Organizational integration, practice capabilities, and outcomes in clinically complex medicare beneficiaries.

OBJECTIVE: To assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes. DATA SOURCES: Multiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data. STUDY DESIGN: Cross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse. DATA COLLECTION/EXTRACTION METHODS: 1 604 580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414 209 beneficiaries were considered clinically complex (frailty or 2 + chronic conditions). PRINCIPAL FINDINGS: Financial integration and clinical integration were weakly correlated (correlation coefficient = 0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76]). CONCLUSIONS: Higher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients.

Practice composition and sex differences in physician income: observational study.

OBJECTIVE: To assess whether differences in income between male and female physicians vary according to the sex composition of physician practices. DESIGN: Retrospective observational study. SETTING: US national survey of physician salaries, 2014-18. PARTICIPANTS: 18 802 physicians from 9848 group practices (categorized according to proportion of male physicians ≤50%, >50-75%, >75-90%, and >90%). MAIN OUTCOME MEASURES: Sex differences in physician income in relation to the sex composition of physician practices after multivariable adjustment for physician specialty, years of experience, hours worked, measures of clinical workload, practice type, and geography. RESULTS: Among 11 490 non-surgical specialists, the absolute adjusted sex difference in annual income (men versus women) was $36 604 (£29 663; €32 621) (95% confidence interval $24 903 to $48 306; 11.7% relative difference) for practices with 50% or less of male physicians compared with $91 669 ($56 587 to $126 571; 19.9% relative difference) for practices with at least 90% of male physicians (P=0.03 for difference). Similar findings were observed among surgical specialists (n=3483), with absolute adjusted sex difference in annual income of $46 503 ($42 198 to $135 205; 10.2% relative difference) for practices with 50% or less of male physicians compared with $149 460 ($86 040 to $212 880; 26.9% relative difference) for practices with at least 90% of male physicians (P=0.06 for difference). Among primary care physicians (n=3829), sex differences in income were not related to the proportion of male physicians in a practice. CONCLUSIONS: Among both non-surgical and surgical specialists, sex differences in income were largest in practices with the highest proportion of male physicians, even after detailed adjustment for factors that might explain sex differences in income.

Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals.

Importance: Social needs, including food, housing, utilities, transportation, and experience with interpersonal violence, are linked to health outcomes. Identifying patients with unmet social needs is a necessary first step to addressing these needs, yet little is known about the prevalence of screening. Objective: To characterize screening for social needs by physician practices and hospitals. Design, Setting, and Participants: Cross-sectional survey analyses of responses by physician practices and hospitals to the 2017-2018 National Survey of Healthcare Organizations and Systems. Responses were collected from survey participants from June 16, 2017, to August 17, 2018. Exposures: Organizational characteristics, including participation in delivery and payment reform. Main Outcomes and Measures: Self-report of screening patients for food insecurity, housing instability, utility needs, transportation needs, and experience with interpersonal violence. Results: Among 4976 physician practices, 2333 responded, a response rate of 46.9%. Among hospitals, 757 of 1628 (46.5%) responded. After eliminating responses because of ineligibility, 2190 physician practices and 739 hospitals remained. Screening for all 5 social needs was reported by 24.4% (95% CI, 20.0%-28.7%) of hospitals and 15.6% (95% CI, 13.4%-17.9%) of practices, whereas 33.3% (95% CI, 30.5%-36.2%) of practices and 8.0% (95% CI, 5.8%-11.0%) of hospitals reported no screening. Screening for interpersonal violence was most common (practices: 56.4%; 95% CI, 53.3%-2 59.4%; hospitals: 75.0%; 95% CI, 70.1%-79.3%), and screening for utility needs was least common (practices: 23.1%; 95% CI, 20.6%-26.0%; hospitals: 35.5%; 95% CI, 30.0%-41.0%) among both hospitals and practices. Among practices, federally qualified health centers (yes: 29.7%; 95% CI, 21.5%-37.8% vs no: 9.4%; 95% CI, 7.2%-11.6%; P < .001), bundled payment participants (yes: 21.4%; 95% CI, 17.1%-25.8% vs no: 10.7%; 95% CI, 7.9%-13.4%; P < .001), primary care improvement models (yes: 19.6%; 95% CI, 16.5%-22.6% vs no: 9.6%; 95% CI, 6.0%-13.1%; P < .001), and Medicaid accountable care organizations (yes: 21.8%; 95% CI, 17.4%-26.2% vs no: 11.2%; 95% CI, 8.6%-13.7%; P < .001) had higher rates of screening for all needs. Practices in Medicaid expansion states (yes: 17.7%; 95% CI, 14.8%-20.7% vs no: 11.4%; 95% CI, 8.1%-14.6%; P = .007) and those with more Medicaid revenue (highest tertile: 17.1%; 95% CI, 11.4%-22.7% vs lowest tertile: 9.0%; 95% CI, 6.1%-11.8%; P = .02) were more likely to screen. Academic medical centers were more likely than other hospitals to screen (49.5%; 95% CI, 34.6%-64.4% vs 23.0%; 95% CI, 18.5%-27.5%; P < .001). Conclusions and Relevance: This study's findings suggest that few US physician practices and hospitals screen patients for all 5 key social needs associated with health outcomes. Practices that serve disadvantaged patients report higher screening rates. The role of physicians and hospitals in meeting patients' social needs is likely to increase as more take on accountability for cost under payment reform. Physicians and hospitals may need additional resources to screen for or address patients' social needs.

