What sets the conditions for success in community-partnered evaluation work? Multiple perspectives on a small-scale research-practice partnership evaluation.

The goals of this study are: (a) to share reflections from multiple stakeholders involved in a foundation-funded community-partnered evaluation project, (b) to share information that might be useful to researchers, practitioners, and funders considering the merits of researcher/practitioner evaluation projects, and (c) to make specific suggestions for funders and researcher/practitioner teams starting an evaluation project. Three stakeholders in a small-scale research-practice partnership (RPP) reflected on the evaluation project by responding to three prompts. A researcher, community organization leader, and funder at a small foundation share specific tips for those considering a small-scale RPP. Engaging in a small-scale RPPs can be a very meaningful experience for individual researchers and smaller organizations and funders. The benefits and challenges align and differ in many ways with those encountered in larger projects.

America's Health Care System is Broken: What Went Wrong and How We Can Fix It. Part 3: Hospitals and Doctors.

Thirty-two percent of US health care spending goes to hospital care, and 20% goes to physicians' charges. The cost of hospital care in the United States is 2-3 times greater than in most similar countries. A large part of the high cost is due to a very large administrative overhead. Both higher quality and lower cost would be achieved if complex procedures were done in fewer centers. Hospitals with a geographic or prestige monopoly receive higher payments than warranted. As physicians are increasingly employed by hospitals rather than independent, costs go up with no added benefit to patients. The United States has too many specialists and too few primary care physicians. Practice guidelines are slanted to favor expensive treatments, often with little solid evidence behind the recommendations.

Evolving Trends in Insurance Coverage of Vascular Surgery Patients in Academic Practice.

BACKGROUND: Insurance coverage of vascular surgery patients may differ from patients with less chronic surgical pathologies. The goal of this study is to identify trends in insurance status of vascular surgery patients over the last 10 years at a busy academic center. METHODS: All consecutive patient visits for a vascular procedure from 2006 to 2016 were retrospectively reviewed from a prospectively collected institutional database. Data points included insurance status, procedures performed, and date of admission. The insurance status was categorized as Medicare, Medicaid, and uninsured. Samples were divided between 2006-2009 and 2011-2016 for comparison. Unpaired t-test, chi-squared test, and regression analysis were used to determine significant trends over the study period. RESULTS: From 2006 to 2016, 6,007 vascular surgery procedures were performed. Procedure volume increased significantly from 1,309 to 4,698 between the 2 timeframes (P < 0.05), whereas the percentage of Medicaid and Medicare patients trended upward but did not achieve significance. There was a significant decrease in the percentage of uninsured patients between the cohorts (5.65% vs. 2.96%, P < 0.05). In 2012, 10.14% of patients were uninsured compared with 2.56% in 2016 (P < 0.05). CONCLUSIONS: Insurance status affects access to care and subsequent outcomes. In our busy academic center, insurance coverage for vascular surgery has significantly increased over the past decade. The number of Medicaid and Medicare patients has slowly increased, but a significant and continuing decline in uninsured patients was observed. Implementation of the Affordable Care Act during this time period may have played a role in providing coverage for patient needing vascular surgery.

A New Community Health Center/Academic Medicine Partnership for Medicaid Cost Control, Powered by the Mega Teaching Health Center.

Community health centers (CHCs), a principal source of primary care for over 24 million patients, provide high-quality affordable care for medically underserved and lower-income populations in urban and rural communities. The authors propose that CHCs can assume an important role in the quest for health care reform by serving substantially more Medicaid patients. Major expansion of CHCs, powered by mega teaching health centers (THCs) in partnership with regional academic medical centers (AMCs) or teaching hospitals, could increase Medicaid beneficiaries' access to cost-effective care. The authors propose that this CHC expansion could be instrumental in limiting the added cost of Medicaid expansion via the Affordable Care Act (ACA) or subsequent legislation. Nevertheless, expansion cannot succeed without developing this CHC-AMC partnership both (1) to fuel the currently deficient primary care provider workforce pipeline, which now greatly limits expansion of CHCs; and (2) to provide more CHC-affiliated community outreach sites to enhance access to care. The authors describe the current status of Medicaid and CHCs, plus the evolution and vulnerability of current THCs. They also explain multiple features of a mega THC demonstration project designed to test this new paradigm for Medicaid cost control. The authors contend that the demonstration's potential for success in controlling costs could provide help to preserve the viability of current and future expanded state Medicaid programs, despite a potential ultimate decrease in federal funding over time. Thus, the authors believe that the new AMC-CHC partnership paradigm they propose could potentially facilitate bipartisan support for repairing the ACA.

