Health Care Reform Efforts Research Articles

Beyond patient care: the impact of healthcare reform on job satisfaction in the Ethiopian public healthcare sector

BackgroundWhile healthcare reform has been a central attention for local governments, its impact on job satisfaction is poorly understood. This study aimed to determine the impact of healthcare reform on job satisfaction in the public healthcare sector in Ethiopia.MethodsThe study was designed as a facility-based cross-sectional survey of healthcare professionals and carried out in all public hospitals in central Ethiopia which have been implementing healthcare reform (n = 5). All healthcare professionals in the hospitals who were involved in the reform from the inception (n = 476) were purposively sourced to complete a self-administered questionnaire adapted from a framework proposed for measuring job satisfaction of health professionals in sub-Saharan Africa. Kaiser-Meyer-Olkin and Bartlett’s tests were conducted to measure sampling adequacy and sphericity for factor analysis. Likert’s transformation formula was used to numerically analyse the satisfaction level of the respondents and to determine the cut-off value of satisfaction levels. Non-parametric and multiple logistic regression analysis were conducted to determine predictors of job satisfaction.ResultsA total of 410 healthcare professionals completed the survey, representing an 88% response rate. The median and mean job satisfaction scores were 50 and 49, respectively, on a scale 1–100, which was equivalent to ‘Job dissatisfied’ on the Likert scale. Only 25% of respondents perceived job satisfaction due to implementation of the reform. Moral satisfaction (adjusted odds ratio (aOR), 177.65; 95% confidence interval (CI), 59.54–530.08), management style (aOR, 4.02; 95% CI, 1.49–10.83), workload (aOR, 2.42; 95% CI, 0.93–6.34), and task (aOR, 5.49; 95% CI, 2.31–13.07) were the most significant predictors. Job satisfaction results were significantly different among the study hospitals (χ2 = 30.56, p < .001).ConclusionsThe healthcare reform significantly and negatively influences public healthcare professionals’ job satisfaction and its overall impact on job satisfaction was poor, which would hinder the ‘Health Sector Transformation’ movement of Ethiopia. Healthcare reform efforts are contingent on job satisfaction of healthcare professionals, and such efforts should balance the demand and supply of both patients and providers for improved healthcare outcomes.

Effectiveness of Adherence to Standardized Hypertension Management by Primary Health Care Workers in China: a Cross-sectional Survey 3 Years after the Healthcare Reform

The standardized hypertension management provided by primary health care workers is an important part of China's recent health care reform efforts. Investigating 5,116 hypertensive patients from a cross-sectional survey conducted by the Chinese Center for Disease Control and Prevention in 2012, this study found that adherence to standardized hypertension management is associated with positive effects on hypertension- related knowledge, healthy lifestyle behavior, antihypertensive medical treatments, and blood pressure control. It will be necessary to provide primary health care workers with sufficient training and reasonable incentives to ensure the implementation and effectiveness of hypertension management.

