Independent Physician Practices Research Articles

Hospital Prices for Physician-Administered Drugs for Patients with Private Insurance

BackgroundHospitals can leverage their position between the ultimate buyers and sellers of drugs to retain a substantial share of insurer pharmaceutical expenditures.MethodsIn this study, we used 2020–2021 national Blue Cross Blue Shield claims data regarding patients in the United States who had drug-infusion visits for oncologic conditions, inflammatory conditions, or blood-cell deficiency disorders. Markups of the reimbursement prices were measured in terms of amounts paid by Blue Cross Blue Shield plans to hospitals and physician practices relative to the amounts paid by these providers to drug manufacturers. Acquisition-price reductions in hospital payments to drug manufacturers were measured in terms of discounts under the federal 340B Drug Pricing Program. We estimated the percentage of Blue Cross Blue Shield drug spending that was received by drug manufacturers and the percentage retained by provider organizations.ResultsThe study included 404,443 patients in the United States who had 4,727,189 drug-infusion visits. The median price markup (defined as the ratio of the reimbursement price to the acquisition price) for hospitals eligible for 340B discounts was 3.08 (interquartile range, 1.87 to 6.38). After adjustment for drug, patient, and geographic factors, price markups at hospitals eligible for 340B discounts were 6.59 times (95% confidence interval [CI], 6.02 to 7.16) as high as those in independent physician practices, and price markups at noneligible hospitals were 4.34 times (95% CI, 3.77 to 4.90) as high as those in physician practices. Hospitals eligible for 340B discounts retained 64.3% of insurer drug expenditures, whereas hospitals not eligible for 340B discounts retained 44.8% and independent physician practices retained 19.1%.ConclusionsThis study showed that hospitals imposed large price markups and retained a substantial share of total insurer spending on physician-administered drugs for patients with private insurance. The effects were especially large for hospitals eligible for discounts under the federal 340B Drug Pricing Program on acquisition costs paid to manufacturers. (Funded by Arnold Ventures and the National Institute for Health Care Management.)

Biosimilar Use Among 38 ASCO PracticeNET Practices, 2019-2021.

Biosimilars offer increased patient choice and potential cost-savings, compared with originator biologics. We studied 3 years of prescribed biologics among US physician practices to determine the relationship of practice type and payment source to oncology biosimilar use. We acquired biologic utilization data from 38 practices participating in PracticeNET. We focused on six biologics (bevacizumab, epoetin alfa, filgrastim, pegfilgrastim, rituximab, and trastuzumab) for the period from 2019 to 2021. We complemented our quantitative analysis with a survey of PracticeNET participants (prescribers and practice leaders) to reveal potential motivators and barriers to biosimilar use. We implemented logistic regression to evaluate the biosimilar use for each biologic, with covariates including time, practice type, and payment source, and accounted for clusters of practices. Use of biosimilars increased over the 3-year period, reaching between 51% and 80% of administered doses by the fourth quarter of 2021, depending on the biologic. Biosimilar use varied by practice, with independent physician practices having higher use of biosimilars for epoetin alfa, filgrastim, rituximab, and trastuzumab. Compared with commercial health plans, Medicaid plans had lower biosimilar use for four biologics; traditional Medicare had lower use for five biologics. The average cost per dose decreased between 24% and 41%, dependent on the biologic. Biosimilars have, through increased use, lowered the average cost per dose of the studied biologics. Biosimilar use differed by originator biologic, practice type, and payment source. There remains further opportunity for increases in biosimilar use among certain practices and payers.

Trainee Physician Milestone Ratings and Patient Complaints in Early Posttraining Practice

