Building Research Capacity in Primary Care Practices That Serve Predominantly Racial and Ethnic Minority Populations

In this commentary, we report on lessons learned over 2 years (2020-2022) from conducting primary care research through a novel alliance of an ACO consisting of independent practices, a health plan, and several academic researchers, with the support of a private foundation. Am J Manag Care. 2023;29(6):In Press _____ Takeaway Points The process of collaborating on research was mutually beneficial for a network of independent practices and a group of academic researchers. * The process benefited the practices by facilitating more precise thinking about quality improvement, motivating the staff, and enabling readiness for health system change. * The process benefited the researchers by illuminating nuances of clinical and organizational workflow and revealing the practices' in-depth understanding of the communities they serve. * If practices have more federally funded opportunities to consistently participate in research, it could help speed greater adoption of payment reform models to promote health equity at the state and national levels. _____ A 2021 National Academies of Sciences, Engineering, and Medicine report, Implementing High-Quality Primary Care, has called out the persistent "neglect of basic primary care research" in the United States.1 A 2020 study by the RAND Corporation found that primary care research represents only 1% of all federally funded projects (including projects funded by the National Institutes of Health, the Agency for Healthcare Research and Quality [AHRQ], and the Veterans Health Administration).2 However, innovation in primary care is central to advancing health care delivery. Leaders in health care innovation recently called for CMS to test a proposal for primary care payment reform in accountable care organizations (ACOs) composed of independent practices (ie, practices not owned by hospitals).3 By innovating in independent practices, these leaders argued that CMS would provide incentives for those practices to stay independent, thereby potentially decreasing the vertical market consolidation that contributes to rising health care costs.3 Yet these same practices may have less experience with the kind of systematic innovation that leads to generalizable insights, because what little funding is available for primary care research is mostly awarded to large academic medical centers.1 AHRQ's practice-based research networks have not fully addressed this gap, as they have struggled to find infrastructure and maintain funding.1 In this commentary, we report on the lessons we learned over 2 years (2020-2022) from conducting primary care research through a novel alliance of an ACO consisting of independent practices, a health plan, and several academic researchers, with the support of a private foundation. [...]ACPNY found that experience with research facilitates innovation and readiness for health system change (lesson 1C).

Lessons Learned in the Transformation of a Multispecialty Medical Group to a Management Services Organization Supporting Multiple Service Lines

A three-year growth of 30% in the number of providers within our health system's multispecialty medical group, Centra Medical Group (CMG), was associated with increasing operational costs, redundancies and inefficiencies of unfocused incentivized production, and poor alignment around population-based healthcare2 to support the Quadruple Aim.3 Service lines (SLs) of clinical care that are patientfocused and efficient have been proposed as a method to meet these rapidly changing goals of combined clinical value and cost-efficient care. Operational support of these SLs needs to be consistent, effective, and include many elements of the multispecialty medical group that can now be better described as a management services organization (MSO).4,5 Such dramatic changes in healthcare require leaders6 with insight, courage, and clinical acumen who have empathy with the patient and the patient care delivery team. Self-governance of the SLs by way of the SL Council reporting to senior leaders and not the CMG emerged from the Executive Clinical Enterprise Medical Leaders Forum (ECEMLF) in Period II, facilitated by COVID-19 (Table 1;Self Governance). In February 2020, the ECEMLF recommended to the CEO and senior leaders that elective procedures be discontinued and that critical care areas be shifted to COVID-19 areas well before this action became a national trend (Table 1;Self-Governance).

Telemedicine Policy Availability and Awareness: Directions for Improvement

Background: There is a shift towards increased use of telemedicine applications for healthcare service provision and delivery. Thus, awareness among healthcare practitioners of telemedicine policies is critical for proper implementation and utilization of telemedicine technology. Objective: This study assesses the level of computer access and literacy, knowledge of telemedicine policies and technology, perceptions, and willingness to use telemedicine among healthcare practitioners working in ambulatory care clinics. Methods: An observational cross-sectional study was conducted at King Fahad Armed Forces Hospital in Jeddah. Data were collected between February and March 2021 using a self-completed online survey. Results: Of 136 healthcare practitioners surveyed, we found that over half had average to high knowledge about telemedicine technology, tools, guidelines, security, and privacy policies within the hospital. 95% were willing to use telemedicine to consult with large centers in their medical or clinical specialty and support further implementation of telemedicine technology in the hospital. 90% expressed a need for continuous training in the use of telemedicine. Conclusion: The current study shows that there is inadequate computer access and knowledge of telemedicine, but there were very positive perceptions and willingness related to telemedicine among healthcare practitioners working in the ambulatory care clinics. There is an urgent need for orientation and training programs that focus on the technology and applications of telemedicine, as well as current policies.

