RESUMEN
BACKGROUND: We evaluated a 14-county quality improvement program of care delivery and payment of a dental care organization for child and adolescent managed care Medicaid beneficiaries after 2 years of implementation. METHODS: Counties were randomly assigned to either the intervention (PREDICT) or control group. Using Medicaid administrative data, difference-in-difference regression models were used to estimate PREDICT intervention effects (formally, "average marginal effects") on dental care utilization and costs to Medicaid, controlling for patient and county characteristics. RESULTS: Average marginal effects of PREDICT on expected use and expected cost of services per patient (child or adolescent) per quarter were small and insignificant for most service categories. There were statistically significant effects of PREDICT (p < .05), though still small, for certain types of service: (1) Expected number of diagnostic services per patient-quarter increased by .009 units; (2) Expected number of sealants per patient-quarter increased by .003 units, and expected cost by $0.06; (3) Total expected cost per patient-quarter for all services increased by $0.64. These consistent positive effects of PREDICT on diagnostic and certain preventive services (i.e., sealants) were not accompanied by increases in more costly service types (i.e., restorations) or extractions. CONCLUSION: The major hypothesis that primary dental care (selected preventive services and diagnostic services in general) would increase significantly over time in PREDICT counties relative to controls was supported. There were small but statistically significant, increases in differential use of diagnostic services and sealants. Total cost per beneficiary rose modestly, but restorative and dental costs did not. The findings suggest favorable developments within PREDICT counties in enhanced preventive and diagnostic procedures, while holding the line on expensive restorative and extraction procedures.
Asunto(s)
Atención Dental para Niños , Medicaid , Adolescente , Niño , Atención a la Salud , Humanos , Programas Controlados de Atención en Salud , Servicios Preventivos de Salud , Atención Primaria de Salud , Estados UnidosRESUMEN
BACKGROUND: The HITECH Act of 2009 enabled the Centers for Medicare & Medicaid Services (CMS) to provide financial incentives to health care providers who demonstrate "meaningful use" (MU) of their electronic health records (EHRs). Despite stakeholder involvement in the rule-making phase, formal input about the MU program from a cross section of providers has not been reported since incentive payments began. OBJECTIVE: To examine the perspectives and experiences of a random sample of health care professionals eligible for financial incentives (eligible professionals or EPs) for demonstrating meaningful use of their EHRs. It was hypothesized that EPs actively participating in the MU program would generally view the purported benefits of MU more positively than EPs not yet participating in the incentive program. DESIGN: Survey data were collected by mail from a random sample of EPs in Washington State and Idaho. Two follow-up mailings were made to non-respondents. PARTICIPANTS: The sample included EPs who had registered for incentive payments or attested to MU (MU-Active) and EPs not yet participating in the incentive program (MU-Inactive). MAIN MEASURES: The survey assessed perceptions of general realities and influences of MU on health care; views on the influence of MU on clinics; and personal views about MU. EP opinions were assessed with close- and open-ended items. KEY RESULTS: Close-ended responses indicated that MU-Active providers were generally more positive about the program than MU-Inactive providers. However, the majority of respondents in both groups felt that MU would not reduce care disparities or improve the accuracy of patient information. The additional workload on EPs and their staff was viewed as too great a burden on productivity relative to the level of reimbursement for achieving MU goals. The majority of open-ended responses in each group reinforced the general perception that the MU program diverted attention from treating patients by imposing greater reporting requirements. CONCLUSIONS: Survey results indicate the need by CMS to step up engagement with EPs in future planning for the MU program, while also providing support for achieving MU standards.
