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1.
J Manag Care Spec Pharm ; 25(9): 995-1000, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31456493

RESUMO

The shift to a value-based health care system has incentivized providers to implement strategies that improve population health outcomes while minimizing downstream costs. Given their accessibility and expanded clinical care models, community pharmacists are well positioned to join interdisciplinary care teams to advance efforts in effectively managing the health of populations. In this Viewpoints article, we discuss the expanded role of community pharmacists and potential barriers limiting the uptake of these services. We then explore strategies to integrate, leverage, and sustain these services in a value-based economy. Although community pharmacists have great potential to improve population health outcomes because of their accessibility and clinical interventions that have demonstrated improved outcomes, pharmacists are not recognized as merit-based incentive eligible providers and, as a result, may be underutilized in this role. Additional barriers include lack of formal billing codes, which limits patient access to services such as hormonal contraception; fragmentation of Medicare, which prevents alignment of medical and pharmaceutical costs; and continued fee-for-service payment models, which do not incentivize quality. Despite these barriers, there are several opportunities for continued pharmacist involvement in new care models such as patient-centered medical homes (PCMH), accountable care organizations, and other value-based payment models. Community pharmacists integrated within PCMHs have demonstrated improved hemoglobin A1c, blood pressure control, and immunization rates. Likewise, other integrated, value-based models that used community pharmacists to provide medication therapy management services have reported a positive return on investment in overall health care costs. To uphold these efforts and effectively leverage community pharmacist services, we recommend the following: (a) recognition of pharmacists as providers to facilitate full participation in performance-based models, (b) increased integration of pharmacists in emerging delivery and payment models with rapid cycle testing to further clarify the role and value of pharmacists, and (c) enhanced collaborative relationships between pharmacists and other providers to improve interdisciplinary care. DISCLOSURES: This article was funded by the National Association of Chain Drug Stores. The authors have no potential conflicts of interest to report.


Assuntos
Serviços Comunitários de Farmácia/organização & administração , Serviços Comunitários de Farmácia/normas , Conduta do Tratamento Medicamentoso/organização & administração , Conduta do Tratamento Medicamentoso/normas , Farmacêuticos/organização & administração , Farmacêuticos/normas , Organizações de Assistência Responsáveis/organização & administração , Organizações de Assistência Responsáveis/normas , Redução de Custos/normas , Planos de Pagamento por Serviço Prestado/normas , Custos de Cuidados de Saúde/normas , Humanos , Medicare/organização & administração , Medicare/normas , Equipe de Assistência ao Paciente/organização & administração , Equipe de Assistência ao Paciente/normas , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/normas , Papel Profissional , Estados Unidos
3.
Rev. clín. esp. (Ed. impr.) ; 219(2): 90-95, mar. 2019.
Artigo em Espanhol | IBECS | ID: ibc-185705

RESUMO

Los objetivos de gestión, en ocasiones, plantean importantes conflictos de valor, hasta el momento poco estudiados. En el presente artículo se analiza qué cuestiones éticas plantean los objetivos operativos de gestión a los médicos que trabajan en hospitales españoles. Estas cuestiones son las siguientes: 1) en el sistema actual se prima la cantidad sobre la calidad, lo que supone una perspectiva de gestión predominantemente economicista; 2) se trata de un sistema jerarquizado, en el que apenas hay participación y en el que los clínicos carecen de capacidad decisoria y 3) los objetivos se centran en actividades desfasadas respecto a la realidad del sistema sanitario actual, por lo que deben ser actualizados considerando, por ejemplo, la cronicidad o la continuidad asistencial. Al analizar estas cuestiones, se realiza una propuesta de elaboración de los objetivos de gestión basada en 3 aspectos: priorizar la calidad asistencial (lo que finalmente repercute en una gestión eficiente), elaborar los objetivos de forma participativa y mixta (con objetivos colectivos e individuales) y diseñar nuevos objetivos acordes con la realidad del actual sistema sanitario. No es complicado poner en práctica esta propuesta, ya que la meta final de los clínicos y de la gerencia es la de proporcionar una asistencia sanitaria óptima


