value for children with disabilities (CWD), we examined CWD prevalence within a commercially insured population and compared outpatient care quality and annual health plan spending levels for CWD relative to children with complex medical conditions without disabilities; children with chronic conditions that are not complex; and children without disabling, complex, or chronic conditions. METHODS: This cross-sectional study comprised 1,118,081 person-years of Blue Cross Blue Shield Massachusetts data for beneficiaries aged 1 to 19years old during 2008 to 2012. We combined the newly developed and validated Children with Disabilities Algorithm with the Pediatric Medical Complexity Algorithm to identify CWD and non-CWD subgroups. We used 14 validated or National Quality Forum-endorsed measures to assess outpatient care quality and paid claims to examine annual plan spending levels and components. RESULTS: CWD constituted 4.5% of all enrollees. Care quality for CWD was between 11% and 59% for 8 of 14 quality measures and >80% for the 6 remaining measures and was generally comparable to that for non-CWD subgroups. Annual plan spending among CWD was a median and mean 23% and 53% higher than that for children with complex medical conditions without disabilities, respectively; CWD mean and median values were higher than for all other groups as well. CONCLUSIONS: CWD were prevalent in our commercially insured population. CWD experienced suboptimal levels of care, but those levels were comparable to non-CWD groups. Improving the care value for CWD involves a deeper understanding of what higher spending delivers and additional aspects of care quality.

What drives variation in spending for breast cancer patients within geographic regions?

OBJECTIVE: To estimate and describe factors driving variation in spending for breast cancer patients within geographic region. DATA SOURCE: Surveillance, Epidemiology, and End Results (SEER)-Medicare database from 2009-2013. STUDY DESIGN: The proportion of variation in monthly medical spending within geographic region attributed to patient and physician factors was estimated using multilevel regression models with individual patient and physician random effects. Using sequential models, we estimated the contribution of differences in patient and disease characteristics or use of cancer treatment modalities to patient-level and physician-level variance in spending. Services associated with high spending physicians were estimated using linear regression. DATA EXTRACTION METHOD: A total of 20 818 women with a breast cancer diagnosis in 2010-2011. PRINCIPAL FINDINGS: We observed substantial between-patient and between-provider variation in spending following diagnosis and at the end-of-life. Immediately following diagnosis, 48% of between-patient and 31% of between-physician variation were driven by differences in delivery of cancer treatment modalities to similar patients. At the end-of-life, patients of high spending physicians had twice as many inpatient days, double the chemotherapy spending, and slightly more hospice days. CONCLUSIONS: Similar patients receive very different treatments, which yield significant differences in spending. Efforts to reduce unwanted variation may need to target treatment choices within patient-doctor discussions.

Association of Team-Based Primary Care With Health Care Utilization and Costs Among Chronically Ill Patients.

