Early Impact Of CareFirst's Patient-Centered Medical Home With Strong Financial Incentives.

In 2011 CareFirst BlueCross BlueShield, a large mid-Atlantic health insurance plan, implemented a payment and delivery system reform program. The model, called the Total Care and Cost Improvement Program, includes enhanced payments for primary care, significant financial incentives for primary care physicians to control spending, and care coordination tools to support progress toward the goal of higher-quality and lower-cost patient care. We conducted a mixed-methods evaluation of the initiative's first three years. Our quantitative analyses used spending and utilization data for 2010-13 to compare enrollees who received care from participating physician groups to similar enrollees cared for by nonparticipating groups. Savings were small and fully shared with providers, which suggests no significant effect on total spending (including bonuses). Our qualitative analysis suggested that early in the program, many physicians were not fully engaged with the initiative and did not make full use of its tools. These findings imply that this and similar payment reforms may require greater time to realize significant savings than many stakeholders had expected. Patience may be necessary if payer-led reform is going to lead to system transformation.

Risk contracting and operational capabilities in large medical groups during national healthcare reform.

OBJECTIVES: Little is known about the scope of alternative payment models outside of Medicare. This study measures the full complement of public and private payment arrangements in large, multi-specialty group practices as a barometer of payment reform among advanced organizations. STUDY DESIGN AND METHODS: We collected information from 33 large, multi-specialty group practices about the proportion of their total revenue in 7 payment models, physician compensation strategies, and the implementation of selected performance management initiatives. We grouped respondents into 3 categories based on the proportion of their revenue in risk arrangements: risk-based (45%-100%), mixed (10%-35%), and fee-for-service (FFS) (0%-10%). We analyzed changes in contracting and operating characteristics between 2011 and 2013. RESULTS: In 2013, 68% of groups' total patient revenue was from FFS payments and 32% was from risk arrangements (unweighted average). Risk-based groups had 26% FFS revenue, whereas mixed-payment and FFS groups had 75% and 98%, respectively. Between 2011 and 2013, 9 groups increased risk contract revenue by about 15 percentage points and 22 reported few changes. Risk-based groups reported more advanced implementation of performance management strategies and were more likely to have physician financial incentives for quality and patient experience. CONCLUSIONS: The groups in this study are well positioned to manage risk-based contracts successfully, but less than one-third receive a majority of their revenue from risk arrangements. The experience of these relatively advanced groups suggests that expanding risk-based arrangements across the US health system will likely be slower and more challenging than many people assume.

Race/Ethnicity and Health Care Communication: Does Patient-Provider Concordance Matter?

BACKGROUND: Although many minority patients would prefer a provider of their own race/ethnicity, the influence of this relationship on patient-provider communication remains unknown. This analysis examined the effect of patient-provider race/ethnicity concordance on patient-reported provider communication quality using data from the Medical Expenditure Panel Survey years 2002-2012. METHODS: Ordinary least squares regressions were executed on communication rating, measured by the Consumer Assessment of Health Providers and Systems. RESULTS: Only 13.8% of black, non-Hispanic patients reported their usual source of care provider matched their race/ethnicity, compared with 94.4% of white, non-Hispanic patients and 43.8% of Hispanic patients. Differences in communication ratings were driven by patient race, rather than provider race. Although black, non-Hispanic patients rate their communication significantly higher than their counterparts overall, there was no significant influence of patient-provider racial concordance on ratings of communication when controlling for other sociodemographic variables. CONCLUSIONS: Minorities may seek the services of minority providers, but they are not more satisfied with patient-provider communication experience than when in race-discordant provider arrangements.

The Changing Nature of Scientific Sharing and Withholding in Academic Life Sciences Research: Trends From National Surveys in 2000 and 2013.