Price Effects Of Vertical Integration And Joint Contracting Between Physicians And Hospitals In Massachusetts

Vertical integration in health care has recently garnered scrutiny by antitrust authorities and state regulators. We examined trends, geographic variation, and price effects of vertical integration and joint contracting between physicians and hospitals, using physician affiliations and all-payer claims data from Massachusetts from the period 2013-17. Vertical integration and joint contracting with small and medium health systems rose from 19.5 percent in 2013 to 32.8 percent in 2017 for primary care physicians and from 26.1 percent to 37.8 percent for specialists. Vertical integration and joint contracting with large health systems slightly declined, whereas geographic variation in these physician affiliations rose. We found that vertical integration and joint contracting led to price increases from 2013 to 2017, from 2.1 percent to 12.0 percent for primary care physicians and from 0.7 percent to 6.0 percent for specialists, with the greatest increases seen in large health systems. These findings can inform policy makers seeking to limit growth in health care prices.

6 steps for easing physicians’ burden from coding, documentation and risk adjustment

The article focuses on multiple steps for easing physicians' burden from coding, documentation and risk adjustment. Topics discussed include the patient also began experiencing symptoms of high blood pressure and severely reduced access to healthy food as result of the increased financial strain brought on by the pandemic;and the patient did not see a physician in 2020, none of this information was documented in their medical record or coded.

Pandemic Pause: Systematic Review of Cost Variables for Ambulatory Care Organizations Participating in Accountable Care Organizations.

Ambulatory health care provider organizations participating in Accountable Care Organizations (ACOs) organizations assume costs beyond typical practice operations that are directly associated with value-based care initiatives. Identifying these variables that influence such costs are essential to an organization's financial viability. To enable the U.S. healthcare system to respond to the COVID-19 pandemic CMS issued blanket waivers that permit enhanced flexibility, extension, and other emergency declaration changes to ACO reporting requirements through the unforeseen future. This relaxation and even pausing of reporting requirements encouraged the researchers to conduct a systematic review and identify variables that have influenced costs incurred by ambulatory care organizations participating in ACOs prior to the emergency declaration. The research findings identified ACO-ambulatory care variables (enhanced patient care management, health information technology improvements, and organizational ownership/reimbursement models) that helped to reduce costs to the ambulatory care organization. Additional variables (social determinants of health/environmental conditions, lack of integration/standardization, and misalignment of financial incentives) were also identified in the literature as having influenced costs for ambulatory care organizations while participating in an ACO initiative with CMS. Findings can assist ambulatory care organizations to focus on new and optimized strategies as they begin to prepare for the post-pandemic resumption of ACO quality reporting requirements once the emergency declaration is eventually lifted.

A new kind of gatekeeper: The increasing prevalence of Advanced Practice Nurses as case managers in US hospitals.

Case management is a representation of managed care, cost-containment organizational practices in healthcare, where managed care and its constitutive parts are situated against physician autonomy and decision-making. As a professional field, case management has evolved considerably, with the role recently taken up increasingly by Advanced Practice Nurses in various health care settings. We look at this evolution of a relatively new work task for Advanced Practice Nurses using a countervailing powers perspective, which allows us to move beyond discussions of case management effectiveness and best practices, and draw connections to trends in the social organization of healthcare, especially hospitals. We evaluated organizational (hospital-level) and environmental (county and state-level) characteristics associated with hospitals' use of Advanced Practice Nurses as case managers, using data from U.S. community acute care hospitals for 2016-2018, collected from three data sources: American Hospital Association annual survey (AHA), Centers for Medicare and Medicaid Services (CMS), and Area Resource File. Among organizational characteristics, we found that hospitals that are a part of established Accountable Care Organizations (OR = 2.55, p = 0.009; 95% CI = 1.26-5.14) and those that serve higher acuity patients, as indicated by possessing a higher Case Mix Index (OR = 1.32, p = 0.001; 95% CI = 1.13-1.55), were more likely to use Advanced Practice Nurses as case managers. Among environmental characteristics, having higher local Advanced Practice Nurses concentrations (OR = 1.24, p < 0.001; 95% CI = 1.11-1.39) was associated with hospital Advanced Practice Nurses case management service provision. Beyond the health impacts of Covid-19, its associated recession is placing families, governments and insurers under unprecedented financial stress. Governments and insurers alike are looking to reduce costs anywhere possible. This will inevitably result in increasing amounts of managed care, and decreasing reimbursements to hospitals, likely resulting in higher demand for APRN patient navigators.