Physician-hospital Organizations Research Articles

Hospital Characteristics Associated With Clinically Integrated Network Participation.

Increased integration of physician organizations and hospitals into health systems has not necessarily improved clinical integration or patient outcomes. However, federal regulators have issued favorable opinions for clinically integrated networks (CINs) as a way to pursue coordination between hospitals and physicians. Hospital organizational affiliations, including independent practice associations (IPA), physician-hospital organizations (PHOs), and accountable care organizations (ACOs), may support CIN participation. No empirical evidence, however, exists about factors associated with CIN participation. Data from the 2019 American Hospital Association survey (n = 4405) were analyzed to quantify hospital CIN participation. Multivariable logistic regression models were estimated to examine whether IPA, PHO, and ACO affiliations were associated with CIN participation, controlling for market factors and hospital characteristics. In 2019, 34.6% of hospitals participated in a CIN. Larger, not-for-profit, and metropolitan hospitals were more likely to participate in CINs. In adjusted analyses, hospitals participating in CINs were more likely to have an IPA (9.5% points, P < 0.001), a PHO (6.1% points, P < 0.001), and ACO (19.3% points, P < 0.001) compared with hospitals not participating in a CIN. Over one-third of hospitals participate in a CIN, despite limited evidence about their effectiveness in delivering value. Results suggest that CIN participation may be a response to integrative norms. Future work should attempt to better define CIN participation and strive to disentangle overlapping organizational participation.

Performance Management in Accountable Care Organizations in the U.S. and Germany: From external reporting requirements to enabling internal performance management in physician practices

Background : USA: Performance management systems (PMSYSs) are an important tool for increasing the performance (quality, efficiency, effectiveness) of accountable care organizations (ACOs), and enable continuous improvement in affiliated physician practices. So far, there is limited knowledge about the extent of their implementation in US physician practices and about factors associated with their implementation. In addition, although performance measurement is seen as a core element of ACOs and is externally enforced, sparse information exists as to the interplay of external reporting requirements and incentives for internal PMSYSs. Germany: Whereas there are currently over 800 ACOs in the USA, Germany has only a few comparable ACO flagship projects. Also external financial and non-financial performance measurement requirements are, in comparison to the US, in an early stage. However, accountable, integrated care and performance measurement initiatives have moved up the political agenda. There may arise important insights for policy makers and health care managers from the experiences in the USA. Methods : A mixed-method approach using survey data analyses of a nationally representative sample of US physician practices (total n = 1,328; ACO practices n = 316) and case studies in the US (n=3) and Germany (n=1, Gesundes Kinzigtal) was used. Results : On average, practices affiliated with an ACO (24%) used only approximately half (53.1 points out of 100) of the measured PMSYS processes, whereas practices not participating in ACOs (76%) used even fewer PMSYS processes on average (22.6 points). Participating in an ACO was one of the strongest differentiators of US physician organizations with robust PMSYSs versus those with underdeveloped PMSYSs. Also participation in other forms of networks, such as Independent Physician Associations or Physician Hospital Organizations, and greater health information technology (HIT) capabilities and chronic disease registries were factors associated with a greater implementation of PMSYS. The use of financial and non-financial incentives offered mixed results in the survey analysis. The case studies indicate that a culture of quality drives the internal implementation and use of PMSYSs. Financial incentives play a minor role, and nonfinancial external incentives, such as public reporting, are secondary in the studied organizations. External incentives may even compete for internal PMSYS resources. Implications for the US : These findings highlight that policies to further strengthen ACOs or other networks could be a viable strategy to help physician practices strengthen their internal organizational capabilities and prepare for the new performance measurement requirements, such as the MACRA value-based payment models. External requirements have to be balanced with the strengthening of internal capabilities, such as HIT functionality. Cultural aspects and potential adverse effects of financial incentives (e.g. on intrinsic motivation) have to be considered. Implications for Germany : Although the quantitative findings are based in the US, the findings may generalize to physician practices and networks in other countries, as indicated by the German ACO case. For the advancement of performance measurement in Germany external requirements should be simplified by synchronizing initiatives and eliminating unnecessary, invalid demands, to free resources for internal PMSYS. In addition, further strengthening of networks could facilitate PMSYS implementation.