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Actitud del Personal de Salud , Registros Electrónicos de Salud/estadística & datos numéricos , Uso Significativo , Femenino , Reforma de la Atención de Salud/economía , Reforma de la Atención de Salud/métodos , Investigación sobre Servicios de Salud/métodos , Humanos , Idaho , Masculino , Uso Significativo/economía , Planes de Incentivos para los Médicos , WashingtónRESUMEN
BACKGROUND: Not all primary care clinics are prepared to implement care coordination services for chronic conditions, such as diabetes. Understanding true capacity to coordinate care is an important first-step toward establishing effective and efficient care coordination. Yet, we could identify no diabetes-specific instruments to systematically assess readiness and/or status of primary care clinics to engage in diabetes care coordination. OBJECTIVE: This report describes the development and initial validation of the Diabetes Care Coordination Readiness Assessment (DCCRA), which is intended to measure primary care clinic readiness to coordinate care for adult patients with diabetes. DESIGN: The instrument was developed through iterative item generation within a framework of five domains of care coordination: Organizational Capacity, Care Coordination, Clinical Management, Quality Improvement, and Technical Infrastructure. PARTICIPANTS: Validation data was collected on 39 primary care clinics. MAIN MEASURES: Content validity, inter-rater reliability, internal consistency, and construct validity of the 49-item instrument were assessed. KEY RESULTS: Inter-rater agreement indices per item ranged from 0.50 to 1.0. Cronbach's alpha of the entire instrument was 0.964, and for the five domain scales ranged from 0.688 to 0.961. Clinics with existing care coordinators were rated as more ready to support care coordination than clinics without care coordinators for the entire DCCRA and for each domain, supporting construct validity. CONCLUSIONS: As providers increasingly attempt to adopt patient-centered approaches, introduction of the DCCRA is timely and appropriate for assisting clinics with identifying gaps in provision of care coordination services. The DCCRA's strengths include promising psychometric properties. A valid measure of diabetes care coordination readiness should be useful in diabetes program evaluation, assistance with quality improvement initiatives, and measurement of patient-centered care in research.
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Prestación Integrada de Atención de Salud/organización & administración , Diabetes Mellitus Tipo 2/terapia , Atención Primaria de Salud/organización & administración , Adulto , Anciano , Instituciones de Atención Ambulatoria/organización & administración , Actitud del Personal de Salud , Creación de Capacidad/organización & administración , Accesibilidad a los Servicios de Salud/organización & administración , Investigación sobre Servicios de Salud/métodos , Humanos , Persona de Mediana Edad , Innovación Organizacional , Grupo de Atención al Paciente/organización & administración , Proyectos Piloto , Evaluación de Programas y Proyectos de Salud/métodos , Psicometría , Reproducibilidad de los Resultados , Estados UnidosRESUMEN
CONTEXT: In recent decades, practitioners and policymakers have turned to value-based payment initiatives to help contain spending on health care and to improve the quality of care. The Robert Wood Johnson Foundation funded 7 grantees across the country to design and implement value-based, multistakeholder payment reform projects in 6 states and 3 regions of the United States. METHODS: As the external evaluator of these projects, we reviewed documents, conducted Internet searches, interviewed key stakeholders, cross-validated factual and narrative interpretation, and performed qualitative analyses to derive cross-site themes and implications for policy and practice. FINDINGS: The nature of payment reform and its momentum closely reflects the environmental context of each project. Federal legislation such as the Patient Protection and Affordable Care Act and federal and state support for the development of the patient-centered medical home and accountable care organizations encourage value-based payment innovation, as do local market conditions for payers and providers that combine a history of collaboration with independent innovation and experimentation by individual organizations. Multistakeholder coalitions offer a useful facilitating structure for galvanizing payment reform. But to achieve the objectives of reduced cost and improved quality, multistakeholder payment innovation must overcome such barriers as incompatible information systems, the technical difficulties and transaction costs of altering existing billing and payment systems, competing stakeholder priorities, insufficient scale to bear population health risk, providers' limited experience with risk-bearing payment models, and the failure to align care delivery models with the form of payment. CONCLUSIONS: From the evidence adduced in this article, multistakeholder, value-based payment reform requires a trusted, widely respected "honest broker" that can convene and maintain the ongoing commitment of health plans, providers, and purchasers. Change management is complex and challenging, and coalition governance requires flexibility and stable leadership, as market conditions and stakeholder engagement and priorities shift over time. Another significant facilitator of value-based payment reform is outside investment that enables increased investment in human resources, information infrastructure, and care management by provider organizations and their collaborators. Supportive community and social service networks that enhance population health management also are important enablers of value-based payment reform. External pressure from public and private payers is fueling a "burning bridge" between the past of fee-for-service payment models and the future of payments based on value. Robust competition in local health plan and provider markets, coupled with an appropriate mix of multistakeholder governance, pressure from organized purchasers, and regulatory oversight, has the potential to spur value-based payment innovation that combines elements of "reformed" fee-for-service with bundled payments and global payments.