Importance: Empirical study findings to date are mixed on the association between team-based primary care initiatives and health care use and costs for Medicaid and commercially insured patients, especially those with multiple chronic conditions. Objective: To evaluate the association of establishing team-based primary care with patient health care use and costs. Design, Setting, and Participants: We used difference-in-differences to compare preutilization and postutilization rates between intervention and comparison practices with inverse probability weighting to balance observable differences. We fit a linear model using generalized estimating equations to adjust for clustering at 18 academically affiliated primary care practices in the Boston, Massachusetts, area between 2011 and 2015. The study included 83 953 patients accounting for 138 113 patient-years across 18 intervention practices and 238 455 patients accounting for 401 573 patient-years across 76 comparison practices. Data were analyzed between April and August 2018. Exposures: Practices participated in a 4-year learning collaborative that created and supported team-based primary care. Main Outcomes and Measures: Outpatient visits, hospitalizations, emergency department visits, ambulatory care-sensitive hospitalizations, ambulatory care-sensitive emergency department visits, and total costs of care. Results: Of 322 408 participants, 176 259 (54.7%) were female; 64 030 (19.9%) were younger than 18 years and 258 378 (80.1%) were age 19 to 64 years. Intervention practices had fewer participants, with 2 or more chronic conditions (n = 51 155 [37.0%] vs n = 186 954 [46.6%]), more participants younger than 18 years (n = 337 931 [27.5%] vs n = 74 691 [18.6%]), higher Medicaid enrollment (n = 39 541 [28.6%] vs n = 81 417 [20.3%]), and similar sex distributions (75 023 women [54.4%] vs 220 097 women [54.8%]); however, after inverse probability weighting, observable patient characteristics were well balanced. Intervention practices had higher utilization in the preperiod. Patients in intervention practices experienced a 7.4% increase in annual outpatient visits relative to baseline (95% CI, 3.5%-11.3%; P < .001) after adjusting for patient age, sex, comorbidity, zip code level sociodemographic characteristics, clinician characteristics, and plan fixed effects. In a subsample of patients with 2 or more chronic conditions, there was a statistically significant 18.6% reduction in hospitalizations (95% CI, 1.5%-33.0%; P = .03), 25.2% reduction in emergency department visits (95% CI, 6.6%-44.0%; P = .007), and a 36.7% reduction in ambulatory care-sensitive emergency department visits (95% CI, 9.2%-64.0%; P = .009). Among patients with less than 2 comorbidities, there was an increase in outpatient visits (9.2%; 95% CI, 5.10%-13.10%; P < .001), hospitalizations (36.2%; 95% CI, 12.2-566.6; P = .003), and ambulatory care-sensitive hospitalizations (50.6%; 95% CI, 7.1%-329.2%; P = .02). Conclusions and Relevance: While establishing team-based care was not associated with differences in the full patient sample, there were substantial reductions in utilization among a subset of chronically ill patients. Team-based care practice transformation in primary care settings may be a valuable tool in improving the care of sicker patients, thereby reducing avoidable use; however, it may lead to greater use among healthier patients.

Assessment of Hospitalist-Subspecialist Agreement About Who Should Be in Charge and Comparison With Actual Assignment Practices.

BACKGROUND: A key juncture in patient hospitalization is determining which type of physician should be primarily responsible for directing treatment. We (1) examine the frequency hospitalists and subspecialists agree on preferred assignments and (2) compare preferred assignment with actual assignment. METHODS: Using a mixed methods approach, we first surveyed 66 physicians in 8 specialties about hospitalist assignments versus subspecialist assignments for 176 diagnoses at an academic children's hospital. Agreement was calculated by using the interrater reliability coefficient, Pi . We subsequently compared survey responses to actual hospitalization data from January 2009 to August 2015. RESULTS: Specialty and physician response rates were 100% and 44%, respectively. For preferred assignment among hospitalists and specialists, some diagnoses (eg, gastroesophageal reflux, syncope) experienced high agreement (π = 0.714-1.000); other diagnoses (eg, Guillain-Barre, encephalopathy) had less agreement (π = 0.000-0.600). Hematologists and oncologists agreed among themselves most frequently (73%); endocrinologists agreed among themselves least frequently (9%). Perceptions of agreement were often higher than actual survey results. Of the 25 highest volume diagnoses, 7 were conditions with consensus (Pi ≥ 0.6) about assignment, and of those conditions, 6 were assigned to a subspecialist at least 50% of the time, although consensus indicated a hospitalist should have been assigned (1597 hospitalizations). CONCLUSIONS: This is the first study used to analyze preferences of hospitalist-subspecialist assignment and show variation from actual practice. Although physicians assessed the same patient information, agreement on preferred assignment varied noticeably across diagnoses and subspecialties. With our results, we reveal potential challenges in integrating hospitalists with other specialists and provide evidence for standardizing certain aspects of physician roles.

A Cost Analysis of Universal versus Targeted Cholesterol Screening in Pediatrics.

