Accountable Care Research Articles

Social Risk, Social Need, and Use of the Emergency Department

This cohort study examines the association of social risk and social need with emergency department use by patients within a Medicaid accountable care organization who were screened for adverse social determinants of health in primary care.

Classification Algorithm to Distinguish Between Type 1 and Type 2 Myocardial Infarction in Administrative Claims Data.

Type 2 myocardial infarction (T2MI) and type 1 myocardial infarction (T1MI) differ with respect to demographics, comorbidities, treatments, and clinical outcomes. Reliable quality and outcomes assessment depends on the ability to distinguish between T1MI and T2MI in administrative claims data. As such, we aimed to develop a classification algorithm to distinguish between T1MI and T2MI that could be applied to claims data. Using data for beneficiaries in a Medicare accountable care organization contract in a large health care system in New England, we examined the distribution of MI diagnosis codes between 2018 to 2021 and the patterns of care and coding for beneficiaries with a hospital discharge diagnosis International Classification of Diseases, Tenth Revision code for T2MI, compared with those for T1MI. We then assessed the probability that each hospitalization was for a T2MI versus T1MI and examined care occurring in 2017 before the introduction of the T2MI code. After application of inclusion and exclusion criteria, 7759 hospitalizations for myocardial infarction remained (46.5% T1MI and 53.5% T2MI; mean age, 79±10.3 years; 47% female). In the classification algorithm, female gender (odds ratio, 1.26 [95% CI, 1.11-1.44]), Black race relative to White race (odds ratio, 2.48 [95% CI, 1.76-3.48]), and diagnoses of COVID-19 (odds ratio, 1.74 [95% CI, 1.11-2.71]) or hypertensive emergency (odds ratio, 1.46 [95% CI, 1.00-2.14]) were associated with higher odds of the hospitalization being for T2MI versus T1MI. When applied to the testing sample, the C-statistic of the full model was 0.83. Comparison of classified T2MI and observed T2MI suggest the possibility of substantial misclassification both before and after the T2MI code. A simple classification algorithm appears to be able to differentiate between hospitalizations for T1MI and T2MI before and after the T2MI code was introduced. This could facilitate more accurate longitudinal assessments of acute myocardial infarction quality and outcomes.

Post-hospitalization remote monitoring for patients with heart failure or chronic obstructive pulmonary disease in an accountable care organization

BackgroundPost-hospitalization remote patient monitoring (RPM) has potential to improve health outcomes for high-risk patients with chronic medical conditions. The purpose of this study is to determine the extent to which RPM for patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) is associated with reductions in post-hospitalization mortality, hospital readmission, and ED visits within an Accountable Care Organization (ACO).MethodsNonrandomized prospective study of patients in an ACO offered enrollment in RPM upon hospital discharge between February 2021 and December 2021. RPM comprised of vital sign monitoring equipment (blood pressure monitor, scale, pulse oximeter), tablet device with symptom tracking software and educational material, and nurse-provided oversight and triage. Expected enrollment was for at least 30-days of monitoring, and outcomes were followed for 6 months following enrollment. The co-primary outcomes were (a) the composite of death, hospital admission, or emergency care visit within 180 days of eligibility, and (b) time to occurrence of this composite. Secondary outcomes were each component individually, the composite of death or hospital admission, and outpatient office visits. Adjusted analyses involved doubly robust estimation to address confounding by indication.ResultsOf 361 patients offered remote monitoring (251 with CHF and 110 with COPD), 140 elected to enroll (106 with CHF and 34 with COPD). The median duration of RPM-enrollment was 54 days (IQR 34–85). Neither the 6-month frequency of the co-primary composite outcome (59% vs 66%, FDR p-value = 0.47) nor the time to this composite (median 29 vs 38 days, FDR p-value = 0.60) differed between the groups, but 6-month mortality was lower in the RPM group (6.4% vs 17%, FDR p-value = 0.02). After adjustment for confounders, RPM enrollment was associated with nonsignificantly decreased odds for the composite outcome (adjusted OR [aOR] 0.68, 99% CI 0.25–1.34, FDR p-value 0.30) and lower 6-month mortality (aOR 0.41, 99% CI 0.00–0.86, FDR p-value 0.20).ConclusionsRPM enrollment may be associated with improved health outcomes, including 6-month mortality, for selected patient populations.

