Health Care Delivery Reform Research Articles

Demystifying hospital size distribution: A geographical approach

Hospital size distribution, i.e., the uneven allocation of healthcare resources between hospitals of different size classes, significantly impacts healthcare equality and efficiency and challenges healthcare governance. Yet, its variation is inadequately explained by two prevalent approaches to size distribution – the statistical approach merely works on statistical patterns, while the economic approach has difficulties in calculating hospital cost-returns. This study provides an alternative – a geographical approach – to demystify hospital size distribution. Incorporating the distinctiveness of healthcare into George Stigler's (1958) classic survivor analysis of firm size distribution, we conceptualize hospital size distribution as the result of hospitals' interactions with their socio-economic-technical environment in a defined area, and thus its pattern and variation could be understood through its coevolution with geographical contexts. We substantiate this idea with a study on China's provincial hospital size distributions between 2002 and 2019. During this period, hospitals with 0–99 beds maintained a stable proportion, while the size class of 800+ beds grew significantly, in contrast to the reduction in the size class of 100–799 beds. Cluster analysis identifies four clusters of provinces dominated by different hospital size classes after healthcare delivery reform in 2012. Cross-sectional time-series regression models find evolving impacts from market power, government intervention, and advancement of medical technology. We also offer a novel approach to understanding healthcare resource distribution by examining the structure rather than merely the number of healthcare resources.

Health Care Value in Plastic Surgery Practice.

As value-based care gains traction in response to towering health care expenditures and issues of health care inequity, hospital capacity, and labor shortages, it is important to consider how a value-based approach can be achieved in plastic surgery. Value is defined as outcomes divided by costs across entire cycles of care. Drawing on previous studies and policies, this article identifies key opportunities in plastic surgery to move the levers of costs and outcomes to deliver higher value care. Specifically, outcomes in plastic surgery should include conventional measures of complication rates and patient-reported outcome measures to drive quality improvement and benchmark payments. Meanwhile, cost reduction in plastic surgery can be achieved through value-based payment reform, efficient workflows, evidence-based and cost-conscious selection of medical devices, and greater use of outpatient surgical facilities. Lastly, the authors discuss how the diminished presence of third-party payers in aesthetic surgery exemplifies the cost-conscious and patient-centered nature of value-based plastic surgery. To lead in future health policy and care delivery reform, plastic surgeons should strive for high-value care, remain open to new ways of care delivery, and understand how plastic surgery fits into overall health care delivery.

The Health Equity Discourse of Immigrant Public Health Leaders: A Critical Application of the IDEA Model

ABSTRACT During the COVID-19 pandemic, health experts emerged to deliver crisis messaging to a public that needed information to understand the nature of the mega-crisis and to know how to mitigate the risk of infection. Some of the public health experts were immigrants who drew attention to healthcare disparities in the U.S. and called for systemic reform of healthcare delivery. This study critically examines the health equity discourse of immigrant public health leaders (IPHLs). Employing a critical application of the IDEA Model of crisis messaging, the study interrogates how three IPHLs navigated and disrupted their stereotyped identities as “model minorities” who were medical experts and advocates of equitable healthcare.

Prioridades de políticas de salud. Encuentro SESPAS en la XXXIII Escuela de Salud Pública de Menorca

ObjectiveIn September 2022, the Sociedad Española de Salud Pública y Administración Sanitaria (SESPAS) brought together a panel of experts with the aim of defining and prioritizing health policy proposals, from the perspective of the Spanish State as a whole, to adapt the National Health System (NHS) to current risks and to contemporary/present-day society. MethodExpert meeting structured using a mix of procedures adapted from brainstorming, nominal group and Rand consensus method techniques. Relevance and feasibility of proposals identified were assessed individually by each panelist. Proposals were then ordered thematically and ranked according to the median and quartile deviation of relevance scores. ResultsPanelists identified and prioritized several proposals in different areas: governance and funding of the NHS, reform of the portfolio of services and benefits and of the NHS human resources, public health and health policy, actions against inequality and poverty, and healthcare delivery reform, including socio-sanitary, primary and end-of-life care. ConclusionsThe results of the meeting show the urgent need to address in-depth changes in many state-wide health policies, including a major reconfiguration of governance, public health, and health care structures. They also point out potential areas of improvement, constituting a tentative guide of prioritized issues to be addressed.

