Use of Propranolol in the Treatment of Chylous Effusions in Infants.

Chylothorax and chyloperitoneum are rare in infants and challenging to definitively diagnose by using current criteria extrapolated from the adult population. They can be of primary or secondary etiologies, including congenital lymphatic malformations and postoperatively, after cardiothoracic or abdominal surgery. Current first-line management consists of bowel rest, parenteral nutrition, and a modified diet of medium-chain triglycerides but can often take weeks to be effective. Off-label use of octreotide has been reported in numerous case studies for the management of chylous effusions. However, there are no definitive neonatal data available regarding dosing, safety, and efficacy; moreover, octreotide has a side effect profile that been linked to serious morbidities, such as pulmonary hypertension and necrotizing enterocolitis. Propranolol, commonly used for the treatment of infantile hemangiomas, is currently gaining interest as a novel therapy for chylous effusions. In this case series review, we describe the use of propranolol in 4 infants with presumed chylous effusions: 1 with congenital pleural effusions and 3 infants who developed postoperative chylothorax and/or chylous ascites. Clinical improvement was noted within a few days of initiating oral propranolol, and the maximum dose used in our cases was 6 mg/kg per day. In previous case reports, researchers describe the use of oral propranolol in infants with chylous effusions, with the dose used ranging from 0.5 to 4 mg/kg per day. However, this is the first case series in which researchers report its use exclusively in infants with chylothorax and chyloperitoneum. Although further research is needed to establish safety and efficacy, our experiences suggest that propranolol could be an acceptable treatment option for chylous effusions in infants.

Are Changes in Medical Group Practice Characteristics Over Time Associated With Medicare Spending and Quality of Care?

Physician practices have been growing in size, and becoming more commonly owned by hospitals, over time. We use survey data on physician practices surveyed at two points in time, linked to Medicare claims data, to investigate whether changes in practice size or ownership are associated with changes in the use of care management, health information technology (HIT), or quality improvement processes. We find that practice growth and becoming hospital-owned are associated with adoption of more quality improvement processes, but not with care management or HIT. We then investigate whether growth or becoming hospital-owned are associated with changes in Medicare spending, 30-day readmission rates, or ambulatory care sensitive admission rates. We find little evidence for associations with practice size and ownership, but the use of care management practices is associated with lower rates of ambulatory care sensitive admissions.

The characteristics of physician practices joining the early ACOs: looking back to look forward.

OBJECTIVES: To assess whether the characteristics and capabilities of individual practices intending to join the early Medicare accountable care organization (ACO) programs differed from those of practices not intending to join. STUDY DESIGN: Data from a 2012-2013 national survey of 1398 physician practices were linked to 2012 Medicare beneficiary claims data to examine differences between practices intending to join a Medicare ACO and practices not intending to join a Medicare ACO. METHODS: Differences were examined with regard to patient sociodemographic characteristics and disease burden, practice characteristics and capabilities, and cost and quality measures. Logistic regression was used to examine the differences. RESULTS: Practices intending to join were more likely to have better care management capabilities (odds ratio [OR], 1.72; P <.003), health information technology functionality (OR, 1.87; P <.001), and use of quality improvement methods (OR, 1.52; P <.04). They were also more likely to have had prior pay-for-performance experience (OR, 1.59; P <.02) and less likely to be physician-owned (OR, 0.51; P <.001). However, the practices with the greater capabilities still used half or less of them. CONCLUSIONS: Physician practices that intended to join the early ACO programs had greater capabilities and experience to manage risk than those practices that decided not to join. The early ACO programs thus attracted the more capable physician practices, but those practices still fell short of implementing key recommended behaviors. The findings have implications for future physician practice selection into ACOs.

Medical Group Characteristics and the Cost and Quality of Care for Medicare Beneficiaries.

