Costs of using evidence-based implementation strategies for behavioral health integration in a large primary care system.

OBJECTIVE: To describe the cost of using evidence-based implementation strategies for sustained behavioral health integration (BHI) involving population-based screening, assessment, and identification at 25 primary care sites of Kaiser Permanente Washington (2015-2018). DATA SOURCES/STUDY SETTING: Project records, surveys, Bureau of Labor Statistics compensation data. STUDY DESIGN: Labor and nonlabor costs incurred by three implementation strategies: practice coaching, electronic health records clinical decision support, and performance feedback. DATA COLLECTION/EXTRACTION METHODS: Personnel time spent on these strategies was estimated for five broad roles: (a) project leaders and administrative support, (b) practice coaches, (c) clinical decision support programmers, (d) performance metric programmers, and (e) primary care local implementation team members. PRINCIPAL FINDING: Implementation involved 286 persons, 18 131 person-hours, costing $1 587 139 or $5 per primary care visit with screening or $38 per primary care visit identifying depression, suicidal thoughts and/or alcohol or substance use disorders, in a single year. The majority of person-hours was devoted to project leadership (35%) and practice coaches (34%), and 36% of costs were for the first three sites. CONCLUSIONS: When spread across patients screened in a single year, BHI implementation costs were well within the range for commonly used diagnostic assessments in primary care (eg, laboratory tests). This suggests that implementation costs alone should not be a substantial barrier to population-based BHI.

Addressing challenges in tuberculosis adherence via performance-based payments for integrated case management: protocol for a cluster randomized controlled trial in Georgia.

BACKGROUND: Tuberculosis is one of the greatest global health concerns and disease management is challenging particularly in low- and middle-income countries. Despite improvements in addressing this epidemic in Georgia, tuberculosis remains a significant public health concern due to sub-optimal patient management. Low remuneration for specialists, limited private-sector interest in provision of infectious disease care and incomplete integration in primary care are at the core of this problem. METHODS: This protocol sets out the methods of a two-arm cluster randomized control trial which aims to generate evidence on the effectiveness of a performance-based financing and integrated care intervention on tuberculosis loss to follow-up and treatment adherence. The trial will be implemented in health facilities (clusters) under-performing in tuberculosis management. Eligible and consenting facilities will be randomly assigned to either intervention or control (standard care). Health providers within intervention sites will form a case management team and be trained in the delivery of integrated tuberculosis care; performance-related payments based on monthly records of patients adhering to treatment and quality of care assessments will be disbursed to health providers in these facilities. The primary outcomes include loss to follow-up among adult pulmonary drug-sensitive and drug-resistant tuberculosis patients. Secondary outcomes are adherence to treatment among drug-sensitive and drug-resistant tuberculosis patients and treatment success among drug-sensitive tuberculosis patients. Data on socio-demographic characteristics, tuberculosis diagnosis and treatment regimen will also be collected. The required sample size to detect a 6% reduction in loss to follow-up among drug-sensitive tuberculosis patients and a 20% reduction in loss to follow-up among drug-resistant tuberculosis patients is 948 and 136 patients, respectively. DISCUSSION: The trial contributes to a limited body of rigorous evidence and literature on the effectiveness of supply-side performance-based financing interventions on tuberculosis patient outcomes. Realist and health economic evaluations will be conducted in parallel with the trial, and associated composite findings will serve as a resource for the Georgian and wider regional Ministries of Health in relation to future tuberculosis and wider health policies. The trial and complementing evaluations are part of Results4TB, a multidisciplinary collaboration engaging researchers and Georgian policy and practice stakeholders in the design and evaluation of a context-sensitive tuberculosis management intervention. TRIAL REGISTRATION: ISRCTN, ISRCTN14667607 . Registered on 14 January 2019.

Effect of the Salary Model on Sustainability of a Professional Practice Environment.