PURPOSE: Since 2000, federal funders and many journals have established policies requiring more open sharing of data and materials post-publication, primarily through online supplements and third-party repositories. This study examined changes in sharing and withholding practices among academic life scientists, particularly geneticists, between 2000 and 2013. METHOD: In 2000 and 2013, the authors surveyed separate samples of 3,000 academic life scientists at the 100 U.S. universities receiving the most National Institutes of Health funding. Respondents were asked to estimate the number of requests for information, data, and materials they made to and received from other academic researchers in the past three years. They were also asked about potential consequences of sharing and withholding. RESULTS: Response rates were 63.9% (1,849/2,893) in 2000 and 40.8% (1,165/2,853) in 2013. Proportions of faculty in 2000 and 2013 who received, denied, made, or were denied at least one request were not statistically different. However, the total volume of requests received from or made to other scientists dropped substantially (19.4 received in 2000 versus 10.8 in 2013, P < .001; 8.4 made in 2000 versus 6.6 in 2013, P < .001). Faculty in 2013 also made an average of 8.4 requests to third-party repositories. Researchers in 2013 were less likely to report sharing resulted in new research or collaborations. CONCLUSIONS: The results show a dramatic shift in sharing mechanisms, away from a peer-to-peer sharing model toward one based on central repositories. This may increase efficiency, but collaborations may suffer if personal communication among scientists is deemphasized.

Codifying collegiality: recent developments in data sharing policy in the life sciences.

Over the last decade, there have been significant changes in data sharing policies and in the data sharing environment faced by life science researchers. Using data from a 2013 survey of over 1600 life science researchers, we analyze the effects of sharing policies of funding agencies and journals. We also examine the effects of new sharing infrastructure and tools (i.e., third party repositories and online supplements). We find that recently enacted data sharing policies and new sharing infrastructure and tools have had a sizable effect on encouraging data sharing. In particular, third party repositories and online supplements as well as data sharing requirements of funding agencies, particularly the NIH and the National Human Genome Research Institute, were perceived by scientists to have had a large effect on facilitating data sharing. In addition, we found a high degree of compliance with these new policies, although noncompliance resulted in few formal or informal sanctions. Despite the overall effectiveness of data sharing policies, some significant gaps remain: about one third of grant reviewers placed no weight on data sharing plans in their reviews, and a similar percentage ignored the requirements of material transfer agreements. These patterns suggest that although most of these new policies have been effective, there is still room for policy improvement.

Many large medical groups will need to acquire new skills and tools to be ready for payment reform.

Federal and state policy makers are now experimenting with programs that hold health systems accountable for delivering care under predetermined budgets to help control health care spending. To assess how well prepared medical groups are to participate in these arrangements, we surveyed twenty-one large, multispecialty groups. We evaluated their participation in risk contracts such as capitation and the degree of operational support associated with these arrangements. On average, about 25 percent of the surveyed groups' patient care revenue stemmed from global capitation contracts and 9 percent from partial capitation or shared risk contracts. Groups with a larger share of revenue from risk contracts were more likely than others to have salaried physicians, advanced data management capabilities, preferred relationships with efficient specialists, and formal programs to coordinate care for high-risk patients. Our findings suggest that medical groups that lack risk contracting experience may need to develop new competencies and infrastructure to successfully navigate federal payment reform programs, including information systems that track performance and support clinicians in delivering good care; physician-level reward systems that are aligned with organizational goals; sound physician leadership; and an organizational commitment to supporting performance improvement. The difficulty of implementing these changes in complex health care organizations should not be underestimated.

Tightening conflict-of-interest policies: the impact of 2005 ethics rules at the NIH.

PURPOSE: To determine both the intended and unintended effects of the National Institutes of Health (NIH) 2005 ethics rules by examining changes in publishing rates and the frequency of external relationships among NIH scientists. METHOD: After identifying eligible intramural scientists and administrators from institutes' Web pages and central directories, a mailed survey was administered to 900 NIH research faculty between October 2008 and January 2009 (response rate 70.1%). RESULTS: Eighty percent of respondents believed the NIH ethics rules were too restrictive. Whereas 45% of respondents believed the rules positively impacted the public's trust in the NIH, 77% believed the rules hindered the NIH's ability to complete its mission. Implementation of the ethics rules significantly decreased self-reported government-industry relationships among NIH faculty (from 51.8% to 33.2%, P < .01), including significant drops in consulting (33.1% to 7.8%, P < .01) and scientific advisory board membership (31.5% to 16.0%, P < .01), both of which may be allowed under the new regulations in restricted situations with increased oversight. The policy had limited impact on NIH faculty participation in nonindustrial professional service roles and had no detectable change in publishing behavior (5.29 articles per researcher per year from 2002-2005 versus 5.26 from 2005-2008, P = .88). CONCLUSIONS: The NIH ethics rules accomplished much of what they were intended to do, limiting relationships with industry while maintaining NIH researchers' association with external scientific and professional organizations. However, the rules negatively affected personnel morale and the perceived progress of research.