Management objectives at times create significant value conflicts that have so far been seldom studied. This article analyses the ethical issues created by the operational objectives of management for physicians who work in Spanish hospitals. These issues are as follows: 1) the current system places quantity above quality, which represents a predominantly economist management perspective; 2) the system is hierarchical, lacks participation and deprives clinicians of decision-making authority; 3) the objectives are focused on outdated activities in terms of the current reality of the healthcare system and should therefore be updated considering, for example, chronicity and the continuity of care. After analysing these issues, we created a proposal for developing management objectives based on prioritising quality care (which ultimately results in efficient management), developing objectives in a participatory and mixed manner (with group and individual objectives) and designing new objectives in keeping with the current reality of the healthcare system. Putting this proposal into practice is not complicated because the final goal of clinicians and management is to provide optimal health care


Assuntos
Humanos , Ética Institucional , Administração Hospitalar/ética , Objetivos Organizacionais , Dissidências e Disputas , Organizações de Assistência Responsáveis/organização & administração
4.
Med Care ; 57(4): 300-304, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30807454

RESUMO

BACKGROUND: Hospitals affiliated with Accountable Care Organizations (ACOs) may have a greater capacity to collaborate with providers across the care continuum to coordinate care, due to formal risk sharing and payment arrangements. However, little is known about the extent to which ACO affiliated hospitals implement care coordination strategies. OBJECTIVES: To compare the implementation of care coordination strategies between ACO affiliated hospitals (n=269) and unaffiliated hospitals (n=502) and examine whether the implementation of care coordination strategies varies by hospital payment model types. MEASURES: We constructed a care coordination index (CCI) comprised of 12 indicators that describe evidence-based care coordination strategies. Each indicator was scored on a 5-point Likert scale from 1="not used at all" to 5="used widely" by qualified representatives from each hospital. The CCI aggregates scores from each of the 12 individual indicators to a single summary score for each hospital, with a score of 12 corresponding to the lowest and 60 the highest use of care coordination strategies. RESEARCH DESIGN: We used state-fixed effects multivariable linear regression models to estimate the relationship between ACO affiliation, payment model type, and the use care coordination strategies. RESULTS: We found ACO affiliated hospitals reported greater use of care coordination strategies compared to unaffiliated hospitals. Fee-for-service shared savings and partial or global capitation payment models were associated with a greater use of care coordination strategies among ACO affiliated hospitals. CONCLUSION: Our findings suggest ACO affiliation and multiple payment model types are associated with the increased use of care coordination strategies.


Assuntos
Organizações de Assistência Responsáveis/organização & administração , Continuidade da Assistência ao Paciente/organização & administração , Hospitais/estatística & dados numéricos , Planejamento Estratégico/economia , Organizações de Assistência Responsáveis/estatística & dados numéricos , Continuidade da Assistência ao Paciente/economia , Humanos
5.
Med Care Res Rev ; 76(3): 255-290, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-29231131

RESUMO

Since 2010, more than 900 accountable care organizations (ACOs) have formed payment contracts with public and private insurers in the United States; however, there has not been a systematic evaluation of the evidence studying impacts of ACOs on care and outcomes across payer types. This review evaluates the quality of evidence regarding the association of public and private ACOs with health service use, processes, and outcomes of care. The 42 articles identified studied ACO contracts with Medicare ( N = 24 articles), Medicaid ( N = 5), commercial ( N = 11), and all payers ( N = 2). The most consistent associations between ACO implementation and outcomes across payer types were reduced inpatient use, reduced emergency department visits, and improved measures of preventive care and chronic disease management. The seven studies evaluating patient experience or clinical outcomes of care showed no evidence that ACOs worsen outcomes of care; however, the impact on patient care and outcomes should continue to be monitored.