Innovative Health Care Financing Strategies for Children and Youth With Special Health Care Needs.

* Abbreviations: CYSHCN — : children and youth with special health care needs VBID — : value-based insurance design VBP — : value-based purchasing There is increasing interest in maximizing value in health care purchasing by promoting delivery and payment strategies that are cost-effective and also achieve optimal health outcomes. Although these strategies are often called value-based purchasing (VBP), no 1 shared definition of VBP exists. Damberg et al1 suggest that VBP includes a range of methods that link health care payment and incentives to provider performance. The Centers for Medicare and Medicaid Services has launched a Medicare hospital VBP program that rewards acute care hospitals with financial incentives for meeting specific performance outcomes.2 Payment reform provisions in the Affordable Care Act promote VBP strategies to achieve the Triple Aim of lower cost, increased efficiency, and improved population health.3 Value-based insurance design (VBID) is closely related to VBP. Chernew et al4 identified 2 basic approaches to VBID: reduced copayments for clinically valuable services in general; and reduced copayments for specific groups of patients who receive selected high-value services for specific diagnoses. Within this broad landscape of purchasing and insurance design strategies, other innovative financing approaches can promote the Triple Aim including bundled payments, accountable care organizations, and integrated care systems that link primary care and behavioral health services, among others. The impact of these strategies, especially on children and youth with special health care needs (CYSHCN), is currently unclear and, without careful planning, could present additional risk to an already vulnerable population of children. The issues involved in developing VBP for CYSCHN are critically important for this group of children who, by definition, use more health care services than other children and inevitably incur higher costs.5 Yet, organizing the incentives and payment structures appropriately could reward better care and outcomes also for CYSHCN. Working with the American Academy of Pediatrics, … Address correspondence to James M. Perrin, MD, 125 Nashua Street Boston, MA 02114. E-mail: jperrin{at}mgh.harvard.edu

The Implementation of Performance Management Systems in U.S. Physician Organizations.

Performance management systems (PMSYS) aid in improving the quality and efficiency of care, but little is known about factors that influence more robust PMSYS among physician organizations. Using a nationally representative survey of U.S. medical practices, we examined the extent to which organizational capabilities and external factors were associated with more developed PMSYS. Linear regression estimated the relative impact of these factors on PMSYS. On average, practices implemented a minority (32 points out of 100) of the PMSYS processes assessed. Practices evaluated ( p < .01) or financially incentivized by external entities ( p < .01), receiving data from health plans ( p < .01), participating in an accountable care organization ( p < .01), affiliating with an independent practice association and/or physician-hospital organization ( p < .01), and using health information technology ( p < .01) and chronic disease registries ( p < .01) to greater degrees had more robust PMSYS. PMSYS of medical practices are underdeveloped, although both external incentives and organizational capabilities may support PMSYS development.

Single Institution Early Experience with the Bundled Payments for Care Improvement Initiative.

The Centers for Medicare & Medicaid Services (CMS) implemented the Bundled Payments for Care Improvement (BPCI) initiative in 2011. Through BPCI, organizations enlisted into payment agreements that include both performance and financial accountability for episodes of care. To succeed, BPCI requires quality maintenance and care delivery at lower costs. This necessitates physicians and hospitals to merge interests. Orthopaedic surgeons must assume leadership roles in cost containment, surgical safety, and quality assurance to deliver cost-effective care. Because most orthopaedic surgeons practice independently and are not employed by hospitals, models of physician-hospital alignment (e.g., physician-hospital organizations) or contracted gainsharing arrangements between practices and hospitals may be necessary for successful bundled pricing. Under BPCI, hospitals, surgeons, or third parties share rewards but assume risks for the bundle.For patients, cost savings must be associated with maintenance or improvement in quality metrics. However, the definition of quality can vary, as can the rewards for processes and outcomes. Risk stratification for potential complications should be considered in bundled pricing agreements to prevent the exclusion of patients with substantial comorbidities and higher care costs (e.g., hip fractures treated with prostheses). Bundled pricing depends on economies of scale for success; smaller institutions must be cautious, as 1 costly patient could substantially impact the finances of its entire program. CMS recommends a minimum of 100 to 200 cases yearly. We also suggest that participants utilize technologies to maximize efficiency and provide the best possible environment for implementation of bundled payments. Substantial investment in infrastructure is required to develop programs to improve coordination of care, manage quality data, and distribute payments. Smaller institutions may have difficulty devoting resources to these infrastructural changes, although changes may be implemented more thoroughly once initiated. Herein, we discuss our early total joint arthroplasty BPCI experience at our tertiary-care academic medical center.