The mechanics of risk adjustment and incentives for coding intensity in Medicare.

To study diagnosis coding intensity across Medicare programs, and to examine the impacts of changes in the risk model adopted by the Centers for Medicare and Medicaid Services (CMS) for 2024. Claims and encounter data from the CMS data warehouse for Traditional Medicare (TM) beneficiaries and Medicare Advantage (MA) enrollees. We created cohorts of MA enrollees, TM beneficiaries attributed to Accountable Care Organizations (ACOs), and TM non-ACO beneficiaries. Using the 2019 Hierarchical Condition Category (HCC) software from CMS, we computed HCC prevalence and scores from base records, then computed incremental prevalence and scores from health risk assessments (HRA) and chart review (CR) records. We used CMS's 2019 random 20% sample of individuals and their 2018 diagnosis history, retaining those with 12 months of Parts A/B/D coverage in 2018. Measured health risks for MA and TM ACO individuals were comparable in base records for propensity-score matched cohorts, while TM non-ACO beneficiaries had lower risk. Incremental health risk due to diagnoses in HRA records increased across coverage cohorts in line with incentives to maximize risk scores: +0.9% for TM non-ACO, +1.2% for TM ACO, and + 3.6% for MA. Including HRA and CR records, the MA risk scores increased by 9.8% in the matched cohort. We identify the HCC groups with the greatest sensitivity to these sources of coding intensity among MA enrollees, comparing those groups to the new model's areas of targeted change. Consistent with previous literature, we find increased health risk in MA associated with HRA and CR records. We also demonstrate the meaningful impacts of HRAs on health risk measurement for TM coverage cohorts. CMS's model changes have the potential to reduce coding intensity, but they do not target the full scope of hierarchies sensitive to coding intensity.

Factors affecting Accountable Care Organizations' decisions to remain in or exit the Medicare Shared Savings Program following Pathways to Success.

The Medicare Shared Savings Program (MSSP) is an alternative payment model launched in 2012, creating Accountable Care Organizations (ACOs) to improve quality and lower costs for Traditional Medicare patients. Most MSSP participants were expected to shift from bearing no financial risk to a 2-sided risk model (ie, bonus if spending reduced below historical benchmarks, penalty if not), yet fewer than 20% did. Therefore, in 2019, the Centers for Medicare and Medicaid Services launched the Pathways to Success program, which required shifting to a 2-sided model within 12 months. For the first time, more ACOs exited than entered the MSSP. To understand these participation decisions, we conducted qualitative interviews with ACO leaders. Pathways caused ACOs to reassess their potential shared savings vs losses, particularly in light of benchmarking methodology changes; reconsider perceived nonrevenue benefits; and reassess participation in the MSSP vs other programs. As ACOs, particularly those assuming downside risk, have contained costs and enhanced care quality, policymakers should strive to improve MSSP enrollment rates in downside-risk models through strategies that allow ACOs to achieve shared savings and deliver accountable care.

The National Health Policy, 2017: Health Seeker’s Profile and Accrued Benefit Analysis

The landscape of health is fast changing in developing countries. India being a signatory to the Alma Ata Declaration on “Health for All” has transformed the landscape of health in the country through Constitutional guarantees, plans, and policy measures. Constitutional bindings like those like Art 21, 38, 39(A) and the Directive Principles of State Policy have put compulsion on the Government of India to take measures for the universalization of health care and this is one of the ambitious targets of the 12th five-year plan aimed at comprehensive health care security to all. It mandates the country to ensure affordable, accountable, appropriate promotive, preventive, curative, and rehabilitative health care services and equitable access to health care to all citizens of India despite their caste, class, gender, religion, etc. In this context. In 2017, the Government of India introduced its health policy to provide coverage to the entire population of the developing country, i.e., India. It was a welcome initiative on the part of the country. After 6 years, the present article tries to map the health seekers' profile and how far benefits of health reform have been accrued by them. The researchers in this article have employed descriptive design with quantitative methods of data collection in the city of Bhubaneswar. The study concludes that the 2017 Healthcare policy has undoubtedly addressed the discrepancies in healthcare services to the population in terms of gender, age, and economic status, but still finds private healthcare services to cover more commoners and ensure services to them.