Assuntos
Organizações de Assistência Responsáveis/organização & administração , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Medicina Preventiva , Gerenciamento Clínico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Medicaid/organização & administração , Medicare/organização & administração , Qualidade da Assistência à Saúde , Estados Unidos
6.
Gerontol Geriatr Educ ; 40(1): 121-131, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-29630470

RESUMO

There is a well-described need to increase the competence of the primary care workforce in the principles of geriatrics and palliative care, and as value-based payment models proliferate, there is increased incentive for the acquisition of these skills. Through a Geriatric Workforce Enhancement Program grant, we developed an adaptable curriculum around commonly encountered topics in palliative care and geriatrics that can be delivered to multidisciplinary clinicians in primary care settings. All participants in this training were part of an Accountable Care Organization (ACO) and were motivated to improve to care for complex older adults. A needs assessment was performed on each practice or group of learners and the curriculum was adapted accordingly. With the use of patient education and screening tools with strong validity evidence, the participants were trained in the principals of geriatrics and palliative care with a focus on advance care planning and assessing for frailty and functional decline. Comparison of pre- and post-test scores demonstrated increased confidence and knowledge in goals of care and basic geriatric assessment. Participants described feeling more able to address needs, have conversations around goals of care, and more able to recognize patients who would benefit from collaboration with geriatrics and palliative care.


Assuntos
Geriatria/educação , Relações Interprofissionais , Cuidados Paliativos/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , Organizações de Assistência Responsáveis/organização & administração , Idoso , Idoso de 80 Anos ou mais , Comportamento Cooperativo , Currículo , Avaliação Geriátrica , Humanos , Planejamento de Assistência ao Paciente , Educação de Pacientes como Assunto/organização & administração , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade/organização & administração
7.
Int J Health Serv ; 49(1): 5-16, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30189784

RESUMO

The period of sustained financial austerity since 2009 has led to a shift in competition policy within the English National Health Service. Policymakers have directed their attention away from the preexisting priority to support quicker access to routine and planned hospital care and have focused instead on improving emergency, cancer, and general practitioner services. This has prompted the development of a new policy framework and, in particular, a desire to create collaborative health systems focused on specific populations. In addition, previous policy initiatives to engage the leadership of general practitioners in planning services have been revisited. The overall effect has been to shift emphasis away from competitive markets and back toward a planning approach.


Assuntos
Competição Econômica/organização & administração , Reforma dos Serviços de Saúde/organização & administração , Acesso aos Serviços de Saúde/organização & administração , Medicina Estatal/organização & administração , Organizações de Assistência Responsáveis/organização & administração , Institutos de Câncer/organização & administração , Comportamento Cooperativo , Serviço Hospitalar de Emergência/organização & administração , Medicina Geral/organização & administração , Acesso aos Serviços de Saúde/economia , Hospitalização , Humanos , Inovação Organizacional , Medicina Estatal/economia , Reino Unido
9.
Milbank Q ; 96(4): 755-781, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30537369

RESUMO

Policy Points Accountable care organizations (ACOs) form alliances with management partners to access financial, technical, and managerial support. Alliances between ACOs and management partners are subject to destabilizing tension around decision-making authority, distribution of shared savings, and conflicting goals and values. Management partners may serve either as trainers, ultimately breaking off from the ACO, or as central drivers of the ACO. Management partner participation in ACOs is currently unregulated, and management partners may receive a significant portion (in some cases, majority) of shared savings. CONTEXT: Accountable care organizations (ACOs) are a prominent payment and delivery model. Though ACOs are often described as groups of health care providers, nearly 4 in 10 ACOs partner with a management company for services such as financial investment, contracting, data analytics, and care management, according to recent research. However, we know little about how and why these partnerships form. This article aims to understand the reasons providers seek partners, the nature of these relationships, and factors critical to the success or failure of these alliances. METHODS: We used qualitative data collected longitudinally from 2012 to 2017 at 2 ACOs to understand relationships between management partners and ACO providers. The data include 115 semistructured interviews and observational data from 7 site visits. Two coders applied 48 codes to the data. We reviewed coded data for emergent themes in the context of alliance life cycle theory. FINDINGS: Qualitative data revealed that management partners brought specific skills and services and also gave providers confidence in pursuing an ACO. Over time, tension between providers and management partners arose around decision-making authority, distribution of shared savings, and conflicting goals and values. We observed 2 outcomes of partnerships: cemented partnerships and dissolution. Key factors distinguishing alliance outcome in these 2 cases include degree of trust between organizations in the alliance; approach to conflict resolution; distribution of power in the alliance; skills and confidence acquired by the ACO over the life of the alliance; continuity of management partner delivery on promised resources; and proportion of savings going to the management partner. CONCLUSIONS: The diverging paths for ACOs with management partners suggest 2 different roles that management partners may play in ACO development. In some cases, management partners may serve as trainers, with the partnership dissolving once the ACO gains skills and confidence to work alone. In other cases, the management partner is a central driver of the ACO and unlikely to break off.