Obama Signs Landmark Legislation With Major Mental Health Provisions

Back to table of contents Previous article Next article Government NewsFull AccessObama Signs Landmark Legislation With Major Mental Health ProvisionsAaron LevinAaron LevinSearch for more papers by this authorPublished Online:30 Dec 2016https://doi.org/10.1176/appi.pn.2017.1a10AbstractThe last major piece of health legislation from the 114th Congress links treatment and research to prior efforts on health care reform, says President Obama.President Barack Obama signed the wide-ranging $6 billion 21st Century Cures Act into law on December 13, 2016, a week after it passed by overwhelming margins in both the House of Representatives and Senate.In one of his last official acts at the White House, President Barack Obama signs the 21st Century Cures Act in an emotional ceremony that recognized the bipartisan support that pushed the legislation over the finish line. The new law contains a number of provisions that will benefit people with mental illness.Aaron LevinThe law includes significant mental health and substance abuse treatment components as well as research funding for Obama’s Precision Medicine Initiative, the BRAIN initiative, and Vice President Joe Biden’s cancer “moonshot.” There are also provisions intended to speed up the Food and Drug Administration’s review of new drugs.At the White House signing ceremony, the president thanked Democrats and Republicans who had worked together on the legislation.“I’m confident that it will lead to better years and better lives for millions of Americans, the work that you’ve done,” said Obama. “I hope in the years ahead, Congress keeps working together in a bipartisan fashion to move us forward and not backward in the health of our people.”Among other provisions, the law establishes an assistant secretary for mental health and substance abuse who will take over the functions of the current SAMHSA administrator. The assistant secretary will appoint a chief medical officer (CMO) to evaluate existing programs and promote evidence-based clinical care. The CMO will not necessarily be a psychiatrist, but the qualifications include holding a medical degree and having experience treating patients with mental illness or substance use disorders.In addition, the law will promote workforce development and integrated care, strengthen enforcement of parity, and improve how the federal government finances and manages evidence-based mental health services.“It was an honor to see the president sign this significant piece of legislation,” said APA President Maria A. Oquendo, M.D., Ph.D., who attended the ceremony. “This marks the passage of the first mental health reform bill in more than 50 years and is long overdue. We should enjoy this moment, but that does not mean our work is over.”“Everything in the act has been authorized, and the continuing resolution that funds government operations until April 28 also appropriates $20 million for the FDA, $352 million for NIH, and $500 million in grants to states to combat the opioid abuse epidemic,” said Ariel González, J.D., M.A., chief of APA’s Department of Government Relations.Obama noted that his administration’s health care reform efforts set the foundation for the 21st Century Cures Act, which now provides access to services for the 20 million Americans newly insured by the Affordable Care Act.The law incorporates elements of legislation previously put forth by Reps. Tim Murphy (R-Pa.) and Eddie Bernice Johnson (D-Texas) in the Helping Families in Mental Health Crisis Act and the Mental Health Reform Act of 2016, sponsored by Sens. Chris Murphy (D-Conn.) and Bill Cassidy (R-La.). APA worked closely with those legislators over the past three years to help craft the mental health provisions in the final bill.“In 2013, a group of Pennsylvania psychiatrists asked me to join in helping Rep. Murphy work on a new comprehensive mental health reform bill,” recalled APA CEO and Medical Director Saul Levin, M.D., M.P.A. “It took three years working with Rep. Murphy to reach the final bipartisan law included in the 21st Century Cures Act. I am proud that APA signed on from the beginning, and that APA President Maria Oquendo, M.D., Ph.D., could attend the signing by President Obama.”To combat the opioid epidemic, the law provides $1 billion over two years to bolster prescription drug monitoring programs, implement prevention activities, provide training for health care providers, and expand access to opioid treatment programs.The law also supports recruitment, training, and retention of the mental health workforce by authorizing a demonstration program that provides five-year grants for residents and fellows who practice psychiatry and addiction medicine in underserved communities. Other mental health clinicians are eligible for similar grants.The act calls for “clarification” of the uses and disclosures of health information covered by the Health Information Portability and Accountability Act (HIPAA), a longstanding complaint of patients’ families. ■“Remarks by the President and the Vice President at the 21st Century Cures Act Bill Signing” can be accecssed here. ISSUES NewArchived

Value-Based Approaches for Emergency Care in a New Era

Although emergency departments (EDs) play an integral role in the delivery of acute unscheduled care, they have not been fully integrated into broader health care reform efforts. Communication and coordination with the ambulatory environment remain limited, leaving ED care disconnected from patients' longitudinal care. In a value-based environment focused on improving quality, decreasing costs, enhancing population health, and improving the patient experience, this oversight represents a missed opportunity for emergency care. When integrated with primary and subspecialty care, emergency care might meet the needs of patients, providers, and payers more efficiently than yet realized. This article uses the Merit-Based Incentive Payment System from the Medicare Access and CHIP Reauthorization Act as a framework to outline a strategy for improving the value of emergency care, including integrating quality and resource use measures across health care delivery settings and populations, encouraging care coordination from the ED, and implementing robust health information exchange systems.

Exploring the Impact of Medicaid Expansion on West Virginia’s Primary Care System

Studies exploring the impact of Medicaid expansion on the primary care system have been limited to date. Using key informant interviews of administrators and providers within primary care centers, this manuscript explores the impact on patient care and practice, patient load, and other potential impacts of Medicaid expansion in West Virginia. Key findings include the lack of major increases in patient load and few changes in perceptions of patient care and practice. Providers and administrators expressed some increases in the ease and ability to refer to specialist care and lab testing. Further, the expansion was seen in an overwhelmingly positive light as creating the potential for better health outcomes for West Virginians in the long term. The manuscript concludes with thoughts about how sliding scale fees and the West Virginia Connect pilot project may have eased transition into the Medicaid expansion for our state and the importance of robust planning in future health care reform efforts.

