Accountable Care Research Articles

Association of Clinician Practice Ownership With Ability of Primary Care Practices to Improve Quality Without Increasing Burnout

Work environments and practice structural features are associated with both burnout and the ability of practices to enhance quality of care. To characterize factors associated with primary care practices successfully improving quality scores without increasing clinician and staff burnout. This cross-sectional study assessed small- to medium-sized primary care practices that participated in the EvidenceNOW: Advancing Heart Health initiative using surveys that were administered at baseline (September 2015 to April 2017) and after the intervention (January 2017 to October 2018). Data were analyzed from February 2022 to January 2023. The primary outcome of being a quality and well-being positive deviant practice was defined as a practice with a stable or improved percentage of clinicians and staff reporting burnout over the study period and with practice-level improvement in all 3 cardiovascular quality measures: aspirin prescribing, blood pressure control, and smoking cessation counseling. Of 727 practices with complete burnout and aspirin prescribing, blood pressure control, and smoking cessation counseling data, 18.3% (n = 133) met the criteria to be considered quality and well-being positive deviant practices. In analyses adjusted for practice location, accountable care organization and demonstration project participation, and practice specialty composition, clinician-owned practices had greater odds of being a positive deviant practice (odds ratio, 2.02; 95% CI, 1.16-3.54) than practices owned by a hospital or health system. In this cross-sectional study, clinician-owned practices were more likely to achieve improvements in cardiovascular quality outcomes without increasing staff member burnout than were practices owned by a hospital or health system. Given increasing health care consolidation, our findings suggest the value of studying cultural features of clinician-owned practices that may be associated with positive quality and experience outcomes.

Changes in Medicare Accountable Care Organization Spending, Utilization, and Quality Performance 2 Years Into the COVID-19 Pandemic

This cohort study uses data from the Medicare Shared Savings Program to assess changes in spending, utilization, and quality performance from before the COVID-19 pandemic (2019) to year 2 of the pandemic (2021).

Perioperative Medicine: What the Future Can Hold for Anesthesiology.

Perioperative Medicine: What the Future Can Hold for Anesthesiology.

The Impact of Nurse Practitioner Care and Accountable Care Organization Assignment on Skilled Nursing Services and Hospital Readmissions.

Accountable care organizations (ACOs) and the employment of nurse practitioners (NP) in place of physicians are strategies that aim to reduce the cost and improve the quality of routine care delivered in skilled nursing facilities (SNF). The recent expansion of ACOs and nurse practitioners into SNF settings in the United States may be associated with improved health outcomes for patients. To determine the relationship between ACO attribution and NP care delivery during SNF visits and the relationship between NP care delivery during SNF visits and unplanned hospital readmissions. We obtained a sample of 527,329 fee-for-service Medicare beneficiaries with 1 or more SNF stays between 2012 and 2017. We used logistic regression to measure the association between patient ACO attribution and evaluation and management care delivered by NPs in addition to the relationship between evaluation and management services delivered by NPs and hospital readmissions. ACO beneficiaries were 1.26% points more likely to receive 1 or more E&M services delivered by an NP during their SNF visits [Marginal Effect (ME): 0.0126; 95% CI: (0.009, 0.0160)]. ACO-attributed beneficiaries receiving most of their E&M services from NPs during their SNF visits were at a lower risk of readmission than ACO-attributed beneficiaries receiving no NP E&M care (5.9% vs. 7.1%; P <0.001). Greater participation by the NPs in care delivery in SNFs was associated with a reduced risk of patient readmission to hospitals. ACOs attributed beneficiaries were more likely to obtain the benefits of greater nurse practitioner involvement in their care.

Maternity care clinician inclusion in Medicaid Accountable Care Organizations.