The Journey from Volume to Volume plus Value

THE FEATURE ARTICLES in this issue of Frontiers outline the compelling reasons a health system might consider developing a provider-sponsored health plan (PSHP). As the authors of both articles demonstrate-Breon at Spectrum Health and Johnson at Health First-entering the health plan business requires careful thought, thorough planning, buy-in from a variety of audiences, and, for some organizations, the selection of staff to assist in developing and implementing the program. Most important, however, is an alignment between the health plan and the organization's mission.Why a Provider-Sponsored Health Plan?Premier Health, based in Dayton, Ohio, has a mission to build healthier communities. The not-for-profit health system is the largest health system in southwest Ohio and operates four hospitals: Miami Valley Hospital (including Miami Valley Hospital South), Good Samaritan Hospital-Dayton, Atrium Medical Center, and Upper Valley Medical Center. In addition, the health system offers a large primary and specialty care network, as well as home health services, Premier Health Group (a physician-hospital organization), and the Premier Health Plans.Premier Health's mission of building healthier communities and the system's strategic business plan laid the groundwork for creating our PSHP. Taking care of the sick and injured has been the traditional focus of hospitals and health systems across the country, and feefor-service has been the traditional model of payment. An approach that emphasizes wellness and prevention has always been attractive, but it simply has not been part of the traditional payment model. Finding a way to move from a volume-based model to a volume-plus-value model is challenging, but the goal is exciting. Premier Health's impetus to change was our mission to build healthier communities, and with the support of our communitybased board of trustees, we embarked on a journey that is already benefiting our region. We subscribed to the premise that a health plan could be the foundation of a population health model focused on the individual and ultimately having a positive effect on the entire community.A health system's leaders must consider a variety of risks and barriers before creating a PSHP. Although some generalizations can be made, the reasons a particular health system might embark on this path are unique, as are the various challenges that often depend on the health system's circumstances and environment. Before entering this new arena, Premier Health began weighing the benefits against the risks.Our organization's healthcare environment is unusual in that no county hospital or university hospital is located in its primary service area. As a result, Premier has become the predominant healthcare provider for the uninsured and underinsured. This scenario creates unique financial pressures in a time of decreasing federal and state subsidies.Like the feature article authors, we realized that the U S healthcare system was broken and current spending was unsustainable. Furthermore, Dayton has experienced an exodus of major employers in recent decades as manufacturing jobs have left the state. Premier Health concluded that a transformational change in the way it delivers healthcare was needed to respond to these problems. Our strategic plan, developed with the input of hundreds of physicians and staff members, defined a path that took a systematic approach to capturing economies of scale, reorganizing internal structures, and reducing healthcare delivery costs to the lowest quartile nationally by aligning organizational metrics to achieve top decile performance on quality measures and developing competencies in population health management. These marks of performance are necessary to attain the value creation needed to excel.In 2010, Premier Health made the tactical decision to become a population health company that also sold health insurance. Our focus became more consumer driven as we aimed to build or develop relationships with atypical partners to manage the continuum of care of individuals and families. …

Market Power, Transactions Costs, and the Entry of Accountable Care Organizations in Health Care

ACOs were promoted in the 2010 Patient Protection and Affordable Care Act (ACA) to incentivize integrated care and cost control. Because they involve vertical and horizontal collaboration, ACOs also have the potential to harm competition. In this paper, we analyze ACO entry and formation patterns with the use of a unique, proprietary database that includes public (Medicare) and private ACOs. We estimate an empirical model that explains county-level ACO entry as a function of: physician, hospital, and insurance market structure; demographics; and other economic and regulatory factors. We find that physician concentration by organization has little effect. In contrast, physician concentration by geographic site—which is a new measure of locational concentration of physicians—discourages ACO entry. Hospital concentration generally has a negative effect. HMO penetration is a strong predictor of ACO entry, while physician-hospital organizations have little effect. Small markets discourage entry, which suggests economies of scale for ACOs. Predictors of public and private ACO entry are different. State regulations of nursing and the corporate practice of medicine have little effect.