Pediatric-Informed Facilitation of Patient-Centered Medical Home Transformation.

Patient-centered medical home (PCMH) transformation has been challenging for pediatric practices, in part because of the National Committee for Quality Assurance (NCQA) PCMH focus on conditions and processes specific to adult patients. Realizing the potential challenges faced by pediatric practices, Vermont supported pediatric-informed facilitators to help practices during PCMH transformation. This study characterizes the impact of pediatric-informed facilitators; provides benchmark data on NCQA scores, number of facilitation meetings, and the time between facilitation start and end; and compares pediatric- and adult-serving practices. We found no difference between pediatric and matched adult-serving practices in NCQA score, number of facilitation meetings, or weeks to NCQA scoring. These results suggest that pediatric-informed facilitators can help pediatric practices achieve NCQA PCMH recognition on par with practices serving adult patients. Supporting primary care practices with specialty-informed facilitators can assist integration into health care reform efforts.

A qualitative analysis of interprofessional healthcare team members' perceptions of patient barriers to healthcare engagement.

BackgroundHealthcare systems increasingly engage interprofessional healthcare team members such as case managers, social workers, and community health workers to work directly with patients and improve population health. This study elicited perspectives of interprofessional healthcare team members regarding patient barriers to health and suggestions to address these barriers.MethodsThis is a qualitative study employing focus groups and semi-structured interviews with 39 interprofessional healthcare team members in Philadelphia to elicit perceptions of patients’ needs and experiences with the health system, and suggestions for positioning health care systems to better serve patients. Themes were identified using a content analysis approach.ResultsThree focus groups and 21 interviews were conducted with 26 hospital-based and 13 ambulatory-based participants. Three domains emerged to characterize barriers to care: social determinants, health system factors, and patient trust in the health system. Social determinants included insurance and financial shortcomings, mental health and substance abuse issues, housing and transportation-related limitations, and unpredictability associated with living in poverty. Suggestions for addressing these barriers included increased financial assistance from the health system, and building a workforce to address these determinants directly. Health care system factors included poor care coordination, inadequate communication of hospital discharge instructions, and difficulty navigating complex systems. Suggestions for addressing these barriers included enhanced communication between care sites, patient-centered scheduling, and improved patient education especially in discharge planning. Finally, factors related to patient trust of the health system emerged. Participants reported that patients are often intimidated by the health system, mistrusting of physicians, and fearful of receiving a serious diagnosis or prognosis. A suggestion for mitigating these issues was increased visibility of the health system within communities to foster trust and help providers gain a better understanding of unique community needs.ConclusionThis work explored interprofessional healthcare team members’ perceptions of patient barriers to healthcare engagement. Participants identified barriers related to social determinants of health, complex system organization, and patient mistrust of the health system. Participants offered concrete suggestions to address these barriers, with suggestions supporting current healthcare reform efforts that aim at addressing social determinants and improving health system coordination and adding new insight into how systems might work to improve patient and community trust.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1751-5) contains supplementary material, which is available to authorized users.

Bridging the Silos of Service Delivery for High-Need, High-Cost Individuals.

Health care reform efforts that emphasize value have increased awareness of the importance of nonmedical factors in achieving better care, better health, and lower costs in the care of high-need, high-cost individuals. Programs that care for socioeconomically disadvantaged, high-need, high-cost individuals have achieved promising results in part by bridging traditional service delivery silos. This study examined 5 innovative community-oriented programs that are successfully coordinating medical and nonmedical services to identify factors that stimulate and sustain community-level collaboration and coordinated care across silos of health care, public health, and social services delivery. The authors constructed a conceptual framework depicting community health systems that highlights 4 foundational factors that facilitate community-oriented collaboration: flexible financing, shared leadership, shared data, and a strong shared vision of commitment toward delivery of person-centered care.

Oral Health Care Delivery Within the Accountable Care Organization

The accountable care organization (ACO) provides an opportunity to strategically design a comprehensive health system in which oral health works within primary care. A dental hygienist/therapist within the ACO represents value-based health care in action. BackgroundInspired by health care reform efforts in Minnesota, a vision of an accountable care organization that integrates oral health into primary health care was developed. Dental hygienists and dental therapists can help accelerate the integration of oral health into primary care, particularly in light of the compelling evidence confirming the cost-effectiveness of care delivered by an allied workforce. MethodsA dental insurance Chief Operating Officer and a dental hygiene educator used their unique perspectives and experience to describe the potential of an interdisciplinary team-based approach to individual and population health, including oral health, via an accountable care community. ConclusionsThe principles of the patient-centered medical home and the vision for accountable care communities present a paradigm shift from a curative system of care to a prevention-based system that encompasses the behavioral, social, nutritional, economic, and environmental factors that impact health and well-being. Oral health measures embedded in the spectrum of general health care have the potential to ensure a truly comprehensive healthcare system.

