Patient-Centered Payment for Care of Chronic Conditions.

Current payment systems make it difficult for both specialists and primary care practices to provide all of the services needed by patients with chronic conditions. "Value-based payment" programs have failed to solve these problems. In a patient-centered payment system, there should be 4 separate payments designed specifically to support each of the phases of chronic condition care: (1) Diagnosis Payment, (2) Care Planning Payment, (3) Initial Condition Management Payment, and (4) Monthly Condition Management Payments. Physicians should be accountable for delivering evidence-based services to patients in each phase of care, and payment amounts should be higher for more complex patients.

Building Sustainable Practice Transformation Through Payment Reform Initiatives.

PURPOSE: Novel value-based payment approaches provide an opportunity to deploy and sustain health care delivery interventions, such as treatment planning documentation. However, limited data are available on implementation costs. METHODS: We described key factors affecting the cost of implementing care improvements under value-based payments, using treatment planning and Medicare's Oncology Care Model as examples. We estimated expected costs of implementing treatment plans for years 1 and 2-6 under (1) different staffing models, (2) use of technology, and (3) differences in the patients engaged. We compared costs to the payment amounts under the Oncology Care Model. RESULTS: Team-based models where staffing is aligned with skills needed for key tasks (eg, a combination of lay navigator, nurse, and physician) are more financially feasible when compared with using physicians or nurses alone. When existing staff are at or near capacity, hiring new staff focused on practice transformation activities allows adequate time for new initiatives without negative impacts on existing services. Investments in information technology can enhance staff productivity, but initial costs may be high. Interventions may not be financially feasible if implemented for a small patient volume or only for patients insured by a particular payer. Finally, costs may be higher for disadvantaged populations, and equity in care delivery may require higher payments from payers. CONCLUSION: Estimating the cost of implementing an intervention in different types of practice settings with various types of patients is essential to ensure that a value-based payment system will adequately support desired improvements in quality of care for all patients.

Test-Enhanced Learning and Incentives in Biology Education.

Cognitive scientists have recommended the use of test-enhanced learning in science classrooms. Test-enhanced learning includes the testing effect, in which learners' recall of information encountered in testing exceeds that of information not tested. The influence of incentives (e.g., points received) on learners who experience the testing effect in classrooms is less understood. The objective of our study was to examine the effects of incentives in a postsecondary biology course. We administered exams in the course using a quasi-experimental design with low and high point incentives and measured student learning. Although exposure to exams predicted better learning, incentive level did not moderate this effect, an outcome that contradicted recent laboratory findings that higher incentives decreased student recall. We discuss possible explanations of the disparate outcomes as well as the implications for further research on the testing effect in postsecondary biology classrooms.

Impact of Travel Time on Health Care Costs and Resource Use by Phase of Care for Older Patients With Cancer.

PURPOSE: Many community cancer clinics closed between 2008 and 2016, with additional closings potentially expected. Limited data exist on the impact of travel time on health care costs and resource use. METHODS: This retrospective cohort study (2012 to 2015) evaluated travel time to cancer care site for Medicare beneficiaries age 65 years or older in the southeastern United States. The primary outcome was Medicare spending by phase of care (ie, initial, survivorship, end of life). Secondary outcomes included patient cost responsibility and resource use measured by hospitalization rates, intensive care unit admissions, and chemotherapy-related hospitalization rates. Hierarchical linear models with patients clustered within cancer care site (CCS) were used to determine the effects of travel time on average monthly phase-specific Medicare spending and patient cost responsibility. RESULTS: Median travel time was 32 (interquartile range, 18-59) minutes for the 23,382 included Medicare beneficiaries, with 24% of patients traveling longer than 1 hour to their CCS. During the initial phase of care, Medicare spending was 14% higher and patient cost responsibility was 10% higher for patients traveling longer than 1 hour than those traveling 30 minutes or less. Hospitalization rates were 4% to 13% higher for patients traveling longer than 1 hour versus 30 minutes or less in the initial (61 v 54), survivorship (27 v 26), and end-of-life (310 v 286) phases of care (all P < .05). Most patients traveling longer than 1 hour were hospitalized at a local hospital rather than at their CCS, whereas the converse was true for patients traveling 30 minutes or less. CONCLUSION: As health care locations close, patients living farther from treatment sites may experience more limited access to care, and health care spending could increase for patients and Medicare.