Alternative Payment Models and Patient-Reported Quality of Preparation for Discharge: A Retrospective Longitudinal Study

Preparing patients for posthospital care may improve readmission risk. Alternative payment models (APMs) incent hospitals to reduce readmissions by tying payment to outcomes. The impact of APMs on preparation for discharge is not well understood. We assessed whether patient-reported preparation for posthospital care was associated with reduced readmissions, and whether APM participation was associated with improved preparation for posthospital care. We used mixed-effects regression on retrospective (2013–2017) observational data for 2685 U.S. hospitals. We measured patient-reported preparation for posthospital care using the 3-Item Care Transition Measure and readmission using 30-day all-cause risk-adjusted readmissions from Hospital Compare. Participation in accountable care organizations (ACOs), Medical Homes, and Medicare's Bundled Payments for Care Improvement program was obtained from Medicare, the American Hospital Association's Annual Survey, and Leavitt Partner's ACO database. We found that APMs are not associated with improved preparation for posthospital care, even though it was associated with reduced readmissions (Marginal Effect: −0.012 percentage points). This may be because hospitals are not investing in patient engagement. This study has limited insight into causality and reduced generalizability among smaller, rural, and non-teaching hospitals.

Assessment of Accountable Care Organization Strategies: A Qualitative Approach

Assessment of Accountable Care Organization Strategies: A Qualitative Approach

ACO Clinicians Have Higher Medicare Part B Medical Services Payments Than MIPS Clinicians Under the Quality Payment Program.

The Quality Payment Program (QPP) is a Medicare value-based payment program with 2 tracks: -Advanced Alternative Payment Models (A-APMs), including two-sided risk Accountable Care Organizations (ACOs), and Merit-based Incentive Payment System (MIPS). In 2020, A-APM eligible ACO clinicians received an additional 5% positive, and MIPS clinicians received up to 5% negative or 2% positive performance-based adjustments to their Medicare Part B medical services payments. It is unclear whether the different payment adjustments have differential impacts on total medical services payments for ACO and MIPS participants. We compare Medicare Part B medical services payments received by primary care clinicians participating in ACO and MIPS programs using Medicare Provider Utilization and Payment Public Use Files from 2014 to 2018 using difference-in-differences regressions. We have 254 395 observations from 50 879 unique clinicians (ACO = 37.86%; MIPS = 62.14%). Regression results suggest that ACO clinicians have significantly higher Medicare Part B medical services payments ($1003.88; 95% CI: [579.08, 1428.69]) when compared to MIPS clinicians. Our findings suggest that ACO clinicians had a greater increase in medical services payments when compared to MIPS clinicians following QPP participation. Increased payments for Medicare Part B medical services among ACO clinicians may be driven partly by higher payment adjustment rates for ACO clinicians for Part B medical services. However, increased Part B medical services payments could also reflect clinicians switching to increased outpatient services to prevent potentially costly inpatient services. Policymakers should examine both aspects when evaluating QPP effectiveness.

Financial Performance of Accountable Care Organizations: A 5-Year National Empirical Analysis.

Of 513 accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) in 2020, 67% generated a positive shared savings of approximately $2.3 billion. This research aimed to examine their financial performance trends and drivers over time. The unit of analysis was the ACO in each year of the study period from 2016 to 2020. The dependent variable was the ACOs' total shared savings earned annually per beneficiary. The independent variables included ACO age, risk model, clinician staffing type, and provider type (hybrid, hospital-led, or physician-led). Covariates were the average risk score among beneficiaries, payer type, and calendar year. The Centers for Medicare & Medicaid Services (CMS) public use files (PUFs) and a commercial healthcare data aggregator were the data sources. ACOs' earned shared savings grew annually by 35%, while the proportions of ACOs with positive shared savings grew by 21%. For 1-year increase in ACO age, an additional $0.57 of shared savings per beneficiary was observed. ACOs with two-sided risk contracting were associated with an average marginal increase of $109 in shared savings per beneficiary compared to ACOs with one-sided risk contracting. Primary care physicians were associated with the greatest increase in earned shared savings per beneficiary. In contrast, nurse practitioners/physician assistants/clinical nurse specialists were associated with a reduction in earned shared savings. Under a one-sided risk model, hospital-led ACOs were associated with $18 higher average shared savings earning per beneficiary compared to hybrid ACOs, while physician-led ACOs were associated with lower average saved shared earnings per beneficiary at -$2 compared to hybrid ACOs. Provider-type results were not statistically significant at the 5% nominal level. No statistically significant differences were observed between provider types under a two-sided risk model. For all ACO provider types, building broader primary care provider networks was correlated with positive financial results. Future research should examine whether ACOs are conducting specific preventive screenings for cancer or monitoring conditions such as diabetes, hypertension, heart disease, obesity, mental disorders, and joint disorders. Such studies may answer health policy and strategy questions about the effects of incentives for improved ACO performance in serving a healthier population.