Evaluation of trainees in graduate medical education training programs using Milestones has been in place since 2013. It is not known whether trainees who have lower ratings during the last year of training go on to have concerns related to interactions with patients in posttraining practice. To investigate the association between resident Milestone ratings and posttraining patient complaints. This retrospective cohort study included physicians who completed Accreditation Council for Graduate Medical Education (ACGME)-accredited programs between July 1, 2015, and June 30, 2019, and worked at a site that participated in the national Patient Advocacy Reporting System (PARS) program for at least 1 year. Milestone ratings from ACGME training programs and patient complaint data from PARS were collected. Data analysis was conducted from March 2022 to February 2023. Lowest professionalism (P) and interpersonal and communication skills (ICS) Milestones ratings 6 months prior to the end of training. PARS year 1 index scores, based on recency and severity of complaints. The cohort included 9340 physicians with median (IQR) age of 33 (31-35) years; 4516 (48.4%) were women physicians. Overall, 7001 (75.0%) had a PARS year 1 index score of 0, 2023 (21.7%) had a score of 1 to 20 (moderate), and 316 (3.4%) had a score of 21 or greater (high). Among physicians in the lowest Milestones group, 34 of 716 (4.7%) had high PARS year 1 index scores, while 105 of 3617 (2.9%) with Milestone ratings of 4.0 (proficient), had high PARS year 1 index scores. In a multivariable ordinal regression model, physicians in the 2 lowest Milestones rating groups (0-2.5 and 3.0-3.5) were statistically significantly more likely to have higher PARS year 1 index scores than the reference group with Milestones ratings of 4.0 (0-2.5 group: odds ratio, 1.2 [95% CI, 1.0-1.5]; 3.0-3.5 group: odds ratio, 1.2 [95% CI, 1.1-1.3]). In this study, trainees with low Milestone ratings in P and ICS near the end of residency were at increased risk for patient complaints in their early posttraining independent physician practice. Trainees with lower Milestone ratings in P and ICS may need more support during graduate medical education training or in the early part of their posttraining practice career.

Training Generations of Clinician Educators: Applying the Novel Clinician Educator Milestones to Faculty Development

Training Generations of Clinician Educators: Applying the Novel Clinician Educator Milestones to Faculty Development

Trends in Industry Payments to Physicians in the First 6 Years After Graduate Medical Training

Financial incentives and conflicts of interest may influence physician decision-making. It is important to understand financial interactions between the pharmaceutical and medical device industries and newly independent physicians who have recently completed their graduate medical education using a national transparency program. To identify trends in industry payments to recent graduates of Accreditation Council for Graduate Medical Education-accredited residency or fellowship programs in orthopedic surgery, neurosurgery, and internal medicine. This retrospective cohort study analyzed Open Payments reports of industry payments made between July 1, 2015, and June 30, 2021, to newly independent physicians from residency or fellowship programs in neurosurgery, orthopedic surgery, and internal medicine who graduated between January 1, 2015, and December 31, 2019. Specialties (neurosurgery and orthopedic surgery, with internal medicine as a comparison group). Industry payments to newly independent physicians, including any general payments (noninvestment or nonresearch) and at least $5000 of general payments in aggregate value per year, which are considered significant financial conflicts of interest. The percentage of newly independent physicians accepting general payments during the first 6 years after graduation was analyzed by specialty and sex using cumulative incidence curves and hazard ratios (HRs) in univariable and multivariable analyses. There were 45 745 recent graduates (28 137 men [62%]; median age at graduation, 33.0 [IQR, 31.0-35.0 years]) in neurosurgery (n = 595), orthopedic surgery (n = 3481), and internal medicine (n = 41 669). In the first 2 years of independent practice, 95% (n = 3297), 92% (n = 546), and 59% (n = 24 522) of newly independent physicians in orthopedic surgery, neurosurgery, and internal medicine, respectively, accepted any general payments. A higher percentage of the newly independent physicians in orthopedic surgery and neurosurgery accepted any general payments (orthopedic surgery vs internal medicine: HR, 5.36 [95% CI, 4.42-6.51] for women and 7.01 [95% CI, 6.35-7.73] for men; neurosurgery vs internal medicine: HR, 3.25 [95% CI, 2.24-4.72] for women and 4.08 [95% CI, 3.37-4.94] for men; P = .03). A higher percentage of male physicians compared with female physicians accepted any general payments (orthopedic surgery, 2884 of 3026 [95%] vs 413 of 455 [91%]; P < .001; neurosurgery, 466 of 502 [93%] vs 80 of 93 [86%]; P = .01; and internal medicine, 15 462 of 24 609 [63%] vs 9043 of 17 034 [53%]; P < .001) and at least $5000 of general payments (orthopedic surgery, 763 of 3026 [25%] vs 71 of 455 [16%]; P < .001; neurosurgery, 87 of 502 [17%] vs 5 of 93 [5%%]; P < .001; and internal medicine, 882 of 24 609 [4%] vs 210 of 17 034 [1%]; P < .001). In this cohort study of newly independent physicians in orthopedic surgery, neurosurgery, and internal medicine, the financial relationship with potential conflicts of interest between newly independent physicians and industry began to develop soon after training programs and continued to expand in the early years of newly independent physician practice. Newly independent physicians in surgical specialties and male physicians accepted significantly higher industry payments. Further studies are needed to evaluate whether modifiable factors are associated with the future outcome of newly independent physicians accepting general payments.

