Practice Transformation in the Transforming Clinical Practice Initiative and Emergency Department Use.

To provide insight on how ambulatory care practices can reduce emergency department (ED) visits, we studied changes in Medicare ED visits for primary and specialty care practices in the Transforming Clinical Practice Initiative. We compared practices that transformed more vs less during the 6-year period ending in 2021 (3,773 practices). Using data from a practice transformation assessment tool completed at multiple intervals, we found improvement in the transformation score was associated with reduced ED visits by 6% and 4% for primary and specialty care practices, respectively, 3 to 4 years after first assessment. Transformation in 5 of 8 domains contributed to reduced ED visits.

Toward understanding EHR use in small physician practices.

This article presents insights into the use of electronic health records (EHRs) by small physician practices participating in a CMS pay-for-performance demonstration. Site visits to four States reveal slow movement toward improved EHR use. Factors facilitating use of EHRs include customization of EHR products and being owned by a larger organization. Factors limiting use of EHRs include system limitations, cost, and lack of strong incentives to improve. Practices in one State were moving more vigorously toward improved EHR use than those in the other States. Many practices also increased use of medical assistants after implementing EHRs.

Public reporting of quality information on Medicaid health plans.

Transparency through public reporting of quality data is key to achieving the Institute of Medicine's (IOM) vision for 21st century health care. This article reviews the status of States' voluntary public reporting of Medicaid managed care (MMC) quality data, and analyzes these data. Twenty-one States, including 17 of the 20 largest managed care States, have made plan-level data publicly available online, although the data are sometimes thin, with few measures reported, hard-to-access, and old. We conclude that CMS could better leverage the power of public reporting for quality improvement (QI) by increasing the visibility of health plan employer data and information set (HEDISV) data that States already collect.

Hospital response to public reporting of quality indicators.

Senior hospital executives responding to a 2005 national telephone survey conducted for the Centers for Medicare & Medicaid Services (CMS) report that Hospital Compare and other public reports on hospital quality measures have helped to focus hospital leadership attention on quality matters. They also report increased investment in quality improvement (QI) projects and in people and systems to improve documentation of care. Additionally, more consideration is given to best practice guidelines and internal sharing of quality measure results among hospital staff Large, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredited hospitals appear to be responding to public reporting efforts more consistently than small, non-JCAHO accredited hospitals.

Back to the drawing board: new directions in health plans' care management strategies.

The backlash against managed care has pressured health plans to reexamine their approaches to controlling utilization and managing their members' health care needs, but how much has really changed? Interviews with health plans and others in twelve nationally representative markets suggest that the changes are significant. New and refined disease management programs are improving the care experience of participants with certain prevalent chronic illnesses, while utilization management changes are reducing the administrative burden for providers. Still, disease management programs will need to greatly expand in scope and scale if plans are to succeed in addressing the complex health care needs of aging populations and those with chronic diseases.

Monitoring local safety-net providers: do they have adequate capacity?

The safety-net providers that serve the nation's thirty-nine million uninsured residents are vulnerable organizations even in good economic times, yet efforts to monitor their capacity have been limited at best. This study of the safety-net in five cities found that capacity was strained for specialty services and that access to pharmaceuticals was difficult, while primary care capacity was more often adequate to serve those who presented themselves for care. Also, free clinics grew during the 1990s, while many other safety-net providers focused on improving their efficiency and collecting more fees from patients.

Do quality improvement strategies for Medicaid enrollees differ in Medicaid-dominant versus commercial managed care organizations?

OBJECTIVE: To examine whether it matters, in terms of quality improvement initiatives and access to commercial networks, whether states contract with Medicaid-dominant or commercial managed care plans. STUDY DESIGN: A 2001 telephone survey of Medicaid managed care plans in 11 states that together account for about half of the national Medicaid managed care enrollment. METHODS: The survey was developed in consultation with a panel of individuals knowledgeable about Medicaid managed care. Information on plan characteristics and network design was obtained from the plan CEO or person most knowledgeable about the topics. The rest of the data were obtained from the person the CEO named as most knowledgeable about quality improvement initiatives. RESULTS: Surveyed plans reported an extensive array of quality improvement initiatives. Programs are in many ways similar across Medicaid-dominant and commercial plans. Medicaid-dominant plans tend to specialize more in conditions of greatest priority to Medicaid beneficiaries. Commercial plans tend to develop programs for accreditation by the National Committee for Quality Assurance, and to limit measurement specific to the Medicaid population. They draw on their commercial networks to support the Medicaid product line, but how much they expand provider access is not clear. Both types of programs face barriers that limit the effectiveness of the plans' initiatives. CONCLUSION: This study shows extensive development of quality initiatives in Medicaid managed care plans, with limited differences across Medicaid-dominant and commercial plans.

Making pay-for-performance work in Medicaid.

Findings from a Medicaid pay-for-performance (P4P) demonstration suggest that "money talks" only sometimes, when supportive program elements give it voice. In this paper we examine five Medicaid-focused health plans that implemented new financial incentives for physicians to improve the timeliness of well-baby care. By contrasting the experiences of plans with better and worse outcome trends, we identify key program features--including strong communication with providers and placing enough dollars at stake to compensate providers for the effort required to obtain them--taking into account the starting point. The findings also highlight barriers to improvement that future Medicaid P4P efforts should consider.

Health care access for low-income people: significant safety net gaps remain.

Despite signs that low-income and uninsured people's access to primary health care services has improved, serious gaps in care exist, especially for specialty physician, mental health and dental care, according to the Center for Studying Health System Change's (HSC) 2002-03 site visits to 12 nationally representative communities. Key factors contributing to these gaps in the safety net include declining private physician and dentist involvement, changes in funding and facilities, and more people in need. Community leaders have developed a variety of innovative strategies to add specialty, mental health and dental services but could benefit from more support from state and federal policy makers.