Medicaid Accountable Care Organizations (ACO) are increasingly common, but the network breadth for maternity care is not well described. The inclusion of maternity care clinicians in Medicaid ACOs has significant implications for access to care for pregnant people, who are disproportionately insured by Medicaid. To address this, we evaluate obstetrician-gynecologists (OB/GYN), maternal-fetal medicine specialists (MFM), certified nurse midwives (CNM), and acute care hospital inclusion in Massachusetts Medicaid ACOs. Using publicly available provider directories for Massachusetts Medicaid ACOs (n = 16) from December 2020 -January 2021, we quantify obstetrician-gynecologists, maternal-fetal medicine specialists, CNMs, and acute care hospital with obstetric department inclusion in each Medicaid ACO. We compare maternity care provider and acute care hospital inclusion across and within ACO type. For Accountable Care Partnership Plans, we compare maternity care clinician and acute care hospital inclusion to ACO enrollment. Primary Care ACO plans include 1185 OB/GYNs, 51 MFMs, and 100% of Massachusetts acute care hospitals, but CNMs were not easily identifiable in the directories. Across Accountable Care Partnership Plans, a mean of 305 OB/GYNs (median: 97; range: 15-812), 15 MFMs (Median: 8; range: 0-50), 85 CNMs (median: 29; range: 0-197), and half of Massachusetts acute care hospitals (median: 23.81%; range: 10%-100%) were included. Substantial differences exist in maternity care clinician inclusion across and within ACO types. Characterizing the quality of included maternity care clinicians and hospitals across ACOs is an important target of future research. Highlighting maternal healthcare as a key area of focus for Medicaid ACOs-including equitable access to high-quality obstetric providers-will be important to improving maternal health outcomes.

Provider survey of the roles of clinical pharmacists in primary care in a Federally Qualified Health Center versus an Accountable Care Organization

BackgroundHealthcare providers at primary care Federally Qualified Healthcare Centers (FQHC) and an Accountable Care Organizations (ACO) collaborated with clinical pharmacists in providing patient care utilizing the comprehensive medication management (CMM) framework. The intention of CMM was to generate more time for providers to see patients, and to improve overall patient quality of life. ObjectivesThe purpose of this study was to survey the providers' views of clinical pharmacy services, and to compare and contrast the shared-visit model in rural FQHCs and an ACO collaborative practice agreement model in a mid-sized metropolitan area. MethodsPrimary care providers completed a five-domain 22-item survey of provider patient care, provider pharmacy consults, provider ranking of pharmacy-services, disease treatment and provider views on the value of clinical pharmacists. ResultsFQHC pharmacists were available one day per week (75%), while 69% of ACO pharmacists were available five days per week. FQHC providers requested <5 pharmacist consults per week (46%), while ACO requested >10 consults per week (44%). Both organizations had nearly identical provider rankings and impact on patient care for clinical pharmacy services and disease-focused pharmacy services. The provider survey of satisfaction with pharmacy consultations were highly positive and scored as strongly agree with FQHC and ACO, with the exception of three items with the FQHC. Overall providers at both organizations report highly effective medication-related improvements, disease outcomes and also recommend clinical pharmacists to other providers and primary care teams. Regression analysis revealed relevant clinical associations between survey statements not seen with individual survey items alone. ConclusionPrimary care providers report high satisfaction with, and benefits of, clinical pharmacy services. Drug information resource and disease-focused management were documented by providers as valuable pharmacy services. Providers promoted expanding the role of clinical pharmacists with providers, and integration into primary care teams.

INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR PHARMACEUTICAL UTILIZATION AND FINANCIAL IMPACT IN A VALUE-BASED CARE PROGRAM.

To investigate trends and the potential impact of the COVID-19 pandemic on the utilization of intravitreal antivascular endothelial growth factor (anti-VEGF) pharmaceuticals in an accountable care organization (ACO). We retrospectively analyzed the Centers for Medicare and Medicaid Services beneficiary claims for all patients in the Houston Methodist Coordinated Care ACO registry during the years 2018, 2019, and 2020. Across the 3 years studied, a mean of 708 patients received anti-VEGF injections per year. The percentage of patients who received anti-VEGF injections decreased in each sequential year, with a steeper decline during the COVID-19 pandemic in the year 2020 (decrease by 0.4% from 2019 to 2020, P < 0.001; decrease by 0.2% from 2018 to 2019, P = 0.1453). The percentage of patients receiving bevacizumab of the total number of patients receiving any anti-VEGF treatment decreased (bevacizumab decreased by 6% from 2019 to 2020, P = 0.0174; decreased by 7% from 2018 to 2019, P = 0.0074). The COVID-19 pandemic did not seem to correlate with a change in the distribution of the specific anti-VEGF injection used. Despite the lower price which may correlate with value-based care, bevacizumab was the least used anti-VEGF treatment. COVID-19 correlated with a larger decrease in the utilization of all three anti-VEGF drugs.