OBJECTIVE: To estimate the relationship between outcomes of care and medical practices' structure and use of organized care improvement processes. DATA SOURCES/STUDY SETTING: We linked Medicare claims data to our national survey of physician practices (2012-2013). Fifty percent response rate; 1,040 responding practices; 31,888 physicians; 868,213 attributed Medicare beneficiaries. STUDY DESIGN: Cross-sectional observational analysis of the relationship between practice characteristics and total spending, readmissions, and ambulatory care-sensitive admissions (ACSAs), for all beneficiaries and five categories of beneficiary defined by predicted need for care. PRINCIPAL FINDINGS: Practices with 100+ physicians and 50-99 physicians had, respectively, annual spending per high-need beneficiary that was $1,870 (12.5 percent) and $1,824 higher than practices with 1-2 physicians, and readmission rates 1.64 and 1.71 higher. ACSA rates did not vary significantly by practice size. Outcomes did not vary significantly by ownership or by practices' use of organized processes to improve care. CONCLUSIONS: Large practices had higher spending and readmission rates than the smallest practices, especially for high-need beneficiaries. There were no significant performance differences between physician-owned and hospital-owned practices. Policy makers should consider the effects of specific policies on provider organization, pending further research to learn which types of practice provide better care.

Financial Incentives and Physician Practice Participation in Medicare's Value-Based Reforms.

OBJECTIVES: To evaluate whether greater experience and success with performance incentives among physician practices are related to increased participation in Medicare's voluntary value-based payment reforms. DATA SOURCES/STUDY SETTING: Publicly available data from Medicare's Physician Compare (n = 1,278; January 2012 to November 2013) and nationally representative physician practice data from the National Survey of Physician Organizations 3 (NSPO3; n = 907,538; 2013). STUDY DESIGN: We used regression analysis to examine practice-level relationships between prior exposure to performance incentives and participation in key Medicare value-based payment reforms: accountable care organization (ACO) programs, the Physician Quality Reporting System ("Physician Compare"), and the Meaningful Use of Health Information Technology program ("Meaningful Use"). Prior experience and success with financial incentives were measured as (1) the percentage of practices' revenue from financial incentives for quality or efficiency; and (2) practices' exposure to public reporting of quality measures. DATA COLLECTION/EXTRACTION METHODS: We linked physician participation data from Medicare's Physician Compare to the NSPO3 survey. PRINCIPAL FINDINGS: There was wide variation in practices' exposure to performance incentives, with 64 percent exposed to financial incentives, 45 percent exposed to public reporting, and 2.2 percent of practice revenue coming from financial incentives. For each percentage-point increase in financial incentives, there was a 0.9 percentage-point increase in the probability of participating in ACOs (standard error [SE], 0.1, p < .001) and a 0.8 percentage-point increase in the probability of participating in Meaningful Use (SE, 0.1, p < .001), controlling for practice characteristics. Financial incentives were not associated with participation in Physician Compare. Among ACO participants, a 1 percentage-point increase in incentives was associated with a 0.7 percentage-point increase in the probability of being "very well" prepared to utilize cost and quality data (SE, 0.1, p < .001). CONCLUSIONS: Physicians organizations' prior experience and success with performance incentives were related to participation in Medicare ACO arrangements and participation in the meaningful use criteria but not to participation in Physician Compare. We conclude that Medicare must complement financial incentives with additional efforts to address the needs of practices with less experience with such incentives to promote value-based payment on a broader scale.

Spending per Medicare Beneficiary Is Higher in Hospital-Owned Small- and Medium-Sized Physician Practices.

OBJECTIVE: To examine the relationship of physician versus hospital ownership of small- and medium-sized practices with spending and utilization of care. DATA SOURCE/STUDY SETTING/DATA COLLECTION: Survey data for 1,045 primary care-based practices of 1-19 physicians linked to Medicare claims data for 2008 for 282,372 beneficiaries attributed to the 3,010 physicians in these practices. STUDY DESIGN: We used generalized linear models to estimate the associations between practice characteristics and outcomes (emergency department visits, index admissions, readmissions, and spending). PRINCIPAL FINDINGS: Beneficiaries linked to hospital-owned practices had 7.3 percent more emergency department visits and 6.4 percent higher total spending compared to beneficiaries linked to physician-owned practices. CONCLUSIONS: Physician practices are increasingly being purchased by hospitals. This may result in higher total spending on care.