Assuntos
Organizações de Assistência Responsáveis/organização & administração , Organizações de Assistência Responsáveis/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Fundos de Seguro/organização & administração , Medicare/organização & administração , Medicare/estatística & dados numéricos , Humanos , Estados Unidos
10.
Cancer ; 124(22): 4366-4373, 2018 11 15.
Artigo em Inglês | MEDLINE | ID: mdl-30412287

RESUMO

BACKGROUND: Despite the rapid diffusion of accountable care organizations (ACOs), the effect of ACO enrollment on cancer diagnosis, treatment, and survivorship remains unknown. The objective of this study was to determine whether Medicare Shared Savings Program (MSSP) ACO enrollment was associated with changes in screening for breast, colorectal, and prostate cancers. METHODS: The authors built a cohort of Medicare beneficiaries from 2006 through 2014 comprising 39,218,652 person-years of observation before and 17,252,345 person-years of observation after MSSP enrollment. The Centers for Medicare & Medicaid Services attribution methodology was recapitulated; and screening services were identified for breast, colorectal, and prostate cancer, implementing both sensitive and specific definitions of cancer screening. Adjusted difference-in-differences analyses were performed using linear regression to characterize changes in annual screening rates after ACO enrollment relative to contemporaneous changes in a non-ACO control group of Medicare beneficiaries. RESULTS: Medicare beneficiaries attributed to ACO-enrolled providers had higher rates of breast, colorectal, and prostate cancer screening before enrollment. A 1.8% relative reduction in breast cancer screening was observed among women attributed to ACO providers (P < .0001), a 2.4% relative increase was observed in colorectal cancer screening (P = .0259), and a 3.4% relative reduction was observed in prostate cancer screening among men attributed to ACO providers (P = .0025) compared with contemporaneous changes in non-ACO controls. CONCLUSIONS: Small-magnitude reductions were observed in breast and prostate cancer screening rates, and a small increase was observed in colorectal cancer screening associated with ACO enrollment. Although ACO enrollment does not appear to drive wholesale changes in cancer screening, small differences may map to meaningful changes in the epidemiology of screen-detected cancers among Medicare beneficiaries.


Assuntos
Organizações de Assistência Responsáveis/organização & administração , Neoplasias da Mama/diagnóstico , Neoplasias Colorretais/diagnóstico , Neoplasias da Próstata/diagnóstico , Organizações de Assistência Responsáveis/economia , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/epidemiologia , Neoplasias Colorretais/epidemiologia , Detecção Precoce de Câncer/economia , Detecção Precoce de Câncer/estatística & dados numéricos , Feminino , Humanos , Masculino , Programas de Rastreamento/economia , Programas de Rastreamento/estatística & dados numéricos , Medicare , Neoplasias da Próstata/epidemiologia , Estados Unidos/epidemiologia
11.
PLoS One ; 13(10): e0205279, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30307974

