Group Practice Size Consolidation in Emergency Medicine.

STUDY OBJECTIVE: Practice consolidation is common and has been shown to affect the quality and cost of care across multiple health care delivery settings, including hospitals, nursing homes, and physician practices. Despite a long history of large practice management group formation in emergency medicine and intensifying media attention paid to this topic, little is known about the recent practice consolidation trends within the specialty. METHODS: All data were obtained from the Centers for Medicare and Medicaid Services Physician Compare database, which contains physician and group practice data from 2012 to 2020. We assessed practice size changes for both individual emergency physicians and groups. RESULTS: From 2012 to 2020, the proportion of emergency physicians in groups sized less than 25 has decreased substantially from 40.2% to 22.7%. Physicians practicing in groups of more than or equal to 500 physicians increased from 15.5% to 24%. CONCLUSION: Since 2012, we observed a steady trend toward increased consolidation of emergency department practice with nearly 1 in 4 emergency physicians nationally working in groups with more than 500 physicians in 2020 compared with 1 in 7 in 2012. Although the relationship between consolidation is likely to draw the most attention from policymakers or payers seeking to negotiate prices in the near term and advance payment models in the long term, greater attention is required to understand the effects of practice consolidation on emergency care.

Using Consistently Low Performance to Identify Low-Quality Physician Groups.

Importance: There has been a growth in the use of performance-based payment models in the past decade, but inherently noisy and stochastic quality measures complicate the assessment of the quality of physician groups. Examining consistently low performance across multiple measures or multiple years could potentially identify a subset of low-quality physician groups. Objective: To identify low-performing physician groups based on consistently low performance after adjusting for patient characteristics across multiple measures or multiple years for 10 commonly used quality measures for diabetes and cardiovascular disease (CVD). Design, Setting, and Participants: This cross-sectional study used medical and pharmacy claims and laboratory data for enrollees ages 18 to 65 years with diabetes or CVD in an Aetna health insurance plan between 2016 and 2019. Each physician group's risk-adjusted performance for a given year was estimated using mixed-effects linear probability regression models. Performance was correlated across measures and time, and the proportion of physician groups that performed in the bottom quartile was examined across multiple measures or multiple years. Data analysis was conducted between September 2020 and May 2021. Exposures: Primary care physician groups. Main Outcomes and Measures: Performance scores of 6 quality measures for diabetes and 4 for CVD, including hemoglobin A1c (HbA1c) testing, low-density lipoprotein testing, statin use, HbA1c control, low-density lipoprotein control, and hospital-based utilization. Results: A total of 786 641 unique enrollees treated by 890 physician groups were included; 414 655 (52.7%) of the enrollees were men and the mean (SD) age was 53 (9.5) years. After adjusting for age, sex, and clinical and social risk variables, correlations among individual measures were weak (eg, performance-adjusted correlation between any statin use and LDL testing for patients with diabetes, r = -0.10) to moderate (correlation between LDL testing for diabetes and LDL testing for CVD, r = .43), but year-to-year correlations for all measures were moderate to strong. One percent or fewer of physician groups performed in the bottom quartile for all 6 diabetes measures or all 4 cardiovascular disease measures in any given year, while 14 (4.0%) to 39 groups (11.1%) were in the bottom quartile in all 4 years for any given measure other than hospital-based utilization for CVD (1.1%). Conclusions and Relevance: A subset of physician groups that was consistently low performing could be identified by considering performance measures across multiple years. Considering the consistency of group performance could contribute a novel method to identify physician groups most likely to benefit from limited resources.

Group Antenatal Care: A Paradigm Shift to Explore for Positive Impacts in Resource-poor Settings.

The delivery of high-quality antenatal care is a perennial global concern for improving maternal and neonatal outcomes. Antenatal care is currently provided mainly on a one-to-one basis, but growing evidence has emerged to support the effectiveness of group antenatal care. Providing care in a small group gives expectant mothers the opportunity to have discussions with their peers about certain issues and concerns that are unique to them and to form a support system that will improve the quality and utilization of antenatal care services. The aim of this article is to promote group antenatal care as a means to increase utilization of healthcare.

