Disparate Practice Patterns and Survival Outcomes: The Impact of Centralization of Cancer Care for Adrenocortical Carcinoma in the United States.

PURPOSE: Adrenocortical carcinoma is a rare but aggressive malignancy. While centralization of care to referral centers improves outcomes across common urological malignancies, there exists a paucity of data for low-incidence cancers. We sought to evaluate differences in practice patterns and overall survival in patients with adrenocortical carcinoma across types of treating facilities. MATERIALS AND METHODS: We identified all patients diagnosed with adrenocortical carcinoma from 2004-2016 in the National Cancer Database. The Kaplan-Meier method was used to evaluate overall survival and multivariable Cox regression analysis was used to investigate independent predictors of overall survival. The chi-square test was used to analyze differences in practice patterns. RESULTS: We identified 2,886 patients with adrenocortical carcinoma. Median overall survival was 21.8 months (95% CI 19.8-23.8). Academic centers had improved overall survival versus community centers on unadjusted Kaplan-Meier analysis (p <0.05) and had higher rates of adrenalectomy or radical en bloc resection (p <0.001), performed more open surgery (p <0.001), administered more systemic therapy (p <0.001) and had lower rates of positive surgical margins (p=0.03). On multivariable analysis, controlling for treatment modality, academic centers were associated with significantly decreased risk of death (HR 0.779, 95% CI 0.631-0.963, p=0.021). CONCLUSIONS: Treatment of adrenocortical carcinoma at an academic center is associated with improved overall survival compared to community programs. There are significant differences in practice patterns, including more aggressive surgical treatment at academic facilities, but the survival benefit persists on multivariable analysis controlling for treatment modality. Further studies are needed to identify the most important predictors of survival in this at-risk population.

Provider-owned insurers in the individual market.

OBJECTIVES: To describe the number and availability of individual market plans sold by provider-owned insurers and compare differences in premiums between traditional and provider-owned insurers. STUDY DESIGN: Cross-sectional analysis. METHODS: Using the Robert Wood Johnson Foundation's HIX Compare data, we identified insurers selling Affordable Care Act (ACA)-compliant policies in the individual market and identified those insurers owned by health systems by using information on their websites. We determined the number of insurers selling policies in each market and the size of the population living in areas where provider-owned insurers sold plans in 2016 and 2017. We used least squares regression to compare premiums between traditional and provider-owned insurers within markets, and we adjusted standard errors for clustering at the market and insurer level. RESULTS: There were 149 insurers that sold ACA-compliant plans in 2017, of which 51 were provider owned. Provider-owned insurers operated in 208 of the 503 exchange markets. We estimate that about 62% of US residents (more than 170 million people) live in a market in which a provider-owned insurer sells plans. Premiums did not differ significantly between traditional and provider-owned plans in 2017. CONCLUSIONS: Provider-owned insurers play a prominent role in the individual insurance market. Although health systems that sell insurance have incentives to reduce costs, provider-owned insurers and traditional insurers have similar premiums.

Low-Value Service Use in Provider Organizations.

OBJECTIVE: To assess whether provider organizations exhibit distinct profiles of low-value service provision. DATA SOURCES: 2007-2011 Medicare fee-for-service claims and enrollment data. STUDY DESIGN: Use of 31 services that provide minimal clinical benefit was measured for 4,039,733 beneficiaries served by 3,137 provider organizations. Variation across organizations, persistence within organizations over time, and correlations in use of different types of low-value services within organizations were estimated via multilevel modeling, with adjustment for beneficiary sociodemographic and clinical characteristics. PRINCIPAL FINDINGS: Organizations provided 45.6 low-value services per 100 beneficiaries on average, with considerable variation across organizations (90th/10th percentile ratio, 1.78; 95 percent CI, 1.72-1.84), including substantial between-organization variation within hospital referral regions (90th/10th percentile ratio, 1.66; 95 percent CI, 1.60-1.71). Low-value service use within organizations was highly correlated over time (r, 0.98; 95 percent CI, 0.97-0.99) and positively correlated between 13 of 15 pairs of service categories (average r, 0.26; 95 percent CI, 0.24-0.28), with the greatest correlation between low-value imaging and low-value cardiovascular testing and procedures (r, 0.54). CONCLUSIONS: Use of low-value services in provider organizations exhibited substantial variation, high persistence, and modest consistency across service types. These findings are consistent with organizations shaping the practice patterns of affiliated physicians.

The Role of a Provider-Sponsored Health Plan in Achieving Scale and Integration.

