Association of Clinician Health System Affiliation With Outpatient Performance Ratings in the Medicare Merit-based Incentive Payment System.

Importance: Integration of physician practices into health systems composed of hospitals and multispecialty practices is increasing in the era of value-based payment. It is unknown how clinicians who affiliate with such health systems perform under the new mandatory Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS) relative to their peers. Objective: To assess the relationship between the health system affiliations of clinicians and their performance scores and value-based reimbursement under the 2019 MIPS. Design, Setting, and Participants: Publicly reported data on 636 552 clinicians working at outpatient clinics across the US were used to assess the association of the affiliation status of clinicians within the 609 health systems with their 2019 final MIPS performance score and value-based reimbursement (both based on clinician performance in 2017), adjusting for clinician, patient, and practice area characteristics. Exposures: Health system affiliation vs no affiliation. Main Outcomes and Measures: The primary outcome was final MIPS performance score (range, 0-100; higher scores intended to represent better performance). The secondary outcome was MIPS payment adjustment, including negative (penalty) payment adjustment, positive payment adjustment, and bonus payment adjustment. Results: The final sample included 636 552 clinicians (41% female, 83% physicians, 50% in primary care, 17% in rural areas), including 48.6% who were affiliated with a health system. Compared with unaffiliated clinicians, system-affiliated clinicians were significantly more likely to be female (46% vs 37%), primary care physicians (36% vs 30%), and classified as safety net clinicians (12% vs 10%) and significantly less likely to be specialists (44% vs 55%) (P < .001 for each). The mean final MIPS performance score for system-affiliated clinicians was 79.0 vs 60.3 for unaffiliated clinicians (absolute mean difference, 18.7 [95% CI, 18.5 to 18.8]). The percentage receiving a negative (penalty) payment adjustment was 2.8% for system-affiliated clinicians vs 13.7% for unaffiliated clinicians (absolute difference, -10.9% [95% CI, -11.0% to -10.7%]), 97.1% vs 82.6%, respectively, for those receiving a positive payment adjustment (absolute difference, 14.5% [95% CI, 14.3% to 14.6%]), and 73.9% vs 55.1% for those receiving a bonus payment adjustment (absolute difference, 18.9% [95% CI, 18.6% to 19.1%]). Conclusions and Relevance: Clinician affiliation with a health system was associated with significantly better 2019 MIPS performance scores. Whether this represents differences in quality of care or other factors requires additional research.

The Contribution of Physician-System Integrating Structure to Select Health System Outcomes.

Physician groups are increasingly being vertically integrated with hospitals and health systems; yet, the evidence on the impact of physician-system integration on health system outcomes is mixed. The objective of this study was to examine the impact of increased physician-system integration on select health system outcomes. We used a mixed-methods approach: (1) a fixed-effects multivariate mediation analysis; and (2) a qualitative analysis of interviews with health executives (n = 25). Our findings showed that hospitals spent $633 375.22 to $827 110.24 for each "level" increase in integration. This relationship was attenuated, however, by the presence of care coordination mechanisms.

Landscape of Health Systems in the United States.

Despite the prevalence of vertical integration, data and research focused on identifying and describing health systems are sparse. Until recently, we lacked an enumeration of health systems and an understanding of how systems vary by key structural attributes. To fill this gap, the Agency for Healthcare Research and Quality developed the Compendium of U.S. Health Systems, a data resource to support research on comparative health system performance. In this article, we describe the methods used to create the Compendium and present a picture of vertical integration in the United States. We identified 626 health systems in 2016, which accounted for 70% of nonfederal general acute care hospitals. These systems varied by key structural attributes, including size, ownership, and geographic presence. The Compendium can be used to study the characteristics of the U.S. health care system and address policy issues related to provider organizations.

Trends in Outpatient Antibiotic Use in 3 Health Plans.