Health system affiliation of physician organizations and quality of care for Medicare beneficiaries who have high needs.

OBJECTIVE: To test the hypothesis that health systems provide better care to patients with high needs by comparing differences in quality between system-affiliated and nonaffiliated physician organizations (POs) and to examine variability in quality across health systems. DATA SOURCES: 2015 Medicare Data on Provider Practice and Specialty linked physicians to POs. Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and IRS Form 990 data identified health system affiliations. Fee-for-service Medicare enrollment and claims data were used to examine quality. STUDY DESIGN: This cross-sectional analysis of beneficiaries with high needs, defined as having more than twice the expected spending of an average beneficiary, examined six quality measures: continuity of care, follow-up visits after hospitalizations and emergency department (ED) visits, ED visits, all-cause readmissions, and ambulatory care-sensitive hospitalizations. Using a matched-pair design, we estimated beneficiary-level regression models with PO random effects to compare quality of care in system-affiliated and nonaffiliated POs. We then limited the sample to system-affiliated POs and estimated models with system random effects to examine variability in quality across systems. PRINCIPAL FINDINGS: Among 2 323 301 beneficiaries with high needs, 52.3% received care from system-affiliated POs. Rates of ED visits were statistically significantly different in system-affiliated POs (117.5 per 100) and nonaffiliated POs (106.8 per 100, P < .0001). Small differences in the other five quality measures were observed across a range of sensitivity analyses. Among systems, substantial variation was observed for rates of continuity of care (90% of systems had rates between 70.8% and 89.4%) and follow-up after ED visits (90% of systems had rates between 56.9% and 73.5%). CONCLUSIONS: Small differences in quality of care were observed among beneficiaries with high needs receiving care from system POs and nonsystem POs. Health systems may not confer hypothesized quality advantages to patients with high needs.

Racial and ethnic disparities in care for health system-affiliated physician organizations and non-affiliated physician organizations.

OBJECTIVE: To assess racial and ethnic disparities in care for Medicare fee-for-service (FFS) beneficiaries and whether disparities differ between health system-affiliated physician organizations (POs) and nonaffiliated POs. DATA SOURCES: We used Medicare Data on Provider Practice and Specialty (MD-PPAS), Medicare Provider Enrollment, Chain, and Ownership System (PECOS), IRS Form 990, 100% Medicare FFS claims, and race/ethnicity estimated using the Medicare Bayesian Improved Surname Geocoding 2.0 algorithm. STUDY DESIGN: Using a sample of 16 007 POs providing primary care in 2015, we assessed racial/ethnic disparities on 12 measures derived from claims (2 cancer screenings; diabetic eye examinations; continuity of care; two medication adherence measures; three measures of follow-up visits after acute care; all-cause emergency department (ED) visits, all-cause readmissions, and ambulatory care-sensitive admissions). We decomposed these "total" disparities into within-PO and between-PO components using models with PO random effects. We then pair-matched 1853 of these POs that were affiliated with health systems to similar nonaffiliated POs. We examined differences in within-PO disparities by affiliation status by interacting each nonwhite race/ethnicity with an affiliation indicator. DATA COLLECTION/EXTRACTION METHODS: Medicare Data on Provider Practice and Specialty identified POs billing Medicare; PECOS and IRS Form 990 identified health system affiliations. Beneficiaries age 18 and older were attributed to POs using a plurality visit rule. PRINCIPAL FINDINGS: We observed total disparities in 12 of 36 comparisons between white and nonwhite beneficiaries; nonwhites received worse care in 10. Within-PO disparities exceeded between-PO disparities and were substantively important (>=5 percentage points or>=0.2 standardized differences) in nine of the 12 comparisons. Among these 12, nonaffiliated POs had smaller disparities than affiliated POs in two comparisons (P < .05): 1.6 percentage points smaller black-white disparities in follow-up after ED visits and 0.6 percentage points smaller Hispanic-white disparities in breast cancer screening. CONCLUSIONS: We find no evidence that system-affiliated POs have smaller racial and ethnic disparities than nonaffiliated POs. Where differences existed, disparities were slightly larger in affiliated POs.