Collaborating for COVID-19: Hospital Health Information Exchange and Public Health Partnership.

Background: The coronavirus disease (COVID-19) pandemic highlighted the need for effective communication and information sharing among health care organizations and public health systems (PHSs). Health information exchange (HIE) plays a vital role in improving quality control and efficiency in hospital settings, particularly in underserved areas. Objective: This study aimed to investigate the variation of HIE availability among hospitals based on their collaboration with the PHS and affiliation with Accountable Care Organizations (ACOs) in 2020, as well as variation by community social determinants of health. Methods: The primary data set used for this study comprised the linked data set of the 2020 American Hospital Association (AHA) Annual Survey and the AHA Information Technology Supplement. The measures used included the hospital's participation in HIE networks, availability of data exchange, and HIE measures during the COVID-19 pandemic, including whether hospitals effectively received electronically transmitted information from outside providers for COVID-19 treatment. Results: The sample size of hospitals ranged from 1,316 to 1,436, depending on different outcomes related to HIE questions. Of the hospitals surveyed, ∼67% reported public health collaboration and ACO affiliation, while 7% reported neither. Hospitals without public health collaboration or ACO affiliation were more likely to be located in underserved areas. Compared with hospitals without public health collaboration or ACO affiliation, hospitals with both were 9% more likely to report the availability of electronically transmitted clinical information from outside providers and to participate in local and national HIE networks. Furthermore, these hospitals were 30% (marginal effect [ME] = 0.30, p < 0.001) more likely to report effective receipt of information from outside providers for COVID-19 treatment and 12% (ME = 0.12, p = 0.02) more likely to always/often receive clinical information for COVID-19 treatment electronically. Conclusions: Hospital collaboration with the PHS and ACO affiliation are associated with greater availability of electronic health data, particularly during the COVID-19 pandemic.

Medicaid ACOs on MH care outcomes for Massachusetts children to be examined

A University of Massachusetts Amherst public health researcher has been awarded a five‐year, $2.2 million grant from the National Institutes of Health (NIH) to examine the impact of Medicaid accountable care organizations (ACOs) on the quality and outcomes of behavioral/mental health care for children in Massachusetts, a news release stated. ACOs are the value‐based health care delivery model designed to reduce Medicare and Medicaid costs while improving coordination and quality of care. “Fundamental changes in health care are needed to address socioeconomic and racial/ethnic disparities in behavioral health care quality and outcomes for children in vulnerable populations,” the grant summary states. In the past decade, the prevalence of mental health disorders among children has climbed in Massachusetts, said lead investigator Sarah Goff, M.D., Ph.D., a practicing pediatrician and internist and associate professor/chair of health promotion and policy in the UMass Amherst School of Public Health and Health Sciences. The researchers will use an innovative mixed methods approach to investigate how the launching of 17 new Medicaid ACOs in Massachusetts in 2018 may have impacted mental health care for children. Findings from the study are expected to inform providers, payers and policymakers responsible for the care of vulnerable populations of children with mental health disorders.

Restructuring Healthcare Financing to Enable Effective Integrated Care and Population Health

