Medicaid Integrated Purchasing for Physical and Behavioral Health: Early Adopters' Perceptions of Payment Reform Implementation in Washington State.

The Centers for Medicare and Medicaid Innovation (CMMI) gave rise to the State Innovation Models (SIMs). Medicaid Integrated Purchasing for Physical and Behavioral Health, referred to as Payment Model 1 (PM1), was a core payment redesign area of the Washington State SIM project under which our research team was contracted to provide an evaluation. In doing so, we leveraged an open systems conceptual model to assess qualitatively Early Adopter stakeholders' perceived effects of implementation. Between 2017 and 2019, we conducted three rounds of interviews, examining themes of care coordination, common facilitators and barriers to integration, and potential concerns for sustaining the initiative into the future. Further, we noted the initiative's complexity may require the establishment of enduring partnerships, secure funding sources, and committed regional leadership to ensure longer-term success.

Evaluation of a Multilevel Laboratory Stewardship Intervention Targeted to Cardiac and Thoracic Surgical Services at an Academic Medical Center.

CONTEXT.­: Unnecessary laboratory tests are ordered because of factors such as preselected orders on order sets, clinician habits, and trainee concerns. Excessive use of laboratory testing increases patient discomfort via unnecessary phlebotomy, contributes to iatrogenic anemia, increases risk of bloodstream infections, and increases the cost of care. OBJECTIVE.­: To address these concerns, we implemented a multilevel laboratory stewardship intervention to decrease unnecessary laboratory testing, measured by laboratory tests per day attributed to service, across 2 surgical divisions with high laboratory use. DESIGN.­: The multilevel intervention included 5 components: stakeholder engagement, provider education, computerized provider order entry modification, performance feedback, and culture change supported by leadership. The primary outcome of the study was laboratory tests ordered per patient-day. Secondary outcomes included the number of blood draws per patient-day, total lab-associated costs, length of stay, discharge to a nursing facility, 30-day readmissions, and deaths. A difference-in-differences analytic approach assessed the outcome measures in the intervention period, with other surgical services as controls. RESULTS.­: The primary outcome of laboratory tests per patient-day showed a significant decrease across both thoracic and cardiac surgery services, with between 1.5 and 2 fewer tests ordered per patient-day for both services and an estimated 20 000 fewer tests performed during the intervention period. Blood draws per patient-day were also significantly decreased on the thoracic surgery service but not for cardiac surgery. CONCLUSIONS.­: A multilevel laboratory stewardship intervention targeted to 2 surgical services resulted in a significant decrease in laboratory test use without negatively impacting length of stay, readmissions, or mortality.

Organizational factors affecting successful physician-system integration: A qualitative study of Washington State health executives.

BACKGROUND: Health care delivery is moving toward a value-based environment, which calls for increased integration between physician groups and health systems. Health executives sit at a key nexus point for determining how and when physician-system integration occurs. PURPOSE: The objective of this study was to identify the organizational factors that health executives perceived to have made physician-system integration successful. METHODOLOGY/APPROACH: We used a multiple-case study research design. We conducted semistructured, qualitative interviews with 25 health executives in the roles of CEO, chief medical officer, chief financial officer and physician group chief executives from eight of Washington State's largest integrated delivery systems. To guide our analysis, we employed open systems theory and Porter's Value Chain to identify physician group and hospital factors that were integral to successful integration. RESULTS: Using the executives' perspectives, the factors grouped into three themes: (1) organizational structure-a mix of integration contracts united by common structural characteristics between physician groups and hospitals); (2) organizational culture-alignment of leadership between physician groups and hospitals; and (3) strategic resources-designated resources to establish and support care coordination activities. CONCLUSION: Our work indicates that health systems should focus on the pathway to integration success through the alignment of structure (not just the integration contract), culture, and resources and not on an end goal of the physician employment model. PRACTICE IMPLICATIONS: Health system executives are key drivers for when and how physician groups are integrated into health services organizations. This article provides executives with an evidence-based model to aid in formulating integration approaches that combine elements of organizational structure, organizational culture, and strategic resources.

The Contribution of Physician-System Integrating Structure to Select Health System Outcomes.

Physician groups are increasingly being vertically integrated with hospitals and health systems; yet, the evidence on the impact of physician-system integration on health system outcomes is mixed. The objective of this study was to examine the impact of increased physician-system integration on select health system outcomes. We used a mixed-methods approach: (1) a fixed-effects multivariate mediation analysis; and (2) a qualitative analysis of interviews with health executives (n = 25). Our findings showed that hospitals spent $633 375.22 to $827 110.24 for each "level" increase in integration. This relationship was attenuated, however, by the presence of care coordination mechanisms.

Community Readiness for Increasing Older Adult Physical Activity Levels in Kazakhstan.