Use of Internal Performance Measurement to Guide Improvement Within Medical Groups.

BACKGROUND: Public reporting of provider performance currently encompasses a range of measures of quality, cost, and patient experience of care. However, little is known about how medical groups use measures for performance improvement. This information could help medical groups undertake internal measurement while helping payers, policy makers, and measurement experts develop more useful publicly reported measures and quality improvement strategies. METHODS: An exploratory, qualitative study was conducted of ambulatory care medical groups across the United States that currently gather their own performance data. RESULTS: Eighty-three interviews were conducted with 91 individuals representing 37 medical groups. Findings were distilled into three major themes: (1) measures used internally, (2) strategies for using internal measurement for performance improvement, and (3) other uses of internal measurement. Medical groups used both clinical and business process measures, including measures from external measure sets and internally derived measures. Strategies for using internal measurement for quality improvement included taking a gradual, iterative approach and setting clear goals with high priority, finding workable approaches to data sharing, and fostering engagement by focusing on actionable measures. Measurement was also used to check accuracy of external performance reports, clarify and manage conflicting external measurement requirements, and prepare for anticipated external measurement requirements. Respondents in most groups did not report a need to assess costs of internal measurement or the capacity to do so. CONCLUSION: Despite challenges and barriers, respondents found great value in conducting internal measurement. Their experiences may provide valuable lessons and knowledge for medical group leaders in earlier stages of establishing internal measurement programs.

Association of Physician Group Participation in Accountable Care Organizations With Patient Social and Clinical Characteristics.

Importance: Accountable care organizations (ACOs) may increase health care disparities by excluding physician groups that care for socially and clinically vulnerable patients. Objective: To estimate the association between the patient characteristics of a physician group and the group's participation in a newly formed ACO. Design, Setting, and Participants: This retrospective cohort study investigated a 20% random sample of US Medicare fee-for-service beneficiaries attributed to physician groups identified in Medicare claims before ACO participation from January 1, 2010, through December 31, 2011. Physician groups that participated and did not participate in the Medicare Shared Savings Program (MSSP) from January 1, 2012, through December 31, 2014, were identified in the Medicare MSSP 2014 provider file. Data analyses were conducted from September 1, 2017, to March 30, 2018. Exposures: Using multivariable regression, the association between physician group participation in the MSSP and the group's patients' characteristics before ACO formation was estimated focusing on measures of the vulnerability of the group's patients. All ACO-participating physician groups were compared with ACO-nonparticipating physician groups for reference, and estimates were made at the physician and patient level. Main Outcomes and Measures: Percentage of a physician group's patient panel that was socially vulnerable (based on race, dual Medicare and Medicaid enrollment, or living in high-poverty zip code) or clinically high risk. Results: Among 67 891 physician groups caring for 5 394 181 patients, 7215 physician groups (10.6%) participated in an MSSP ACO by 2014. Comparing mean percentages across practices, the patients of non-ACO-participating physician groups, more patients of ACO-participating physician groups were black (mean percentage across practices, 12.1% vs 10.6%), dually enrolled in Medicare and Medicaid (23.0% vs 19.3%), living in poverty (10.7% vs 11.1%), and high risk (34.2% vs 30.2%). After adjustment, physician groups that participated in an ACO had 5.1 percentage points (95% CI, 0.1-10.0 percentage points; P = .05) more dually enrolled patients and 4.0 percentage points (95% CI, 1.9-6.1 percentage points; P < .001) more high-risk patients. At the patient level, patients who were at high risk were more likely to be attributed to a group that became part of an ACO, with 4.5 percentage points (95% CI, 0.5-8.5 percentage points; P = .03) more high-risk patients being attributed to an ACO, but other associations were not statistically different from zero. Conclusions and Relevance: Accountable care organizations may be an effective approach to target care among high-risk patients. In this study, physician groups that participated in the MSSP ACO program cared for more clinically vulnerable patients than did nonparticipating groups, and ACO-participating physician groups cared for an equally large number of socially vulnerable patients compared with nonparticipating physician groups.