Physician Practice Consolidation: Considerations for the Remaining Independents

Summary As independent physician practices face continuing financial pressures, integration with other organizations offers a mix of advantages and drawbacks. Practices may be acquired by hospitals, health plans, physician organizations, and/or private equity firms. Integration can lead to administrative efficiency, leveraged purchasing power, improved care coordination and clinical integration, and better contracting. In this article, the author provides a roadmap for those considering acquisition and shares insights on the processes and the pros and cons of the types of arrangements.

Adoption of Patient-Reported Outcomes by Health Systems and Physician Practices in the USA.

Patient-reported outcome measures (PROs) can help clinicians adjust treatments and deliver patient-centered care, but organizational adoption of PROs remains low. This study examines the extent of PRO adoption among health systems and physician practices nationally and examines the organizational capabilities associated with more extensive PRO adoption. Two nationally representative surveys were analyzed in parallel to assess health system and physician practice capabilities associated with adoption of PROs of disability, pain, and depression. A total of 323 US health system and 2,190 physician practice respondents METHODS: Multivariable regression models separately estimated the association of health system and physician practice capabilities associated with system-level and practice-level adoption of PROs. Health system and physician practice adoption of PROs for depression, pain, and disability. Pain (50.6%) and depression (43.8%) PROs were more commonly adopted by all hospitals and medical groups within health systems compared to disability PROs (26.5%). In adjusted analyses, systems with more advanced health IT functions were more likely to use disability (p<0.05) and depression (p<0.01) PROs than systems with less advanced health IT. Practice-level advanced health IT was positively associated with use of depression PRO (p<0.05), but not disability or pain PRO use. Practices with more chronic care management processes, broader medical and social risk screening, and more processes to support patient responsiveness were more likely to adopt each of the three PROs. Compared to independent physician practices, system-owned practices and community health centers were less likely to adopt PROs. Chronic care management programs, routine screening, and patient-centered care initiatives can enable PRO adoption at the practice level. Developing these practice-level capabilities may improve PRO adoption more than solely expanding health IT functions.

Time and Financial Costs for Physician Practices to Participate in the Medicare Merit-based Incentive Payment System: A Qualitative Study.

The Merit-based Incentive Payment System (MIPS) is a major Medicare value-based purchasing program, influencing payment for more than 1 million clinicians annually. There is a growing concern that MIPS increases administrative burden, and little is known about what it costs physician practices to participate in the program. To examine the costs for independent physician practices to participate in MIPS in 2019. This qualitative study identified and interviewed leaders of physician practices participating in the US Centers for Medicare & Medicaid Services (CMS) MIPS program, including those in MIPS alternative payment models. Time required and financial costs were calculated from responses to in-depth, semistructured interviews conducted from December 12, 2019, to June 23, 2020. Physician practices were categorized by size (small, 1-9 physicians; medium, 10-25; and large, ≥50), specialty (primary care, general surgery, or multispecialty), and US census region. Participants were asked about 2019 costs related to clinician and staff time, information technology, and external vendors. Time was converted to financial costs using the Medical Group Management Association's Provider Compensation and the Management and Staff Compensation databases. Annual time spent by staff on MIPS-related activities and mean per-physician costs to physician practices in 2019. Leaders of 30 physician practices (9 [30.0%] small primary care, 6 [20.0%] small general surgery, 4 [13.3%] medium primary care, 4 [13.3%] medium general surgery, and 7 [23.3%] large multispecialty) represented all US census regions, and 14 of the 30 (46.7%) practices participated in a MIPS alternative payment model in 2019. The mean per-physician cost to practices of participating in MIPS was $12 811 (interquartile range [IQR], $2861-$17 715). Physicians, clinical staff, and administrative staff together spent 201.7 (IQR, 50.9-295.2) hours annually per physician on MIPS-related activities. Medical assistants and nursing staff together spent a mean of 99.2 (IQR, 0-163.3) hours per physician each year; frontline physicians spent 53.6 (IQR, 0.6-55.8) hours; executive administrators spent 28.6 (IQR, 3.1-26.7) hours; other clinicians and staff spent a combined 20.3 (IQR, 0-36.8) hours. Physician time accounted for the greatest proportion of overall MIPS-related costs (54%; $6909; IQR, $94-$9905). In this qualitative study, physician practice leaders reported significant time and financial costs of participating in the MIPS program. Attention to reducing the burden of MIPS may be warranted.