Survey of twelve children’s hospital-based accountable care organizations

Accountable care organizations (ACOs) are a primary focus of value-based healthcare reform strategies, however research is lacking on pediatric-specific ACO development. To present the current landscape of children’s hospital-based pediatric ACOs, researchers conducted semi-structured telephone interviews with executive-level staff from twelve ACOs from November 2013 to February 2014. Interview questions spanned five topics: (1) pathway/strategy; (2) organizational structure; (3) shared savings; (4) provider network; (5) data and quality. Three qualitative frameworks were applied to assess the degree of similarity among pediatric ACO models and between these and promulgated adult ACO components: (1) operational diagrams; (2) spectrums of characteristics; (3) financial and organizational categorization. Organizational structures consisted of five Physician-Hospital Organizations, two System-Based Pediatric Contracts, three Provider-Sponsored Managed Care Organizations, and two Hospital Medical Staff Organizations. Oversight models developed for the ACOs included six separate boards, two board subcommittees, and one dispersed governance. Financial contracts between payers and participants included four shared savings only, one risk corridor, and seven full capitation. Eight participants had provider incentive programs primarily for cost reductions. Nine participants used National Committee for Quality Assurance (NCQA)’s Healthcare Effectiveness Data Information Set (HEDIS) metrics, emphasized utilization management, and invested in separate care coordination resources. Overall, marked variation in pediatric ACO models is developing nationally, and cost savings goals exceed the importance of quality improvement. National pediatric collaboration and state facilitation for ACO quality measures is crucial to improving health outcomes in the pediatric ACO.