Partnerships between podiatrists and vascular surgeons in building effective wound care centers.

This practice memo, a collaborative effort between the Young Physicians' Program of the American Podiatric Medical Association and the Young Surgeons Committee of the Society for Vascular Surgery, is intended to aid podiatrists and vascular surgeons in the early years of their respective careers, especially those involved in the care of patients with chronic wounds. During these formative years, learning how to successfully establish an interprofessional partnership is crucial to provide the best possible care to this important population of patients.

Optimizing urology group partnerships: collaboration strategies and compensation best practices.

Market forces in health care have created substantial regulatory, legislative, and reimbursement changes that have had a significant impact on urology group practices. To maintain viability, many urology groups have merged into larger integrated entities. Although group operations vary considerably, the majority of groups have struggled with the development of a strong culture, effective decision-making, and consensus-building around shared resources, income, and expense. Creating a sustainable business model requires urology group leaders to allocate appropriate time and resources to address these issues in a proactive manner. This article outlines collaboration strategies for creating an effective culture, governance, and leadership, and provides practical suggestions for optimizing the performance of the urology group practice.

Practice improvement, part II: trends in employment versus private practice.

A growing percentage of physicians are selecting employment over solo practice, and fewer family physicians have hospital admission privileges. Results from surveys of recent medical school graduates indicate a high value placed on free time. Factors to consider when choosing a practice opportunity include desire for independence, decision-making authority, work-life balance, administrative responsibilities, financial risk, and access to resources. Compensation models are evolving from the simple fee-for-service model to include metrics that reward panel size, patient access, coordination of care, chronic disease management, achievement of patient-centered medical home status, and supervision of midlevel clinicians. When a practice is sold, tangible personal property and assets in excess of liabilities, patient accounts receivable, office building, and goodwill (ie, expected earnings) determine its value. The sale of a practice includes a broad legal review, addressing billing and coding deficiencies, noncompliant contractual arrangements, and potential litigations as well as ensuring that all employment agreements, leases, service agreements, and contracts are current, have been executed appropriately, and meet regulatory requirements.

Experience of contractual change in UK general practice: a qualitative study of salaried GPs.

BACKGROUND: General practice in the UK underwent major change in 2004, with the introduction of new contracts and a significant element of pay for performance. Although salaried GPs form an increasing proportion of the general practice workforce, little is known of their experiences. AIM: To explore the views and experiences of salaried GPs working in English general practice. DESIGN AND SETTING: Qualitative study using semi-structured interviews in 17 practices across England, between July 2007 and September 2009. METHOD: Interviews were conducted with 23 salaried GPs. A topic guide included questions on motivations for a career in general practice, descriptions of their daily working environment and duties, practice relationships, and future aspirations. RESULTS: The new ability to opt out of out-of-hours responsibilities was deemed positive for the profession but not a major driver for choosing medical speciality. Views regarding the impact of the Quality and Outcomes Framework were ambivalent. Differences in pay were regarded as largely reflective of differences in responsibility between salaried GPs and principals. Most participants reported conducting varied work in collaborative practices. Participants held varying career aspirations. CONCLUSION: Salaried GPs' working experiences were dependent upon personal aspirations and local context. Most salaried GPs were reportedly content with their current position but many also had aspirations of eventually attaining GP principal status. The current lack of available partnerships threatens to undo recent positive workforce progress and may lead to deep dissatisfaction within the profession and a future workforce crisis. Further large-scale quantitative work is required to assess the satisfaction and future expectations of those in salaried posts.

Determinants of general practitioners' wages in England.

We analyse the determinants of annual net income and wages (net income/hours) of general practitioners (GPs) using data for 2271 GPs in England recorded during Autumn 2008. The average GP had an annual net income of £97,500 and worked 43 h per week. The mean wage was £51 per h. Net income and wages depended on gender, experience, list size, partnership size, whether or not the GP worked in a dispensing practice, whether they were salaried of self-employed, whether they worked in a practice with a nationally or locally negotiated contract, and the characteristics of the local population (proportion from ethnic minorities, rurality, and income deprivation). The findings have implications for pay discrimination by GP gender and ethnicity, GP preferences for partnership size, incentives for competition for patients, and compensating differentials for local population characteristics. They also shed light on the attractiveness to GPs in England of locally negotiated (personal medical services) versus nationally negotiated (general medical services) contracts.