Loss Aversion as a Potential Factor in the Sunk-Cost Fallacy.

The sunk-cost fallacy (SCF) occurs when an individual makes an investment with a low probability of a payoff because an earlier investment was made. The investments may be time, effort, or money. Previous researchers showed that larger prior investments were more likely to lead to the SCF than lower investments were, though little research has been focused on comparing investment types. There are several theories of the SCF, but few have implicated loss aversion, the higher sensitivity to losses than to gains, as a potential factor. We studied the differential effects of investment amount and type on the occurrence of the SCF and explored loss aversion as a potential explanation of these differences. There were 168 participants, who completed a sunk-cost task as well as an endowment-effect task, which was a measure of loss aversion. A 3 3 mixed-design ANCOVA was used in which the SCF score was the dependent variable and loss-aversion scores were used as a covariate. The SCF occurred most often with money, less with time, and least with effort. Loss aversion displayed a weak negative relation to the SCF.

La falacia del costo irrecuperable (SCF, por sus siglas en inglés) se produce cuando una persona realiza una inversión con una baja probabilidad de pago porque se realizó una inversión anterior. Las inversiones pueden ser tiempo, esfuerzo o dinero. Diferentes investigadores demostraron que las inversiones previas más grandes tenían mayor probabilidad de conducir al SCF que las inversiones más bajas, aunque pocas investigaciones se han centrado en comparar los tipos de inversión. Existen varias teorías de la SCF, pero pocas han incluido la aversión a las pérdidas, mayor sensibilidad a las pérdidas que a las ganancias, como un factor potencial. Estudiamos los efectos diferenciales del monto y el tipo de inversión en la ocurrencia de la SCF y exploramos la aversión a la pérdida como una posible explicación de estas diferencias. Se contó con 168 participantes, quienes completaron una tarea de costo irrecuperable, así como una tarea de efecto de dotación, que fue una medida de la aversión a la pérdida. Se utilizó un ANCOVA de diseño mixto de 3 3 en el que la puntuación de SCF fue la variable dependiente y las puntuaciones de aversión a la pérdida se usaron como covariables. El SCF se produjo con mayor frecuencia en relación al dinero, seguido por el tiempo y, por último, al esfuerzo. La aversión a la pérdida mostró una relación negativa débil con el SCF.

Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing.

The Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing charts an efficient pathway to a maternity care system that reliably enables all women and newborns to experience healthy physiologic processes around the time of birth, to the extent possible given their health needs and informed preferences. The authors are members of a multistakeholder, multidisciplinary National Advisory Council that collaborated to develop this document. This approach preventively addresses troubling trends in maternal and newborn outcomes and persistent racial and other disparities by mobilizing innate capacities for healthy childbearing processes and limiting use of consequential interventions. It provides more appropriate care to healthier, lower-risk women and newborns who often receive more specialized care, though such care may not be needed and may cause unintended harm. It also offers opportunities to improve the care, experience and outcomes of women with health challenges by fostering healthy perinatal physiologic processes whenever safely possible.

How alternative payment models in emergency medicine can benefit physicians, payers, and patients.

While there has been considerable effort devoted to developing alternative payment models (APMs) for primary care physicians and for episodes of care beginning with inpatient admissions, there has been relatively little attention by payers to developing APMs for specialty ambulatory care, and no efforts to develop APMs that explicitly focus on emergency care. In order to ensure that emergency care is appropriately integrated and valued in future payment models, emergency physicians (EPs) must engage with the stakeholders within the broader health care system. In this article, we describe a framework for the development of APMs for emergency medicine and present four examples of APMs that may be applicable in emergency medicine. A better understanding of how APMs can work in emergency medicine will help EPs develop new APMs that improve the cost and quality of care, and leverage the value that emergency care brings to the system.

The effectiveness of a multidisciplinary, team-based approach to cesarean hysterectomy in modern obstetric practice.