Critical Thinking in the Nursing Profession: Analysis with a Socratic Method and Nurse Theorist Philosophy

Critical thinking skills are increasingly imperative skills in the nursing profession. Both the Socratic method and nursing theorist philosophy can lead to enhance critical skills. The Socratic method has been rooted in ancient Greek Philosophy, whereas nursing theorist philosophy in the 21st century. This paper discusses critical thinking in the nursing profession and compares the critical thinking concept with the Socratic Method and nurse theorist philosophy. The prime aim of this study is to compare which method is effectively utilized in the nursing profession. The literature pertinent to the topic was searched using the database library, including PubMed, BioMed, Google Scholar, PakMediNet, and Cumulative Index to Nursing and Allied Health Literature CINAHL. Literature was searched using keywords including Socratic method, nurse theorist philosophy, critical thinking skills, nursing education, and nursing clinical practice. The full-text article was included in the study. Relevant original articles, systemic reviews, quasi-experimental design, philosophical papers, and cross-sectional studies focusing on nurses' critical thinking skills, the Socratic Method, and nurse theorist philosophy were included. The study analysis portrayed Socratic questioning as primarily embedded in critical thinking concepts which nurses utilized in theoretical knowledge. The Socratic Method is explicitly known as the student-centered method that probes critical thinking in classroom teachings. Critical thinking has become vital in professional accountability and excellent nursing care. Nurse theorists have generally employed critical thinking skills to obtain the maximum patient care outcome. In conclusion, the Socratic method increases critical thinking in academia while nursing’s theorist philosophy in nursing clinical practice.

Interdisciplinary feeding clinic during the coronavirus disease 2019 pandemic: Implementing telehealth and social determinants of health screening.

Interdisciplinary feeding clinic during the coronavirus disease 2019 pandemic: Implementing telehealth and social determinants of health screening.

Development of a value-based care and population health internship for student pharmacists

IntroductionPharmacists assist in achieving desired outcomes and reducing costs of care within newer value-based payment models. The purpose of this article is to describe a summer internship for first- and second-year student pharmacists to gain exposure to value-based care. MethodsUniversity Health Network is a clinically integrated health network and accountable care organization in East Tennessee. Two student interns completed consecutive seven-week programs alongside clinical pharmacist specialists in the primary care settings of the network. Program requirements included direct patient care for chronic disease state management, topic discussions, formal writing assignments and presentations, and a quality improvement project. Student perception of internship activities was measured using a Likert type survey and free response questionnaire. ResultsStudent interns responded positively to program requirements with feelings of enhanced preparedness for advanced pharmacy practice experiences and post-graduate residency positions. Additionally, interns perceived themselves as more competitive for post-graduate positions having completed the internship. ConclusionsAs the US continues to move toward value-based payment models, student pharmacists must be well prepared to contribute to quality and population health initiatives. Student pharmacists benefit from an internship in a clinically integrated health network by gaining an improved understanding of the future of United States healthcare, an expanded clinical skillset, experience in demonstrating a pharmacist's value to the healthcare team, and the ability to overcome barriers to pharmacy services. A pharmacy internship within a clinically integrated health network may help prepare students to successfully contribute to value-based models of healthcare.

Pediatric Ethics Consultation Services.