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Reforma de la Atención de Salud/organización & administración , Compra Basada en Calidad/organización & administración , Conducta Cooperativa , Control de Costos/economía , Control de Costos/organización & administración , Atención a la Salud/economía , Atención a la Salud/organización & administración , Atención a la Salud/normas , Competencia Económica/organización & administración , Humanos , Maine , Massachusetts , Oregon , Innovación Organizacional , Pennsylvania , Calidad de la Atención de Salud/economía , Calidad de la Atención de Salud/organización & administración , Programas Médicos Regionales/organización & administración , Mecanismo de Reembolso/economía , Mecanismo de Reembolso/organización & administración , Estados Unidos , WashingtónRESUMEN
IMPORTANCE: Pay for performance is intended to align incentives to promote high-quality care, but results have been contradictory. OBJECTIVE: To test the effect of explicit financial incentives to reward guideline-recommended hypertension care. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg, nurses, pharmacists). INTERVENTIONS: Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports. MAIN OUTCOMES AND MEASURES: Among a random sample, number of patients achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients prescribed guideline-recommended medications, and number who developed hypotension. RESULTS: Mean (SD) total payments over the study were $4270 ($459), $2672 ($153), and $1648 ($248) for the combined, individual, and practice-level interventions, respectively. The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group, 79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95% CI, -3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other incentive groups did not show a significant change compared with controls for this outcome. For medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61% to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to 80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, -0.28% to 9.28%), respectively. These changes in the use of guideline-recommended medications were not significant in any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect of the incentive was not sustained after a washout. CONCLUSIONS AND RELEVANCE: Individual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared with controls. Further research is needed on the factors that contributed to these findings. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00302718.
Asunto(s)
Adhesión a Directriz , Hipertensión/tratamiento farmacológico , Grupo de Atención al Paciente/economía , Médicos/economía , Reembolso de Incentivo , Anciano , Presión Sanguínea , Atención a la Salud/organización & administración , Femenino , Hospitales de Veteranos , Humanos , Hipotensión , Masculino , Persona de Mediana Edad , Servicio Ambulatorio en Hospital , Grupo de Atención al Paciente/normas , Médicos/normas , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/estadística & datos numéricos , Atención Primaria de Salud , Resultado del TratamientoRESUMEN
BACKGROUND: Patient-centered innovation is spreading at the federal and state levels. A conceptual framework can help frame real-world examples and extract systematic learning from an array of innovative applications currently underway. The statutory, economic, and political environment in Washington State offers a special contextual laboratory for observing the interplay of these factors. PURPOSE: We propose a framework for understanding the process of initiating patient-centered innovations-particularly innovations addressing patient-centered goals of improved access, continuity, communication and coordination, cultural competency, and family- and person-focused care over time. The framework to a case study of a provider organization in Washington State actively engaged in such innovations was applied in this article. METHODS: We conducted a selective review of peer-reviewed evidence and theory regarding determinants of organizational change. On the basis of the literature review and the particular examples of patient-centric innovation, we developed a conceptual framework. Semistructured key informant interviews were conducted to illustrate the framework with concrete examples of patient-centered innovation. FINDINGS: The primary determinants of initiating patient-centered innovation are (a) effective leadership, with the necessary technical and professional expertise and creative skills; (b) strong internal and external motivation to change; (c) clear and internally consistent organizational mission; (d) aligned organizational strategy; (e) robust organizational capability; and (f) continuous feedback and organizational learning. The internal hierarchy of actors is important in shaping patient-centered innovation. External financial incentives and government regulations also significantly shape innovation. PRACTICE IMPLICATIONS: Patient-centered care innovation is a complex process. A general framework that could help managers and executives organize their thoughts around innovation within their organization is presented.