General practitioners' income and activity: the impact of multi-professional group practice in France.

France has first experimented, in 2009, and then generalized a practice level add-on payment to promote Multi-Professional Primary Care Groups (MPCGs). Team-based practices are intended to improve both the efficiency of outpatient care supply and the attractiveness of medically underserved areas for healthcare professionals. To evaluate its financial attractiveness and thus the sustainability of MPCGs, we analyzed the evolution of incomes (self-employed income and wages) of General Practitioners (GPs) enrolled in a MPCG, compared with other GPs. We also studied the impacts of working in a MPCG on GPs' activity through both the quantity of medical services provided and the number of patients encountered. Our analyses were based on a quasi-experimental design, with a panel dataset over the period 2008-2014. We accounted for the selection into MPCG by using together coarsened exact matching and difference-in-differences (DID) design with panel-data regression models to account for unobserved heterogeneity. We show that GPs enrolled in MPCGs during the period exhibited an increase in income 2.5% higher than that of other GPs; there was a greater increase in the number of patients seen by the GPs' (88 more) without involving a greater increase in the quantity of medical services provided. A complementary cross-sectional analysis for 2014 showed that these changes were not detrimental to quality in terms of bonuses related to the French pay-for-performance program for the year 2014. Hence, our results suggest that labor and income concerns should not be a barrier to the development of MPCGs, and that MPCGs may improve patient access to primary care services.

Practice composition and sex differences in physician income: observational study.

OBJECTIVE: To assess whether differences in income between male and female physicians vary according to the sex composition of physician practices. DESIGN: Retrospective observational study. SETTING: US national survey of physician salaries, 2014-18. PARTICIPANTS: 18 802 physicians from 9848 group practices (categorized according to proportion of male physicians ≤50%, >50-75%, >75-90%, and >90%). MAIN OUTCOME MEASURES: Sex differences in physician income in relation to the sex composition of physician practices after multivariable adjustment for physician specialty, years of experience, hours worked, measures of clinical workload, practice type, and geography. RESULTS: Among 11 490 non-surgical specialists, the absolute adjusted sex difference in annual income (men versus women) was $36 604 (£29 663; €32 621) (95% confidence interval $24 903 to $48 306; 11.7% relative difference) for practices with 50% or less of male physicians compared with $91 669 ($56 587 to $126 571; 19.9% relative difference) for practices with at least 90% of male physicians (P=0.03 for difference). Similar findings were observed among surgical specialists (n=3483), with absolute adjusted sex difference in annual income of $46 503 ($42 198 to $135 205; 10.2% relative difference) for practices with 50% or less of male physicians compared with $149 460 ($86 040 to $212 880; 26.9% relative difference) for practices with at least 90% of male physicians (P=0.06 for difference). Among primary care physicians (n=3829), sex differences in income were not related to the proportion of male physicians in a practice. CONCLUSIONS: Among both non-surgical and surgical specialists, sex differences in income were largest in practices with the highest proportion of male physicians, even after detailed adjustment for factors that might explain sex differences in income.

Opioid prescription patterns among radiation oncologists in the United States.