Although guidelines call for the presence of pediatric ethics consultation services (PECS), their existence in children's hospitals remains unquantified. This study determined the prevalence of PECS in children's hospitals and compared the practice environments of those with versus without PECS. The Children's Hospital Association Annual Benchmark Report survey from 2020 and PECS data were analyzed for the association of PECS with domains of care. Two hundred thirty-one hospitals received survey requests, with 148 submitted and 144 reachable to determine PECS (62% response rate), inclusive of 50 states. Ninety-nine (69%) reported having ethics consultation services. Freestanding children's hospitals (28% of all hospitals) were more likely to report the presence of PECS (P <.001), making up 41% of hospitals with a PECS. The median number of staffed beds was 203 (25th quartile 119, 75th quartile 326) for those with PECS compared with 80 for those without (25th quartile 40, 75th quartile 121). Facilities with palliative care, higher trauma ratio, intensive care, and comprehensive programs were more likely to have PECS. Academic affiliation was associated with PECS presence (P <.001). Settings associated with skilled nursing facilities or long-term care programs were not more likely to have PECS. Hospitals designated as federally qualified health centers (P = .04) and accountable care organizations (P = .001) were more likely to have PECS. Although PECS function as formal means to clarify values and mitigate conflict, one-third of children's hospitals lack PECS. Future research is needed to understand barriers to PECS and improve its presence.

Paying for Nursing Home Quality: An Elusive But Important Goal.

Paying for Nursing Home Quality: An Elusive But Important Goal.

Why Are Family Doctors Still Not Addressing Oral Health?

Oral health dramatically affects overall health and vice versa. Oral health is a key health indicator for Healthy People 2030. Yet family physicians are not addressing this important health issue at the same level they address other essential health problems. Studies show that family medicine training and clinical activities are lacking in the area of oral health. The reasons are multi-factorial including insufficient reimbursement, lack of accreditation emphasis, and poor medical-dental communication. There is hope. Robust oral health curricula for family doctors exist and efforts are being made to create primary care oral health education champions. The tide is turning on accountable care organizations adding oral health services, access, and outcomes to their systems. Like behavioral health, oral health can be fully integrated into the care family physicians offer.

Alternative Predictive Models for Medicare Patient Cost

As health care expenditures increase, patient cost mitigation becomes more essential. Cost mitigation through intervention programs such as accountable care organizations relies on the ability to accurately predict patient risk, which is notoriously difficult because of highly skewed data. We examine the Medicare Limited dataset (a 5% sample of Medicare claims) that includes demographics, costs, and health conditions. We first consider the Centers for Medicare and Medicaid Services (CMS) currently used Hierarchical Condition Category (HCC) linear model and then implement more complex two-part generalized additive and random forest models to predict patient costs in a future year based on current-year data. We find that the latter models more accurately predict the entire distribution of Medicare patient costs and can better support the existing cost mitigation frameworks. The two-part lognormal generalized additive model is chosen as the optimal model for its robust performance and reasonable interpretability when the data have extreme values.

A Pharmacy Liaison–Patient Navigation Intervention to Reduce Inpatient and Emergency Department Utilization Among Primary Care Patients in a Medicaid Accountable Care Organization