Physician CEO pushes to include pharmacists on clinical team

Thomas Raskauskas, MD, President and CEO of St. Vincent’s Health Partners (SVHP) in Bridgeport, CT, perked up when he read a December 12, 2013, CEO Blog post from APhA Executive Vice President and CEO Thomas E. Menighan supporting the proposed Grassley– Carper amendment to the “doc fix” bill in Congress that sought to add pharmacists to the list of recognized providers in accountable care organizations (ACOs). Thomas Raskauskas, MD, President and CEO of St. Vincent’s Health Partners (SVHP) in Bridgeport, CT, perked up when he read a December 12, 2013, CEO Blog post from APhA Executive Vice President and CEO Thomas E. Menighan supporting the proposed Grassley– Carper amendment to the “doc fix” bill in Congress that sought to add pharmacists to the list of recognized providers in accountable care organizations (ACOs). Raskauskas immediately picked up the telephone and called Menighan, BSPharm, MBA, ScD (Hon), FAPhA. He wanted to let him know, Raskauskas told Pharmacy Today, "that we've got a team up here in Connecticut that's doing just that." And, indeed, using pharmacists to help respond to what Raskauskas called "gaps of care" has been central to SVHP's collaborative approach since its launch in May 2012 as a clinically integrated network, similar in structure to an ACO. Formed by a diverse group of some 275 Bridgeport-area primary care physicians and specialists and the city's 473- bed St. Vincent's Medical Center, SVHP currently has three insurance contracts covering approximately 14,000 individuals and families who live or work in the Greater Bridgeport area. One contract includes approximately 4,000 Medicare fee-for-service beneficiaries who go to doctors within the SVHP network. A second, also covering about 4,000 individuals, is with Anthem Blue Cross and Blue Shield. The third is St. Vincent's Medical Center's self-insured plan, which covers approximately 6,000 employees and their families. In February, SVHP became the nation's first physician-hospital organization to receive clinical integration accreditation from URAC, the Washington, DC-based accrediting organization. Raskauskas said that many of the physician-hospital networks created under the Affordable Care Act have failed to include pharmacists on their clinical teams, but "the more we look at the problems and the reasons for high costs and readmissions, the more we realize that they are related to what pharmacists deal with on a day-to-day basis." "The problems and the reasons for high costs and readmissions are related to what pharmacists deal with on a day-to-day basis." SVHP has several solutions for leveraging the "scarce resource" that pharmacists represent, according to Raskauskas. For one, he said, pharmacists are used in a kind of "academic detailing" approach to advise physicians on safe and effective alternatives to more expensive drugs, including not only approved generic options but also evidence-based therapeutic equivalents within the same medication classes. At SVHP, pharmacists monitor patients' prescriptions to make sure that they are picked up promptly. Prescriptions are also often delivered at home or to work sites to achieve the same rapid response to therapy. The aim is to prevent complications and costly readmissions, said Michael Hunt, DO, Chief Medical Officer and Chief Medical Information Officer at SVHP. "When patients go home at the end of the day," he said, "they don't always know how to use their drugs appropriately or understand completely why they're taking them." Having a pharmacist on the team can help fill those knowledge gaps, Hunt said. A pharmacist can also detect interactive or duplicate therapies, he added, which is particularly important for patients on multiple medications prescribed by different physicians. MORE ONLINE■APhA's CEO Blog: www.pharmacist.com/CEOBlog/provider-status-game ■APhA's CEO Blog: www.pharmacist.com/CEOBlog/provider-status-game On the inpatient side, the hospital has instituted a "meds to beds" program that gives patients the option to have their discharge medications delivered to their bedside by a pharmacy technician. Additionally, a pharmacist is available by telephone to answer any questions that arise. The telephone connection will soon be replaced by a telehealth system that allows a pharmacist in a central location to interact directly with patients via an in-room television screen. Raskauskas said SVHP is also "working with our hospital partner" to have all of the network's hospital-admitted patients obtain medications at discharge, have their drug lists reconciled, and receive medication therapy counseling. In the future, SVHP is looking to expand its pharmacist integration program. "We want to work with pharmacy schools and pharmacy residency programs to have trainees come and learn what we're doing in population health management and then go on to duplicate what we're doing," said Raskauskas.

Successful HIT Requires Inter-Team Communication

When compared to traditional medical centers, academic medical centers have additional complexity caused by tension between clinical research and patient care, which adds structural and organization differences within the organization. Many academic medical centers have a separate physician practice plan and hospital organization. Usually this means the medical school and its faculty are responsible for outpatient practices, and a separate hospital organization performs the daily management and sustainability of the affiliated academic hospitals. With separate governing and executive bodies, information technology (IT) has additional challenges not found in community hospital settings where one, unified entity exists. Two different financial entities for one unified care delivery model results in differences in technology used at both entities. The hospital organization might use one e-mail system, while the medical school might use another. Though one might argue e-mail system differences are inconsequential, the opposite is true. Different e-mail systems result in meeting cancellations not flowing to the other system, the possibility of an incomplete address book, and security problems. These shortcomings result in user frustration because of inconsistent user experience and inefficient communication between parties. It is important to minimize such frustrations and inefficiencies for user adoption to be successful. Electronic medical records (EMRs) have similar problems. Due to differences in legal and financial responsibilities, the hospital and physician practice plan may have separate EMRs for the inpatient and outpatient experience respectively. This can not only create an incomplete user experience, but also cause interoperability problems. Therefore, whenever the system is changed for enhancement or to fix bugs, careful consideration must be taken to reduce unnecessary user angst.

Independent Practice Associations And Physician-Hospital Organizations Can Improve Care Management For Smaller Practices

Pay-for-performance, public reporting, and accountable care organization programs place pressures on physicians to use health information technology and organized care management processes to improve the care they provide. But physician practices that are not large may lack the resources and size to implement such processes. We used data from a unique national survey of 1,164 practices with fewer than twenty physicians to provide the first information available on the extent to which independent practice associations (IPAs) and physician-hospital organizations (PHOs) might make it possible for these smaller practices to share resources to improve care. Nearly a quarter of the practices participated in an IPA or a PHO that accounted for a significant proportion of their patients. On average, practices participating in these organizations provided nearly three times as many care management processes for patients with chronic conditions as nonparticipating practices did (10.4 versus 3.8). Half of these processes were provided only by IPAs or PHOs. These organizations may provide a way for small and medium-size practices to systematically improve care and participate in accountable care organizations.