Consolidation by Any Other Name? The Emergence of Clinically Integrated Networks

Research ObjectiveA clinically integrated network is a group of health care providers that join together for the stated purpose of improving care and reducing costs. The Federal Trade Commission has established standards for clinically integrated networks for purposes of determining whether cooperation among otherwise competing organizations to jointly negotiate fees runs afoul of antitrust law. However, little is known about how CINs are implemented on the ground and how health systems use CINs to compete in health care markets.Study DesignWe conducted explanatory case studies of 24 health systems using in‐depth interviews of c‐suite executives (n = 162), descriptive surveys, and document review. The interview protocols focused on topics such as market context; origin of the health system; structural organization and governance; and the influence of the health system on hospital and physician organization operations. We developed a codebook based on the interview guides. After a multistage process of testing and refining codes, two researchers independently coded the interview data. A high threshold of interrater reliability was achieved (pooled kappa across all codes was 0.84). We used comparative case study analysis to compare and contrast the development of CINs in our sample of health systems.Population StudiedUsing secondary data sources, we identified the health system affiliations of all physician organizations publicly reporting performance data in four states that host a health care measurement and improvement collaborative. From the universe of health systems, we selected a purposive sample of 24 health systems to achieve variability on important attributes (eg, size and performance).Principal FindingsRespondents in half of the health systems described the use of a CIN, although the organizational structures and the functions of the CINs varied widely. CINs can be classified into three basic types—those made up of primarily closely affiliated practices, those made up of primarily loosely affiliated practices, and those that represent partnerships among health systems.ConclusionsHealth systems are using CINs to adapt to competitive environments and changing payment policies in several ways. CINs allow health systems to (1) move care into lower‐cost settings while retaining referral pathways for their tertiary facilities; (2) extend their geographic reach without the capital and administrative costs of acquiring and onboarding; (3) maximize negotiating leverage while reducing contracting burden; and (4) offer advantages (such as EHR and quality reporting support) to physicians while allowing them to remain in independent practice.Implications for Policy or PracticeResearch on competition in health care markets has concentrated on mergers and acquisitions; however, many health systems have begun to use an affiliation approach to expansion and integration with other providers in their market. This approach allows independent physician practices to benefit from some of the strengths of a larger HS without capital outlays or administrative burden to the HS, and to reduce transactional costs for the providers. It remains unclear whether this new model of integration is achieving the purported objectives of improved quality and reduced costs. CINs may have the same negative impact on health care prices as have traditional mergers and acquisitions, and will face considerable challenges in coordinating care across providers that are not fully integrated.Primary Funding SourceAgency for Healthcare Research and Quality.

The Impact of COVID-19 on Independent Physician Practices

The Impact of COVID-19 on Independent Physician Practices

Annual Spending per Patient and Quality in Hospital-Owned Versus Physician-Owned Organizations: an Observational Study

BackgroundRecent studies that compared patient spending in hospital-owned physician practices versus physician-owned groups did not compare quality of care. Past studies had incomplete measures of physician-hospital integration, or lacked patient-level data.ObjectiveTo measure the association between physician-hospital integration and both spending and quality using patient-level data and explicit physician-hospital contracting information.DesignRetrospective review of claims data from 2014 through 2016. Adjustments were made for patient, physician, and regional characteristics.PatientsPatients aged 19 to 64 enrolled in a Blue Cross Blue Shield Texas Preferred Provider Organization in the four largest metropolitan areas in Texas who could be attributed to a physician practice based on claims.Main Outcomes and MeasuresAnnual spending per patient was compared for patients treated by a physician practice that is billing through a hospital, versus billing through an independent physician practice; spending was also subdivided by BETOS category, by site and type of care, and percent of patients with positive spending by subcategory. Quality measures included readmission within 30 days of discharge for hospitalized patients, appropriate care for diabetic patients, and screening mammography for women ages 50–64.ResultsEstimates suggest that patients in a preferred provider organization incur spending which is 5.8 percentage points higher when treated by doctors in hospital-owned versus physician-owned practices (95% CI 1.7 to 9.9; p = 0.006). Spending is significantly higher for durable medical equipment, imaging, unclassified services, and outpatient care. The spending difference appears attributable to greater service utilization rather than higher prices. There was no consistent difference in care quality for hospital-owned versus physician-owned practices.Conclusions and RelevanceWe find that financial integration between physicians and hospitals raises patient spending, but not care quality. Given that higher spending raises the price of health insurance, policy makers should carefully consider policies that limit consolidation of hospitals and physicians.