Introduction: Physical activity is proven to be a significant element of successful aging, but many seniors worldwide fail to achieve the recommended levels. This study aimed to assess the readiness of the community in Nur-Sultan, Kazakhstan, to act on the issue of physical inactivity among older adults. Methods: In order to achieve this purpose, we conducted qualitative interviews with key informants in the community and applied a validated community readiness tool. Results: The results suggest that the local community is at early stages of readiness to act on the issue of older adult physical inactivity. We identified a number of barriers that prevented seniors from leading active lifestyles, which included community misconceptions about older adult physical activity, family centeredness in older adulthood, scarcity of resources, passive support from the leadership, and lack of efforts in the community. Research findings also highlighted the importance of conducting in-depth analysis of key informant responses in addition to calculating readiness scores, when using the community readiness tool. Conclusions: Community-specific strategies for enhancing the level of physical activity among seniors are required to offset the disease burden associated with aging and to prolong life expectancy in Kazakhstan, and it is of paramount importance to tailor potential efforts as to address the current readiness of the community and its needs.

From Volume- to Value-Based Payment System in Washington State Federally Qualified Health Centers: Innovation for Vulnerable Populations.

The reimbursement system at 16 Federally Qualified Health Centers in Washington State transformed to a per-member-per-month model with a prospective adjustment for quality performance. The results of this qualitative study suggest that 3 to 5 years would be required to achieve significant progress in the Triple Aim goals of the initiative and also demonstrate that Federally Qualified Health Centers are potentially more advanced in their readiness to offer value-based care. By providing positive financial incentives without downside risk, the state is stimulating replicable models of care, and in longer term such reforms may lead to a greater care coordination and a whole person-centered care.

Enhancing Access to Quality Online Training to Strengthen Public Health Preparedness and Response.

OBJECTIVES: To improve access to quality online training materials developed from 2010 to 2015 by 14 Preparedness and Emergency Response Learning Centers (PERLCs) by creating quality standards and enhancing searchability through a new Web-based public health training catalog. METHODS: The PERLC-developed training materials (n = 530) were evaluated for their capability to support development of preparedness competencies as established by 2 evidence-based competency frameworks. Inclusion/exclusion criteria and evaluation guidelines regarding training quality (design, technology, and instructional components) were systematically applied to PERLC products to create a training catalog. Twenty emergency preparedness professionals pilot tested content and provided feedback to improve catalog design and function. RESULTS: Seventy-eight percent of PERLC resources (n = 413) met our quality standards for inclusion in the catalog's searchable database: 358 self-paced courses, 55 informational briefs, and other materials. Twenty-one training bundles were curated. DISCUSSION: We established quality guidelines, identified strengths and weaknesses in PERLC resources, and improved accessibility to trainings. Guidelines established by this work can be generalized to trainings outside the preparedness domain. Enhancing access to quality training resources can serve as a valuable tool for increasing emergency preparedness competence.

Accountable Care Program Implementation and Effects on Participating Health Care Systems in Washington State: A Conceptual Model.

This study is based on key informant interviews with health care executives representing 5 large health systems that had entered into contracts with the Washington State Health Care Authority to provide accountable care network services under the State Innovation Model initiative. The purpose of this study was to explain effects of accountable care program (ACP) implementation on participating health care systems. Between January 2017 and May 2018, we conducted 2 rounds of semistructured interviews (n = 20). Results indicate the need to present a modified conceptual model aligned with ACP implementation in the current context.

The Push-Pull Factors of Physician-System Integration: A Qualitative Study of Washington State Healthcare Executives.

EXECUTIVE SUMMARY: The transition from volume- to value-based care calls for closer working relationships between physician groups and health systems. Healthcare executives are in the position of determining when and how physician groups are integrated into healthcare systems. Leveraging the theory of migration, we aim to describe where physician-system integration is headed and offer recommendations on how executives can respond to physician migration to and from integration. We conducted 25 semistructured interviews with CEOs, chief medical officers, chief financial officers, and physician group chief executives from eight of Washington State's largest integrated delivery systems. These executives predicted tighter integration and more forced alignment; however, some clinician executives were skeptical about whether the physician employment model will be the right course despite the growing demand from younger physicians. The results of these interviews suggest that integration will be driven by push and pull factors stemming from five prevailing forces: social (community), social (physicians), economic, political, and technological. Understanding the factors that influence physicians' decisions to migrate can provide insight for and guidance to executives contemplating integration in the current climate.

How the dual process model of human cognition can inform efforts to de-implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution.

RATIONALE AND OBJECTIVES: One way to understand medical overuse at the clinician level is in terms of clinical decision-making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision-making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De-implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition. RESULTS: We define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as "the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines." We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience "reactance," ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice. We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur. Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together. CONCLUSIONS: By taking into account the dual process model of cognition, we may be able to design de-implementation strategies matched to clinicians' decision-making processes and avoid unintended consequence.