RESUMO

BACKGROUND: Falls are a serious and common problem among older adults. Low-tech, inexpensive, community-based fall prevention programs have been shown to be both effective and cost effective, however, these programs are not well-integrated into clinical practice. RESEARCH DESIGN: We surveyed primary care providers at a convenience sample of two accountable care organizations in Massachusetts to assess their beliefs, attitudes, knowledge, and practices relative to fall risk assessment and intervention for their older patients. RESULTS: Response rate was 71%. Providers' beliefs about the efficacy of fall risk assessment and intervention were mixed. Eighty-seven percent believed that they could be effective in reducing fall risk among their older adult patients. Ninety-six percent believed that all older adults should be assessed for fall risk; and, 85% believed that this assessment would identify fall risk factors that could be modified. Nonetheless, only 52% believed that they had the expertise to conduct fall risk assessment and only 68% believed that assessing older adult patients for fall risk was the prevailing standard of practice among their peer providers. Although most providers believed it likely that an evidence-based program could reduce fall risk among their patients, only 14% were aware of the Centers for Disease Control and Prevention's fall risk assessment algorithm (STEADI Toolkit), and only 15% were familiar with Matter of Balance, the most widely disseminated community fall risk prevention program in Massachusetts. DISCUSSION: New strategies that more directly target providers are needed to accelerate integration of fall risk assessment and intervention into primary care practice.


Assuntos
Acidentes por Quedas/prevenção & controle , Organizações de Assistência Responsáveis/métodos , Determinação de Necessidades de Cuidados de Saúde/estatística & dados numéricos , Médicos de Atenção Primária/estatística & dados numéricos , Atenção Primária à Saúde/métodos , Organizações de Assistência Responsáveis/organização & administração , Idoso , Competência Clínica , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/organização & administração , Feminino , Humanos , Masculino , Projetos Piloto , Atenção Primária à Saúde/organização & administração , Inquéritos e Questionários/estatística & dados numéricos
13.
Am J Occup Ther ; 72(5): 7205090010p1-7205090010p6, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30157003

RESUMO

Accountable care organizations (ACOs) are organized networks or systems that provide services to Medicare beneficiaries under the Patient Protection and Affordable Care Act of 2010 with an emphasis on chronic care management. ACOs were instituted under Medicare to achieve value-based purchasing as opposed to simply providing high-volume, fee-for-service care. ACOs must reduce annual care expenditures through Medicare-covered services. Occupational therapy services often play a role along the care continuum of an ACO. This article examines some of the opportunities for occupational therapy to contribute to ACO quality outcomes and value-based care and considers some barriers for full utilization of occupational therapy practitioners in alternative payment models. Evidence-based and client-centered care provided by occupational therapy practitioners can result in increased inclusion of occupational therapy as a valued component of ACOs and other value-based service models.


Assuntos
Organizações de Assistência Responsáveis/organização & administração , Doença Crônica/reabilitação , Terapia Ocupacional/organização & administração , Prática Clínica Baseada em Evidências/organização & administração , Humanos , Comunicação Interdisciplinar , Colaboração Intersetorial , Patient Protection and Affordable Care Act/organização & administração , Assistência Centrada no Paciente/organização & administração , Garantia da Qualidade dos Cuidados de Saúde , Estados Unidos
14.
Am J Manag Care ; 24(7): e216-e221, 2018 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-30020757

RESUMO

OBJECTIVES: Accountable care organizations (ACOs) are groups of healthcare providers responsible for quality of care and spending for a defined patient population. The elimination of low-value medical services will improve quality and reduce costs and, therefore, ACOs should actively work to reduce the use of low-value services. We set out to identify ACO characteristics associated with implementation of strategies to reduce overuse. STUDY DESIGN: Survey analysis. METHODS: We used the National Survey of ACOs to determine the percentage of responding ACOs aware of the Choosing Wisely campaign and to what degree ACOs have taken steps to reduce the use of low-value services. We identified characteristics of ACOs associated with implementing low-value care-reducing strategies using 3 statistical models (stepwise and LASSO logistic regression and random forest). RESULTS: Responding executives of 155 of 267 ACOs (58%) were aware of Choosing Wisely. Eighty-four of those 155 ACO leaders said that their ACOs also actively implemented strategies to reduce the use of low-value services, largely through educating physicians and stimulating shared decision making. All 3 models identified the presence of at least 1 commercial payer contract and prior joint experience pursuing risk-based payment contracts as the most important predictors of an ACO actively implementing strategies to reduce low-value care. CONCLUSIONS: In the first year of implementation, just one-third of ACOs had taken steps to reduce the use of low-value medical services. Safety-net ACOs and those with little experience as a risk-bearing organization need more time and support from healthcare payers and the Choosing Wisely campaign to prioritize the reduction of overuse.