Morehouse Choice Accountable Care Organization and Education System (MCACO-ES): Integrated Model Delivering Equitable Quality Care.

Accountable Care Organizations (ACOs) seek sustainable innovation through the testing of new care delivery methods that promote shared goals among value-based health care collaborators. The Morehouse Choice Accountable Care Organization and Education System (MCACO-ES), or (M-ACO) is a physician led integrated delivery model participating in the Medicare Shared Savings Program (MSSP) offered through the Centers for Medicare and Medicaid Services (CMS) Innovation Center. The MSSP establishes incentivized, performance-based payment models for qualifying health care organizations serving traditional Medicare beneficiaries that promote collaborative efficiency models designed to mitigate fragmented and insufficient access to health care, reduce unnecessary cost, and improve clinical outcomes. The M-ACO integration model is administered through participant organizations that include a multi-site community based academic practice, independent physician practices, and federally qualified health center systems (FQHCs). This manuscript aims to present a descriptive and exploratory assessment of health care programs and related innovation methods that validate M-ACO as a reliable simulator to implement, evaluate, and refine M-ACO’s integration model to render value-based performance outcomes over time. A part of the research approach also includes early outcomes and lessons learned advancing the framework for ongoing testing of M-ACO’s integration model across independently owned, rural, and urban health care locations that predominantly serve low-income, traditional Medicare beneficiaries, (including those who also qualify for Medicaid benefits (also referred to as “dual eligibles”). M-ACO seeks to determine how integration potentially impacts targeted performance results. As a simulator to test value-based innovation and related clinical and business practices, M-ACO uses enterprise-level data and advanced analytics to measure certain areas, including: 1) health program insight and effectiveness; 2) optimal implementation process and workflows that align primary care with specialists to expand access to care; 3) chronic care management/coordination deployment as an effective extender service to physicians and patients risk stratified based on defined clinical and social determinant criteria; 4) adoption of technology tools for patient outreach and engagement, including a mobile application for remote biometric monitoring and telemedicine; and 5) use of structured communication platforms that enable practitioner engagement and ongoing training regarding the shift from volume to value-based care delivery.

568 The impact of prior authorizations for patients with complex dermatological conditions

The current prior authorization (PA) process poses a significant burden on physician practices, particularly in fields with a high rate of medication prescriptions such as dermatology. Such a cumbersome process may deter physicians from advocating for their patients to receive the services they need, significantly delay treatment, and inhibit patient follow-through. To enhance patient compliance, medication access, and ultimately patient care, further knowledge about the PA process for dermatological practices is needed. Past studies have explored the impact of PAs for acne and psoriasis treatments, but how patients with more complex dermatological conditions are impacted is not well understood. To characterize the problem in this patient population, administrative time spent on addressing these PAs for patients with complex dermatological conditions was assessed. For a single provider’s dermatologic practice, the start and stop time for administrative activities associated with PAs (e.g. form completion, peer-to-peer dialogue) was tracked over the course of 3 months (n=30). For each patient with a prescription requiring PA, median administrative time per patient was 30 min (IQR 17.75-72.5 min) resulting in 43% approvals and 46% initial denials (insurer’s decision still outstanding for 10%). These patients experienced significant delay to treatment; from time of prescription of medication or diagnostic test to time of receipt of treatment or diagnostic procedure, patients were delayed a median of 11 days (IQR: 6-33.5 d), in addition to unquantifiable distress associated with care and in 2 patient cases, inpatient hospitalization to receive the appropriate medication. Thus, an enhanced understanding of the impact of the PA process on patients with complex needs in both the outpatient and inpatient settings will be critical in designing better systems to streamline the process for independent physician practices and the larger U.S. healthcare system.