Exit Rates of Accountable Care Organizations That Serve High Proportions of Beneficiaries of Racial and Ethnic Minority Groups

The Medicare Shared Savings Program provides financial incentives for accountable care organizations (ACOs) to reduce costs of care. The structure of the shared savings program may not adequately adjust for challenges associated with caring for patients with high medical complexity and social needs, a population disproportionately made up of racial and ethnic minority groups. If so, ACOs serving racial and ethnic minority groups may be more likely to exit the program, raising concerns about the equitable distribution of potential benefits from health care delivery reform efforts. To evaluate whether ACOs with a high proportion of beneficaries of racial and ethnic minority groups are more likely to exit the Medicare Shared Savings Program and identify characteristics associated with this disparity. This retrospective observational cohort study used secondary data on Medicare Shared Savings Program ACOs from January 2012 through December 2018. Bivariate and multivariate cross-sectional regression analyses were used to understand whether ACO racial and ethnic composition was associated with program exit, and how ACOs with a high proportion of beneficaries of racial and ethnic minority groups differed in characteristics associated with program exit. Racial and ethnic composition of an ACO's beneficiaries. Shared savings program exit before 2018. The study included 589 Medicare Shared Savings Program ACOs. The ACOs in the highest quartile of proportion of beneficaries of racial and ethnic minority groups were designated high-proportion ACOs (145 [25%]), and those in the lowest 3 quartiles were designated low-proportion ACOs (444 [75%]). In unadjusted analysis, a 10-percentage point increase in the proportion of beneficiaries of racial and ethnic minority groups was associated with a 1.12-fold increase in the odds of an ACO exit (95% CI, 1.00-1.25; P = .04). In adjusted analysis, there were significant associations among high-proportion ACOs between characteristics such as patient comorbidities, disability, and clinician composition and a higher likelihood of exit. The study results suggest that ACOs that served a higher proportion of beneficaries of racial and ethnic minority groups were more likely to exit the Medicare Shared Savings Program, partially because of serving patients with greater disease severity and complexity. These findings raise concerns about how current payment reform efforts may differentially affect racial and ethnic minority groups.

Changes in the Proportion of Gastrointestinal Emergency Endoscopy and Peptic Ulcer Disease During the COVID-19 Pandemic: A Local Retrospective Observational Study From Vietnam.

ObjectivesThe coronavirus disease 2019 (COVID-19) pandemic has disrupted the practice of gastrointestinal (GI) endoscopy units and may increase the risk of digestive disorders. We described the situational changes in GI endoscopy and peptic ulcer disease (PUD) proportion during COVID-19 in Vietnam and examined the associated factors.MethodsA retrospective ecological study was conducted on data of Hanoi Medical University Hospital, Vietnam. The number of upper GI endoscopy and the proportion of GI emergency endoscopy and PUD were compared between 2019 and 2020 by month (January to June). Log-binomial regression was used to explore associated factors of GI emergency endoscopy and PUD.ResultsThe number of endoscopies decreased remarkably during the nationwide social distancing in April 2020. Compared to April 2019, the proportion in April 2020 of both GI emergency endoscopy [4.1 vs. 9.8%, proportion ratio (PR) 2.39, 95% CI 2, 2.87], and PUD [13.9 vs. 15.8%; PR, 1.14; 95% CI, 1.01, 1.29] was significantly higher. In log-binomial models, the proportion of GI emergency endoscopy was higher in April 2020 compared to April 2019 (adjusted PR, 2.41; 95% CI, 2.01, 2.88). Male sex and age of ≥50 years were associated with an increased PUD and GI emergency conditions.ConclusionThe proportion of both GI emergency endoscopy and PUD was significantly higher during the time of the state of emergency due to the ongoing COVID-19 pandemic in 2020 when compared to 2019 at the same health facility in Vietnam. The findings suggest that healthcare delivery reforms during the era of an emerging pandemic are required to reduce digestive disorders, in particular, and chronic diseases in general.

Медичний сектор: орієнтованість на пацієнта як отримувача медичних послуг

Зазначено, що реалії сьогодення вказують на те, що підвищення показників здоров’я населення можливо досягнути, якщо приділяти належну увагу пацієнту. Зауважено, що лікар і пацієнт є основними суб’єктами надання та отримання медичних послуг. Доведено, що основною сутністю їх взаємовідносин стає надання та отримання медичної допомоги, а також задоволення цільових потреб як надавача, так і споживача медичних послуг. Вказано, що орієнтованість медичного сектора на пацієнта як основного отримувача медичних послуг – це важливий показник оцінки якості роботи медичних закладів, а задоволеність пацієнта роботою медичного сектора є показником рівня її якості. Проведено аналіз задоволеності пацієнтами медичними послугами. Проаналізовано основні засади і принципи системи надання медичних послуг пацієнту.