Assuntos
Organizações de Assistência Responsáveis/organização & administração , Sobremedicalização/prevenção & controle , Tomada de Decisões Gerenciais , Humanos , Melhoria de Qualidade , Estados Unidos
15.
Health Serv Res ; 53(6): 4767-4788, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30047138

RESUMO

OBJECTIVE: The concept of shifting from volume (i.e., billing for as many patients and services as possible) to value (i.e., reducing costs while improving quality) has been a key underpinning of the development of accountable care organizations (ACOs), yet the cultural change necessary to make this shift has been previously unexplored. DATA SOURCES/STUDY SETTING: Primary data collected through site visits to four private sector ACOs. STUDY DESIGN: Cross-sectional, semi-structured interview study with analysis done at the ACO level to learn about ACO development. DATA COLLECTION: One hundred and forty-eight interviews recorded and transcribed verbatim followed by rigorous qualitative analysis using a grounded theory approach. PRINCIPAL FINDINGS: The importance of shifting organizational culture from volume to value was emphasized across sites and interviewees, particularly when defining an ACO; describing the shift in organizational focus to value; and discussing how to create value by emphasizing quality over volume. Value was viewed as more than cost-benefit, but rather encapsulated a paradigmatic cultural change in the way care is provided. CONCLUSIONS: We found that moving from volume to value is central to the culture change required of an ACO. Our findings can inform future efforts that aim to create a more effective value-based health care system.


Assuntos
Organizações de Assistência Responsáveis/organização & administração , Cultura Organizacional , Setor Privado , Melhoria de Qualidade , Estudos Transversais , Teoria Fundamentada , Reforma dos Serviços de Saúde , Humanos , Entrevistas como Assunto , Medicare , Pesquisa Qualitativa , Estados Unidos
16.
J Manag Care Spec Pharm ; 24(8): 795-799, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30058987

RESUMO

BACKGROUND: Recent changes in the health care delivery landscape have expanded opportunities for clinical pharmacists in the ambulatory care setting. This article describes the successful integration of a clinical pharmacist-led chronic disease management service in a patient-centered medical home (PCMH) and accountable care organization (ACO) environment. PROGRAM DESCRIPTION: In 2008, the year before PCMH implementation, 36% of patients who were hospitalized at Advocate Trinity Hospital for a heart failure exacerbation were readmitted within 30 days of their hospital stay for heart failure exacerbation. This high rate of heart failure hospital readmissions, compared with national standards, drove the implementation of the PCMH at Advocate Medical Group - Southeast Center (AMG-SE), the adjoining outpatient medical clinic. A clinical pharmacist was added to the health care team to help achieve the collective goal of improving patient outcomes and decreasing hospitalizations. OBSERVATIONS: From November 1, 2009, through August 30, 2010, the clinical pharmacist conducted visits and intervened in the care of 111 chronic heart failure patients. A pre/post analysis of those 111 patients during the 10 months before and after the integration of the clinical pharmacist showed that those patients were hospitalized 63 times in the 10 months before having regularly scheduled visits with the clinical pharmacist and 30 times in the 10 months after establishing care. This reduction from 63 to 30 visits translated to an approximate 50% decrease in heart failure hospitalizations in patients being followed by the clinical pharmacist within the first 10 months. Once the clinical pharmacist became better integrated into the workflow through development of rapport with the medical team, the outcomes improved further. In an 18-month analysis from May 1, 2010, through November 30, 2011, only 2% of patients (3 of 153) designated as high-risk patients managed by the clinical pharmacist had a 30-day readmission for heart failure exacerbation. IMPLICATIONS: Outcomes-based models have expanded opportunities for clinical pharmacist involvement and can provide unique reimbursement options. Demonstration of cost savings and an improvement in quality measures are paramount to establishing and justifying the clinical pharmacist's role in a team-based model of care. DISCLOSURES: No outside funding supported this research. The authors have no conflicts of interest to disclose.