BACKGROUND: Radiation oncologists (ROs) play an important role in managing cancer pain; however, their opioid prescribing patterns remain poorly described. METHODS: The 2016 Medicare Physician Compare National Downloadable and the 2016 Medicare Part D Prescriber Data files were cross-linked to identify RO-written opioid prescriptions. RESULTS: Of 4,627 identified ROs, 1,360 (29.3%) wrote >10 opioid prescriptions. The average number of opioid prescriptions written was significantly (P ≤ .05) associated with the following RO characteristics: sex [13.1 ± 36.5 male vs 7.5 ± 16.9 female]; years since medical school graduation [4.5 ± 11.5 1-10 years vs 12.6 ± 26.0 11-24 years vs 13.3 ± 40.9 ≥25 years]; practice size [15.5 ± 44.6 size ≤10 vs 13.3 ± 25.9 size 11-49 vs 8.5 ± 12.7 size 50-99 vs 8.8 ± 26.9 size ≥100]; Medicare Physician Quality Reporting System (PQRS) participation [12.6 ± 31.8 yes vs 7.0 ± 35.4 no]; and practice location [17.4 ± 47.0 South vs 10.6 ± 29.4 Midwest vs 8.1 ± 13.9 West vs 6.9 ± 15.2 Northeast]. On multivariable regression modeling, male sex (RR 1.29, 95% CI 1.22-1.35, P < .001), ≥25 years since graduation (RR 0.78, 95% CI 0.64-0.70, 1-10 years vs ≥25 years; RR 1.00, 95% CI 0.96 - 1.04, 11-24 years vs ≥25 years; P < .001), practice size <10 members (RR 1.51, CI 1.44-1.59, ≤10 vs ≥100 members, RR 1.27, CI 1.20-1.34, 10-49 vs ≥100 members, RR 0.86, CI 0.80-0.92, 50-99 vs ≥100 members, P < .001), PQRS participation (RR 1.12, CI 1.04-1.19, P < .002), and Southern location (RR 0.67, CI 0.64-0.70, Midwest vs South; RR 0.39, CI 0.37-0.41, Northeast vs South; RR 0.43, CI 0.41-0.46, West vs South; P < .001) were predictive of higher opioid prescription rates. CONCLUSIONS: Factors associated with increased number of RO-written opioid prescriptions were male sex, ≥25 years since graduation, group practice <10, PQRS participation, and Southern location. Additional research is required to establish optimal opioid prescribing practices for ROs.

Changes In Physician Consolidation With The Spread Of Accountable Care Organizations.

While early evidence suggests that accountable care organizations (ACOs) are associated with higher quality and lower costs, there have been simultaneous concerns that ACOs may incentivize consolidation of physician groups. This is particularly concerning as previous research has shown that consolidation is associated with lower quality and higher prices. Using a difference-in-differences strategy and data from the Medicare Shared Savings Program, which began in 2012, we examined whether physician practices consolidated after ACOs entered health care markets. We observed a 4.0-percentage-point increase in large practices (those with fifty or more physicians) in counties with the greatest ACO penetration, compared to counties with zero ACO penetration, and a 2.7-percentage-point decline in the percentage of small practices (ten or fewer physicians) from 2010 to 2015. The growth of large practices was concentrated in specialty and hospital-owned practices. These findings suggest that ACOs may contribute to the concentration of physician practices.

Association Between Clinical Practice Group Adherence to Quality Measures and Adverse Outcomes Among Adult Patients With Diabetes.

Importance: Clinical practice group performance on quality measures associated with chronic disease management has become central to reimbursement. Therefore, it is important to determine whether commonly used process and disease control measures for chronic conditions correlate with utilization-based outcomes, as they do in acute disease. Objective: To examine the associations among clinical practice group performance on diabetes quality measures, including process measures, disease control measures, and utilization-based outcomes. Design, Setting, and Participants: This retrospective, cross-sectional analysis examined commercial claims data from a national health insurance plan. A cohort of eligible beneficiaries with diabetes aged 18 to 65 years who were enrolled for at least 12 months from January 1, 2010, through December 31, 2014, was defined. Eligible beneficiaries were attributed to a clinical practice group based on the plurality of their primary care or endocrinology office visits. Data were analyzed from October 1, 2018, through April 30, 2019. Main Outcomes and Measures: For each clinical practice group, performance on current diabetes quality measures included 3 process measures (2 testing measures [hemoglobin A1c {HbA1c} and low-density lipoprotein {LDL} testing] and 1 drug use measure [statin use]) and 2 disease control measures (HbA1c <8% and LDL level <100 mg/dL). The rates of utilization-based outcomes, including hospitalization for diabetes and major adverse cardiovascular events (MACEs), were also measured. Results: In this cohort of 652 258 beneficiaries with diabetes from 886 clinical practice groups, 42.9% were aged 51 to 60 years, and 52.6% were men. Beneficiaries lived in areas that were predominantly white (68.1%). At the clinical practice group level, except for high correlation between the 2 testing measures, correlations among different quality measures were weak (r range, 0.010-0.244). Rate of HbA1c of less than 8% had the strongest correlation with hospitalization for MACE (r = -0.046; P = .03) and diabetes (r = -0.109; P < .001). Rates of HbA1c control at the clinical practice group level were not significantly associated with likelihood of hospitalization at the individual level. Performance on the process and disease control measures together explained 3.9% of the variation in the likelihood of hospitalization for a MACE or diabetes at the individual level. Conclusions and Relevance: In this study, performance on utilization-based measures-intended to reflect the quality of chronic disease management-was only weakly associated with direct measures of chronic disease management, namely, disease control measures. This correlation should be considered when determining the degree of financial emphasis to place on hospitalization rates as a measure of quality in treatment of chronic diseases.