Direct primary care: Family physician perceptions of a growing model.

INTRODUCTIONDirect Primary Care (DPC) is a relatively new primary care practice model in which patients receive unlimited access to a defined set of primary care services in exchange for a monthly practice-specific membership fee. DPC is a bottom-up physician-driven approach in contrast to typical top-down insurer-centric healthcare delivery reform efforts. The degree to which physicians are aware of this practice model and whether they believe it addresses two key challenges facing primary care, access and administrative burden, are unclear.METHODSAn online survey was distributed in July 2017 to 672 members of a research marketing sample of the American Academy of Family Physicians (n=225; response rate 33%). Based on AAFP definitions, the survey consisted of both open- and close-ended questions that gauged family physicians’ awareness of DPC, as well as their perceptions about the model.RESULTSMost respondents (85%) had heard of DPC and 8% practised in a DPC model at the time of the survey. In general, respondents reported that DPC can offer positive outcomes through lower administrative burden for physicians, improved doctor–patient relationships, and better access. Respondents also suggested DPC may result in improved patient health outcomes and lower overall healthcare spending. Respondents’ concerns included inappropriateness of the model for vulnerable populations and physician shortages. Survey responses differed depending on whether the respondent practised in a DPC model. DPC physicians had a more favorable view of the model and were focused on benefits to patients rather than benefits to physicians.CONCLUSIONSAny changes to practice models will require a better understanding of clear definitions of practice models. Further education is required about the specific benefits to vulnerable patients and practice standards. As the perceptions of DPC vary by practice experience, DPC physicians appear to be strong potential advocates of the model.

Projecting the Prevalence and Costs of Metastatic Breast Cancer From 2015 through 2030.

BackgroundThis study projected the number of metastatic breast cancer (mBC) cases and costs (medical and productivity) attributable to mBC through 2030 among 3 age groups: younger (aged 18-44 years), midlife (aged 45-64 years), and older women (aged 65 years and older).MethodsWe developed a stock/flow model in which women enter the mBC population at initial diagnosis (de novo stage IV) or through progression of an earlier-stage cancer. Women exit the mBC population through death. Input parameters by age and phase of treatment came from the US Census, Surveillance, Epidemiology, and End Results and peer-reviewed literature.ResultsIn 2030, we estimated there would be 246 194 prevalent cases of mBC, an increase of 54.8% from the 2015 estimate of 158 997. We estimated total costs (medical and productivity) of mBC across all age groups and phases of care were $63.4 billion (95% sensitivity range = $59.4-$67.4 billion) in 2015 and would increase to $152.4 billion (95% sensitivity range = $111.6-$220.4 billion) in 2030, an increase of 140%. Trends in estimated costs were higher for younger and midlife women than for older women.ConclusionsThe cost of mBC could increase substantially in the coming decade, especially among younger and midlife women. Although accounting for trends in incidence, progression, and survival, our model did not attempt to forecast structural changes such as technological innovations in breast cancer treatment and health-care delivery reforms. These findings can motivate early detection activities, direct value-driven mBC treatment, and provide a useful baseline against which to measure the effect of prevention and treatment efforts.

The future of health professions education: Emerging trends in the United States.

The future of health professions education: Emerging trends in the United States.

North Carolina's Health Care Transformation to Value: Progress to Date and Further Steps Needed.

North Carolina has received national attention for its approach to health care payment and delivery reform. Importantly, payment reform alone is not enough to drive systematic changes in care delivery. We highlight the importance of progress in four complementary areas to achieve system-wide payment and care reform.

The effects of enhanced primary healthcare interventions on primary care providers\u2019 job satisfaction