Assuntos
Insuficiência Cardíaca/tratamento farmacológico , Readmissão do Paciente/estatística & dados numéricos , Assistência Farmacêutica/organização & administração , Farmacêuticos/organização & administração , Papel Profissional , Organizações de Assistência Responsáveis/economia , Organizações de Assistência Responsáveis/organização & administração , Organizações de Assistência Responsáveis/estatística & dados numéricos , Assistência Ambulatorial/economia , Assistência Ambulatorial/organização & administração , Assistência Ambulatorial/estatística & dados numéricos , Redução de Custos , Humanos , Conduta do Tratamento Medicamentoso/economia , Conduta do Tratamento Medicamentoso/organização & administração , Conduta do Tratamento Medicamentoso/estatística & dados numéricos , Equipe de Assistência ao Paciente/organização & administração , Readmissão do Paciente/tendências , Assistência Centrada no Paciente/economia , Assistência Centrada no Paciente/organização & administração , Assistência Centrada no Paciente/estatística & dados numéricos , Assistência Farmacêutica/economia , Assistência Farmacêutica/estatística & dados numéricos , Farmacêuticos/economia , Farmacêuticos/estatística & dados numéricos , Planos de Incentivos Médicos/organização & administração , Planos de Incentivos Médicos/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Reembolso de Incentivo/organização & administração , Reembolso de Incentivo/estatística & dados numéricos
17.
Med Care ; 56(9): 805-811, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30036235

RESUMO

BACKGROUND: The growth of accountable care organizations (ACOs) and other alternative payment models has prompted concern about whether these models will disadvantage providers who serve vulnerable populations, particularly those living in poverty or with a disability. OBJECTIVE: To examine performance by ACOs in the top quintile of their proportion of beneficiaries dually enrolled in Medicare and Medicaid (high-dual) and the top quintile of disabled beneficiaries (high-disabled). RESEARCH DESIGN: This is a retrospective cohort study. SUBJECTS: The 333 ACOs in the Medicare Shared Savings Program in 2014, followed through 2016. MEASURES: Quality scores, savings per beneficiary, whether or not the ACO shared savings, and amount of shared savings. RESULTS: High-dual and high-disabled ACOs had slightly lower quality and similar or higher baseline spending than other ACOs, but achieved greater savings per beneficiary than other ACOs ($212 vs. $51 for high-dual ACOs, P=0.04; $241 vs. $44 for high-disabled ACOs, P=0.012). Further, these ACOs were equally or more likely to earn shared savings; just over 30% of high-dual ACOs earned shared savings compared with 25% of non-high-dual ACOs (P=0.35) and 38% of high-disabled ACOs earned shared savings compared with 23% of non-high-disabled ACOs (P=0.013). In longitudinal analyses, we found a decrease in the differences in quality between high-social risk and other ACOs over time. Savings remained higher for high-dual and high-disabled ACOs relative to other ACOs over 2014-2016 though the gap narrowed over time. CONCLUSIONS: High-dual and high-disabled ACOs had similar or higher spending than other ACOs at baseline, but achieved greater savings and were equally or more likely to earn shared savings, suggesting that alternative payment models can have positive financial outcomes for providers who serve vulnerable populations.


Assuntos
Organizações de Assistência Responsáveis/organização & administração , Pessoas com Deficiência/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Pobreza/estatística & dados numéricos , Organizações de Assistência Responsáveis/economia , Organizações de Assistência Responsáveis/normas , Organizações de Assistência Responsáveis/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Planos de Pagamento por Serviço Prestado , Feminino , Humanos , Estudos Longitudinais , Masculino , Medicare/economia , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos , Populações Vulneráveis/estatística & dados numéricos
18.
Int J Technol Assess Health Care ; 34(4): 388-392, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29991357