DEVELOPMENT OF AN ECHOCARDIOGRAPHIC QUALITY IMPROVEMENT AND ACCREDITATION PROCESS THROUGH A SUCCESSFUL GOVERNMENT-MEDICAL COLLABORATION

Echocardiography (echo) is a frequently used diagnostic test in Ontario with significant implications for clinical care, patient outcomes, and health system costs. To help ensure quality echo services, the Ontario Ministry of Health and Long Term Care (MOHLTC) and Ontario Medical Association (OMA) convened the Hospital Outpatient and Community-based Echocardiography Working Group, whose recommendations subsequently resulted in CorHealth Ontario releasing the Standards for Provision of Echocardiography in Ontario. Along with the Standards, and in collaboration with the MOHLTC and the Ontario Association of Cardiologists (OAC), CorHealth launched the Echo Quality Improvement Program (EQIP), a process designed to ensure that echo facilities practice according to the Standards. The core elements of the EQIP include an echo facility site visit along with process and case reviews. To facilitate quality improvement in alignment with the Standards, detailed and meaningful feedback is provided in a consistent and structured format. In April 2016 participation in the EQIP became a requirement for physician payment from the Ontario Health Insurance Program. Working with the Ontario Association of Cardiologists (OAC) and the MOHLTC, the EQI Program developed consistent, objective, and transparent processes and reporting requirements to address the shared desire for accountability and quality. As of April 26, 2018, 432 out of 766 operational echo facilities have been reviewed. 175 of the reviewed echo facilities have completed quality improvements and achieved accreditation. The success of the EQIP to date demonstrates the value of government-medical collaboration to improve the quality of echo services across both publicly funded hospitals and independent physician practices in Ontario. The benefits arising from the collaborative effort is positively impacting clinical decision making and patient care and could serve as a foundation for similar diagnostic quality improvement initiatives.

Comparing costs of a senior wellness care redesign in group and independent physician practices of an accountable care organization

Primary care redesign for older adult patients is currently ongoing in countries with aging populations. One of the main challenges of this type of transformations is how to estimate implementation costs in different types of health care delivery organizations. This study compares start-up and incremental expenses of implementing a primary care redesign across 2 organization types: integrated group (n=31) practices and independent practice association (IPA) sites (n=213). Administrators involved with implementing the redesign completed a cost capture template to quantifying expenses. The potential impact of measurement error, recollection bias, and implementation models across sites and geographic regions was examined in sensitivity analyses. Marginal start-up and incremental expenses were higher for Group sites ($122-$328) compared to IPA sites ($31-$227). Group and IPA sites, however, implemented the redesign with different intensities. According to our analyses, if IPA sites implemented the redesign with the same intensity as Group sites, marginal costs would have been $5 to $13 higher for IPA sites than for Group sites. This study shows how a flexible approach to estimate the cost of a wellness care redesign is needed when the intensity of the transformation differs across 2 different types of health care organizations.

The Medicare Access And CHIP Reauthorization Act And The Corporate Transformation Of American Medicine.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) may accelerate the movement of physicians into corporate employment by hospitals and, to a lesser extent, by health insurers and other corporations. This article briefly summarizes the demographics of US physician practice, the potential advantages and disadvantages of physician employment by large corporations, and the evidence to date on the performance of large versus small physician practices and hospital-employed versus independent physicians. It describes the features of MACRA likely to lead physicians to seek corporate employment and the steps the Centers for Medicare and Medicaid Services has taken through MACRA to aid small independent physician practices. I conclude that MACRA's net effect is likely to be accelerated corporate employment of physicians and that there is an urgent need for more evidence on the impact of different types of provider organization on the quality and cost of care, and on patient, physician, and staff experience.