A New Multisource Feedback Tool for Evaluating the Performance of Specialty-Specific Physician Groups: Validity of the Group Monitor Instrument.

INTRODUCTION: Since clinical practice is a group-oriented process, it is crucial to evaluate performance on the group level. The Group Monitor (GM) is a multisource feedback tool that evaluates the performance of specialty-specific physician groups in hospital settings, as perceived by four different rater classes. In this study, we explored the validity of this tool. METHODS: We explored three sources of validity evidence: (1) content, (2) response process, and (3) internal structure. Participants were 254 physicians, 407 staff, 621 peers, and 282 managers of 57 physician groups (in total 479 physicians) from 11 hospitals. RESULTS: Content was supported by the fact that the items were based on a review of an existing instrument. Pilot rounds resulted in reformulation and reduction of items. Four subscales were identified for all rater classes: Medical practice, Organizational involvement, Professionalism, and Coordination. Physicians and staff had an extra subscale, Communication. However, the results of the generalizability analyses showed that variance in GM scores could mainly be explained by the specific hospital context and the physician group specialty. Optimization studies showed that for reliable GM scores, 3 to 15 evaluations were needed, depending on rater class, hospital context, and specialty. DISCUSSION: The GM provides valid and reliable feedback on the performance of specialty-specific physician groups. When interpreting feedback, physician groups should be aware that rater classes' perceptions of their group performance are colored by the hospitals' professional culture and/or the specialty.

Residency Program Characteristics and Individual Physician Practice Characteristics Associated With Family Physician Scope of Practice.

PURPOSE: A family physician's ability to provide continuous, comprehensive care begins in residency. Previous studies show that patterns developed during residency may be imprinted upon physicians, guiding future practice. The objective was to determine family medicine residency characteristics associated with graduates' scope of practice (SCoP). METHOD: The authors used (1) residency program data from the 2012 Accreditation Council for Graduate Medicine Education Accreditation Data System and (2) self-reported data supplied by family physicians when they registered for the first recertification examination with the American Board of Family Medicine (2013-2016)-7 to 10 years after completing residency. The authors used linear regression analyses to examine the relationship between individual physician SCoP (measured by the SCoP for primary care [SP4PC] score [scale of 0-30; low = small scope]) and individual, practice, and residency program characteristics. RESULTS: The authors sampled 8,261 physicians from 423 residencies. The average SP4PC score was 15.4 (standard deviation, 3.2). Models showed that SCoP broadened with increasing rurality. Physicians from unopposed (single) programs had higher SCoP (0.26 increase in SP4PC); those from major teaching hospitals had lower SCoP (0.18 decrease in SP4PC). CONCLUSIONS: Residency program characteristics may influence family physicians' SCoP, although less than individual characteristics do. Broad SCoP may imply more comprehensive care, which is the foundation of a strong primary care system to increase quality, decrease cost, and reduce physician burnout. Some residency program characteristics can be altered so that programs graduate physicians with broader SCoP, thereby meeting patient needs and improving the health system.

Prevalence of burnout among German general practitioners: Comparison of physicians working in solo and group practices.