Getting (Along) With the Guidelines: Reconciling Patient Autonomy and Quality Improvement Through Shared Decision Making.

In past decades, stark differences in practice pattern, cost, and outcomes of care across regions with similar health demographics have prompted calls for reform. As health systems answer the growing call for accountability in the form of quality indices, while responding to increased scrutiny on practice variation in the form of pay for performance (P4P), a rift is widening between the system and individual patients. Currently, three areas are inadequately considered by P4P structures based largely on physician adherence to guidelines: diversity of patient values and preferences; time and financial burden of therapy in the context of multimorbidity; and narrow focus on quantitative measures that distract clinicians from providing optimal care. As health care reform efforts place greater emphasis on value-for-money of care delivered, they provide an opportunity to consider the other “value”—the values of each patient and care delivery that aligns with them.The inherent balance of risks and benefits in every treatment, especially those involving chronic conditions, calls for engagement of patients in decision-making processes, recognizing the diversity of preferences at the individual level. Shared decision making (SDM) is an attractive option and should be an essential component of quality health care rather than its adjunct. Four interwoven steps toward the meaningful implementation of SDM in clinical practice—embedding SDM as a health care quality measure, “real-world” evaluation of SDM effectiveness, pursuit of an SDM-favorable health system, and patient-centered medical education—are proposed to bring focus back to the beneficiary of health care accountability, the patient.

Describing Total Population Health: A Review and Critique of Existing Units.

Total population health is a key tenet of health care reform efforts, evident in initiatives such as the National Quality Strategy, shifts toward population-based payments, and community benefit requirements for tax-exempt hospitals. Representing total population health in a way that guides best practices and establishes shared accountability for geographic communities, however, remains a challenge in part because of differences in how stakeholders define populations. To better understand the landscape of potential denominators for population health, this study examined a selection of relevant geographic units. The approach included a comprehensive review of health services and public health research literature as well as recent pertinent health policy documents. Units were characterized based on whether they: exhibit "breadth" of coverage across the whole US population; are "accurate" or grounded in health care utilization patterns; are "actionable" with mechanisms for implementing funding and regulation; and promote "synergism" or effective coordination of public health and health care activities. Although other key components of a total population health unit may exist and no single identified unit possesses all of the aforementioned features, several promising candidates were identified. Specifically, healthcare coalitions link health care and public health domains to care for a geographic community, but their connection to utilization is not empiric and limited funding exists at the coalition level. Although Accountable Care Organizations do not uniformly incorporate public health or facilitate coordination across all payers or providers, they represent an effective mechanism to increase collaboration within health care systems and represent a potential building block to influence total population health.

Inpatient Readmissions and Emergency Department Visits within 30 Days of a Hospital Admission.

IntroductionInpatient hospital readmissions have become a focus for healthcare reform and cost-containment efforts. Initiatives targeting unanticipated readmissions have included care coordination for specific high readmission diseases and patients and health coaching during the post-discharge transition period. However, little research has focused on emergency department (ED) visits following an inpatient admission. The objective of this study was to assess 30-day ED utilization and all-cause readmissions following a hospital admission.MethodsThis was a retrospective study using inpatient and ED utilization data from two hospitals with a shared patient population in 2011. We assessed the 30-day ED visit rate and 30-day readmission rate and compared patient characteristics among individuals with 30-day inpatient readmissions, 30-day ED discharges, and no 30-day visits.ResultsThere were 13,449 patients who met the criteria of an index visit. Overall, 2,453 (18.2%) patients had an ED visit within 30 days of an inpatient stay. However, only 55.6% (n=1,363) of these patients were admitted at one of these 30-day visits, resulting in a 30-day all-cause readmission rate of 10.1%.ConclusionApproximately one in five patients presented to the ED within 30 days of an inpatient hospitalization and over half of these patients were readmitted. Readmission measures that incorporate ED visits following an inpatient stay might better inform interventions to reduce avoidable readmissions.

