A New Approach to Cancer Bundled Payments in Medicare-The Enhancing Oncology Model.

This Viewpoint describes the new voluntary Center for Medicare and Medicaid Innovation Enhancing Oncology Model for cancer bundled payments, explores its likelihood of success, and discusses potential shortcomings.

How 10 leading health systems pay their doctors.

We conducted interviews with senior executives at 10 leading health systems to better understand how organizations use performance-based compensation. Of the organizations interviewed, five pay physicians using productivity-independent salaries, and five use productivity-adjusted salaries. Performance-based pay is more prevalent in primary care than in subspecialties, and the most consistently identified performance domains are quality, service, productivity, and citizenship. Most organizations have less than 10% of total compensation at risk, with payments distributed across three to five domains, each containing several metrics. Approaches with many metrics--and little at-risk compensation for each metric-may offer weak incentive to achieve any particular goal.

Growth dynamics in the context of pediatric sports injuries and overuse.

The onset and timing of the growth of children and adolescents occurs with considerable variability in cohorts of the same chronological age. The musculoskeletal system changes in proportion over time, and lever-arm changes, altered individual flexibility, and strength lead to age-specific injury patterns in youth sports. In sports, juniors are commonly grouped according to their chronological age. Early- and late-maturing children and adolescents might therefore not routinely be trained in relation to their biology. This not only represents a risk for overuse and injury but might limit their development in sports. To obtain information about the biological age of children is challenging. Numerous methods have been studied and validated. However, the implementation of these methods on a large scale is still to come. This report provides a brief overview of growth dynamics in relation to youth sports injuries and describes a few challenges for the future.

Association between availability of health service prices and payments for these services.

IMPORTANCE: Recent governmental and private initiatives have sought to reduce health care costs by making health care prices more transparent. OBJECTIVE: To determine whether the use of an employer-sponsored private price transparency platform was associated with lower claims payments for 3 common medical services. DESIGN: Payments for clinical services provided were compared between patients who searched a pricing website before using the service with patients who had not researched prior to receiving this service. Multivariable generalized linear model regressions with propensity score adjustment controlled for demographic, geographic, and procedure differences. To test for selection bias, payments for individuals who used the platform to search for services (searchers) were compared with those who did not use the platform to search for services (nonsearchers) in the period before the platform was available. The exposure was the use of the price transparency platform to search for laboratory tests, advanced imaging services, or clinician office visits before receiving care for that service. SETTING AND PARTICIPANTS: Medical claims from 2010-2013 of 502,949 patients who were insured in the United States by 18 employers who provided a price transparency platform to their employees. MAIN OUTCOMES AND MEASURES: The primary outcome was total claims payments (the sum of employer and employee spending for each claim) for laboratory tests, advanced imaging services, and clinician office visits. RESULTS: Following access to the platform, 5.9% of 2,988,663 laboratory test claims, 6.9% of 76,768 advanced imaging claims, and 26.8% of 2,653,227 clinician office visit claims were associated with a prior search on the price transparency platform. Before having access to the price transparency platform, searchers had higher claims payments than nonsearchers for laboratory tests (4.11%; 95% CI, 1.87%-6.41%), higher payments for advanced imaging services (5.57%; 95% CI, 1.83%-9.44%), and no difference in payments for clinician office visits (0.26%; 95% CI; 0.53%-0.005%). Following access to the price transparency platform, relative claim payments for searchers were lower for searchers than nonsearchers by 13.93% (95% CI, 10.28%-17.43%) for laboratory tests, 13.15% (95% CI, 9.49%-16.66%) for advanced imaging, and 1.02% (95% CI, 0.57%-1.47%) for clinician office visits. The absolute payment differences were $3.45 (95% CI, $1.78-$5.12) for laboratory tests, $124.74 (95% CI, $83.06-$166.42) for advanced imaging services, and $1.18 (95% CI, $0.66-$1.70) for clinician office visits. CONCLUSIONS AND RELEVANCE: Use of price transparency information was associated with lower total claims payments for common medical services. The magnitude of the difference was largest for advanced imaging services and smallest for clinical office visits. Patient access to pricing information before obtaining clinical services may result in lower overall payments made for clinical care.