Medical Group Structural Integration May Not Ensure That Care Is Integrated, From The Patient's Perspective.

Structural integration is increasing among medical groups, but whether these changes yield care that is more integrated remains unclear. We explored the relationships between structural integration characteristics of 144 medical groups and perceptions of integrated care among their patients. Patients' perceptions were measured by a validated national survey of 3,067 Medicare beneficiaries with multiple chronic conditions across six domains that reflect knowledge and support of, and communication with, the patient. Medical groups' structural characteristics were taken from the National Study of Physician Organizations and included practice size, specialty mix, technological capabilities, and care management processes. Patients' survey responses were most favorable for the domain of test result communication and least favorable for the domain of provider support for medication and home health management. Medical groups' characteristics were not consistently associated with patients' perceptions of integrated care. However, compared to patients of primary care groups, patients of multispecialty groups had strong favorable perceptions of medical group staff knowledge of patients' medical histories. Opportunities exist to improve patient care, but structural integration of medical groups might not be sufficient for delivering care that patients perceive as integrated.

Increased Health Information Technology Adoption and Use Among Small Primary Care Physician Practices Over Time: A National Cohort Study.

PURPOSE: Implementation and meaningful use of health information technology (HIT) has been shown to facilitate delivery system transformation, yet implementation is far from universal. This study examined correlates of greater HIT implementation over time among a national cohort of small primary care practices in the United States. METHODS: We used data from a 40-minute telephone panel survey of 566 small primary care practices having 8 or fewer physicians to investigate adoption and use of HIT in 2007-2010 and 2012-2013. We used generalized estimating equations (GEE) to estimate the association of practice characteristics and external incentives with the adoption and use of HIT. We studied 18 measures of HIT functionalities, including record keeping, clinical decision support, patient communication, and health information exchange with hospitals and pharmacies. RESULTS: Overall, use of 16 HIT functionalities increased significantly over time, whereas use of 2 decreased significantly. On average, compared with physician-owned practices, hospital-owned practices used 1.48 (95% CI, 1.07-1.88; P <.001) more HIT processes. And relative to smaller practices, practices with 3 to 8 physicians used 2.49 (95% CI, 2.26-2.72; P <.001) more HIT processes. Participation in pay-for-performance programs, participation in public reporting of clinical quality data, and a larger proportion of revenue from Medicare were also associated with greater adoption and use of HIT. CONCLUSIONS: The new Medicare Access and CHIP Reauthorization Act (MACRA) will provide payment incentives and technical support to speed HIT adoption and use by small practices. We found that external incentives were, indeed, positively associated with greater adoption and use of HIT. Our findings also support a strategy of targeting assistance to smaller physician practices and those that are physician owned.

A Multilevel Analysis of Patient Engagement and Patient-Reported Outcomes in Primary Care Practices of Accountable Care Organizations.