Exemplar Pediatric Collaborative Improvement Networks: Achieving Results

A number of pediatric collaborative improvement networks have demonstrated improved care and outcomes for children. Regionally, Cincinnati Children's Hospital Medical Center Physician Hospital Organization has sustained key asthma processes, substantially increased the percentage of their asthma population receiving "perfect care," and implemented an innovative pay-for-performance program with a large commercial payor based on asthma performance measures. The California Perinatal Quality Care Collaborative uses its outcomes database to improve care for infants in California NICUs. It has achieved reductions in central line-associated blood stream infections (CLABSI), increased breast-milk feeding rates at hospital discharge, and is now working to improve delivery room management. Solutions for Patient Safety (SPS) has achieved significant improvements in adverse drug events and surgical site infections across all 8 Ohio children's hospitals, with 7700 fewer children harmed and >$11.8 million in avoided costs. SPS is now expanding nationally, aiming to eliminate all events of serious harm at children's hospitals. National collaborative networks include ImproveCareNow, which aims to improve care and outcomes for children with inflammatory bowel disease. Reliable adherence to Model Care Guidelines has produced improved remission rates without using new medications and a significant increase in the proportion of Crohn disease patients not taking prednisone. Data-driven collaboratives of the Children's Hospital Association Quality Transformation Network initially focused on CLABSI in PICUs. By September 2011, they had prevented an estimated 2964 CLABSI, saving 355 lives and $103,722,423. Subsequent improvement efforts include CLABSI reductions in additional settings and populations.

Revenue in U.S. hospital based outpatient wound centers: Implications for creating accountable care organizations

Background: One of the experimental health care payment and delivery programs proposed under the auspices of the U.S. Center for Medicare and Medicaid Innovation is the Accountable Care Organization (ACO). An example of this is the physician hospital organization (PHO), an association of one or more hospitals and a group of physicians which would “bundle” their payments for an episode of care. However, as potential PHO members consider such joint ventures, they require real-world revenue data from which to determine the relative contribution of the physician and the facility to the collective bill in order to make decisions about the contract structure. In the past, physicians and hospitals have not shared cost and charge data with each other. Methods: Using sophisticated electronic medical record software, real-world billing data were obtained from 3 hospital-based outpatient wound centers and the physicians practicing in them (1 full time equivalent each) in order to establish the relative contribution of each entity to a potential PHO. Results: A total of 6,762 patient visits occurred, comprising 887 initial consultations and 5,875 follow-up visits. Based upon Medicare-allowable reimbursement rates, mean physician revenues represented approximately one quarter of total revenue while procedures provided almost three quarters of the global revenue, on average. Conclusions: Among hospital-based wound centers our results confirm that procedures represent the majority of revenue for both the facility and the physician. Our results represent a starting point for hospitals and physicians to negotiate bundled payments as they attempt to transition to a value- and quality-based model of care. A sophisticated EHR designed specifically for the purpose of capturing charge data, provides the mechanism for future cost effectiveness studies.

Interview with James I. Rodriguez, FACHE, President and Chief Executive Officer of TexHealth Central Texas

