Effects of Home-Based Primary Care on Hospital Use for High-Need Medicare Patients: an Observational Study.

BACKGROUND: High-need, high-cost Medicare patients can have difficulties accessing office-based primary care. Home-based primary care (HBPC) can reduce access barriers and allow a clinician to obtain valuable information not obtained during office visit, possibly leading to reductions in hospital use. OBJECTIVE: To determine whether HBPC for high-need, high-cost patients reduces hospitalizations and Medicare inpatient expenditures. DESIGN: We conducted a matched retrospective cohort study using a difference-in-differences analysis to examine patients 2 years before and 2 years after their first home visit (HBPC group). PARTICIPANTS: The study included high-need, high-cost fee-for-service Medicare patients without prior HBPC use, of which 55,303 were new HBPC recipients and 156,142 were matched comparison patients. INTERVENTION: Receipt of at least two HBPC visits and, within 6 months of the index HBPC visit, a majority of a patient's primary care visits in the home. MAIN MEASURES: Total and potentially avoidable hospitalizations and Medicare inpatient expenditures. KEY RESULTS: HBPC reduced total hospitalization rates, but the marginal effects were not statistically significant: a reduction of 11 total hospitalizations per 1000 patients in the first year (- 0.6%, p = 0.19) and 14 in the second year (- 0.7%, p = 0.16). However, HBPC reduced potentially avoidable hospitalization rates in the second year. The estimated marginal effect was a reduction of 6 potentially avoidable hospitalizations per 1000 patients in the first year (- 1.6%, p = 0.16) and 11 in the second (- 3.1%, p = 0.01). The estimated effect of HBPC was a small decrease in inpatient expenditures of $24 per patient per month (- 1.1%, p = 0.10) in the first year and $0 (0.0%, p = 0.99) in the second. CONCLUSIONS: After high-need, high-cost patients started receiving HBPC, they did not experience fewer total hospitalizations or lower inpatient spending but may have had lower rates of potentially avoidable hospitalizations after 2 years.

Geographic Variation In The Consolidation Of Physicians Into Health Systems, 2016-18.

Physician consolidation into health systems increased in nearly all metropolitan statistical areas (MSAs) from 2016 to 2018. Of the 382 US MSAs, 113 had more than half of their physicians in health systems in 2018. Consolidation of physicians was most notable in the Midwest and Northeast and in small-to-midsize MSAs.

Health system integration with physician specialties varies across markets and system types.

OBJECTIVE: To examine system integration with physician specialties across markets and the association between local system characteristics and their patterns of physician integration. DATA SOURCES: Data come from the AHRQ Compendium of US Health Systems and IQVIA OneKey database. STUDY DESIGN: We examined the change from 2016 to 2018 in the percentage of physicians in systems, focusing on primary care and the 10 most numerous nonhospital-based specialties across the 382 metropolitan statistical areas (MSAs) in the US. We also categorized systems by ownership, mission, and payment program participation and examined how those characteristics were related to their patterns of physician integration in 2018. DATA COLLECTION/EXTRACTION METHODS: We examined local healthcare markets (MSAs) and the hospitals and physicians that are part of integrated systems that operate in these markets. We characterized markets by hospital and insurer concentration and systems by type of ownership and by whether they have an academic medical center (AMC), a 340B hospital, or accountable care organization. PRINCIPAL FINDINGS: Between 2016 and 2018, system participation increased for primary care and the 10 other physician specialties we examined. In 2018, physicians in specialties associated with lucrative hospital services were the most commonly integrated with systems including hematology-oncology (57%), cardiology (55%), and general surgery (44%); however, rates varied substantially across markets. For most specialties, high market concentration by insurers and hospital-systems was associated with lower rates of physician integration. In addition, systems with AMCs and publicly owned systems more commonly affiliated with specialties unrelated to the physicians' potential contribution to hospital revenue, and investor-owned systems demonstrated more limited physician integration. CONCLUSIONS: Variation in physician integration across markets and system characteristics reflects physician and systems' motivations. These integration strategies are associated with the financial interests of systems and other strategic goals (eg, medical education, and serving low-income populations).

Consolidation Of Providers Into Health Systems Increased Substantially, 2016-18.

Provider consolidation into vertically integrated health systems increased from 2016 to 2018. More than half of US physicians and 72 percent of hospitals were affiliated with one of 637 health systems in 2018. For-profit and church-operated systems had the largest increases in system size, driven in part by a large number of system mergers and acquisitions.

The ARRA investment in CER: a description of the midstream evaluation and how the funds were allocated and CER priorities addressed.

AIM: To describe the evaluation design of the American Recovery and Reinvestment Act of 2009 comparative effectiveness research (CER) investment, how funds were allocated and how CER priorities were addressed. MATERIALS & METHODS: Primary and secondary data included information from redacted project proposals, an investigator survey and federal project officers, investigators and expert panel discussions. RESULTS: More than 420 projects (US$1.1 billion) were awarded. Those generating new or synthesizing existing CER made up the plurality (194, or US$524 million). Data infrastructure projects were the second-largest area (28%, US$302 million). More than three-fourths addressed at least one priority population, condition category or intervention category. CONCLUSION: These investments expanded the nation's CER activities and its future capacity to conduct CER.

Evaluating collaborations in comparative effectiveness research: opportunities and challenges for social network analysis.

Multidisciplinary, multi-institutional collaboration has become a key feature of comparative effectiveness research (CER), and CER funders have made promotion of these types of collaboration an implicit, and sometimes explicit, goal of funding. An important challenge in evaluating CER programs is understanding if and how different forms of collaboration are associated with successful CER projects. This article explores the potential use of social network analysis to address research questions about the associations between collaboration and the success of CER projects.

Assessing the long-term impact of public investments in comparative effectiveness research: conceptual framework and lessons learned.

The American Recovery and Reinvestment Act (ARRA) of 2009 directed US$1.1 billion to the US Department of Health and Human Services for support of comparative effectiveness research (CER). As part of this investment, US Department of Health and Human Services commissioned a midstream evaluation of the ARRA CER portfolio. One goal of the evaluation was to identify issues to consider for a future evaluation of the long-term impact of this portfolio and other CER investments. In planning the ARRA CER evaluation, we developed and revised a conceptual framework and related policy research questions that may be useful to future efforts to assess the impact of CER or patient-centered outcomes research investments. In addition, we explored methodological challenges related to designing an evaluation to assess investments in CER that may be informative to any future plans to evaluate the long-term impact of ARRA CER as well subsequent investments made from the Patient-Centered Outcomes Research Trust Fund.