Providing Value-Based Service to a Sprawling Orthopaedics Practice.

Health care in the United States is changing, and diagnostic radiology is attempting to adapt to the new norm. A view of the landscape shows mergers, acquisitions, and radiology practices becoming larger. Musculoskeletal (MSK) radiology is trending toward subspecialization, and orthopaedic surgery practices are demanding quality, convenience, and efficiency in imaging services. In other industries, optimization of operations and strategic deployment of resources are standard, but radiology is not quite there yet. This article details our opportunities in MSK imaging to increase market share through service, added value, and improved operational efficiency.

A Simple Framework for Weighting Panels Across Primary Care Disciplines: Findings From a Large US Multidisciplinary Group Practice.

BACKGROUND: Health system redesign necessitates understanding patient population characteristics, yet many primary care physicians are unable to identify patients on their panel. Moreover, accounting for differential workload due to patient variation is challenging. We describe development and application of a utilization-based weighting system accounting for patient complexity using sociodemographic factors within primary care at a large multidisciplinary group practice. METHODS: A retrospective observational study was conducted of 27 clinics across primary care serving more than 150 000 patients. Before and after implementation, we measured empanelment by comparing weighted to unweighted panel size and the number of physicians who could accept patients. Perceived access was measured by the number of patients strongly agreed that an appointment was available when needed. RESULTS: After instituting weighting, the percentage of physicians with open panels decreased for family physicians and pediatricians, but increased for general internists; the number of active patients increased by 2%. One year after implementation, perceived access improved significantly in family and general internal medicine clinics (P < .05). There were no significant changes for general pediatric and adolescent medicine patients. CONCLUSIONS: The creation of a weighing system accounting for complexity resulted in changes in practice closure, increased total patients, and improved access.

Impact of group practices on patients, physicians and healthcare systems: protocol for a scoping review.

INTRODUCTION: Group practices have potential benefits for patients, physicians and healthcare systems. Although group practices have been around for many years, research in this area is lacking and generally is centred around the economic benefits that may be realised from group practice. The aim of this scoping review is to identify the impact that group practices have on patients, physicians and healthcare systems to guide further research in this area. METHODS AND ANALYSIS: A scoping review will be performed based on the methodology proposed by Arksey and O'Malley and refined by Levac and colleagues. MEDLINE, EMBASE, Cochrane Central and Cochrane Economic Database will be searched from inception to present day to identify relevant studies that assess the impact of group practices on patient care, satisfaction and outcomes; physician quality of life, satisfaction and income and healthcare systems. Titles and abstracts will be screened by two members and the abstraction results charted and verified. Qualitative and quantitative analyses will be performed to identify key themes. ETHICS AND DISSEMINATION: Research ethics board approval is not required for this scoping review. A consultation phase will be used to discuss the results with key stakeholders followed by dissemination at local and national levels. We will also publish the results in a peer-reviewed journal.

Factors That Distinguish High-Performing Accountable Care Organizations in the Medicare Shared Savings Program.