James I. Rodriguez, FACHE, is president and CEO of TexHealth Central Texas in Austin. Prior to this role, Mr. Rodriguez held various leadership positions, including executive director of the University of Texas Medical Branch Galveston's three-share health benefits program and physician-hospital organization (PHO) administrator with Cincinnati Children's Hospital. In addition, he has held leadership positions with provider-owned HMOs, PPOs, and a Medicare Advantage plan.Mr. Rodriguez holds a bachelor's degree in marketing from Wright State University and is a Fellow of ACHE. He is a founding member of the National Multi-Share Coalition, a contributing member of the TexHealth Coalition, and a governing board member of the National Forum for Latino Healthcare Executives.Dr. O'Connor: You have had a long and successful career. What events in your career have been pivotal to your success?Mr. Rodriguez: I graduated from college in the mid-1970s and started a local carpet-cleaning business. That experience imbued me with an entrepreneurial spirit that has served me well. I have always been on the cutting edge of things. When I got married, my wife said, Jim, dress rehearsal is over, you have to get a real job! Because there were not many opportunities available in 1977, 1 took a job as an administrative assistant in a community mental health clinic, working in accounting doing billing and collections and keeping books, which was not my area of training; my business degree was in marketing. But it exposed me to the financial side of the business. Eventually, I started doing some consulting with other community mental health centers and preparing them for their audits with public accounting firms. In due course, I got my license as a public accountant. (In Ohio, you can be licensed without being a CPA; that is, you can be a public accountant.) That experience was good as it was a counterbalance to my marketing training. In 1985, 1 was on the cutting edge helping to start a Medicaid HMO in Ohio. I always wanted to be in healthcare, so it was a good transition because it took me to the payer side, which was important for my career development. Over the years, I was either managing health centers, in leadership positions with payer organizations, or consulting.Later, I was in a small boutique consulting group that was on the edge of the PHO movement in the 1990s when hospitals were buying physician practices. That was when I knew that healthcare was for me, as it exposed me to the things necessary for private practice operations as we were buying physician practices. We built big PHO entities. Those are a few of the key work experiences that allowed me to become a better-rounded leader. Today, folks tend to go unidirectional. That is to say, if they are in accounting, they stay in accounting; they usually don't get experience in the marketing area, and so on. To be a well-rounded individual in a leadership position, one needs to broaden one's experiences by working on both sides of the fence.Dr. O'Connor: What are multi-share health plans? How do they work? What are the benefits and challenges associated with such plans?Mr. Rodriguez: A multi-share plan is like a health benefits program. The Texas Legislature paved the way for such plans to become legal entities. While we are not an actual insurance company, we function very much like a PPO insurer. Basically, we offer limited health benefits programs to small businesses. For example, caps on the number of annual physician visits an enrollee can make are fairly common in today's market, but back in 2007, when we first started these plans, such limits were less common. These plans bring down the cost because of the limits. Essentially, a multi-share plan collects the premium from three different channels. One channel is the employer. The second channel is the employee, who must make a contribution. The third is an outside organization. This third channel could provide grant funding from state or local government or other outside sources. …

A Physician Hospital Organization's Approach to Clinical Integration and Accountable Care

A Physician Hospital Organization's Approach to Clinical Integration and Accountable Care

Ascension Health Partners With Centers for Medicare and Medicaid Services to Provide Patient-Centered Care Through the Pioneer Accountable Care Organization Model

Two of the 32 integrated health networks selected by the Centers for Medicare and Medicaid Services (CMS) to participate in the federal government's Pioneer Accountable Care Organization (ACO) program are part of Ascension Health. The goal of both participants—Seton Health Alliance in Austin, Texas, and Genesys Physician Hospital Organization (PHO) in Flint, Michigan—is to develop systems in which health care professionals who are not necessarily employed by Ascension Health hospitals engage with the organization in population health strategies that include financial risk taking.

Meltdown In Merger Land: A Cautionary 1990s TaleMerger Games: The Medical College of Pennsylvania, Hahnemann University, and the Rise and Fall of the Allegheny Health Care System By Swazey Judith P. with the research collaboration of Carla M. Messikomer and the assistance of Vicki Leeman Hall and Judith C. Watkins Philadelphia (PA) : Temple University Press , 2011 307 pp.,

Meltdown In Merger Land: A Cautionary 1990s TaleMerger Games: The Medical College of Pennsylvania, Hahnemann University, and the Rise and Fall of the Allegheny Health Care System By Swazey Judith P. with the research collaboration of Carla M. Messikomer and the assistance of Vicki Leeman Hall and Judith C. Watkins Philadelphia (PA) : Temple University Press , 2011 307 pp.,

Accountable Care Organization Musical Chairs: Will There Be a Seat Remaining for the Small Group or Solo Project?