BACKGROUND: The growing movement toward more accountable care delivery and the increasing number of people with chronic illnesses underscores the need for primary care practices to engage patients in their own care. OBJECTIVE: For adult primary care practices seeing patients with diabetes and/or cardiovascular disease, we examined the relationship between selected practice characteristics, patient engagement, and patient-reported outcomes of care. DESIGN: Cross-sectional multilevel observational study of 16 randomly selected practices in two large accountable care organizations (ACOs). PARTICIPANTS: Patients with diabetes and/or cardiovascular disease (CVD) who met study eligibility criteria (n = 4368) and received care in 2014 were randomly selected to complete a patient activation and PRO survey (51% response rate; n = 2176). Primary care team members of the 16 practices completed surveys that assessed practice culture, relational coordination, and teamwork (86% response rate; n = 411). MAIN MEASURES: Patient-reported outcomes included depression (PHQ-4), physical functioning (PROMIS SF12a), and social functioning (PROMIS SF8a), the Patient Assessment of Chronic Illness Care instrument (PACIC-11), and the Patient Activation Measure instrument (PAM-13). Patient-level covariates included patient age, gender, education, insurance coverage, limited English language proficiency, blood pressure, HbA1c, LDL-cholesterol, and disease comorbidity burden. For each of the 16 practices, patient-centered culture and the degree of relational coordination among team members were measured using a clinician and staff survey. The implementation of shared decision-making activities in each practice was assessed using an operational leader survey. KEY RESULTS: Having a patient-centered culture was positively associated with fewer depression symptoms (odds ratio [OR] = 1.51; confidence interval [CI] 1.04, 2.19) and better physical function scores (OR = 1.85; CI 1.25, 2.73). Patient activation was positively associated with fewer depression symptoms (OR = 2.26; CI 1.79, 2.86), better physical health (OR = 2.56; CI 2.00, 3.27), and better social health functioning (OR = 4.12; CI 3.21, 5.29). Patient activation (PAM-13) mediated the positive association between patients' experience of chronic illness care and each of the three patient-reported outcome measures-fewer depression symptoms, better physical health, and better social health. Relational coordination and shared decision-making activities reported by practices were not significantly associated with higher patient-reported outcome scores. CONCLUSIONS: Diabetic and CVD patients who received care from ACO-affiliated practices with more developed patient-centered cultures reported lower PHQ-4 depression symptom scores and better physical functioning. Diabetic and CVD patients who were more highly activated to participate in their care reported lower PHQ-4 scores and better physical and social outcomes of care.

The Exnovation of Chronic Care Management Processes by Physician Organizations.

UNLABELLED: Policy Points The rate of adoption of chronic care management processes (CMPs) by physician organizations has been fairly slow in spite of demonstrated effectiveness of CMPs in improving outcomes of chronic care. Exnovation (ie, removal of innovations) by physician organizations largely explains the slow population-level increases in practice use of CMPs over time. Expanded health information technology functions may aid practices in retaining CMPs. Low provider reimbursement by Medicaid programs, however, may contribute to disinvestment in CMPs by physician organizations. CONTEXT: Exnovation is the process of removal of innovations that are not effective in improving organizational performance, are too disruptive to routine operations, or do not fit well with the existing organizational strategy, incentives, structure, and/or culture. Exnovation may contribute to the low overall adoption of care management processes (CMPs) by US physician organizations over time. METHODS: Three national surveys of US physician organizations, which included common questions about organizational characteristics, use of CMPs, and health information technology (HIT) capabilities for practices of all sizes, and Truven Health Insurance Coverage Estimates were integrated to assess organizational and market influences on the exnovation of CMPs in a longitudinal cohort of 1,048 physician organizations. CMPs included 5 strategies for each of 4 chronic conditions (diabetes, asthma, congestive heart failure, and depression): registry use, nurse care management, patient reminders for preventive and care management services to prevent exacerbations of chronic illness, use of nonphysician clinicians to provide patient education, and quality of care feedback to physicians. FINDINGS: Over one-third (34.1%) of physician organizations exnovated CMPs on net. Quality of care data feedback to physicians and patient reminders for recommended preventive and chronic care were discontinued by over one-third of exnovators, while nurse care management and registries were largely retained. Greater proportions of baseline Medicaid practice revenue (incidence rate ratio [IRR] = 1.44, p < 0.001) and increasing proportions of revenue from Medicaid (IRR = 1.02, p < 0.05) were associated with greater CMP exnovation by physician organizations on net. Practices with greater expansion of HIT functionality exnovated fewer CMPs (IRR = 0.91, p < 0.001) compared to practices with less expansion of HIT functionality. CONCLUSIONS: Exnovation of CMPs is an important reason why the population-level adoption of CMPs by physician organizations has remained low. Expanded HIT functions and changes to Medicaid reimbursement and incentives may aid the retention of CMPs by physician organizations.

Comparing and improving chronic illness primary care in Sweden and the USA.