OBJECTIVE: To compare the number of children needed to screen to identify a case of childhood dyslipidemia and estimate costs under universal vs targeted screening approaches. STUDY DESIGN: We constructed a decision-analytic model comparing the health system costs of universal vs targeted screening for hyperlipidemia in US children aged 10 years over a 1-year time horizon. Targeted screening was defined by family history: dyslipidemia in a parent and/or early cardiovascular disease in a first-degree relative. Prevalence of any hyperlipidemia (low-density lipoprotein [LDL] ≥130 mg/dL) and severe hyperlipidemia (LDL ≥190 mg/dL or LDL ≥160 mg/dL with family history) were obtained from published estimates. Costs were estimated from the 2016 Maryland Medicaid fee schedule. We performed sensitivity analyses to evaluate the influence of key variables on the incremental cost per case detected. RESULTS: For universal screening, the number needed to screen to identify 1 case was 12 for any hyperlipidemia and 111 for severe hyperlipidemia. For targeted screening, the number needed to screen was 7 for any hyperlipidemia and 49 for severe hyperlipidemia. The incremental cost per case detected for universal compared with targeted screening was $1980 for any hyperlipidemia and $32 170 for severe hyperlipidemia. CONCLUSIONS: Our model suggests that universal cholesterol screening detects hyperlipidemia at a low cost per case, but may not be the most cost-efficient way to identify children with severe hyperlipidemia who are most likely to benefit from treatment.

Establishing Teams: How Does It Change Practice Configuration, Size, and Composition?

Little is known about how practices reorganize when transitioning from traditional practice organization to team-based care. We compared practice-level (1) configuration as well as practice- and team-level (2) size and (3) composition, before and after establishing teams. We employed a pre-/poststudy using personnel lists of 1571 to 1711 staff (eg, job licenses, titles, and team assignment) and practice manager surveys. All personnel (physician and nonphysician) worked within 18 Massachusetts academic primary care practices participating in a 2-year learning collaborative aimed at establishing team-based care. We found that establishing team-based care can involve changing practice configurations and composition without substantially changing practice size.

Socioeconomic Background and Commercial Health Plan Spending.

BACKGROUND: Risk-adjustment algorithms typically incorporate demographic and clinical variables to equalize compensation to insurers for enrollees who vary in expected cost, but including information about enrollees' socioeconomic background is controversial. METHODS: We studied 1 182 847 continuously insured 0 to 19-year-olds using 2008-2012 Blue Cross Blue Shield of Massachusetts and American Community Survey data. We characterized enrollees' socioeconomic background using the validated area-based socioeconomic measure and calculated annual plan payments using paid claims. We evaluated the relationship between annual plan payments and geocoded socioeconomic background using generalized estimating equations (γ distribution and log link). We expressed outcomes as the percentage difference in spending and utilization between enrollees with high and low socioeconomic backgrounds. RESULTS: Geocoded socioeconomic background had a significant, positive association with annual plan payments after applying standard adjusters. Every 1 SD increase in socioeconomic background was associated with a 7.8% (95% confidence interval, 7.2% to 8.3%; P < .001) increase in spending. High socioeconomic background enrollees used higher-priced outpatient and pharmacy services more frequently than their counterparts from low socioeconomic backgrounds (eg, 25% more outpatient encounters annually; 8% higher price per encounter; P < .001), which outweighed greater emergency department spending among low socioeconomic background enrollees. CONCLUSIONS: Higher socioeconomic background is associated with greater levels of pediatric health care spending in commercially insured children. Including socioeconomic information in risk-adjustment algorithms may address concerns about adverse selection from an economic perspective, but it would direct funds away from those caring for children and adolescents from lower socioeconomic backgrounds who are at greater risk of poor health.

Quality of Primary Care for Children With Disabilities Enrolled in Medicaid.

OBJECTIVE: The quality of primary care delivered to Medicaid-insured children with disabilities (CWD) is unknown. We used the newly validated CWD algorithm (CWDA) to examine CWD prevalence among Medicaid enrollees 1 to 18 years old, primary care quality for CWD, and differences in primary care quality for CWD and non-CWD. METHODS: Cross-sectional study using 2008 Medicaid Analytic eXtract claims data from 9 states, including children with at least 11 months of enrollment (N = 2,671,922 enrollees). We utilized CWDA to identify CWD and applied 12 validated or endorsed pediatric quality measures to assess preventive/screening, acute, and chronic disease care quality. We compared quality for CWD and non-CWD unmatched and matched on age, sex, and number of nondisabling chronic conditions and outpatient encounters. RESULTS: CWDA identified 5.3% (n = 141,384) of our study population as CWD. Care quality levels for CWD were below 50% on 8 of 12 quality measures (eg, adolescent well visits [44.9%], alcohol/drug treatment engagement [24.9%]). CWD care quality was significantly better than the general population of non-CWD by +0.9% to +15.6% on 9 measures, but significantly worse for 2 measures, chlamydia screening (-3.4%) and no emergency department visits for asthma (-5.0%; all P < .01 to .001). Differences in care quality between CWD and non-CWD were generally smaller or changed direction when CWD were compared to a general population or matched group of non-CWD. CONCLUSIONS: One in 20 Medicaid-insured children is CWD, and the quality of primary care delivered to CWD is suboptimal. Areas needing improvement include preventive/screening, acute care, and chronic disease management.