RESUMO

OBJECTIVES: Determine the relationship between quality of an accountable care organization (ACO) and its long-term reduction in healthcare costs. METHODS: We conducted a cost minimization analysis. Using Centers for Medicare and Medicaid cost and quality data, we calculated weighted composite quality scores for each ACO and organization-level cost savings. We used Markov modeling to compute the probability that an ACO transitioned between different quality levels in successive years. Considering a health-systems perspective with costs discounted at 3 percent, we conducted 10,000 Monte Carlo simulations to project long-term cost savings by quality level over a 10-year period. We compared the change in per-member expenditures of Pioneer (early-adopters) ACOs versus Medicare Shared Savings Program (MSSP) ACOs to assess the impact of coordination of care, the main mechanism for cost savings. RESULTS: Overall, Pioneer ACOs saved USD 641.24 per beneficiary and MSSP ACOs saved USD 535.59 per beneficiary. By quality level: (a) high quality organizations saved the most money (Pioneer: USD 459; MSSP: USD 816); (b) medium quality saved some money (Pioneer: USD 222; MSSP: USD 105); and (c) low quality suffered financial losses (Pioneer: USD -40; MSSP: USD -386). CONCLUSIONS: Within the existing fee-for-service healthcare model, ACOs are a mechanism for decreasing costs by improving quality of care. Higher quality organizations incorporate greater levels of coordination of care, which is associated with greater cost savings. Pioneer ACOs have the highest level of integration of services; hence, they save the most money.


Assuntos
Organizações de Assistência Responsáveis/organização & administração , Redução de Custos/economia , Qualidade da Assistência à Saúde/organização & administração , Organizações de Assistência Responsáveis/economia , Continuidade da Assistência ao Paciente/organização & administração , Análise Custo-Benefício , Planos de Pagamento por Serviço Prestado/organização & administração , Cadeias de Markov , Modelos Econométricos , Qualidade da Assistência à Saúde/economia , Estados Unidos
20.
Consult Pharm ; 33(3): 152-158, 2018 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-29720300

RESUMO

OBJECTIVE: To develop heart failure (HF) and chronic obstructive pulmonary disease (COPD) self-management kits in an accountable care organization (ACO) to facilitate patients' self-care and prevent hospital readmissions. SETTING: Pharmacists practice in an outpatient-based ACO. They participate in interprofessional office visits with providers and independently manage maintenance pharmacotherapies. PRACTICE DESCRIPTION: Pharmacists collaborate with an interprofessional team within the ACO including physicians, nurses, case managers, and paramedics. Two commonly encountered diseases are chronic COPD and HF. Reducing preventable readmissions for these conditions are important quality benchmarks and cost-saving strategies. PRACTICE INNOVATION: Pharmacists were responsible for developing HF and COPD self-management kits containing patient education materials and prescriptions to facilitate self-care. Prior to kit development, pharmacists performed a literature review to determine the presence of previously published findings on these topics. MAIN OUTCOME MEASUREMENTS: The interprofessional team continually evaluates the successes and limitations of this initiative. Pharmacists developed training and instructions for ACO allied health professionals in an effort to incorporate the self-management kits in clinical practice. RESULTS: The initial literature search revealed no studies describing the intervention of interest. Innovative programs designed to help reduce preventable readmissions are lacking in primary care. Implementation of the self-management kits was accepted by interprofessional ACO leadership and is currently being integrated into allied health workflow. CONCLUSION: Patients at risk for having an exacerbation of COPD or HF should receive self-management strategies. Prompt therapy prior to exacerbations reduces hospital admissions and readmissions, speeds recovery, and slows disease progression. Pharmacist-facilitated implementation of self-management kits may be developed by interprofessional health care teams.


Assuntos
Insuficiência Cardíaca/terapia , Transferência de Pacientes/organização & administração , Doença Pulmonar Obstrutiva Crônica/terapia , Autocuidado/métodos , Organizações de Assistência Responsáveis/organização & administração , Progressão da Doença , Humanos , Pacientes Ambulatoriais , Equipe de Assistência ao Paciente/organização & administração , Readmissão do Paciente/estatística & dados numéricos , Assistência Farmacêutica/organização & administração , Farmacêuticos/organização & administração , Atenção Primária à Saúde/organização & administração , Papel Profissional , Autogestão
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