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Innovación Organizacional , Atención Dirigida al Paciente/normas , Garantía de la Calidad de Atención de Salud/normas , Actitud del Personal de Salud , Eficiencia Organizacional , Humanos , Liderazgo , Modelos Organizacionales , Estudios de Casos Organizacionales , Cultura Organizacional , Objetivos Organizacionales , Competencia Profesional , Desarrollo de Personal , WashingtónRESUMEN
BACKGROUND: Most public reporting and pay for performance (P4P) programs in the United States continue to be organized and implemented by single insurers. Adequate medical group-level reliability on clinical care process measures is possible in multistakeholder initiatives because patient samples can be pooled across payers. However, the extent to which reliable measurement is achievable in single insurer P4P initiatives remains unclear. METHODS: This study uses 7 years (2001 to 2007) of patient-level clinical care process data from an insurer in Washington State involving 20 medical groups. Eight clinical care process measures were analyzed. We compared the medical group-level reliability and resulting sample size requirements for each of the 8 measures using unadjusted and adjusted binary mixed models. The relation of baseline intraclass correlation coefficients (ICCs) and medical group performance change over time was examined for each clinical care process measure. RESULTS: Only 45% of all medical group measurements (group-years for all observations) had sufficient sample sizes to achieve reliable estimates of group performance. Measures with the largest deficiencies in patient samples per group included appropriate asthma treatment and low-density lipoprotein screening for patients with coronary artery disease. There was an inconsistent relationship between the size of baseline ICCs and medical group performance improvement over time. CONCLUSIONS: Unreliable performance measurement is an important consequence of the prevailing organization and implementation of public reporting and P4P programs in the US. Multi-payer collaborations may be an important vehicle for ensuring reliable medical group performance measurement and comparisons on clinical care process measures.
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Indicadores de Calidad de la Atención de Salud/normas , Reembolso de Incentivo/normas , Asma/terapia , Enfermedad de la Arteria Coronaria/sangre , Hemoglobina Glucada/análisis , Humanos , Aseguradoras/normas , Lipoproteínas LDL/sangre , Reembolso de Incentivo/organización & administración , Reproducibilidad de los Resultados , Tamaño de la Muestra , Factores de Tiempo , WashingtónRESUMEN
BACKGROUND: Growing interest in the promise of patient-centered care has led to numerous health care innovations, including the patient-centered medical home, shared decision-making, and payment reforms. How best to vet and adopt innovations is an open question. Washington State has been a leader in health care reform and is a rich laboratory for patient-centered innovations. We sought to understand the process of patient-centered care innovation undertaken by innovative health care organizations - from strategic planning to goal selection to implementation to maintenance. METHODS: We conducted key-informant interviews with executives at five health plans, five provider organizations, and ten primary care clinics in Washington State. At least two readers of each interview transcript identified themes inductively; final themes were determined by consensus. RESULTS: Innovation in patient-centered care was a strategic objective chosen by nearly every organization in this study. However, other goals were paramount: cost containment, quality improvement, and organization survival. Organizations commonly perceived effective chronic disease management and integrated health information technology as key elements for successful patient-centered care innovation. Inertia, resource deficits, fee-for-service payment, and regulatory limits on scope of practice were cited as barriers to innovation, while organization leadership, human capital, and adaptive culture facilitated innovation. CONCLUSIONS: Patient-centered care innovations reflected organizational perspectives: health plans emphasized cost-effectiveness while providers emphasized health care delivery processes. Health plans and providers shared many objectives, yet the two rarely collaborated to achieve them. The process of innovation is heavily dependent on organizational culture and leadership. Policymakers can improve the pace and quality of patient-centered innovation by setting targets and addressing conditions for innovation.
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Atención Dirigida al Paciente , Atención Primaria de Salud , Continuidad de la Atención al Paciente , Competencia Cultural , Toma de Decisiones , Prestación Integrada de Atención de Salud/economía , Prestación Integrada de Atención de Salud/métodos , Prestación Integrada de Atención de Salud/organización & administración , Reforma de la Atención de Salud/economía , Reforma de la Atención de Salud/organización & administración , Accesibilidad a los Servicios de Salud , Humanos , Innovación Organizacional , Participación del Paciente , Atención Dirigida al Paciente/economía , Atención Dirigida al Paciente/métodos , Atención Dirigida al Paciente/organización & administración , Atención Primaria de Salud/economía , Atención Primaria de Salud/métodos , Atención Primaria de Salud/organización & administración , Evaluación de Procesos, Atención de Salud , Investigación Cualitativa , Reembolso de Incentivo , WashingtónRESUMEN
The Washington State Innovation Model (SIM) $65 million Test Award from the Center for Medicare and Medicaid Innovation is a statewide intervention expected to improve population health, quality of care, and cost growth through 4 initiatives in 2016-2018: (1) regional accountable communities of health linking health and social services to address local needs; (2) a practice transformation support hub; (3) four value-based payment reform pilot projects mainly in state employee and Medicaid populations; and (4) data and analytic infrastructure development to support system transformation with common measures. A mixed-methods study design and data from the 2013-2018 Behavioral Risk Factor Surveillance System Surveys are used to estimate whether SIM resulted in changes in access to care, health behaviors, and health status in Washington's adult population. Semi-structured qualitative interviews also were conducted to assess stakeholder perceptions of SIM performance. SIM may have reduced binge drinking, but no effects were detected for heavy drinking, physical activity, smoking, having a regular doctor checkup, unmet health care needs, and fair or poor health status. Complex interventions, such as SIM, may have unintended consequences. SIM was associated unexpectedly with increased unhealthy days, but whether the association was related to the Initiative or other factors is unclear. Over 3 years, stakeholders generally agreed that SIM was implemented successfully and increased Washington's readiness for system transformation but had not yet produced expected outcomes, partly because SIM had not spread statewide. Stakeholders perceived that scaling up SIM statewide takes time to achieve and remains challenging.