Singapore faces an aging population and spiraling healthcare costs. To address these challenges, Healthier SG will launch in 2023 to shift towards a population health approach to care for Singaporeans, to keep them healthy, and prevent or slow down disease progression. Residents will be encouraged to enrol with a primary care physician and take on an upstream preventive approach to healthcare. Delivery systems must focus on integrated care. In addition, there is a need to bend the rate of growth of cost curve. NHG, as one of the three public healthcare clusters, will take on the role of a “Population Health Manager” responsible for the health outcomes of 1.5M population assigned.&#x0D; Who is it for? Policy makers, health sector decision makers, health managers, health authorities, health and social care professionals, researchers, academia, health experts, and the staff working on implementation of integrated care, healthcare finance professionals&#x0D; Who did you involve and engage with? Singapore Ministry of Health officials, Chief financial officers of hospitals, healthcare professionals, and clinicians (both specialist and primary care physicians) and community care partners.&#x0D; What did you do? NHG restructured itself organisationally to form an Accountable Care Organisation (ACO). The Health Ministry would be providing funding for subsidised care in the form of capitation funding per assigned resident per year (as opposed to the predominant fee for service funding currently) and additional funding for preventive care and health screening. NHG will aggregate the funds to design payment models that cut across different care setting to integrate care delivery. Incentive payments tied to performance outcomes and indicators will be established. Providers will also part-take in shared savings. NHG will also serve as a network of providers to join up care delivery, with focus on primary and preventive care.&#x0D; What results did you get? What impact did you have?We are in the stages of planning and design. The results we hope to achieve are for residents to enrol with a single primary care provider who will be partnering NHG to oversee the end to end care of the enrolled residents. Some of the indicators to be monitored measure resource allocation, resident enrolment rate, primary care physician enrolment rate with NHG, avoidable ED and hospitalisation rates and total subsidised healthcare cost per resident.&#x0D; What is the learning for the international audience? The learnings to share are the importance of engagement of leadership across the ecosystems, appropriate funding and resource allocation based on care needs of the population, setting up of enablers, including IT and data exchange, use of incentives to prompt behaviour changes, and the need for change management to get buy-in.&#x0D; What are the next steps? NHG will be rolling out key activities in the areas of primary care enrolment, designing the financing framework for payment and sharing of incentives with the providers, and is also in the midst of implementing key IT system enablers.

The Evolution of Ontario Health Teams: A Developmental Evaluation

Background: Ontario, Canada’s most populous province, is no stranger to integrated care initiatives. However, none have been as ambitious and far-reaching as the Ontario Health Team (OHT) initiative, announced by its Ministry of Health (MOH) in 2019. Its eventual objective is population health management – every Ontarian will belong to an OHT providing them with seamlessly coordinated care across the hospital-community continuum. Our team conducted a Developmental Evaluation (DE) that sought to understand and guide the development of 6 OHTs over the course of a year. &#x0D; Methods: Six OHTs were chosen, based on their representation of a range of geographies and readiness and willingness to participate. DE employs embedded research and collaboration between researchers and participants to understand and guide development. Findings are co-constructed and shared with participants continuously. DE was paired with ethnography which employs multiple methods and prioritizes close engagement with participants over time. Data collection took place from Spring 2021-2022, led by a team of five embedded researchers. Approximately 275 OHT development meetings were observed and 30 interviews conducted. Key participants were also invited to periodically journal about their experience of working together on OHT development. While analysis was guided by existing frameworks (Context and Capabilities for Integrated Care Framework &amp; the MOH’s 8 “building blocks”), a ground-up inductive approach was privileged. &#x0D; Results: We identified 9 key areas of development: a) developing vision, b) establishing governance, c) strategic planning, d) designing and implementing integrated models, e) advancing digital health, f) engaging primary care, g) partnering with patients, families and caregivers, h) establishing funding and incentive structures, and i) enhancing performance measurement, quality improvement and continuous learning. &#x0D; Discussion &amp; Impact: &#x0D; Local &#x0D; Analysis of our results yielded the following insights: a) OHTs were evolving at different paces, each at a different stage of progress in relation to key areas of development, b) despite differences in evolutionary trajectory, there were shared contexts, structures and cultures that both forwarded and frustrated progress across OHTs, and c) while findings largely overlapped with the MOH’s eight building blocks for OHT maturity, there were key differences. These differences suggest the need for change management that supports the translation of macro-level expectations into local realities, while ensuring on-the-ground realities are reflected in expectations. Recommendations were generated to guide OHT development across the province.&#x0D; International &#x0D; This research contributes to scholarship on the context-bound practice of integrated care - its constant negotiation of both local and systemic contexts. It also provides an important example of how an initiative that is similar in purpose to population health and integrated care initiatives such as the Integrated Care System (ICS) in the UK and Accountable Care Organizations (ACO) in the US, may be differently implemented and experienced across an entire health system. &#x0D; Next Steps: While we have an understanding of OHT struggles with the system and policy environment, we know less about policymakers’ perspectives on these issues. Our next phase of research will therefore explore how policymakers respond to systemic gaps identified by OHTs and where their own concerns lie.