Direct admission to the hospital: An alternative approach to hospitalization.

Appropriate use of emergency departments (EDs) is a focus of national healthcare reform efforts, and patients requiring hospital admission account for a substantial proportion of ED utilization. Despite this, little attention has been paid to evaluating direct admission to the hospital as an alternative to hospital admissions beginning in the ED. In this Perspective, we discuss the role of hospital medicine in the changing epidemiology of hospital admissions, the potential risks and benefits of direct admission to the hospital, and the need for research to evaluate the safety and effectiveness of this admission approach. We propose that transitions of care research and quality improvement, historically focused on hospital-to-home transitions, be expanded to address transitions into the hospital.

Changes in the Care of Patients with Cervical Spine Fractures following Health Reform in Massachusetts

There is a substantial concern among spine surgeons that health care reform efforts will alter the processes through which spine care is delivered and decrease overall quality.

Achieving QoC Goals Linked to Decreased Mortality in HIV-Infected Patients

Increasingly, healthcare reform efforts and funding agencies such as the Ryan White Program require tracking of quality-of-care (QoC) measures. To

A Right to Health Care? Participatory Politics, Progressive Policy and the Price of Loose Language

In this paper I assess the claim that there is a moral human right to health care roughly as set out by Article 12 of the ICESCR. After developing a conception of moral human rights as necessary conditions to legal human rights (by treaty or custom) with prima facie moral force, I argue that while there is a moral human right to health care it is far more modest than that set out by Article 12. I argue also that the human right to health care is thus of limited value in the context of health care reform efforts and that this ought to be accepted by those advocating health care reform, which is for the most part best pursued through a participatory, progressive politics of the common good.

Inertia in health care organizations: A case study of peritoneal dialysis services.

Change is difficult for health care organizations where adoption of new practices is notoriously slow. Inertial behavior may reflect organizations' rational, strategic nonresponse to its environment or latent, institutionalizing preservation of dominant organizational routines and norms. Such strategic and selective influences of organizational inertia have different implications on the efficacy of policy to induce intended change. The aim of this study was to examine whether strategic and selective factors were associated with the provision of peritoneal dialysis (PD) services in outpatient dialysis facilities in the United States between 1995 and 2003. We conducted a longitudinal retrospective study of all outpatient end-stage renal disease dialysis facilities, using 1995-2003 administrative data from the U.S. Renal Data System. Less than half of U.S. dialysis facilities offered PD, and this pattern was stable despite substantial growth of dialysis facilities entering the market. We found little support for strategic influences and some evidence that selective factors were predictive of dialysis facilities' PD provision. Although the design of many policy and health care reform efforts widely accepts the strategic perspective of altering incentives and the environment to induce change, the presence of selective inertial influences raises concerns about the efficacy of policy intervention in the face of institutionalized organizational behavior that may be less amenable to policy intervention. Incentives recently introduced by Medicare to increase facility provision of PD may be less effective than might be expected.

Variation in Use of Pediatric Cardiology Subspecialty Care: A Total Population Study in California, 1983 to 2011

BackgroundAmerican Academy of Pediatrics guidelines emphasize regionalized systems of care for pediatric chronic illness. There remains a paucity of information on the status of regionalized systems of care for pediatric congenital heart disease (CHD). ObjectivesThis study evaluated variations in use of pediatric cardiology specialty care centers (PCSCC) for pediatric patients with CHD in California between 1983 and 2011. MethodsWe performed a retrospective, total population analysis of pediatric CHD patients using the California Office of Statewide Health Planning and Development unmasked database. PCSCCs were identified by California's Title V program. ResultsThere were 164,310 discharges meeting inclusion criterion. Discharges from PCSCCs grew from 58% to 88% between 1983 and 2011. Regionalized care was highest for surgical (96%) versus nonsurgical (71%) admissions. Admissions with a public payer increased from 42% (1983) to 61% (2011). Total bed days nearly doubled, and median length of stay increased from 2 to 3 days (nonspecialty care) and from 4 to 5 days (specialty care). There was a decrease in the pediatric CHD in-hospital death rate from 5.1 to 2.3 per 100,000 between 1983 and 2011, and a shift toward a larger percent of deaths occurring in the newborn period. ConclusionsCalifornia’s inpatient regionalized specialty care of pediatric CHD has increased substantially since 1983, especially for surgical CHD discharges. The death rate has decreased, the number of bed days has increased, and a large proportion of these discharges now have public payers. Health care reform efforts must consider these shifts while protecting advances in regionalization of pediatric CHD care.