In pursuit of two primary strategies-to become an integrated delivery network (IDN) on the local level and to achieve additional overall organizational scale to sustain operations-Health First, based in Rockledge, Florida, relies on the success of its provider-sponsored health plan (PSHP) as a critical asset. For Health First, the PSHP serves as an agent for holding and administering financial risk for the health of populations. In addition, we are learning that our PSHP is a critical asset in support of integrating the components of our care delivery system to manage that financial risk effectively, efficiently, and in a manner that creates a unified experience for the customer.Health First is challenged by continuing pressure on reimbursement, as well as by a substantial regulatory burden, as we work to optimize the environments and tools of care and population health management. Even with strong margins and a healthy balance sheet, we simply do not have the resources needed to bring an IDN robustly to life. However, we have discovered that our PSHP can be the vehicle that carries us to additional scale. Many health systems do not own or otherwise have access to a PSHP to hold and manage financial risk. Health First sought and found a not-for-profit health system with complementary goals and a strong brand to partner with, and we now provide private-label health plan products for that system using its strong name while operating the insurance functions under our license and with our capabilities.

Assessing the Financial Condition of Provider-Sponsored Health Plans.

PURPOSE: The aim of this study was to assess the performance of health plans sponsored by provider organizations, with respect to plans generating strong positive cash flow relative to plans generating weaker cash flow. A secondary aim was to assess their capital adequacy. DESIGN: The study identified 24 provider-sponsored health plans (PSHPs) with an average positive cash flow margin from 2011 through 2013 at or above the top 75th percentile, defined as "strong cash flow PSHPs:" This group was compared with 72 PSHPs below the 75th percentile, defined as "weak cash flow PSHPs:" METHODOLOGY: Atlantic Information Services Directory of Health Plans was used to identify the PSHPs. Financial ratios were computed from 2013 National Association of Insurance Commissioners Financial Filings. The study conducted a t test mean comparison between strong and weak cash flow PSHPs across an array of financial performance and capital adequacy measures. RESULTS: In 2013, the strong cash flow PSHPs averaged a cash-flow margin ratio of 6.6%. Weak cash flow PSHPs averaged a cash-flow margin of -0.4%. The net worth capital position of both groups was more than 4.5 times authorized capital. CONCLUSION: The operational analysis shows that strong cash-flow margin PSHPs are managing their medical costs to achieve this position. Although their medical loss ratio increased by almost 300 basis points from 2011 to 2013, it was still statistically significantly lower than the weaker cash flow PSHP group (P<.001). In terms of capital adequacy, both strong and weak cash-flow margin PSHP groups possessed sufficient capital to ensure the viability of these plans.

Seeking lower prices where providers are consolidated: an examination of market and policy strategies.

The ongoing consolidation between and among hospitals and physicians tends to raise prices for health care services, which poses increasing challenges for private purchasers and payers. This article examines strategies that these purchasers and payers can pursue to combat provider leverage to increase prices. It also examines opportunities for governments to either support or constrain these strategies. In response to higher prices, payers are developing new approaches to benefit and network design, some of which may be effective in moderating prices and, in some cases, volume. These approaches interact with public policy because regulation can either facilitate or constrain them. Federal and state governments also have opportunities to limit consolidation's effect on prices by developing antitrust policies that better address current market environments and by fostering the development of physician organizations that can increase competition and contract with payers under shared-savings approaches. The success of these private- and public-sector initiatives likely will determine whether governments shift from supporting competition to directly regulating payment rates.

Economic impact of converting an interventional pain medicine physician office-based practice into a provider-based ambulatory pain practice.

BACKGROUND: One consequence of the shifting economic health care landscape is the growing trend of physician employment and practice acquisition by hospitals. These acquired practices are often converted into hospital- or provider-based clinics. This designation brings the increased services of the hospital, the accreditation of the hospital, and a new billing structure verses the private clinic (the combination of the facility and professional fee billing). One potential concern with moving to a provider-based designation is that this new structure might make the practice less competitive in a marketplace that may still be dominated by private physician office-based practices. The aim of the current study was to evaluate the impact of the provider-based/hospital fee structure on clinical volume. OBJECTIVE: Determine the effect of transition to a hospital- or provider-based practice setting (with concomitant cost implications) on patient volume in the current practice milieu. SETTING:   Community hospital-based academic interventional pain medicine practice. STUDY DESIGN: Economic analysis of effect of change in price structure on clinical volumes. METHODS: The current study evaluates the effect of a change in designation with price implications on the demand for clinical services that accompany the transition to a hospital-based practice setting from a physician office setting in an academic community hospital. RESULTS: Clinical volumes of both procedures and clinic volumes increased in a mature practice setting following transition to a provider-based designation and the accompanying facility and professional fee structure. Following transition to a provider-based designation clinic visits were increased 24% while procedural volume demand did not change. LIMITATIONS: Single practice entity and single geographic location in southeastern United States. CONCLUSIONS: The conversion to a hospital- or provider-based setting does not negatively impact clinical volume and referrals to community-based pain medicine practice. These results imply that factors other than price are a driver of patient choice.  

Adherence to varenicline and associated smoking cessation in a community-based patient setting.