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Medicaid , Medicare , Anciano , Atención a la Salud , Humanos , Responsabilidad Social , Estados Unidos , WashingtónRESUMEN
OBJECTIVE: Productivity (output per unit of input) is a major driver of dental service capacity. This study uses 2006-2007 data to update available knowledge on dentist productivity. METHODS: In 2006-2007, the authors surveyed 1,604 Oregon general dentists regarding-hours worked, practice size, payment and patient mix, prices, dentist visits, and dentist characteristics. Effects of practice inputs and other independent variables on productivity were estimated by multiple regression and path analysis. RESULTS: The survey response rate was 55.2 percent. Dentists responding to the productivity-related questions were similar to dentists in the overall sampling frame and nationwide. Visits per week are significantly positively related to dentist hours worked, number of assistants, hygienists, and number of operatories. Dentist ownership status, years of experience, and percentage of Medicaid patients are significantly positively related to practice output. The contributions of dentist chairside time and assistants to additional output are smaller for owners, but the number of additional dentist visits enabled by more hygienists is larger for owners. CONCLUSION: As in earlier studies of dental productivity, the key determinant of dentist output is the dentist's own chairside time. The incremental contributions of dentist time, auxiliaries, and operatories to production of dentist visits have not changed substantially over the past three decades. Future studies should focus on ultimate measures of output--oral health--and should develop more precise measures of the practice's actual utilization of auxiliaries and their skill and use of technology.
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Eficiencia Organizacional , Odontología General/economía , Administración de la Práctica Odontológica/economía , Pautas de la Práctica en Odontología/economía , Personal de Odontología/estadística & datos numéricos , Eficiencia Organizacional/estadística & datos numéricos , Femenino , Odontología General/estadística & datos numéricos , Gastos en Salud/estadística & datos numéricos , Humanos , Análisis de los Mínimos Cuadrados , Masculino , Persona de Mediana Edad , Modelos Económicos , Visita a Consultorio Médico/estadística & datos numéricos , Administración de la Práctica Odontológica/estadística & datos numéricos , Pautas de la Práctica en Odontología/estadística & datos numéricos , Encuestas y Cuestionarios , Administración del Tiempo , Estados UnidosRESUMEN
The State of Washington received a State Innovation Models (SIM) $65 million award from the federal Centers for Medicare & Medicaid Services to improve population health and quality of care and reduce the growth of health care costs in the entire state, which has over 7 million residents. SIM is a "complex intervention" that implements several interacting components in a complex, decentralized health system to achieve goals, which poses challenges for evaluation. Our purpose is to present the state-level evaluation methods for Washington's SIM, a 3-year intervention (2016-2018). We apply the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) evaluation framework to structure our evaluation. We create a conceptual model and a plan to use multiple and mixed methods to study SIM performance in the RE-AIM components from a statewide, population-based perspective.
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Atención a la Salud/normas , Evaluación de Programas y Proyectos de Salud/métodos , Calidad de la Atención de Salud , Centers for Medicare and Medicaid Services, U.S. , Humanos , Estados Unidos , WashingtónRESUMEN
This article asks whether financial incentives can improve the quality of health care. A conceptual framework drawn from microeconomics, agency theory, behavioral economics, and cognitive psychology motivates a set of propositions about incentive effects on clinical quality. These propositions are evaluated through a synthesis of extant peer-reviewed empirical evidence. Comprehensive financial incentives--balancing rewards and penalties; blending structure, process, and outcome measures; emphasizing continuous, absolute performance standards; tailoring the size of incremental rewards to increasing marginal costs of quality improvement; and assuring certainty, frequency, and sustainability of incentive payoffs--offer the prospect of significantly enhancing quality beyond the modest impacts of prevailing pay-for-performance (P4P) programs. Such organizational innovations as the primary care medical home and accountable health care organizations are expected to catalyze more powerful quality incentive models: risk- and quality-adjusted capitation, episode of care payments, and enhanced fee-for-service payments for quality dimensions (e.g., prevention) most amenable to piece-rate delivery.
