Exploring Care Attributes of Nephrologists Ranking Favorably on Measures of Value.

BACKGROUND: Despite growth in value-based payment, attributes of nephrology care associated with payer-defined value remains unexplored. METHODS: Using national health insurance claims data from private preferred provider organization plans, we ranked nephrology practices using total cost of care and a composite of common quality metrics. Blinded to practice rankings, we conducted site visits at four highly ranked and three average ranked practices to identify care attributes more frequently present in highly ranked practices. A panel of nephrologists used a modified Delphi method to score each distinguishing attribute on its potential to affect quality and cost of care and ease of transfer to other nephrology practices. RESULTS: Compared with average-value peers, high-value practices were located in areas with a relatively higher proportion of black and Hispanic patients and a lower proportion of patients aged >65 years. Mean risk-adjusted per capita monthly total spending was 24% lower for high-value practices. Twelve attributes comprising five general themes were observed more frequently in high-value nephrology practices: preventing near-term costly health crises, supporting patient self-care, maximizing effectiveness of office visits, selecting cost-effective diagnostic and treatment options, and developing infrastructure to support high-value care. The Delphi panel rated four attributes highly on effect and transferability: rapidly adjustable office visit frequency for unstable patients, close monitoring and management to preserve kidney function, early planning for vascular access, and education to support self-management at every contact. CONCLUSIONS: Findings from this small-scale exploratory study may serve as a starting point for nephrologists seeking to improve on payer-specified value measures.

Critical Lessons From High-Value Oncology Practices.

IMPORTANCE: Cancer care is expensive. Cancer care provided by practice organizations varies in total spending incurred by patients and payers during treatment episodes and in quality of care, and this unnecessary variation contributes to the high cost. OBJECTIVE: To use the variation in total spending and quality of care to assess oncology practice attributes distinguishing "high value" that may be tested and adopted by others to produce similar results. DESIGN, SETTING, AND PARTICIPANTS: "Positive deviance" was used in this exploratory mixed-methods (quantitative and qualitative) analysis of interview results. To quantify value, oncology practices located near the US Pacific Northwest and Midwest with low mean insurer-allowed spending were identified. Among those, practices with high quality were selected. A team then conducted site visits to interview practice personnel from June 2, 2015, through October 3, 2015, and to probe for attributes of high-value care. A qualitative analysis of their interview results was performed, and a panel of experienced oncologists was convened to review attributes occurring uniquely or frequently in low-spending practices for their contribution to value improvement and ease of implementation. Four positive deviant (ie, low-spending) oncology practices and 3 oncology practices that ranked near the middle of the spending distribution were studied. MAIN OUTCOMES AND MEASURES: Thematic saturation in a qualitative analysis of high-value care attributes. RESULTS: From the 7 oncology practices studied, 13 attributes within the following 5 themes emerged: treatment planning and goal setting, services supporting the patient journey, technical support and physical layout, care team organization and function, and external context. Five attributes (ie, conservative use of imaging, early discussion of treatment limitations and consequences, single point of contact, maximal use of registered nurses for interventions, and a multicomponent health care system) most sharply distinguished the high-value practice sites. The expert oncologist panel judged 3 attributes (ie, early and normalized palliative care, ambulatory rapid response, and early discussion of treatment limitations and consequences) to carry the highest immediate potential for lowering spending without compromising the quality of care. CONCLUSIONS AND RELEVANCE: Oncology practice attributes warranting further testing were identified that may lower total spending for high-quality oncology care.

Exploring Attributes of High-Value Primary Care.

PURPOSE: Medicare's merit-based incentive payment system and narrowing of physician networks by health insurers will stoke clinicians' and policy makers' interest in care delivery attributes associated with value as defined by payers. METHODS: To help define these attributes, we analyzed 2009 to 2011 commercial health insurance claims data for more than 40 million preferred provider organization patients attributed to over 53,000 primary care practice sites. We identified sites ranking favorably on both quality and low total annual per capita health care spending ("high-value") and sites ranking near the median ("average-value"). Sites were selected for qualitative assessment from 64 high-value sites and 102 average-value sites with more than 1 primary care physician who delivered adult primary care and provided services to enough enrollees to permit meaningful spending and quality ranking. Purposeful sampling ensured regional diversity. Physicians experienced in primary care assessment and blinded to site rankings visited 12 high-value sites and 4 average-value sites to identify tangible attributes of care delivery that could plausibly explain a high ranking on value. RESULTS: Thirteen attributes of care delivery distinguished sites in the high-value cohort. Six attributes attained statistical significance: decision support for evidence-based medicine, risk-stratified care management, careful selection of specialists, coordination of care, standing orders and protocols, and balanced physician compensation. CONCLUSIONS: Awareness of care delivery attributes that distinguish their high-value peers may help physicians respond successfully to incentives from Medicare and private payers to lower annual health care spending and improve quality of care.