Value-based payment models and management of newly diagnosed prostate cancer.

To examine the effect of urologist participation in value-based payment models on the initial management of men with newly diagnosed prostate cancer. Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019, with 1 year of follow-up, were assigned to their primary urologist, each of whom was then aligned to a value-based payment model (the merit-based incentive payment system [MIPS], accountable care organization [ACO] without financial risk, and ACO with risk). Multivariable mixed-effects logistic regression was used to measure the association between payment model participation and treatment of prostate cancer. Additional models estimated the effects of payment model participation on use of treatment in men with very high risk (i.e., >75%) of non-cancer mortality within 10 years of diagnosis (i.e., a group of men for whom treatment is generally not recommended) and price-standardized prostate cancer spending in the 12 months after diagnosis. Treatment did not vary by payment model, both overall (MIPS-67% [95% CI 66%-68%], ACOs without risk-66% [95% CI 66%-68%], ACOs with risk-66% [95% CI 64%-68%]). Similarly, treatment did not vary among men with very high risk of non-cancer mortality by payment model (MIPS-52% [95% CI 50%-55%], ACOs without risk-52% [95% CI 50%-55%], ACOs with risk-51% [95% CI 45%-56%]). Adjusted spending was similar across payment models (MIPS-$16,501 [95% CI $16,222-$16,780], ACOs without risk-$16,140 [95% CI $15,852-$16,429], ACOs with risk-$16,117 [95% CI $15,585-$16,649]). How urologists participate in value-based payment models is not associated with treatment, potential overtreatment, and prostate cancer spending in men with newly diagnosed disease.

Accountable Care Organization Attribution and Post-Acute Skilled Nursing Facility Outcomes for People Living With Dementia

ObjectivesUnder the Accountable Care Organization (ACO) model, reductions in healthcare spending have been achieved by targeting post-acute care, particularly in skilled nursing facilities (SNFs). People with Alzheimer disease and related dementias (ADRD) are frequently discharged to SNF for post-acute care and may be at particular risk for unintended consequences of SNF cost reduction efforts. We examined SNF length of stay (LOS) and outcomes among ACO-attributed and non–ACO-attributed ADRD patients. DesignObservational serial cross-sectional study. Setting and ParticipantsTwenty percent national random sample of fee-for-service Medicare beneficiaries (2013-2017) to identify beneficiaries with a diagnosis of ADRD and with a hospitalization followed by SNF admission (n = 263,676). MethodsOur primary covariate of interest was ACO (n = 66,842) and non-ACO (n = 196,834) attribution. Hospital readmission and death were measured for 3 time periods (<30, 31-90, and 91-180 days) following hospital discharge. We used 2-stage least squares regression to predict LOS as a function of ACO attribution, and patient and facility characteristics. ResultsACO-attributed ADRD patients have shorter SNF LOS than their non-ACO counterparts (31.7 vs 32.8 days; P < .001). Hospital readmission rates for ACO vs non-ACO differed at ≤30 days (13.9% vs 14.6%; P < .001) but were similar at 31-90 days and 91-180 days. No significant difference was observed in mortality post–hospital discharge for ACO vs non-ACO at ≤30 days; however, slightly higher mortality was observed at 31-90 days (8.4% vs 8.8%; P = .002) and 91-180 days (7.6% vs 7.9%; P = .011). No significant association was found between LOS and readmission, with small effects on mortality favoring ACOs in fully adjusted models. Conclusions and ImplicationsBeing an ACO-attributed patient is associated with shorter SNF LOS but is not associated with changes in readmission or mortality after controlling for other factors. Policies that shorten LOS may not have adverse effects on outcomes for people living with dementia.