BackgroundIn response to the rising burden of cardiovascular risk factors, the Malaysian government has implemented Enhanced Primary Healthcare (EnPHC) interventions in July 2017 at public clinic level to improve management and clinical outcomes of type 2 diabetes and hypertensive patients. Healthcare providers (HCPs) play crucial roles in healthcare service delivery and health system reform can influence HCPs’ job satisfaction. However, studies evaluating HCPs’ job satisfaction following primary care transformation remain scarce in low- and middle-income countries. This study aims to evaluate the effects of EnPHC interventions on HCPs’ job satisfaction.MethodsThis is a quasi-experimental study conducted in 20 intervention and 20 matched control clinics. We surveyed all HCPs who were directly involved in patient management. A self-administered questionnaire which included six questions on job satisfaction were assessed on a scale of 1–4 at baseline (April and May 2017) and post-intervention phase (March and April 2019). Unadjusted intervention effect was calculated based on absolute differences in mean scores between intervention and control groups after implementation. Difference-in-differences analysis was used in the multivariable linear regression model and adjusted for providers and clinics characteristics to detect changes in job satisfaction following EnPHC interventions. A negative estimate indicates relative decrease in job satisfaction in the intervention group compared with control group.ResultsA total of 1042 and 1215 HCPs responded at baseline and post-intervention respectively. At post-intervention, the intervention group reported higher level of stress with adjusted differences of − 0.139 (95% CI -0.266,-0.012; p = 0.032). Nurses, being the largest workforce in public clinics were the only group experiencing dissatisfaction at post-intervention. In subgroup analysis, nurses from intervention group experienced increase in work stress following EnPHC interventions with adjusted differences of − 0.223 (95% CI -0.419,-0.026; p = 0.026). Additionally, the same group were less likely to perceive their profession as well-respected at post-intervention (β = − 0.175; 95% CI -0.331,-0.019; p = 0.027).ConclusionsOur findings suggest that EnPHC interventions had resulted in some untoward effect on HCPs’ job satisfaction. Job dissatisfaction can have detrimental effects on the organisation and healthcare system. Therefore, provider experience and well-being should be considered before introducing healthcare delivery reforms to avoid overburdening of HCPs.

The ACA's Choice Problem.

The Affordable Care Act (ACA) is in many ways a success. Millions more Americans now have access to health care, and the ACA catalyzed advances in health care delivery reform. Simultaneously, it has reinforced and bolstered a problem at the heart of American health policy and regulation: a love affair with choice. The ACA's insurance reforms doubled down on the particularly American obsession with choice. This article describes three ways in which that doubling down is problematic for the future of US health policy. First, pragmatically, health policy theory predicts that choice among health plans will produce tangible benefits that it does not actually produce. Most people do not like choosing among health plan options, and many people-even if well educated and knowledgeable-do not make good choices. Second, creating the regulatory structures to support these choices built and reinforced a massive market bureaucracy. Finally, and most important, philosophically and sociologically the ACA reinforces the idea that the goal of health regulation should be to preserve choice, even when that choice is empty. This vicious cycle seems likely to persist based on the lead up to the 2020 presidential election.

Envisioning a Better U.S. Health Care System for All: Health Care Delivery and Payment System Reforms.

The American College of Physicians (ACP) has long advocated for universal access to high-quality health care in the United States. Yet, it is essential that the U.S. health system goes beyond ensuring coverage, efficient delivery systems, and affordability. Fundamental restructuring of payment policies and delivery systems is required to achieve a health care system that puts patients' interests first and supports physicians and their care teams to deliver high-value, patient- and family-centered care. The ACP calls for reform of U.S. payment, delivery, and information technology systems to achieve this vision. The ACP's recommendations include increased investment in primary care; alignment of financial incentives to achieve better patient outcomes, lower costs, reduce inequities in health care, and facilitate team-based care; freeing patients and physicians of inefficient administrative and billing tasks and documentation requirements; and development of health information technologies that enhance the patient-physician relationship.

Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians.

Visual Abstract.Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians Visual Abstract. Envisioning a Better U.S. Health Care System for All: A...

Differences in Rates of High-Value and Low-Value Care Between Community Health Centers and Private Practices.

Community health centers (CHCs) are an integral part of the health care safety net. As health systems seek to improve value, it is important to understand the quality of care provided by CHCs. To evaluate the performance of CHCs compared with private practices on a comprehensive set of high-value and low-value care measures. This cross-sectional study used data from the National Ambulatory Medical Care Survey from 2010 through 2012. We compared CHCs with private practices using logistic regression models that adjusted for age, sex, race/ethnicity, insurance, number of chronic illnesses, rural versus urban location, region of country, and survey year. We included outpatient visits to generalist physicians at either CHCs or private practices by patients 18 years and older. We examined 12 measures of high-value care and 7 measures of low-value care. A total of 29,155 physician visits, representing 584,208,173 weighted visits, from 2010 through 2012 were included. CHCs were more likely to provide high-value care by ordering beta-blockers in CHF (46.9% vs. 36.5%; aOR 2.56; 95%CI 1.18-5.56), statins in diabetes (37.0% vs 35.5%; aOR 1.35; 95%CI 1.02-1.79), and providing treatment for osteoporosis (35.7% vs 23.2%; aOR 1.77; 95%CI 1.05-3.00) compared with private practices. CHCs were more likely to avoid low-value screening EKGs (98.7% vs. 88.0%; aOR 11.03; 95%CI 2.67-45.52), CBCs (75.9% vs. 65.7%; aOR 1.72; 95%CI 1.18-2.53), or urinalyses (86.0% vs. 80.5%; aOR 1.87; 95%CI 1.11-3.14) during a general medical exam. CHCs were also less likely to prescribe antibiotics for a URI (48.3% vs. 63.1%; aOR 0.59; 95%CI 0.40-0.88). On a number of high-value and low-value measures of care, CHCs performed similar to or better than private practices. As healthcare delivery reforms continue to progress, CHCs are well positioned to provide high-value healthcare.