Purpose - The purpose of this paper is to identify opportunities for improving primary care services for people with chronic illnesses by comparing how Sweden and US services use evidence-based practices (EBPs), including digital health technologies (DHTs). Design/methodology/approach - A national primary healthcare center (PHCC) heads surveys in 2012-2013 carried out in both countries in 2006. Findings - There are large variations between the two countries. The largest, regarding effective DHT use in primary care centers, were that few Swedish primary healthcare compared to US heads reported having reminders or prompts at the point of care (38 percent Sweden vs 84 percent USA), despite Sweden's established electronic medical records (EMR). Swedish heads also reported 30 percent fewer centers receiving laboratory results (67 percent Sweden vs 97 percent USA). Regarding following other EBPs, 70 percent of Swedish center heads reported their physicians had easy access to diabetic patient lists compared to 14 percent in the USA. Most Swedish PHCC heads (96 percent) said they offered same day appointment compared to 36 percent in equivalent US practices. Practical implications - There are opportunities for improvement based on significant differences in effective practices between the countries, which demonstrates to primary care leaders that their peers elsewhere potentially provide better care for people with chronic illnesses. Some improvements are under primary care center control and can be made quickly. There is evidence that people with chronic illnesses in these two countries are suffering unnecessarily owing to primary care staff failing to provide proven EBP, which would better meet patient needs. Public finance has been invested in DHT, which are not being used to their full potential. Originality/value - The study shows the gaps between current and potential proven effective EBPs for services to patients with chronic conditions. Findings suggest possible explanations for differences and practical improvements by comparing the two countries. Many enhancements are low cost and the proportionate reduction in suffering and costs they bring is high.

Using multi-stakeholder alliances to accelerate the adoption of health information technology by physician practices.

BACKGROUND: Multi-stakeholder alliances - groups of payers, purchasers, providers, and consumers that work together to address local health goals - are frequently used to improve health care quality within communities. Under the Aligning Forces for Quality (AF4Q) initiative, multi-stakeholder alliances were given funding and technical assistance to encourage the use of health information technology (HIT) to improve quality. We investigated whether HIT adoption was greater in AF4Q communities than in other communities. METHODS: Drawing upon survey data from 782 small and medium-sized physician practices collected as part of the National Study of Physician Organizations during July 2007 - March 2009 and January 2012-November 2013, we used weighted fixed effects models to detect relative changes in four measures representing three domains: use of electronic health records (EHRs), receipt of electronic information from hospitals, and patients' online access to their medical records. RESULTS: Improvement on a composite EHR adoption measure was 7.6 percentage points greater in AF4Q communities than in non-AF4Q communities, and the increase in the probability of adopting all five EHR capabilities was 23.9 percentage points greater in AF4Q communities. There was no significant difference in improvement in receipt of electronic information from hospitals or patients' online access to medical records between AF4Q and non-AF4Q communities. CONCLUSION: By linking HIT to quality improvement efforts, AF4Q alliances may have facilitated greater adoption of EHRs in small and medium-sized physician practices, but not receipt of electronic information from hospitals or patients' online access to medical records. IMPLICATIONS: Multi-stakeholder alliances charged with promoting HIT to advance quality improvement may accelerate adoption of EHRs.

Care Management Processes Used Less Often For Depression Than For Other Chronic Conditions In US Primary Care Practices.

Primary care physicians play an important role in the diagnosis and management of depression. Yet little is known about their use of care management processes for depression. Using national survey data for the period 2006-13, we assessed the use of five care management processes for depression and other chronic illnesses among primary care practices in the United States. We found significantly less use for depression than for asthma, congestive heart failure, or diabetes in 2012-13. On average, practices used fewer than one care management process for depression, and this level of use has not changed since 2006-07, regardless of practice size. In contrast, use of diabetes care management processes has increased significantly among larger practices. These findings may indicate that US primary care practices are not well equipped to manage depression as a chronic illness, despite the high proportion of depression care they provide. Policies that incentivize depression care management, including additional quality metrics, should be considered.