Changes in the care of patients with cervical spine fractures following health reform in Massachusetts

IntroductionThere is a substantial concern among spine surgeons that healthcare reform efforts will alter the processes through which spinal care is delivered and decrease overall quality.We used the Statewide Inpatient Dataset for Massachusetts to evaluate changes in hospital processes and quality of care for patients with cervical fractures following the implementation of health reform. MethodsThis was a pre–post retrospective analysis of patients (n=9,387) treated for cervical fractures in Massachusetts between 2003–2006 and 2008–2010. Changes in hospital processes (surgical intervention, length of stay (LOS) and environment of care) and quality of care (mortality, complications, reoperation and failure to rescue (FTR)) were the outcomes of interest. FTR is a quality measure that evaluates a hospital's capacity to avoid mortality following the occurrence of a sentinel complication. Patients treated between 2003 and 2006 were considered the pre-reform group. The post-reform cohort consisted of those treated from 2008 to 2010. Baseline differences between cohorts were evaluated using chi-square or Mann–Whitney U tests. Unadjusted comparisons between the dependent variables and the onset of healthcare reform were performed, followed by regression techniques that adjusted for differences in case-mix and whether a surgical intervention was performed. Multivariable logistic regression was used for categorical variables and negative binomial regression was employed for continuous variables. ResultsThe rates of surgical intervention remained unchanged pre- and post-reform (p=0.25). Hospital length of stay (RC: −0.18, 95% CI: −0.22, −0.14) and the FTR rate following surveillance insensitive complications (OR: 0.49, 95% CI: 0.25, 0.94) were significantly reduced following health reform. Post-reform, academic centers experienced a 22% reduction in mortality (95% CI: 0.61, 0.99) a 40% decrease in FTR (95% CI: 0.40, 0.89), a 30% decrease in surveillance insensitive complications (95% CI: 0.51, 0.96) and a 67% reduction in FTR after surveillance insensitive morbidity (95% CI: 0.11, 0.94). ConclusionsIn the period following Massachusetts healthcare reform, significant improvements were noted in hospital process and quality measures around the care of patients with cervical spine fractures. Such findings were particularly robust among academic centers. These results may forecast changes in the delivery of spine surgical care following other health reform initiatives.Level of Evidence III.

Provider and Consumer Engagement in Care Coordination Models: Evidence from the U.S.

Overview: Current health care reform efforts in the United States, supported by the Affordable Care Act, generally focus on a series of reform models -including Accountable Care Organizations, Medical Homes and Health Care Homes -that rely on care coordination to provide more efficient, higher quality care. Many of these concepts were originally developed and tested as Medicare program pilot projects and demonstrations. This presentation will examine how these initial pilots and demonstrations. as well as early ACA funded models, have performed -some successfully, others less so. The presentation will specifically focus on the factors that may influence the degree of in using care coordination to drive efficiency and quality. Methods: This research is based on review of demonstration and pilot program as well as current ACA mandated pay-for-performance, value-based purchasing, gainhsaring and other care coordination-related reform projects. Methods used to evaluate success of projects include findings from focus groups and site visits, trend performance (relying on difference-in-difference techniques) on expenditures, utilization and quality of care monitoring. Specific focus will be placed on the degree of physician, other health care provider and consumer engagement in care coordination. Results: Success in using care coordination-based models to simultaneously lower health care costs while maintaining/improving quality of care is mixed so far. Some of the most promising reform models have faced some difficulties in translation beyond a select group of initial health care providers who pioneered the models. Many models have struggled to achieve the level of physician engagement necessary to use care coordination to impact costs and utilization. Consumers in the U.S. tend to be reluctant to accept care coordination by their providers. Some models have suffered from costly and complex data reporting that is difficult to understand and burdensome to providers. Rewards to participating providers are, in some cases, very small. In other cases, the ability of many practices to accept and managed potentially significant financial risk is a growing concern. Conclusion: Initial evidence of large impacts by care coordination driven reform models on quality of care and cost reductions have been limited. While there is no evidence to date that these types of models negatively impact quality of care, there is also limited evidence that they are able to consistently achieve reductions in costs, utilization and health care expenditures. International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117006 – http://www.ijic.org/ 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2