Patients with unmet health-related social needs are at high risk for preventable health care utilization. Prior interventions to identify health-related social needs and provide navigation services with community resources have not taken place in pharmacy settings. To evaluate an enhancement of pharmacy care to reduce hospital admissions and emergency department (ED) visits among primary care patients in a Medicaid accountable care organization (ACO). This nonrandomized controlled trial was conducted from May 1, 2019, through March 4, 2021, with 1 year of follow-up. Study allocation was determined by odd or even medical record number. The study was performed at a general internal medicine practice at a large safety-net hospital in Boston, Massachusetts. Patients who qualified for the hospital's pharmacy care program (aged 18-64 years and within the third to tenth percentile for health care utilization and cost among Medicaid ACO membership) who attended a visit with a primary care clinician were eligible. Of 770 eligible patients, 577 were approached, 127 declined, and 86 could not be contacted. Patients in the control group received usual pharmacy care focused on medication adherence. Patients in the intervention group received enhanced pharmacy care with an additional focus on identification of and intervention for health-related social needs. The intervention took place for 1 year. The primary outcome was inpatient hospital admissions and ED visits (composite outcome) in the 12 months after enrollment during the intervention period. Among 364 allocated patients (mean [SD] age, 50.1 [10.1] years; 216 women [59.3%]), 35 were Hispanic of any race (9.6%) and 214 were non-Hispanic Black (58.8%). All participants were included in the intention-to-treat analysis. In analyses controlling for baseline hospital admissions and ED visits the year prior to enrollment, the enhanced pharmacy care group was not associated with the odds of having any hospital admission or ED visit (adjusted odds ratio, 0.62 [95% CI, 0.23-1.62]; P = .32) among all patients and was not associated with the visit rates among those with any visit (adjusted rate ratio, 0.93 [95% CI, 0.71-1.22]; P = .62) relative to the usual pharmacy care group in the year following enrollment. The findings of this nonrandomized controlled trial suggest that inpatient and ED utilization among Medicaid ACO members at a safety-net hospital was not significantly different between groups at 1-year follow-up. ClinicalTrials.gov Identifier: NCT03919084.

Using a Claims-Based Frailty Index to Investigate Frailty, Survival, and Healthcare Expenditures among Older Adults Hospitalized for COVID-19 at an Academic Medical Center

Frailty is associated with mortality in older adults hospitalized with COVID-19, yet few studies have quantified healthcare utilization and spending following COVID-19 hospitalization. To evaluate whether survival and follow-up healthcare utilization and expenditures varied as a function of claims-based frailty status for older adults hospitalized with COVID-19. Retrospective cohort study. 136 patients aged 65 and older enrolled in an Accountable Care Organization (ACO) risk contract at an academic medical center and hospitalized for COVID-19 between March 11, 2020 - June 3, 2020. We linked a COVID-19 Registry with administrative claims data to quantify a frailty index and its relationship to mortality, healthcare utilization, and expenditures over 6 months following hospital discharge. Kaplan Meier curves and Cox Proportional Hazards models were used to evaluate survival by frailty. Kruskal-Wallis tests were used to compare utilization. A generalized linear model with a gamma distribution was used to evaluate differences in monthly Medicare expenditures. Much of the cohort was classified as moderate to severely frail (65.4%), 24.3% mildly frail, and 10.3% robust or pre-frail. Overall, 27.2% (n=37) of the cohort died (n=26 during hospitalization, n=11 after discharge) and survival did not significantly differ by frailty. Among survivors, inpatient hospitalizations during the 6-month follow-up period varied significantly by frailty (p=0.02). Mean cost over follow-up was $856.37 for the mild and $4914.16 for the moderate to severe frailty group, and monthly expenditures increased with higher frailty classification (p <.001). In this cohort, claims-based frailty was not significantly associated with survival but was associated with follow-up hospitalizations and Medicare expenditures.

Evaluating Inpatient Hospital Charges Associated With Trauma Service Patients Participating in an Accountable Care Organization.

The Medicare Accountable Care Organization (ACO) Program has created a vehicle for providers who practice cost containment and exceed quality for the Medicare population. The success of ACO's nationwide have been well documented. However, there is little research evaluating if there is a cost saving benefit in trauma care with respect to participating in an ACO. Thus, the primary objective of this study was to evaluate inpatient hospital charges associated with trauma service utilization of patients participating in the ACO compared to non-ACO patients. This case-control retrospective study includes a comparison of inpatients charges of ACO patients (cases) and general trauma patients (controls) presenting to our trauma center in Staten Island, New York from January 1st, 2019 to December 31st, 2021. A 1:1 matching of case to control was performed based on age, sex, race, and injury severity score. Statistical analysis was performed with IBM SPSS, with P < .05 as significant. A total of 80 patients were included in the ACO cohort and 80 matched in the General Trauma cohort. Patient demographics were similar. Comorbidities were similar with the exception of a higher in incidence of hypertension (75.0% vs 47.5%, P < .001) and cardiac disease (35.0% vs 17.5%, P = .012) in the ACO cohort. Both the ACO and general trauma cohort had similar Injury Severity Scores, number of visits and lenght of stay. Both charge total ($76 148.93 vs $70 916.82, P = .630) receipt total ($15 080.26 vs $14 180, P = .662) charges were similar between ACO and General Trauma patients. In spite of increased incidence of hypertension and cardiac disease in ACO trauma patients, mean Injury Severity Score, number of visits, length of hospital stay, ICU admission rate and charge total was similar compared to general trauma patients presenting to our Level 1 Adult Trauma Center.