Trends in hospital ownership of physician practices and the effect on processes to improve quality.

OBJECTIVES: Reports suggest a trend for physician practices to change ownership from physicians to hospitals. It remains unclear how this change affects quality of patient care. We report the effect of a change to hospital ownership on the use of care management processes (CMPs) and health information technology (IT) among practices in the United States. STUDY DESIGN: Trend analyses of 3 large national surveys of physician practices. METHODS: We included 2 cohorts of practices: large practices with 20 or more physicians and small/medium practices with fewer than 20 physicians. The main outcomes were the changes in CMP and health IT indices among practices that were acquired by hospitals. We used multivariate logistic regression to assess these changes. RESULTS: Large practices acquired by hospitals had larger increases in their CMP index than those that remained physician-owned (11.0-point increase vs 7.0-point decrease; adjusted P = .03). Small/medium practices acquired by hospitals had smaller but significantly higher increases in their CMP score (3.8 points vs 2.6 points; adjusted P = .04). Among all practices, there were no significant differences in the change of the health IT index. CONCLUSIONS: We found a significant increase in the use of CMPs among practices that were acquired by hospitals and no difference in health IT use. These findings suggest that a trend for hospitals to own physician practices may have a positive effect on chronic disease management and quality of care.

Patient-Centered Medical Home Adoption: Results From Aligning Forces For Quality.

To improve health care quality within communities, increasing numbers of multistakeholder alliances-groups of payers, purchasers, providers, and consumers-have been created. We used data from two rounds (conducted in July 2007-March 2009 and January 2012-November 2013) of a large nationally representative survey of small and medium-size physician practices. We examined whether the adoption of patient-centered medical home processes spread more rapidly in fourteen Robert Wood Johnson Foundation Aligning Forces for Quality communities, where multistakeholder health care alliances promoted their use, than in other communities. We found no difference in the overall growth of adoption of the processes between the two types of communities. However, improvement on a care coordination subindex was 7.17 percentage points higher in Aligning Forces for Quality communities than in others. Despite the enthusiasm for quality improvement led by multistakeholder alliances, such alliances may not be a panacea for spreading patient-centered medical home processes across a community.

A Longitudinal Study of Medical Practices' Treatment of Patients Who Use Tobacco.

INTRODUCTION: Many patients who use tobacco have never been encouraged by their healthcare providers to quit. In recent years, incentives have been provided for medical practices to incorporate tobacco-cessation processes into routine care. This study examined growth in use of these processes as well as organizational and policy factors associated with their implementation. METHODS: Data from three National Study of Physician Organizations surveys fielded in 2006-2013 were analyzed in 2014. The analyses estimated multivariate longitudinal and cross-sectional linear regression models to assess the relationship between implementation of cessation processes and change in practices' characteristics and external incentives, including state mandates for tobacco-cessation coverage. RESULTS: Systematic identification of patients who use tobacco increased in large (26% to 91%, p<0.0001) and small-medium practices (69% to 83%, p<0.0001). Neither routine advice to quit nor referral to counseling and guideline-based point-of-care reminders increased. Practice feedback to physicians on their use of cessation interventions increased (18% to 29%, p<0.0001) for small-medium practices. State-mandated coverage was associated with the use of cessation processes in small-medium practices (p<0.0001), as was pay for performance participation (p<0.0001); public reporting (p<0.0001); Medicaid revenue (p=0.02); and practice size (p<0.0001). Among large practices, predictors were practice size (p<0.0001); hospital ownership (p=0.004); public reporting (p=0.03); and primary care practice (p=0.04). CONCLUSIONS: The findings suggest that state-mandated coverage for tobacco-cessation treatment and increased use of external incentives such as pay for performance and public reporting programs may improve care for patients who use tobacco.

Increased Use of Care Management Processes and Expanded Health Information Technology Functions by Practice Ownership and Medicaid Revenue.