OBJECTIVES: Previous analyses of data from 3 large health plans suggested that the substantial downward trend in antibiotic use among children appeared to have attenuated by 2010. Now, data through 2014 from these same plans allow us to assess whether antibiotic use has declined further or remained stable. METHODS: Population-based antibiotic-dispensing rates were calculated from the same health plans for each study year between 2000 and 2014. For each health plan and age group, we fit Poisson regression models allowing 2 inflection points. We calculated the change in dispensing rates (and 95% confidence intervals) in the periods before the first inflection point, between the first and second inflection points, and after the second inflection point. We also examined whether the relative contribution to overall dispensing rates of common diagnoses for which antibiotics were prescribed changed over the study period. RESULTS: We observed dramatic decreases in antibiotic dispensing over the 14 study years. Despite previous evidence of a plateau in rates, there were substantial additional decreases between 2010 and 2014. Whereas antibiotic use rates decreased overall, the fraction of prescribing associated with individual diagnoses was relatively stable. Prescribing for diagnoses for which antibiotics are clearly not indicated appears to have decreased. CONCLUSIONS: These data revealed another period of marked decline from 2010 to 2014 after a relative plateau for several years for most age groups. Efforts to decrease unnecessary prescribing continue to have an impact on antibiotic use in ambulatory practice.

MACRA likely to accelerate consolidation; will the regulatory framework support it?

It took 17 years and more than a dozen acts of Congress before the Medicare sustainable growth-rate formula was replaced by the Medicare Access and CHIP Reauthorization Act in April 2015.

Difficulties in consummating a meaningful hospital-physician collaboration.

Although there is a vast literature concerning the virtues of hospital-physician collaborative efforts, their actual performance to date in the United States according to rigorous research studies is far less than impressive. Hospitals are usually the party most interested in initiating such alignments, but physicians, as they respond to a patient's clinical needs, control almost all healthcare expenditures. Discussions between the parties have the potential of creating serious conflicts, primarily because of the lack of trust between physicians and hospital executives. The most frequent issues that arise are those relating to the sharing of ambulatory care revenues and who will be responsible for various clinical operations.

Integration: from structural to functional.

Because of trends that are driving increased consolidation in the healthcare industry, community healthcare systems in the future will have fewer independent medical practices. Hospitals and physician practices can be structurally or functionally integrated, but those that are structurally integrated only, do not function as integrated health systems. For successful integration, leaders from many disciplines need to engage in a partnership and be willing to create conditions for a functional integration.

The psychology of organizational structure in integrated health systems.

Examine a social learning theory model as a framework to guide health system leaders as they consider the psychology of organizational design as it pertains to the successful integration.

"When I first started going I was going in on my knees, but I came out and I was skipping": exploring rheumatoid arthritis patients' perceptions of receiving treatment with acupuncture.

OBJECTIVES: To outline rheumatoid arthritis (RA) patients' experiences of receiving treatment with acupuncture, exploring the impact of practitioner affiliation to a traditional or western theoretical base. DESIGN: Qualitative study utilising grounded theory method. Convenience sample of thirteen patients with RA. Data collection, organisation and analysis performed concurrently. In-depth semi-structured interviews were tape-recorded and transcribed. Field notes were also taken. Open, axial and selective coding performed. Emergent categories and themes identified and informed the topics to be discussed in subsequent interviews. RESULTS: Patients perceived acupuncture as alleviating a number of RA symptoms including the relief of rheumatic pain and improvements in mobility. Acupuncture was additionally perceived as alleviating a number of consequential secondary symptoms of RA, such as fatigue, depression and sleeplessness. These effects allowed patients to feel normal again and regain their lives, and resulted in improvements in patients' lifestyle, emotional well-being and self-image. Acupuncturist affiliation impacts on both patient experience and perception of effects. CONCLUSIONS: Acupuncture elicits a range of effects which contribute to improvements in RA patients' quality of life. Varied levels of congruence were identified between the intended therapeutic effect of acupuncture [Hughes JG, Goldbart J, Fairhurst E, Knowles K. Exploring acupuncturists' perceptions of treating patients with rheumatoid arthritis. Complementary Therapies in Medicine 2007;15:101-8] and patients' perceptions of effects. Acupuncturist affiliation has demonstrable implications for the practice and research of acupuncture.

Seven durable ideas.

Partners Healthcare, and its affiliated hospitals, have a long track record of accomplishments in clinical information systems implementations and research. Seven ideas have shaped the information systems strategies and tactics at Partners; centrality of processes, organizational partnerships, progressive incrementalism, agility, architecture, embedded research, and engage the field. This article reviews the ideas and discusses the rationale and steps taken to put the ideas into practice.