When it was introduced in the Affordable Care Act of 2010 as the new 2012 payment model for Medicare, an accountable care organization (ACO) was a new and untested concept in healthcare delivery and payment. The authors estimated the likelihood of engagement in ACOs by small group and solo healthcare practitioners. An evaluation of five case studies showed that significant organizational, financial, and technological challenges had to be met in order to launch an ACO. Sufficient resources to meet those challenges were best supplied by large organizations. Small or solo practices participated only through varying levels of integration as salaried physicians or in independent practice associations or physician hospital organizations.

Gastroenterology in a New Era of Accountability: Part 3. Accountable Care Organizations

Gastroenterology in a New Era of Accountability: Part 3. Accountable Care Organizations

Addition of generic medication vouchers to a pharmacist academic detailing program: effects on the generic dispensing ratio in a physician-hospital organization.

Generic dispensing ratio (GDR) is an important measure of efficiency in pharmacy benefit management. A few studies have examined the effects of academic detailing or generic drug samples on GDR. On July 1, 2007, a physician-hospital organization (PHO) with a pay-for-performance incentive for generic utilization initiated a pilot generic medication voucher program that augmented its existing pharmacist-led academic detailing efforts. No published studies have examined the role of generic medication vouchers in promoting generic drug utilization. To determine if supplementing an existing academic detailing initiative in a PHO with a generic medication voucher program would be more effective in increasing the GDR compared with academic detailing alone. The intervention took place over the 9-month period from July 1, 2007, through March 31, 2008. Vouchers provided patients with the first fill of a 30-day supply of a generic drug at no cost to the patient for 8 specific generic medications obtained through a national community pharmacy chain. The study was conducted in a PHO composed of 7 hospitals and approximately 2,900 physicians (900 primary care providers [PCPs] and 2,000 specialists). Of the approximately 300 PCP practices, 21 practices with at least 2 physicians each were selected on the basis of high prescription volume (more than 500 pharmacy claims for the practice over a 12-month pre-baseline period) and low GDR (practice GDR less than 55% in the 12-month pre-baseline period). These 21 practices were then randomized to a control group of academic detailing alone or the intervention group that received academic detailing plus generic medication vouchers. One of 10 intervention groups declined to participate, and 2 of 11 control groups dropped out of the PHO. GDR was calculated monthly for all pharmacy claims including the 8 voucher medications. GDR was defined as the ratio of the total number of paid generic pharmacy claims divided by the total number of paid pharmacy claims for 108 prescriber identification numbers (Drug Enforcement Administration [DEA] or National Provider Identifier [NPI]) for 9 intervention groups [n = 53 PCPs] and 9 control groups [n = 55 PCPs]). For both intervention and control arms, the GDR for each month from July 2007 (start of 2007 Q3, intervention start date) through September 2008 (end of 2008 Q3, 6 months after intervention end date) was compared with the same month in the previous year. A descriptive analysis compared a 9-month baseline period from 2006 Q3 through 2007 Q1 with a 9-month voucher period from 2007 Q3 to 2008 Q1. A panel data regression analysis assessed GDR for 18 practices over 27 months (12 months pre-intervention and 15 months post-intervention). A total of 656 vouchers were redeemed over the 9-month voucher period from July 1, 2007, through March 31, 2008, for an average of about 12 vouchers per participating physician; approximately one-third of the redeemed vouchers were for generic simvastatin. The GDR increase for all drugs, including the 8 voucher drugs, was 7.4 points for the 9 PCP group practices with access to generic medication vouchers, from 53.4% in the 9-month baseline period to 60.8% in the 9-month voucher period, compared with a 6.2 point increase for the control group from 55.9% during baseline to 62.1% during the voucher period. The panel data regression model estimated that the medication voucher program was associated with a 1.77-point increase in overall GDR compared with academic detailing alone (P = 0.047). Compared with academic detailing alone, a generic medication voucher program providing a 30-day supply of 8 specific medications in addition to academic detailing in PCP groups with low GDR and high prescribing volume in an outpatient setting was associated with a small but statistically significant increase in adjusted overall GDR.