OBJECTIVE: This replication study examined differences in RN perception of the professional practice environment (PPE) between salary- and hourly-wage compensation models over time. BACKGROUND: A previous study demonstrated that nurses in a salary-wage model had a significantly higher perception of the PPE compared with their peers receiving hourly wages. METHODS: A descriptive, comparative design was used to examine the Revised Professional Practice Environment (RPPE) scale of nurses in the same units surveyed in the previous study 2 years later. RESULTS: Mean scores on the RPPE continued to be significantly lower for hourly-wage RNs compared with the RNs in the salary-wage model. CONCLUSIONS: Nurses in an hourly-wage unit have significantly lower perceptions of the clinical practice environment than their peers in a salary-wage unit, indicating that professional practice perceptions in a salary-wage unit were sustained for a 2-year period and may provide a more effective PPE.

The Academic RVU: Ten Years Developing a Metric for and Financially Incenting Academic Productivity at Oregon Health & Science University.

PURPOSE: Established metrics reward academic faculty for clinical productivity. Few data have analyzed a bonus model to measure and reward academic productivity. This study's objective was to describe development and use of a departmental academic bonus system for incenting faculty scholarly and educational productivity. METHOD: This cross-sectional study analyzed a departmental bonus system among emergency medicine academic faculty at Oregon Health & Science University, including growth from 2005 to 2015. All faculty members with a primary appointment were eligible for participation. Each activity was awarded points based on a predetermined education or scholarly point scale. Faculty members accumulated points based on their activity (numerator), and the cumulative points of all faculty were the denominator. Variables were individual faculty member (deidentified), academic year, bonus system points, bonus amounts awarded, and measures of academic productivity. Data were analyzed using descriptive statistics, including measures of variance. RESULTS: The total annual financial bonus pool ranged from $211,622 to $274,706. The median annual per faculty academic bonus remained fairly constant over time ($3,980 in 2005-2006 vs. $4,293 in 2014-2015), with most change at the upper quartile of academic bonus (max bonus $16,920 in 2005-2006 vs. $39,207 in 2014-2015). Bonuses rose linearly among faculty in the bottom three quartiles of academic productivity, but increased exponentially in the 75th to 100th percentile. CONCLUSIONS: Faculty academic productivity can be measured and financially rewarded according to an objective academic bonus system. The "academic point" used to measure productivity functions as an "academic relative value unit."

Assessing the productivity of advanced practice providers using a time and motion study.

The Resource-Based Relative Value Scale is widely used to measure healthcare provider productivity and to set payment standards. The scale, however, is limited in its assessment of pre- and postservice work and other potentially non-revenue-generating healthcare services, what we have termed service-valued activity (SVA). In an attempt to quantify SVA, we conducted a time and motion study of providers to assess their productivity in inpatient and outpatient settings. Using the Standard Time and Motion Procedures checklist as a methodological guide, we provided personal digital assistants (PDAs) that were prepopulated with 2010 Current Procedural Terminology codes to 19 advanced practice providers (APPs). The APPs were instructed to identify their location and activity each time the PDA randomly alarmed. The providers collected data for 3 to 5 workdays, and those data were separated into revenue-generating services (RGSs) and SVAs. Multiple inpatient and outpatient departments were assessed. The inpatient APPs spent 61.6 percent of their time on RGSs and 35.1 percent on SVAs. Providers in the outpatient settings spent 59.0 percent of their time on RGSs and 38.2 percent on SVAs. This time and motion study demonstrated an innovative method and tool for the quantification and analysis of time spent on revenue- and non-revenue-generating services provided by healthcare professionals. The new information derived from this study can be used to accurately document productivity, determine clinical practice patterns, and improve deployment strategies of healthcare providers.

Guidance for structuring team-based incentives in healthcare.

New payment methods designed to incentivize more efficient care delivery are accelerating the movement of healthcare providers into organized provider groups. More efficient healthcare delivery requires explicit structuring of care delivery processes around teams of clinicians working toward common patient care goals. Provider organizations accepting new payment methods will need to design and implement compensation systems that provide incentives for team-based care. While lessons from studies performed both outside and inside healthcare provide some guidance on designing and implementing team-based incentives, organized delivery systems face several significant barriers to accomplishing this.