The Effect of Price Information on the Ordering of Images and Procedures.

BACKGROUND AND OBJECTIVES: Ordering rates for imaging studies and procedures may change if clinicians are shown the prices of those tests while they are ordering. We studied the effect of 2 forms of paid price information, single median price and paired internal/external median prices, on how often pediatric-focused and adult-oriented clinicians (most frequently general pediatricians and adult specialists caring for pediatric-aged patients, respectively) order imaging studies and procedures for 0- to 21-year-olds. METHODS: In January 2014, we randomized 227 pediatric-focused and 279 adult-oriented clinicians to 1 of 3 study arms: Control (no price display), Single Median Price, or Paired Internal/External Median Prices (both with price display in the ordering screen of electronic health record). We used 1-way analysis of variance and paired t tests to examine how frequently clinicians (1) placed orders and (2) designated tests to be completed internally within an accountable care organization. RESULTS: For pediatric-focused clinicians, there was no significant difference in the rates at which orders were placed or designated to be completed internally across the study arms. For adult-oriented clinicians caring for children and adolescents, however, those in the Single Price and Paired Price arms placed orders at significantly higher rates than those in the Control group (Control 3.2 [SD 4.8], Single Price 6.2 [SD 6.8], P < .001 and Paired Prices 5.2 [SD 7.9], P = .04). The rate at which adult-oriented clinicians designated tests to be completed internally was not significantly different across arms. CONCLUSIONS: The effect of price information on ordering rates appears to depend on whether the clinician is pediatric-focused or adult-oriented.

How Primary Care Physicians Integrate Price Information into Clinical Decision-Making.

BACKGROUND: Little is known about how primary care physicians (PCPs) in routine outpatient practice use paid price information (i.e., the amount that insurers finally pay providers) in daily clinical practice. OBJECTIVE: To describe the experiences of PCPs who have had paid price information on tests and procedures for at least 1 year. DESIGN: Cross-sectional study using semi-structured interviews and the constant comparative method of qualitative analysis. PARTICIPANTS: Forty-six PCPs within an accountable care organization. INTERVENTION: Via the ordering screen of their electronic health record, PCPs were presented with the median paid price for commonly ordered tests and procedures (e.g., blood tests, x-rays, CTs, MRIs). APPROACH: We asked PCPs for (a) their "gut reaction" to having paid price information, (b) the situations in which they used price information in clinical decision-making separate from or jointly with patients, (c) their thoughts on who bore the chief responsibility for discussing price information with patients, and (d) suggestions for improving physician-targeted price information interventions. KEY RESULTS: Among "gut reactions" that ranged from positive to negative, all PCPs were more interested in having patient-specific price information than paid prices from the practice perspective. PCPs described that when patients' out-of-pocket spending concerns were revealed, price information helped them engage patients in conversations about how to alter treatment plans to make them more affordable. PCPs stated that having price information only slightly altered their test-ordering patterns and that they avoided mentioning prices when advising patients against unnecessary testing. Most PCPs asserted that physicians bear the chief responsibility for discussing prices with patients because of their clinical knowledge and relationships with patients. They wished for help from patients, practices, health plans, and society in order to support price transparency in healthcare. CONCLUSIONS: Physician-targeted price transparency efforts may provide PCPs with the information they need to respond to patients' concerns regarding out-of-pocket affordability rather than that needed to change test-ordering habits.