Making Health Care Markets Work

Many studies have examined trends toward increasing consolidation of physician practices and hospitals in the US health care system and the negative effects of decreased competition on the quality of patient care and health care costs.1 Since 2010, there have been 561 hospital mergers,2 and nearly half of hospital markets are highly concentrated.3 Independent physician practice has declined; 33% of 929 419 active physicians in 2013 were employed by hospitals4 and many more are in affiliate relationships. A recent article acknowledged that there is little evidence of the promised benefits of such consolidation to patients or society, and it called on the presidential administration to “ensure that we have a dynamic health care marketplace.”5

A Pediatric Emergency Department at Lynchburg General Hospital

The emergency department (ED) at Lynchburg General Hospital (LGH) was operating at well over its capacity, and too many patients were leaving without being seen by a doctor. Chris Thomson, chairman and medical director of the LGH-ED, was charged with bringing the numbers back on track, and he began by ramping up the ED's Lean program. Thomson and the ED's new process engineer, Jennifer Stowers, set out to enhance quality, service, and efficiency while standardizing and streamlining all processes to make the ED more efficient in every way. They also felt strongly that creating a new pediatric ED would be beneficial. But would the hospital as a whole be receptive to the changes Thomson and Stowers were proposing? This case has been used in Darden's course elective “Management of Service Operations.” Excerpt UVA-OM-1523 Jan. 27, 2015 A Pediatric Emergency Department at Lynchburg General Hospital The emergency department (ED) at Lynchburg General Hospital (LGH) was the primary site where Centra Emergency Services Group (CESG) practiced. CESG was an employed-physician group comprising roughly 40 emergency-medicine physicians and 15 advanced-practice professionals. In 2010, when he was promoted to chairman and medical director of the LGH-ED, Chris Thomson, MD, would oversee system-wide emergency services at both LGH and Southside Community Hospital (SCH) in Farmville, Virginia. The LGH-ED serviced around 95,000 patients per year, and SCH-ED around 30,000 patients, bringing the combined total to 125,000 ED visits per year. The two EDs recorded $ 217million in charges and $ 89 million in collections annually. Thomson was charged with enhancing quality, service, and efficiency while standardizing all processes during an important transition from a single-hospital practice to a multisite practice serving an integrated hospital system. Exhibit 1 provides details about LGH. Prior to 2007, CESG was a democratic, independent physician practice called Lynchburg Emergency Physicians (LEP), but in 2007, LEP was dissolved and the physicians became employees of Centra Health. CESG spent the years 2007 to 2010 transitioning to this new employment model. Once the model was stable, attention turned to developing the system-wide, multisite practice. Integrating the groups, processes, and physician standards was part of the challenge that Thomson took on in 2010. . . .

Success in the Face of Reform

We hear repeatedly that health reform will dramatically affect the way postacute and long-term care (PA/LTC) will participate in the U.S. health care system. New models of care delivery include accountable care organization, medical homes, and demonstration projects that combine Medicare and Medicaid dollars. All have core principles of accountability, integration of care, emphasis on long-term health outcomes, and better transitions. So, where do physicians look for guidance in the postreform world? Many of us immediately think of innovative centers such as the Cleveland Clinic and the Mayo Clinics. There is certainly much to learn from them, but how transferable are their practices? How dependent are their models on concentrated populations and resources? What do they offer to rural or suburban practices? At the same time, some independent physician practices are trying to chart their own paths through the changing environment without sacrificing physician leadership. One such model is Chappel Health and Wellness in central Florida. It's led by Chris Chappel, MD, CMD, and includes three other physicians and six physician assistants. They operate three clinics and provide medical direction to 25 PA/LTC facilities in the three counties around Orlando. What makes Dr. Chappel's practice model unusual is that it incorporates “discharge clinics” in cooperation with local hospitals. These clinics streamline transitions from the acute setting by giving patients on-site access to a pharmacy, a home health agency, and a durable medical equipment provider. The discharge clinics also set the immediate follow-up appointments with primary care physicians and specialists. The pharmacy's presence alone mitigates what is a major contributor to hospital readmissions, medication errors. Each Chappell clinic also has a wellness program incorporating diet and exercise coaching in a 5,500 square-foot gym. In a final twist, Chappel Health and Wellness has a clinical research arm staffed by a pharmacist and two physicians. Dr. Chappel has been working with Florida's Quality Improvement Organization on a project to reduce hospital readmissions. The collaboration includes four nursing homes, two home health agencies, and a patient-advocacy and coaching organization. The project targets seven of the leading readmission diagnoses, including heart failure, chronic obstructive pulmonary disease, and sepsis. The linchpins of the project are two: immediately offering a health coach to a patient at hospital discharge and use of the Interventions to Reduce Acute Care Transfers (INTERACT) program for improving long-term care transitions. The results have been dramatic. Nursing homes have become more comfortable treating patients with complex diagnoses and talking with family members about care-setting choice. Hospital admission rates of residents in the four nursing homes have decreased from 26% to 17% and are still falling. Thus, Chappel Health and Wellness is firmly planted in both community-based and facility-based long-term care. Dr. Chappel describes the model as a medical village concept within a clinic. He and his colleagues strive to follow the Institute of Medicine's advice on how to give appropriate and affordable care: “Deliver the right care at the right time by the right provider in the right setting.” Is Dr. Chappel naïve in trying to go it alone in the post–health reform world? He says that he is striving to let primary care do what it does best and eliminate or reduce the need for the administrative middle man of an accountable care organization (ACO), for instance. “I think we are years away from bundled payments for physician services in the outpatient world. If it happens sooner, our concept will be ready for it and will have a track record, especially when it comes to decreasing 30-day readmits,” Dr. Chappel said. Maybe he's not naïve. He says that physician groups partnering with hospitals, nursing homes, insurance companies, and other entities is inevitable. “We are starting small to work out the bugs, then expanding in whatever direction it takes us.” The handwriting is on the wall. Governmental payers, employers, and health insurance companies are all pushing for more integrated health care systems, where physicians and hospitals are held accountable for the overall cost and quality of care. It is likely that all physicians will need to participate in systems requiring more communication, care coordination, and quality-data reporting. The Chappel Health and Wellness model strives for coordinated services that are rooted deeply in a profound respect for patients. In Dr. Chappel's view, hospitals, LTC facilities, and physicians' practices can and must work together effectively.