Practice ownership and Medicaid revenue may affect the use of care management processes (CMPs) for chronic conditions and expansion of health information technology (HIT). Using a national cohort of medical practices, we compared the use of CMPs and HIT from 2006/2008 to 2013 by practice ownership and level of Medicaid revenue. Poisson regression models estimated changes in CMP use, and linear regression estimated changes in HIT, by practice ownership and Medicaid patient revenue, controlling for other practice characteristics. Compared with physician-owned practices, system-owned practices adopted a greater number of CMPs and HIT functions over time (p < .001). High Medicaid revenue (≥30.0%) was associated with less adoption of CMPs (p < .001) and HIT (p < .01). System-owned practices (p < .001) and community health centers (p < .001) with high Medicaid revenue were more likely than physician-owned practices with high Medicaid revenue to adopt CMPs over time. System and community health center ownership appear to help high Medicaid practices overcome CMP adoption constraints.

Salary and Quality Compensation for Physician Practices Participating in Accountable Care Organizations.

BACKGROUND: The accountable care organization (ACO) is a new organizational form to manage patients across the continuum of care. There are numerous questions about how ACOs should be optimally structured, including compensation arrangements with primary care physicians. METHODS: Using data from a national survey of physician practices, we compared primary care physicians' compensation between practices in ACOs and practices that varied in their financial risk for primary care costs using 3 groups: practices not participating in a Medicare ACO and with no substantial risk for primary care costs; practices not participating in an ACO but with substantial risk for primary care costs; and practices participating in an ACO regardless of their risk for primary care costs. We measured physicians' compensation as the percentage of compensation based on salary, productivity, clinical quality or patient experience, and other factors. Regression models estimated physician compensation as a function of ACO participation and risk for primary care costs while controlling for other practice characteristics. RESULTS: Physicians in ACO and non-ACO practices with no substantial risk for costs on average received nearly one-half of their compensation from salary, slightly less from productivity, and about 5% from quality and other factors. Physicians not in ACOs but with substantial risk for primary care costs received two-thirds of their compensation from salary, nearly one-third from productivity, and slightly more than 1% from quality and other factors. Participation in ACOs was associated with significantly higher physician compensation for quality; however, participation was not significantly associated with compensation from salary, whereas financial risk was associated with much greater compensation from salary. CONCLUSION: Although practices in ACOs provide higher compensation for quality, compared with practices at large, they provide a similar mix of compensation based on productivity and salary. Incentives for ACOs may not be sufficiently strong to encourage practices to change physician compensation policies for better patient experience, improved population health, and lower per capita costs.

Accountable Care Organizations: The National Landscape.

There are now more than seven hundred accountable care organizations (ACOs) in the United States. This article describes some of their most salient characteristics including the number and types of contracts involved, organizational structures, the scope of services offered, care management capabilities, and the development of a three-category taxonomy that can be used to target technical assistance efforts and to examine performance. The current evidence on the performance of ACOs is reviewed. Since California has the largest number of ACOs (N=67) and a history of providing care under risk-bearing contracts, some additional assessments of quality and patient experience are made between California ACOs and non-ACO provider organizations. Six key issues likely to affect future ACO growth and development are discussed, and some potential "diagnostic" indicators for assessing the likelihood of potential antitrust violations are presented.

An Early Assessment of Accountable Care Organizations' Efforts to Engage Patients and Their Families.

Accountable care organizations (ACOs) have incentives to meet quality and cost targets to share in any resulting savings. Achieving these goals will require ACOs to engage more actively with patients and their families. The extent to which ACOs do so is currently unknown. Using mixed methods, including a national survey, phone interviews, and site-visits, we examine the extent to which ACOs actively engage patients and their families, explore challenges involved, and consider approaches for dealing with those challenges. Results indicate that greater ACO use of patient activation and engagement (PAE) activities at the point-of-care may be related to positive perceptions among ACO leaders of the impact of PAE investments on ACO costs, quality, and outcomes of care. We identify a number of important practices associated with greater PAE, including high-level leadership commitment, goal-setting supported by adequate resources, extensive provider training, use of interdisciplinary care teams, and frequent monitoring and reporting on progress.