Policy and Health in Jordan: Finance and Allocating Public Expenditures: a worldwide review

Background: This article offers evaluations of healthcare expenditures by sponsors that face increasing challenges as healthcare costs rise. Purposes: The aim of this action report is to ensure adequate health care services coupled with financial resources to fulfill the health challenges within the light-weight of the worse economic scenario. Methods: This article presents a read of healthcare spending in Jordan that focuses on the sectors that finance healthcare. Therefore, all the information published was used. Results: Jordan’s government wouldn’t be ready to continue providing health services at the present trend: fast increase in demand over publicly funded services within the absence efficiency gains (six types); reforms to create upon the strength of public and private sector improve quality of care and increase accessibility; and, enhance patient satisfaction and long-term financial sustainability. Conclusion: For the care system to be considered efficient and equitable the cash burden ought to be progressive throughout of pocket payments, and to cut back monetary barriers to access. Recommendation: There was a progressive impact of the reform on healthcare supplying and finance systems once contributor’s expenses are used to build it; however, the findings don’t seem to be conclusive. Keywords: Equity, Financing, Efficiency, Expenditures, Health Care Delivery and Financing Systems Reform

From Universal Health Coverage to Universal Health Gains - Mainstreaming HPH for Healthcare Delivery Reform in Taiwan

From Universal Health Coverage to Universal Health Gains - Mainstreaming HPH for Healthcare Delivery Reform in Taiwan

A framework for oral health care value-based payment approaches

BackgroundDental practice has remained relatively insulated from payment upheavals in the broader health care system. The prevailing value-based payment (VBP) models in health care are largely absent in oral health care. The authors present an oral health care value-based payment framework for dentistry. MethodsThe authors developed a VBP framework for oral health care, which describes 9 distinct methods to create VBP approaches in dentistry. The framework is based on the Centers for Medicare & Medicaid Services Learning Action Network framework for health care payment reform. ResultsThe oral health care value-based payment framework includes 4 payment categories and 9 separate payment mechanisms. These 9 payment mechanisms range on a value continuum, each with different financial risks and rewards as well as distinct value implications. ConclusionsAlthough dental practice has made extraordinary advances in restorative dentistry, payers and policy makers are advocating for greater value outcomes. VBP models seek to deliver better care more efficiently by means of providing oral health providers the resources needed to increase the value proposition. With relatively minor modifications in practice patterns, VBP models can be developed and implemented for oral health care. Practical ImplicationsThis article can be used as a road map to take steps toward oral health care VBP approaches. The framework highlights how dentistry can learn from payment reforms under way in the health care system and present a model for oral health care payment and care delivery reform, and provides recommendations to advance oral health care VBP.

Cost and Utilization with Enrollment in a Medical Home for Individuals with an Autism Spectrum Disorder and/or Intellectual Disability

Individuals with intellectual and/or developmental disabilities (IDD) tend to incur high health care costs. The Neurobehavior HOME Program (HOME) is an interdisciplinary program that cares for this population. This study will evaluate the health care costs and utilization of individuals during their first year of enrollment in HOME and identify factors associated with higher cost and utilization. Secondary analysis of claims data were used to identify cost and utilization. Generalized linear regression and negative binomial regression were used to calculate utilization and cost. The mean total cost of care during the initial year of enrollment (n=239) per individual was $11,095.87, with $4,640.83 attributed to inpatient care. Those with diabetes (p=0.01), epilepsy (p=0.02), or mood disorders (p=0.03) were more likely to be admitted to the hospital and utilize the emergency department. These findings will enable systems and payers to better construct health care delivery reforms for this high-need population.