Workplace-based assessment instruments in the health sciences.

A historical overview of the development of assessment instruments in the health sciences is presented here, with specific attention paid to workplace-based assessment instruments. Three instruments are reviewed in detail: the mini clinical evaluation exercise (mCEX), direct observation of procedural skills (DOPS), and multi-source feedback (MSF). Features common to these instruments include their authenticity, their use in assessing professional skills, and the opportunities they afford for the provision of feedback. Although almost exclusively used in graduate medical training, they are likely to play an increasingly important role in the assessment of veterinary undergraduate students in preparation for professional practice. However, the time and cost associated with implementing these instruments raises questions about their feasibility. The continued search for the holy grail of assessment instruments and the challenges relating to the need for trained assessors leads us to conclude that ultimately, the competence of health professionals should continue to be measured using several complementary instruments.

More than just the mean: moving to a dynamic view of performance-based compensation.

Compensation decisions have important consequences for employees and organizations and affect factors such as retention, motivation, and recruitment. Past research has primarily focused on mean performance as a predictor of compensation, promoting the implicit assumption that alternative aspects of dynamic performance are not relevant. To address this gap in the literature, we examined the influence of dynamic performance characteristics on compensation decisions in the National Basketball Association (NBA). We predicted that, in addition to performance mean, performance trend and variability would also affect compensation decisions. Results revealed that performance mean and trend, but not variability, were significantly and positively related to changes in compensation levels of NBA players. Moreover, trend (but not mean or variability) predicted compensation when controlling for future performance, suggesting that organizations overweighted trend in their compensation decisions. Theoretical and practical implications are discussed.

Employer burden of mild, moderate, and severe major depressive disorder: mental health services utilization and costs, and work performance.

BACKGROUND: Treatment utilization/costs and work performance for persons with major depressive disorder (MDD) by severity of illness is not well documented. METHODS: Using National Comorbidity Survey-Replication (2001-2002) data, US workforce respondents (n=4,465) were classified by clinical severity (not clinically depressed, mild, moderate, severe) using a standard self-rating scale [Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR)]. Outcomes included 12-month prevalence of medical services/medications use/costs and workplace performance. Treatment costs (employer's perspective) were estimated by weighing utilization measures by unit costs obtained for similar services used by MDD patients in claims data. Descriptive analysis across three severity groups generated chi(2) results. RESULTS: Using a sample of 539 US workforce respondents with MDD, 13.8% were classified mild, 38.5% moderate, and 47.7% severe cases. Mental health services usage, including antidepressants, increased significantly with severity, with average treatment costs substantially higher for severe than for mild cases both regarding mental health services ($697 vs. $388, chi(2)=4.4, P=.019) and antidepressants ($256 vs. $88, chi(2)=9.0, P=.001). Prevalence rates of unemployment/disability increased significantly (chi(2)=11.7, P=.003) with MDD severity (15.7, 23.3, and 31.3% for mild, moderate, and severe cases). Severely and moderately depressed workers missed more work than nondepressed workers; the monthly salary-equivalent lost performance of $199 (severely depressed) and $188 (moderately depressed) was significantly higher than for nondepressed workers (chi(2)=10.3, P<.001). Projected to the US workforce, monthly depression-related worker productivity losses had human capital costs of nearly $2 billion. CONCLUSIONS: MDD severity is significantly associated with increased treatment usage/costs, treatment adequacy, unemployment, and disability and with reduced work performance.

A pediatrician's opinion.

Pediatricians are inundated by phrases such as "pay for performance" and "enhancement of payments tied into quality measurements." Although there is no argument that we must provide high quality care to our patients and must continuously improve ourselves, we need flexibility within the managed care criteria. Medicine is not only a science, but it is also an art with many interpretations.