BACKGROUND: Studies from general practitioner (GP) populations from various European countries show a high prevalence of burnout, yet data from Germany are scarce and there are no data comparing GPs from solo versus group practices. METHODS: This cross-sectional survey addressed all GPs from a German network of family medicine practices comprising 185 practices. Participants were asked to fill in a self-administered questionnaire addressing socio-demographic and job-related characteristics. The German version of the Maslach Burnout Inventory was used to measure the dimensions emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Each participant was categorized as having high EE, high DP and low PA following pre-defined cut-offs. RESULTS: A total of 214 GPs from 129 practices participated: 65.9% male, 24.8% solo practice. Of all GPs, 34.1% (n = 73) scored high for EE, 29.0% (n = 62) high for DP, 21.5% (n = 46) low for PA and 7.5% (n = 16) for all three dimensions. A higher risk for EE was found among female physicians, those unsatisfied with their job, those using few stress-regulating measures regularly and those reporting bad work-life balance. Burnout prevalence was higher in GPs in group than in solo practices (37.9% vs. 28.8% had high EE, 33.1% vs. 18.9% had high DP and 22.8% vs. 18.9% had low PA). A significantly higher prevalence of burnout symptoms was found in group practice employees compared to group practice owners. CONCLUSION: Burnout prevalence was higher among physicians in group practices compared to solo practices. In group practices, employed, young, female and part-time working physicians showed a higher burnout risk.

National survey of urogynecological practice patterns among United States OB/GYN oral board examinees in different practice settings.

INTRODUCTION AND HYPOTHESIS: The current urogynecological surgical experience of recent OB/GYN graduates in different practice settings is unclear. The aim of this study was to evaluate differences in urogynecological surgical care between private practitioners (PPs) and other generalist OB/GYN oral board examinees. METHODS: A total of 699 OB/GYN oral board examination examinees were administered a survey during board preparatory courses with a 70.7% response rate. The primary outcome was to determine differences in subjective reported performance of urogynecological surgery with and without apical support procedures (female pelvic medicine and reconstructive surgery, FPMRS, ± apical) between PP and generalists in other practice models (academic, managed care, other). Secondary outcomes included urogynecological case list reporting, referral patterns, and residency training. RESULTS: A total of 473 surveys were completed; after excluding subspecialists, 210 surveys were completed by PP and 162 by individuals in other settings. 6.7% of PPs subjectively reported that they perform FPMRS + apical surgery compared with 4.3% of those in other practice settings (p = 0.33). Although 29.2% of PPs reported adequate FPMRS training in residency compared with 39.7% of those in other practice settings (p = 0.04), 53.6% of PPs reported that they refer patients with pelvic organ prolapse (POP), compared with 66.5% of those in other practice settings (p = 0.013). 38.9% of PPs report that they performed POP surgery compared with 27.8% of non-PPs (p = 0.014). CONCLUSIONS: Regardless of practice setting, surgical volumes are low and few general OB/GYN board examinees report that they perform comprehensive FPMRS ± apical support surgery. The practice environment may affect providers' management of patients with pelvic floor disorders.

A Simple Framework for Weighting Panels Across Primary Care Disciplines: Findings From a Large US Multidisciplinary Group Practice.

BACKGROUND: Health system redesign necessitates understanding patient population characteristics, yet many primary care physicians are unable to identify patients on their panel. Moreover, accounting for differential workload due to patient variation is challenging. We describe development and application of a utilization-based weighting system accounting for patient complexity using sociodemographic factors within primary care at a large multidisciplinary group practice. METHODS: A retrospective observational study was conducted of 27 clinics across primary care serving more than 150 000 patients. Before and after implementation, we measured empanelment by comparing weighted to unweighted panel size and the number of physicians who could accept patients. Perceived access was measured by the number of patients strongly agreed that an appointment was available when needed. RESULTS: After instituting weighting, the percentage of physicians with open panels decreased for family physicians and pediatricians, but increased for general internists; the number of active patients increased by 2%. One year after implementation, perceived access improved significantly in family and general internal medicine clinics (P < .05). There were no significant changes for general pediatric and adolescent medicine patients. CONCLUSIONS: The creation of a weighing system accounting for complexity resulted in changes in practice closure, increased total patients, and improved access.