Abstract 174: Organization of Cardiologists in the United States - An Early View in the Era of Accountable Care Organizations

Objective: To understand the organization of cardiologists in the United States and territories with an emphasis on identifying the characteristics of practices where cardiologists practice. Data: The Healthcare Organization Services database, which provides information on the designation, specialties and business associations, or affiliations, of healthcare professionals across the US and territories. These data were updated as of September 2013. Methods: Cardiologists were defined as providers with an MD or DO, who have an active clinical practice, and either: (1) have Cardiology as primary specialty, or (2) who have Internal Medicine, Pediatrics or Family Medicine indicated as primary specialty, with Cardiology as secondary specialty. Cardiologists were linked to businesses and descriptive analyses were conducted to characterize the organization of cardiologists. Findings: We identified 33,745 cardiologists; 22,461 of these cardiologists had at least one affiliation with an ambulatory practice or independent physician association (AP/IPA), while 30,567 had at least one hospital affiliation. Approximately 57.6% (19,453 of 33,745) of cardiologists were affiliated with both the AP/IPA and hospital settings. The overwhelming majority of ambulatory practices linked to hospital-AP/IPA affiliated cardiologists are medical groups (7,839 of 9,838), while independent physician practices comprise the next largest category (1,498 of 9,838). Of the 7,839 medical groups, 3,809 are cardiology specialty, 1,316 are multispecialty group practices, and 2,060 are family practice, general practice, geriatric medicine, internal medicine, pediatric medicine or primary care. Among all non-multispecialty medical groups (n=6,523), 59.2% (3,862 of 6,523) have 1-2 affiliated cardiologists, 21.7% (1,413 of 6,523) have 3-5, 12.6% (821 of 6,523) have 6-10 and 6.5% (427 of 6,523) have more than 10 affiliated cardiologists. Focusing at the provider level, 17,639 hospital-AP/IPA cardiologists had any affiliation with a medical group (MG), with 12,840 cardiologists with any cardiology specialty MG affiliation, 3,215 with any multispecialty group practice MG affiliation, and 3,051 with any family practice, general practice, geriatric medicine, internal medicine, pediatric medicine or primary care MG affiliation. Overall, 15,476 hospital-AP/IPA cardiologists had any affiliation with at least one non-multi-specialty group practice (non-MSGP), with 4,279 affiliated with one or more non-MSGP(s) with 1-2 cardiologists, 4,378 with one or more non-MSGP(s) with 3-5 cardiologists, and 4,861 and 5,099 affiliated with one or more non-MSGP(s) with 6-10 and &gt;10 cardiologists, respectively. Conclusion: The majority of cardiologists were affiliated with both a hospital and ambulatory practice or IPA. Of this subset, most cardiologists were affiliated with at least one group practice.