OBJECTIVE: To identify factors that promote the effective performance of accountable care organizations (ACOs) in the Medicare Shared Savings Program. DATA SOURCES/STUDY SETTING: Data come from a convenience sample of 16 Medicare Shared Savings ACOs that were organized around large physician groups. We use claims data from the Center for Medicaid and Medicare Services and data from 60 interviews at three high-performing and three low-performing ACOs. STUDY DESIGN: Explanatory sequential design, using qualitative data to account for patterns observed in quantitative assessment of ACO performance. DATA COLLECTION METHODS: A total of 16 ACOs were first rank-ordered on measures of cost and quality of care; we then selected three high and three low performers for site visits; interview data were content-analyzed. PRINCIPAL FINDINGS: Results identify several factors that distinguish high- from low-performing ACOs: (1) collaboration with hospitals; (2) effective physician group practice prior to ACO engagement; (3) trusted, long-standing physician leaders focused on improving performance; (4) sophisticated use of information systems; (5) effective feedback to physicians; and (6) embedded care coordinators. CONCLUSIONS: Shorter interventions can improve ACO performance-use of embedded care coordinators and local, regional health information systems; timely feedback of performance data. However, longer term interventions are needed to promote physician-hospital collaboration and skills of physician leaders. CMS and other stakeholders need realistic timelines for ACO performance.

Critical Lessons From High-Value Oncology Practices.

IMPORTANCE: Cancer care is expensive. Cancer care provided by practice organizations varies in total spending incurred by patients and payers during treatment episodes and in quality of care, and this unnecessary variation contributes to the high cost. OBJECTIVE: To use the variation in total spending and quality of care to assess oncology practice attributes distinguishing "high value" that may be tested and adopted by others to produce similar results. DESIGN, SETTING, AND PARTICIPANTS: "Positive deviance" was used in this exploratory mixed-methods (quantitative and qualitative) analysis of interview results. To quantify value, oncology practices located near the US Pacific Northwest and Midwest with low mean insurer-allowed spending were identified. Among those, practices with high quality were selected. A team then conducted site visits to interview practice personnel from June 2, 2015, through October 3, 2015, and to probe for attributes of high-value care. A qualitative analysis of their interview results was performed, and a panel of experienced oncologists was convened to review attributes occurring uniquely or frequently in low-spending practices for their contribution to value improvement and ease of implementation. Four positive deviant (ie, low-spending) oncology practices and 3 oncology practices that ranked near the middle of the spending distribution were studied. MAIN OUTCOMES AND MEASURES: Thematic saturation in a qualitative analysis of high-value care attributes. RESULTS: From the 7 oncology practices studied, 13 attributes within the following 5 themes emerged: treatment planning and goal setting, services supporting the patient journey, technical support and physical layout, care team organization and function, and external context. Five attributes (ie, conservative use of imaging, early discussion of treatment limitations and consequences, single point of contact, maximal use of registered nurses for interventions, and a multicomponent health care system) most sharply distinguished the high-value practice sites. The expert oncologist panel judged 3 attributes (ie, early and normalized palliative care, ambulatory rapid response, and early discussion of treatment limitations and consequences) to carry the highest immediate potential for lowering spending without compromising the quality of care. CONCLUSIONS AND RELEVANCE: Oncology practice attributes warranting further testing were identified that may lower total spending for high-quality oncology care.

Behavioral Health Integration in Large Multi-group Pediatric Practice.

There is increasing interest in methods to improve access to behavioral health services for children and adolescents. Children's Community Pediatric Behavioral Health Service (CCPBHS) is an integrated behavioral health service whose method of (a) creating a leadership team with empowered administrative and clinical stakeholders who can act on a commitment to change and (b) having a clear mission statement with integrated administrative and clinical care processes can serve as a model for implementing integration efforts within the medical home. Community Pediatrics Behavioral Health Service (CPBHS) is a sustainable initiative that improved the utilization of physical health and behavioral health systems for youth and improved the utilization of evidence-based interventions for youth served in primary care.

The Transition of Primary Care Group Practices to Next Generation Models: Satisfaction of Staff, Clinicians, and Patients.