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Atención Primaria de Salud , Calidad de la Atención de Salud/economía , Reembolso de Incentivo , Atención a la Salud/economía , Atención a la Salud/normas , Economía Hospitalaria , Hospitales/normas , Humanos , Atención Primaria de Salud/economía , Atención Primaria de Salud/normas , Reembolso de Incentivo/economía , Estados UnidosRESUMEN
This study is based on key informant interviews with health care executives representing 5 large health systems that had entered into contracts with the Washington State Health Care Authority to provide accountable care network services under the State Innovation Model initiative. The purpose of this study was to explain effects of accountable care program (ACP) implementation on participating health care systems. Between January 2017 and May 2018, we conducted 2 rounds of semistructured interviews (n = 20). Results indicate the need to present a modified conceptual model aligned with ACP implementation in the current context.
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Organizaciones Responsables por la Atención/organización & administración , Implementación de Plan de Salud , Humanos , Entrevistas como Asunto , Modelos Organizacionales , Estudios de Casos Organizacionales , Innovación Organizacional , WashingtónRESUMEN
The Institute of Medicine argues that poorly designed delivery systems are a major cause of low-quality care in the United States but does not present methods for evaluating whether its recommendations, when implemented by a health care organization, actually improve quality of care. We describe how time-series study designs using individual-level longitudinal data can be applied to address methodological challenges in our evaluation of the impact of the Group Health Cooperative "Access Initiative," an integrated set of 7 "patient-centered" reforms in its integrated delivery system that are consistent with the Institute of Medicine's recommendations. The methods may be generalizable to evaluating similar reforms in other integrated delivery systems with representative patient and physician data sources.
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Prestación Integrada de Atención de Salud/normas , Estudios de Evaluación como Asunto , Garantía de la Calidad de Atención de Salud , Reforma de la Atención de Salud , Accesibilidad a los Servicios de Salud , Modelos Organizacionales , Atención Dirigida al Paciente , Factores de Tiempo , WashingtónRESUMEN
BACKGROUND: Dentists increasingly are employed in large group practices that use financial incentive systems to influence provider performance. The authors describe the design and initial implementation of a pay-for-performance (P4P) incentive program for a large capitated Oregon group dental practice that cares primarily for patients receiving Medicaid. The authors do not assess the effectiveness of the incentive system on provider and staff member performance. METHODS: The data come from use of care files and integrated electronic health records, provider and staff member surveys, and interviews and community surveys from 6 counties. Quarterly individual- and team-level incentives focused on 3 performance metrics. RESULTS: The program was challenged by many complex administrative issues. The key issues included designing a P4P system for different types of providers and administrative staff members who were employed centrally and in different communities, setting realistic performance metrics, building information systems that provided timely information about performance, and educating and gaining the support of a diverse workforce. Adjustments are being made in the incentive scheme to meet these challenges. CONCLUSIONS: This is the first report of a P4P compensation system for dental care providers and supporting staff members. The complex administrative challenges will require several years to address. PRACTICAL IMPLICATIONS: Large, capitated dental practice organizations will employ more dental care providers and administrative staff members to care for patients who receive Medicaid and patients who are privately insured. It is critical to design and implement a P4P system that the workforce supports.
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Práctica de Grupo , Reembolso de Incentivo , Práctica Odontológica de Grupo , Humanos , Medicaid , Motivación , Estados UnidosRESUMEN
Health plans, healthcare purchasers, and provider organizations throughout the United States are crafting pay-for-performance programs with the intent of improving the quality of care and with recognition of the need to restrain rapidly rising costs. Health plans and large, self-insured employers have typically led the movement toward using quality scorecards with which to gauge hospital and physician performance, coupled with the use of financial incentives directed at hospitals, physician group practices, and individual physicians and practice teams. In this article we provide a conceptual perspective for understanding the objectives and constraints of payers and providers as they wrestle with the next generation of pay-for-quality (P4Q) programs. We identify a set of practical issues that must be addressed in developing and conducting P4Q programs in different market environments. Those issues include specific strategies for choosing quality metrics, units of accountability, size of incentive, data and measurement systems, payout formulas, and collaboration among payers. We illuminate these issues by considering different approaches in light of real-world P4Q demonstrations underway in the Rewarding Results program, in Bridges to Excellence program, and in specific provider organizations we interviewed over the years. The discussion of practical issues highlights principles and examples directly relevant to hospitals and physician organizations that are considering participation in P4Q as well as to those reexamining their physician compensation mechanisms.