Activities, productivity, and compensation of men and women in the life sciences.

PURPOSE: To determine whether professional activities, professional productivity, and salaries of life sciences faculty differ by gender. The authors undertook this study because previous studies found differences in the academic experiences of women and men. METHOD: In 2007, the authors conducted a mailed survey of 3,080 life sciences faculty at the 50 universities whose medical schools received the greatest amount of National Institutes of Health funding in 2004. The response rate was 74% (n = 2,168). The main outcome measures were a faculty member's total number of publications; number of publications in the past three years; average impact score of the journals in which he or she had published; professional activities; work hours per week; the numbers of hours spent specifically in teaching, patient care, research, professional activities, and administrative activities; and annual income. RESULTS: Among professors, the women reported greater numbers of hours worked per week and greater numbers of administrative and professional activities than did the men. Female faculty members reported fewer publications across all ranks. After control for professional characteristics and productivity, female researchers in the life sciences earned, on average, approximately $13,226 less annually than did their male counterparts. CONCLUSIONS: Men and women in the academic life sciences take on different roles as they advance through their careers. A substantial salary gap still exists between men and women that cannot be explained by productivity or other professional factors. Compensation and advancement policies should recognize the full scope of the roles that female researchers play.

Participation of academic scientists in relationships with industry.

Relationships between academic researchers and industry have received considerable attention in the past twenty years. However, current data on the prevalence, magnitude, and trends in such relationships are rare. In a mailed survey of 3,080 academic life science researchers conducted in 2007, we found that 52.8 percent have some form of relationship with industry. Life science faculty with industry research support were more productive than faculty without such support on virtually every measure. However, we also found a significant decrease in industry support of university research, which could have major consequences for the academic life science research sector.

Life-science research within US academic medical centers.

CONTEXT: Besides the generic "basic" vs "applied" labels, little information is known about the types of life-science research conducted within academic medical centers (AMCs). OBJECTIVE: To determine the relative proportion, characteristics, funding, and productivity of AMC faculty by the type of research they conduct. DESIGN: Mailed survey conducted in 2007 of 3080 life-science faculty at the 50 universities with medical schools that received the most funding from the National Institutes of Health in 2004. Response rate was 74%. SETTING AND PARTICIPANTS: Research faculty affiliated with a medical school or teaching hospital, representing 77% of respondents (n = 1663). MAIN OUTCOME MEASURES: Type of research (basic, translational, clinical trials, health services research/clinical epidemiology, multimode, other), total funding, industry funding, publications, professional activities, patenting behavior, and industry relationships. RESULTS: Among AMC research faculty, 33.6% exclusively conducted basic science research as principal investigators compared with translational researchers (9.1%), clinical trial investigators (7.1%), and health services researchers/clinical epidemiologists (9.0%). While principal investigators garnered a mean of $410,755 in total annual research funding, 22.1% of all AMC research faculty were unsponsored, a proportion that ranged from 11.5% for basic science researchers to 46.8% for health services researchers (P < .001). The average AMC faculty member received $33,417 in industry-sponsored funding, with most of this money concentrated among clinical trial ($110,869) and multimode ($59,916) principal investigators. Translational (61.3%), clinical trial (67.3%), and multimode (70.9%) researchers were significantly more likely than basic science researchers (41.9%) to report a relationship with industry and that these relationships contributed to their most important scientific work (P < .05 for all comparisons). CONCLUSION: The research function of AMCs is active and diverse, incorporating a substantial proportion of faculty who are conducting research and publishing without sponsorship.