INTRODUCTION: Restructuring primary care is essential to achieve the triple aim. This case study examines the human factors of extensive redesign on 2 midsized primary care clinics (clinics A and B) in the Midwest United States that are owned by a large health care system. The transition occurred when while the principles for patient-centered medical home were being rolled out nationally, and before the Affordable Care Act. METHODS: After the transition, interviews and discussions were conducted with 5 stakeholder groups: health system leaders, clinic managers, clinicians, nurses, and reception staff. Using a culture assessment instrument, the responses of personnel at clinics A and B were compared with comparison clinics from another health system that had not undergone transition. Patient satisfaction scores are presented. RESULTS: Clinics A and B were similar in size and staffing. Three human factor themes emerged from interviews: responses to change, professional and personal challenges due to role redefinition, and the importance of communication. The comparison clinics had an equal or higher mean culture scores compared with the transition clinics (A and B). Patient satisfaction in improved in Clinic A. CONCLUSIONS: The transition took more time than expected. Health system leaders underestimated the stress and the role adjustments for clinicians and nurses. Change leaders need to anticipate the challenge of role redefinition until health profession schools graduate trainees with more experience in new models of team-based care. Incorporating experience with team based, interprofessional care into training is essential to properly prepare future health professionals.

Large Independent Primary Care Medical Groups.

PURPOSE: In the turbulent US health care environment, many primary care physicians seek hospital employment. Large physician-owned primary care groups are an alternative, but few physicians or policy makers realize that such groups exist. We wanted to describe these groups, their advantages, and their challenges. METHODS: We identified 21 groups and studied 5 that varied in size and location. We conducted interviews with group leaders, surveyed randomly selected group physicians, and interviewed external observers-leaders of a health plan, hospital, and specialty medical group that shared patients with the group. We triangulated responses from group leaders, group physicians, and external observers to identify key themes. RESULTS: The groups' physicians work in small practices, with the group providing economies of scale necessary to develop laboratory and imaging services, health information technology, and quality improvement infrastructure. The groups differ in their size and the extent to which they engage in value-based contracting, though all are moving to increase the amount of financial risk they take for their quality and cost performance. Unlike hospital-employed and multispecialty groups, independent primary care groups can aim to reduce health care costs without conflicting incentives to fill hospital beds and keep specialist incomes high. Each group was positively regarded by external observers. The groups are under pressure, however, to sell to organizations that can provide capital for additional infrastructure to engage in value-based contracting, as well as provide substantial income to physicians from the sale. CONCLUSIONS: Large, independent primary care groups have the potential to make primary care attractive to physicians and to improve patient care by combining human scale advantages of physician autonomy and the small practice setting with resources that are important to succeed in value-based contracting.

The role of medical group practice administrators in the adoption and implementation of Medicare's physician quality reporting system.

BACKGROUND: Although there are numerous studies of the factors influencing the adoption of quality assurance (QA) programs by medical group practices, few have focused on the role of group practice administrators. PURPOSE: To gain insights into the role these administrators play in QA programs, we analyzed how medical practices adopted and implemented the Medicare Physician Quality Reporting System (PQRS), the largest physician quality reporting system in the United States. METHODOLOGY: We conducted focus group interviews in 2011 with a national convenience sample of 76 medical group practice administrators. Responses were organized and analyzed using the innovation decision framework of Van de Ven and colleagues. FINDINGS: Administrators conducted due diligence on PQRS, influenced how the issue was presented to physicians for adoption, and managed implementation thereafter. Administrators' recommendations were heavily influenced by practice characteristics, financial incentives, and practice commitments to early adoption of quality improvement innovations. Virtually, all who attempted it agreed that PQRS was straightforward to implement. However, the complexities of Medicare's PQRS reports impeded use of the data by administrators to support quality management. DISCUSSION: Group practice administrators are playing a prominent role in activities related to the quality of patient care--they are not limited to the business side of the practice. Especially, as PQRS becomes more nearly universal after 2014, Medicare should take account of the role that administrators play, by more actively engaging administrators in shaping these programs and making it easier for administrators to use the results. PRACTICE IMPLICATIONS: More research is needed on the rapidly evolving role of nonphysician administration in medical group practices. Practice administrators have a larger role than commonly understood in how quality reporting initiatives are adopted and used and are in an exceptional position to influence the more appropriate use of these resources if supported by more useful forms of quality reporting.