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Garantía de la Calidad de Atención de Salud/economía , Reembolso de Incentivo/organización & administración , Sector de Atención de Salud , Implementación de Plan de Salud , Investigación sobre Servicios de Salud , Humanos , Desarrollo de Programa , Responsabilidad Social , Estados UnidosRESUMEN
INTRODUCTION: Strategic and budgetary considerations have shifted local health departments (LHDs) away from safety net clinical services and toward population-focused services. Federally Qualified Health Centers (FQHCs) play an increasing role in the safety net, and may complement or substitute for LHD clinical services. The authors examined the association between FQHC service levels in communities and the presence of specific LHD clinical services in 2010 and 2013. METHODS: Data from LHD surveys and FQHC service data were merged for 2010 and 2013. Multivariate regression and instrumental variable methods were used to examine FQHC service levels that might predict related LHD service presence or discontinuation from 2010 to 2013. RESULTS: There were modest reductions in LHD service presence and increases in FQHC service volume over the time period. LHD primary care and dental service presence were inversely associated with higher related FQHC service volume. LHD prenatal care service presence, as well as a measure of change in general service approach, were not significantly associated with FQHC service volume. CONCLUSIONS: LHDs were less likely to provide certain clinical services where FQHCs provide a greater volume of services, suggesting a substitution effect. However, certain clinical services, such as prenatal care, may complement the public health mission-and LHDs may be strategically placed to continue to deliver these services.
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Atención Odontológica/organización & administración , Gobierno Local , Atención Prenatal/organización & administración , Atención Primaria de Salud/organización & administración , Atención Odontológica/estadística & datos numéricos , Atención Prenatal/estadística & datos numéricos , Atención Primaria de Salud/estadística & datos numéricos , Estados UnidosRESUMEN
BACKGROUND: Health plans, self-insured employers, health plans, and provider organizations are currently introducing financial incentives that reward physicians for delivering high-quality medical care. Yet a review of existing research reveals virtually no empirical studies of the effect of direct, internal quality incentives on physician performance. Key-informant interviews with leaders of provider organizations should shed new light on evolving quality incentives within organizations. METHODS: Structured key-informant interviews with administrators and medical directors in 22 medical groups and 9 hospitals affiliated with 10 large, integrated health systems were conducted from July 2003 through January 2004. FINDINGS: Views on the role of financial incentives varied widely and were related to a number of other factors, including institutional culture, community context, organizational strategy and structure, organizational stability, quality measurement, nature and size of incentives, and the sustainability of interventions. DISCUSSION: These findings have implications for the acceptability and structure of financial incentives for quality directed to health care provider organizations. A set of considerations for the design and implementation of quality incentives relate to the incentives' scope, controllability, transparency, size, and orientation (individual or team), as well as the relationship between the extrinsic financial incentives and professionals' intrinsic motivation.
Asunto(s)
Médicos , Garantía de la Calidad de Atención de Salud/organización & administración , Reembolso de Incentivo/organización & administración , Administradores de Hospital/organización & administración , Humanos , Cultura Organizacional , Objetivos Organizacionales , Ejecutivos Médicos/organización & administración , Garantía de la Calidad de Atención de Salud/normas , Indicadores de Calidad de la Atención de Salud/organización & administración , Reembolso de Incentivo/normasRESUMEN
This article develops a conceptual framework for implementation of value-based payment (VBP) reform and then draws on that framework to systematically examine six distinct multi-stakeholder coalition VBP initiatives in three different regions of the United States. The VBP initiatives deploy the following payment models: reference pricing, "shadow" primary care capitation, bundled payment, pay for performance, shared savings within accountable care organizations, and global payment. The conceptual framework synthesizes prior models of VBP implementation. It describes how context, project objectives, payment and care delivery strategies, and the barriers and facilitators to translating strategy into implementation affect VBP implementation and value for patients. We next apply the framework to six case examples of implementation, and conclude by discussing the implications of the case examples and the conceptual framework for future practice and research.