Maternal Health Equity in Medicaid Accountable Care Organizations: Early Lessons from the Massachusetts Experience.

There are substantial inequities by race and ethnicity in maternal health care utilization and health outcomes across the perinatal period. As Medicaid covers 42% of births nationally and almost two-thirds of births to Black birthing people, state Medicaid financing and delivery system reforms have substantial scope to impact these inequities. Twenty-one states have implemented Medicaid Accountable Care Organizations (ACOs) at some point since 2015. Using public documents and interviews with ACO administrators, we examine the implications of Massachusetts Medicaid ACOs, implemented in March 2018, for maternal health equity. Although these Medicaid ACOs have the potential to impact maternal health equity, they face many challenges in doing so. We review future steps within Massachusetts Medicaid ACOs and Medicaid programs more generally to incorporate policies that may better address racial and ethnic inequities.

Associations Between Physician Practice Models and Health Information Exchange

The interaction between emerging physician practice models and the use of health information exchange (HIE) remains understudied. We examined associations between the use of emerging practice models and the use of HIE. We also examined barriers to HIE adoption among physicians who were not utilizing HIE. Survey data came from a 2019-2021 statewide census of all physicians in Arizona collected at the time of license renewal (n = 3312, or 17.9% of all practicing physicians). Primary outcomes were physician-reported HIE use for patient care summaries and for laboratory results. Secondary outcomes were 5 common HIE barriers among non-HIE users. The primary predictor was physician practice model: accountable care organization (ACO), clinically integrated network (CIN), or integrated delivery network (IDN) vs traditional care delivery model. Covariates included physician specialty, age, gender, and county of practice. Compared with physicians in traditional care delivery models, physicians in ACOs, CINs, or IDNs had significantly higher odds of using HIE to share both patient care summaries (P < .01) and laboratory results (P < .05 for ACOs), although associations varied across provider and practice characteristics. ACO providers not using HIE were more likely to cite a lack of connectivity and lack of information as HIE barriers. Providers in an emerging practice model are more likely to use HIE than those in a traditional care delivery model. However, nuances in these associations suggest a persistence of previously identified HIE gaps, and the barriers cited provide guidance for increasing HIE use among different practice types.

The Intersection of Finance and Healthcare: Financing Healthcare Delivery Systems

The Intersection of Finance and Healthcare: Financing Healthcare Delivery Systems" explores the complex relationship between finance and healthcare, focusing on the financing of healthcare delivery systems. The article discusses the importance of effective financial management in healthcare organizations, including budgeting, revenue cycle management, cost containment, and financial reporting. It also examines the role of finance in promoting patient care and saving costs through strategies like accountable care organizations and value-based care models. The article highlights the significance of financing for medical innovation, research, and the creation of novel treatments and cures. The article also discusses the importance of financing for attracting, training, and retaining a competent healthcare workforce. The article emphasizes the significance of sustainable finance in accomplishing universal health coverage and mitigating inefficiencies within the health system. The article examines various healthcare financing models, including tax-funded healthcare systems, social health insurance programs, private health insurance models, and hybrid healthcare finance models. The article also discusses the historical perspectives of healthcare financing, including the creation of publicly funded healthcare systems and the Affordable Care Act. The article concludes by examining the current landscape of healthcare financing, including global trends in healthcare spending and funding schemes. The article emphasizes the importance of balancing clinical efficacy and financial efficiency in healthcare finance systems and overcoming obstacles like fragmentation of services, bureaucratic obstacles, and administrative inefficiencies.