Management strategies to effect change in intensive care units: lessons from the world of business. Part I. Targeting quality improvement initiatives.

The business community has developed strategies to ensure the quality of the goods or services they produce and to improve the management of multidisciplinary work teams. With modification, many of these techniques can be imported into intensive care units (ICUs) to improve clinical operations and patient safety. In Part I of a three-part ATS Seminar series, we argue for adopting business management strategies in ICUs and set forth strategies for targeting selected quality improvement initiatives. These tools are relevant to health care today as focus is placed on limiting low-value care and measuring, reporting, and improving quality. In the ICU, the complexity of illness and the need to standardize processes make these tools even more appealing. Herein, we highlight four techniques to help prioritize initiatives. First, the "80/20 rule" mandates focus on the few (20%) interventions likely to drive the majority (80%) of improvement. Second, benchmarking--a process of comparison with peer units or institutions--is essential to identifying areas of strength and weakness. Third, root cause analyses, in which structured retrospective reviews of negative events are performed, can be used to identify and fix systems errors. Finally, failure mode and effects analysis--a process aimed at prospectively identifying potential sources of error--allows for systems fixes to be instituted in advance to prevent negative outcomes. These techniques originated in fields other than health care, yet adoption has and can help ICU managers prioritize issues for quality improvement.

Management strategies to effect change in intensive care units: lessons from the world of business. Part III. Effectively effecting and sustaining change.

Reaping the optimal rewards from any quality improvement project mandates sustainability after the initial implementation. In Part III of this three-part ATS Seminars series, we discuss strategies to create a culture for change, improve cooperation and interaction between multidisciplinary teams of clinicians, and position the intensive care unit (ICU) optimally within the hospital environment. Coaches are used throughout other industries to help professionals assess and continually improve upon their practice; use of this strategy is as of yet infrequent in health care, but would be easily transferable and potentially beneficial to ICU managers and clinicians alike. Similarly, activities focused on improving teamwork are commonplace outside of health care. Simulation training and classroom education about key components of successful team functioning are known to result in improvements. In addition to creating an ICU environment in which individuals and teams of clinicians perform well, ICU managers must position the ICU to function well within the hospital system. It is important to move away from the notion of a standalone ("siloed") ICU to one that is well integrated into the rest of the institution. Creating a "pull-system" (in which participants are active in searching out needed resources and admitting patients) can help ICU managers both provide better care for the critically ill and strengthen relationships with non-ICU staff. Although not necessary, there is potential upside to creating a unified critical care service to assist with achieving these ends.

Management strategies to effect change in intensive care units: lessons from the world of business. Part II. Quality-improvement strategies.

The success of quality-improvement projects relies heavily on both project design and the metrics chosen to assess change. In Part II of this three-part American Thoracic Society Seminars series, we begin by describing methods for determining which data to collect, tools for data presentation, and strategies for data dissemination. As Avedis Donabedian detailed a half century ago, defining metrics in healthcare can be challenging; algorithmic determination of the best type of metric (outcome, process, or structure) can help intensive care unit (ICU) managers begin this process. Choosing appropriate graphical data displays (e.g., run charts) can prompt discussions about and promote quality improvement. Similarly, dashboards/scorecards are useful in presenting performance improvement data either publicly or privately in a visually appealing manner. To have compelling data to show, ICU managers must plan quality-improvement projects well. The second portion of this review details four quality-improvement tools-checklists, Six Sigma methodology, lean thinking, and Kaizen. Checklists have become commonplace in many ICUs to improve care quality; thinking about how to maximize their effectiveness is now of prime importance. Six Sigma methodology, lean thinking, and Kaizen are techniques that use multidisciplinary teams to organize thinking about process improvement, formalize change strategies, actualize initiatives, and measure progress. None originated within healthcare, but each has been used in the hospital environment with success. To conclude this part of the series, we demonstrate how to use these tools through an example of improving the timely administration of antibiotics to patients with sepsis.