OBJECTIVE: To examine the effectiveness of a multidisciplinary, team-based approach to management of cesarean hysterectomy. METHODS: In a retrospective chart review, data were analyzed from a quality assurance database of hysterectomies performed after cesarean delivery at one institution in the USA. Patients were identified through billing codes for cesarean delivery, cross-referenced to codes for hysterectomy. Demographic, reproductive, and outcome data were compared before (2000-2005) and after (2011-2013) implementation of a multidisciplinary team-based protocol. RESULTS: Across the two study periods, 107 cesarean hysterectomies were identified (69 pre-implementation, 38 post-implementation). In univariate analysis, the post-implementation group had fewer days in surgical intensive care than did the pre-implementation group (0.21 ± 0.41 vs 1.04 ± 2.44 days; P=0.011), and a lower frequency of febrile morbidity (4 [11%] vs 22 [32%]; P=0.033]. In multivariate analysis with adjustment for potential confounders, the likelihood of postoperative febrile morbidity was higher during the pre-implementation than the post-implementation period (adjusted odds ratio 3.5, 95% confidence interval 1.09-13.65; P=0.048). CONCLUSION: Outcomes were improved after the multidisciplinary team-based approach to cesarean hysterectomy was implemented. Team-based approaches to care of women undergoing cesarean hysterectomy are important to improve outcomes.

Making Value-Based Payment Work for Academic Health Centers.

Under fee-for-service payment systems, physicians and hospitals can be financially harmed by delivering higher-quality, more efficient care. The author describes how current "value-based purchasing" initiatives fail to address the underlying problems in fee-for-service payment and can be particularly problematic for academic health centers (AHCs). Bundled payments, warranties, and condition-based payments can correct the problems with fee-for-service payments and enable physicians and hospitals to redesign care delivery without causing financial problems for themselves. However, the author explains several specific actions that are needed to ensure that payment reforms can be a "win-win-win" for patients, purchasers, and AHCs: (1) disconnecting funding for teaching and research from payment for service delivery, (2) providing predictable payment for essential hospital services, (3) improving the quality and efficiency of care at AHCs, and (4) supporting collaborative relationships between AHCs and community providers by allowing each to focus on their unique strengths and by paying AHC specialists to assist community providers in diagnosis and treatment. With appropriate payment reforms and a commitment by AHCs to redesign care delivery, medical education, and research, AHCs could provide the leadership needed to improve care for patients, lower costs for health care purchasers, and maintain the financial viability of both AHCs and community providers.

Utilization of psychiatric services by postpartum women in a predominantly minority, low-socioeconomic-status, urban population.

This study describes the utilization of health care services related to psychiatric diagnoses in an inner city community health organization with a largely Hispanic population of low socioeconomic status. We reviewed the frequency and timing of postpartum mental health diagnoses among 5,731 patients who delivered babies and were followed-up for postpartum care. 286 women (5 %) had at least one mental health diagnosis. The rates in white, black, and Hispanic women were 12, 8, and 5 % respectively (p < .05). White and black women were 2.5 (95 % CI 1.24, 5.07), and 1.62 (95 % CI 1.09, 2.40) times more likely to have a mental health diagnosis, respectively, compared to Hispanic women. The most common diagnoses were mood disorders (64 %) followed by anxiety disorders (29 %). 87 % of cases were diagnosed after 4 weeks postpartum. The postpartum mental health diagnosis rate seen here is lower than might be expected, particularly among Hispanic women. Possible explanations are discussed.

A laser beam quality definition based on induced temperature rise.

Laser beam quality metrics like M(2) can be used to describe the spot sizes and propagation behavior of a wide variety of non-ideal laser beams. However, for beams that have been diffracted by limiting apertures in the near-field, or those with unusual near-field profiles, the conventional metrics can lead to an inconsistent or incomplete description of far-field performance. This paper motivates an alternative laser beam quality definition that can be used with any beam. The approach uses a consideration of the intrinsic ability of a laser beam profile to heat a material. Comparisons are made with conventional beam quality metrics. An analysis on an asymmetric Gaussian beam is used to establish a connection with the invariant beam propagation ratio.