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.

Directing Improvements in Primary Care Patient Experience through Analysis of Service Quality.

OBJECTIVE: To examine the influence of dimensions of service quality on patient experience of primary care. DATA SOURCES/STUDY SETTING: Data from the national GP Patient Survey in England 2014/15, with responses from 858,351 patients registered at 7,918 practices. STUDY DESIGN: Expert panel and principal component analysis helped identify relevant dimensions of service quality. Regression was then used to examine the relationships between these dimensions and reported patient experience. DATA COLLECTION/EXTRACTION METHODS: Aggregated scores for each practice were used, comprising the proportion of positive responses to each element of the study. PRINCIPAL FINDINGS: Of eight service quality dimensions identified, six have statistically significant impacts on patient experience but only two have large effects. Patient experience is highly influenced by practice responsiveness and the interactions with the physician. Other dimensions have small or even slightly negative influence. Service quality provided by nurses has negligible effect on patient experience. CONCLUSIONS: To improve patient experience in primary health care, efforts should focus on practice responsiveness and interactions with the physician. Other areas have little influence over patient experience. This suggests a gap in patients' perspectives on health care, which has policy implications for patient education.

Patient centred medical home (PCMH) and patient-practitioner orientation: Is there a relationship?

BACKGROUND: The patient-centred medical home (PCMH) and utilisation of a patient-centred care approach have been promoted as opportunities to improve healthcare quality while controlling expenditures. OBJECTIVES: To determine the penetration of PCMH within physician practices, and to evaluate physician attitudes towards patient-practitioner orientation. The ultimate objective was to explore relationships between the patient-practitioner orientation of respondents and the presence of PCMH elements within their practice. METHODS: A survey instrument was developed following a comprehensive literature review. Lead physicians practicing in four states were surveyed. RESULTS: The adjusted response rate was 26.7%. Responses indicated increased utilisation of PCMH elements (electronic medical records, e-mail and telephone consultations, and physician performance monitoring and feedback) compared with previous research. Within a logistic regression model, medical school graduation year (1990 or later >prior to 1990), practice size (group >solo), and percentage of time allocated to patient care (less >more) were significant predictors of working in a high PCMH alignment setting. Physician and practice characteristics did not predict the level of patient-practitioner orientation, though rural physicians were more patient-centred than urban physicians. A non-linear correlation between patient-practitioner orientation and the likelihood of practicing in a low or high PCMH-aligned practice was observed. CONCLUSIONS: There is a non-linear correlation between patient-practitioner orientation and the likelihood of a physician practicing in a low or high PCMH-aligned practice. The ability of a physician to work in a PCMH setting or practicing patient-centred care can go beyond a physician's aspirations to work and practice in that manner.

Survey of Patch Test Business Models in the United States by the American Contact Dermatitis Society.

BACKGROUND: Allergic contact dermatitis (ACD) remains a significant burden of disease in the United States. Patch testing is the criterion standard for diagnosing ACD, but its use may be limited by reimbursement challenges. OBJECTIVE: This study aimed to assess the current rate of patch test utilization among dermatologists in academic, group, or private practice settings to understand different patch testing business models that address these reimbursement challenges. METHODS: All members of the American Contact Dermatitis Society received an online survey regarding their experiences with patch testing and reimbursement. RESULTS: A "yes" response was received from 28% of survey participants to the question, "Are you or have you been less inclined to administer patch tests or see patients needing patch tests due to challenges with receiving compensation for patch testing?" The most commonly reported barriers include inadequate insurance reimbursement and lack of departmental support. CONCLUSIONS: Compensation challenges to patch testing limit patient access to appropriate diagnosis and management of ACD. This can be addressed through a variety of innovative business models, including raising patch testing caps, negotiating relative value unit compensation, using a fixed salary model with directorship support from the hospital, and raising the percentages of collection reimbursement for physicians.