Expectations of clients, insurers, and providers: a qualitative responsiveness assessment among private health insurance sector in Kampala-Uganda

BackgroundThere is less attention to assessing how health services meet the expectations of private health insurance (PHI) actors, clients, insurers, and providers in developing countries. Interdependently, the expectations of each actor are stipulated during contract negotiations (duties, obligations, and privileges) in a PHI arrangement. Complementary service roles performed by each actor significantly contribute to achieving their expectations. This study assessed the role of PHI in meeting the expectations of clients, insurers, and providers in Kampala. Lessons from this study may inform possible reviews and improvements in Uganda’s proposed National Health Insurance Scheme (NHIS) to ensure NHIS service responsiveness.MethodsThis study employed a qualitative case-study design. Eight (8) focus group discussions (FGDs) with insured clients and nine (9) key informant interviews (KIIs) with insurer and provider liaison officers between October 2020 and February 2021 were conducted. Participants were purposively selected from eligible institutions. Thematic analysis was employed, and findings were presented using themes with corresponding anonymized narratives and quotes.ResultsClient-Provider, Client-Insurer, and Provider-Insurer expectations were generally not met. Client-provider expectations: Although most facilities were clean with a conducive care environment, clients experienced low service care responsiveness characterized by long waiting times. Both clients and providers received inadequate feedback about services they received and delivered respectively, in addition to prompt care being received by a few clients. For client-insurer expectations, under unclear service packages, clients received low-quality medicines. Lastly, for provider-insurer expectations, delayed payments, selective periodic assessments, and inadequate orientation of clients on insurance plans were most reported. Weak coordination between the client-provider and insurer did not support delivery processes for responsive service.ConclusionHealth care service responsiveness was generally low. There is a need to commit resources to support the setting up of clearer service package orientation programs, and efficient monitoring and feedback platforms. Uganda’s proposed National Health Insurance Act may use these findings to: Inform its design initiatives focusing on operating under realistic expectations, investment in quality improvement systems and coordination, and efficient and accountable client care relationships.

Information as a relation: Defining Indigenous information literacy

Informed by relationality and reciprocity, Indigenous librarians who teach play a key role in creating learning opportunities for students to gain information literacy (IL) skills and become better users and creators of information. Through unstructured interviews with seven Indigenous librarians, we find that Indigenous identity and ways of knowing based on relationality and reciprocity are key components shaping the pedagogy of Indigenous librarians, as it informs the ways they enact accountability, build relationships, set boundaries, and practice care. Through this work, we offer a definition of Indigenous information literacy, which is the ability to use information and create or gain knowledge, while practicing the Indigenous concepts of relationality, reciprocity, and respect. This work lays the groundwork for further explorations of relationality, kinship, and Indigenous ways of knowing in information literacy and Indigenous librarianship.

Study: ACO model not serving needs of Medicare clients with depression

A new longitudinal study concludes that the accountable care organization (ACO) model, in which groups of providers offer coordinated care to a designated population, is failing Medicare beneficiaries with mental health needs. The study's corresponding author told MHW that the results reflect the lingering disparity in care between chronic medical illnesses and common mental health conditions such as depression.

Patient-Reported Outcome-Based Performance Measures in Alternative Payment Models: Current Use, Implementation Barriers, and Principles to Succeed

ObjectivesPatient-reported outcome (PRO)-based performance measures (PRO-PMs) offer opportunities to aggregate survey data into a reliable and valid assessment of performance at the entity-level (eg, clinician, hospital, and accountable care organization). Our objective was to address the existing literature gap regarding the implementation barriers, current use, and principles for PRO-PMs to succeed. MethodsAs quality measurement experts, we first highlighted key principles of PRO-PMs and how alternative payment models (APMs) may be integral in promoting more widespread use. In May 2023, we reviewed the Centers for Medicare and Medicaid Services (CMS) Measures Inventory Tool for active PRO-PM usage within CMS programs. We finally present principles to prioritize as part PRO-PMs succeeding within APMs. ResultsWe identified 5 implementation barriers to PRO-PM use: original development of instrument, response rate sufficiency, provider burden, hesitancy regarding fairness, and attribution of desired outcomes. There existed 54 instances of active PRO-PM usage across CMS programs, including 46 unique PRO-PMs within 14 CMS programs. Five principles to prioritize as part of greater PRO-PM development and incorporation within APMs include the following: (1) clinical salience, (2) adequate sample size, (3) meaningful range of performance among measured entities and the ability to detect performance change in a reasonable time frame, (4) equity focus, and (5) appropriate risk adjustment. ConclusionsIdentified barriers and principles to prioritize should be considered during PRO-PM development and implementation phases to link available and novel measures to payment programs while ensuring provider and stakeholder engagement.