BACKGROUND: Varenicline, a selective α4ß2 nicotinic acetylcholine receptor partial agonist, is a pharmacotherapy indicated for smoking cessation treatment. To our knowledge, no studies have described varenicline treatment adherence and efficacy from real-world treatment patterns in a U.S. primary care setting. OBJECTIVE: To estimate adherence to varenicline prescription orders and subsequent quit rates among smokers in a primary care setting. METHODS: In this retrospective cohort study, eligible patients were enrolled with Geisinger Health Plan, had an initial varenicline prescription written by a Geisinger provider between January 1, 2006, and December 31, 2009, and had a follow-up clinic visit within the subsequent 12 months. Adherence was derived from linking electronic prescriptions with adjudicated pharmacy claims. Smoking status was collected at each health care encounter. RESULTS: Of the 1,477 eligible patients, 823 (55.7%) were primary nonadherent, having failed to initiate on the prescribed varenicline therapy. Of the remaining 654 patients, 359 (54.9%) were adherent, having completed a full 12-week course of therapy, and 295 (45.1%) were partially adherent, having initiated but not completed the full course of therapy. A total of 521 patients (35.3%) ceased smoking during the 12-month follow-up period: 182 (50.7%) of the adherent cohort, 82 (27.8%) of the partially adherent population, and 257 (31.2%) of the nonadherent cohort. No significant difference was found in quit rates between the partially adherent and nonadherent patient cohorts (adjusted HR 0.88 [95% CI=0.69-1.13]). However, patients adherent to the varenicline regimen were almost twice as likely to succeed in quitting smoking compared with completely nonadherent patients (HR 1.93 [95% CI=1.59-2.33]). CONCLUSION: Smoking cessation occurred more often among individuals adherent to varenicline therapy; however, medication nonadherence was common. After prescribing varenicline, clinicians and payers could consider active patient follow-up to maximize adherence and optimize treatment outcomes.

New partnership opportunities for payers and providers.

Healthcare finance executives should consider several key factors when forming partnerships with physicians and insurers: Market expansion opportunities. Resources. Risk sharing. Capturing created value. Market response.

Organizaciones sanitarias integradas y otros ejemplos de colaboración entre proveedores. Informe SESPAS 2012 / Integrated delivery systems and other examples of collaboration among providers. SESPAS report, 2012

La cada vez mayor complejidad de la atención, debida a la alta especialización y la intervención de numerosos servicios, junto al incremento de los pacientes crónicos y pluripatológicos, hacen aún más necesaria la coordinación asistencial, que se ha convertido en prioridad de los sistemas de salud. Los diferentes servicios regionales a los cuales se ha descentralizado el Sistema Nacional de Salud en España han desarrollado experiencias distintas para la mejora de la colaboración entre los diversos proveedores que intervienen en la atención al paciente. El objetivo de este artículo es analizar las experiencias de organizaciones sanitarias integradas en Cataluña y el País Vasco, y los programas de atención a la patología crónica en el País Vasco. Así, en Cataluña, que promovió la separación de la financiación y la provisión, y mantuvo la diversidad en la titularidad de los proveedores, se han ido creando paulatinamente organizaciones que gestionan de manera conjunta entidades proveedoras del continuo asistencial, las denominadas organizaciones sanitarias integradas (OSI). Estas organizaciones han evolucionado y, aunque mantienen algunas características comunes, también presentan diferencias en sus énfasis, por ejemplo en instrumentos formales o bien en la mejora de mecanismos de coordinación o estructuras más orgánicas. Esto se refleja también en sus resultados en cuanto a la cultura y la coordinación percibida en la organización. En el País Vasco, además de la creación de una OSI se están desarrollando experiencias para la mejora de la coordinación en la atención de la patología crónica, mediante el establecimiento de diversas formas de colaboración entre los diferentes servicios que intervienen (AU)

Because of the steady increase in healthcare complexity, due to high specialization and the involvement of a number of services, as well as the increase in patients with chronic diseases and pluripathology, coordination has become a high-priority need in healthcare systems. The distinct regional services that comprise the decentralized Spanish National Health System have developed a number of experiences to improve collaboration among the providers involved in the healthcare process. The present article aims to analyze the experiences with integrated healthcare providers in Catalonia and the Basque Country and the chronic diseases programs of the latter. In Catalonia, which promoted the purchaser-provider split and maintained diversity in providers’ ownership, organizations were slowly created that manage the provision of the healthcare continuum, known as integrated healthcare organizations (IHO). These organizations have evolved and, despite some common characteristics, they also show some differences, such as the emphasis on formal instruments or on coordination mechanisms and organic structures. This is also reflected in their results regarding culture and perceived coordination across the organization. In the Basque Country, in addition to the establishment of an IHO, a variety of integration experiences have been developed to improve the care of chronic diseases (AU)

Why are health plans buying physician groups?

Most insurers say they have no intention of buying doc practices. Those that have done so, say it's just one tool in their accountable care strategy.