A comparison of relative resource use and quality in Medicare Advantage health plans versus traditional Medicare.

Objectives: Prior analyses of Medicare health plans have examined either utilization of services or quality of care, but not both jointly. Our objective was to compare utilization and quality for Medicare Advantage (MA) enrollees with diabetes or cardiovascular disease to that for similarly defined traditional Medicare (TM) beneficiaries.

Study Design: Cross-sectional matched observational study using data for 2007.

The evolving role of physician organizations in quality related activities.

As the fields of quality assessment and improvement become integral parts of medical practice, the roles of National Medical Associations, and other physician organizations in these endeavors have undergone major changes in scope and intensity as well. The survey based report in this journal by Levi et al. suggests some major overall trends but also notes wide variation from country to country.

Seeking lower prices where providers are consolidated: an examination of market and policy strategies.

The ongoing consolidation between and among hospitals and physicians tends to raise prices for health care services, which poses increasing challenges for private purchasers and payers. This article examines strategies that these purchasers and payers can pursue to combat provider leverage to increase prices. It also examines opportunities for governments to either support or constrain these strategies.

Medicare beneficiaries more likely to receive appropriate ambulatory services in HMOs than in traditional medicare.

With quality-of-care bonus payments now available for Medicare Advantage health maintenance organizations (HMOs) and for accountable care organizations in traditional Medicare, the need to understand the relative quality of care delivered to Medicare enrollees has increased. We compared the quality of ambulatory care from 2003 through 2009 between beneficiaries enrolled in Medicare Advantage HMOs and those enrolled in traditional Medicare, and we assessed how the performance of various types of Medicare HMOs differed from that of traditional Medicare for these same measures. We found that beneficiaries in Medicare HMOs were consistently more likely than those in traditional Medicare to receive appropriate breast cancer screening, diabetes care, and cholesterol testing for cardiovascular disease.

Physician professionalism and accountability: the role of collaborative improvement networks.

The medical profession is facing an imperative to deliver more patient-centered care, improve quality, and reduce unnecessary costs and waste. With significant unexplained variation in resource use and outcomes, even physicians and health care organizations with "the best" reputations cannot assume they always deliver the best care possible. Going forward, physicians will need to demonstrate professionalism and accountability in a different way: to their peers, to society in general, and to individual patients.

Multiple risk factors and the likelihood of patient-physician communication and health maintenance services in medicare health plans.

This study examined both individual and combined effects of race, education, and health-based risk factors on health maintenance services among Medicare plan members. Data were from 110 238 elderly completing the 2006 Medicare Health Outcomes Survey. Receipt of recommended patient-physician communication and interventions for urinary incontinence, physical activity, falls, and osteoporosis was modeled as a function of risk factors.

Analysis Of Medicare Advantage HMOs compared with traditional Medicare shows lower use of many services during 2003-09.

Enrollment in Medicare Advantage, the managed care program for Medicare beneficiaries, has grown rapidly, from 4.6 million enrollees in 2003 to 12.8 million by 2012, or 27 percent of all current Medicare beneficiaries.

Are characteristics of the medical home associated with diabetes care costs?

Objective: To examine the relationship between primary care medical home clinical practice systems corresponding to the domains of the Chronic Care Model and annual diabetes-related health care costs incurred by members of a health plan with type-2 diabetes and receiving care at one of 27 Minnesota-based medical groups.

Study Design: Cross-sectional analysis of the relation between patient-level costs and Patient-Centered Medical Home (PCMH) practice systems as measured by the Physician Practice Connections Readiness Survey.

Methods: Multivariate regressions adjusting for patient demographics, health status, and comorbidities estimated the relationship between the use of PCMH clinical practice systems and 3 annual cost outcomes: total costs of diabetes-related care, outpatient medical costs of diabetes-related care, and inpatient costs of diabetes-related care (ie, inpatient and emergency care).

Classification of health plans based on relative resource use and quality of care.

Objective: To examine variation among commercial health plans in resource use and quality of care for patients with diabetes mellitus or cardiovascular disease.

Study Design: Cohort study using Healthcare Effectiveness Data and Information Set data submitted to the National Committee for Quality Assurance in 2008.

Methods: Composite measures were estimated for diabetes and cardiovascular disease resource use and quality of care.

What the United States could learn from Israel about improving the quality of health care.

In 1999 Israel began to implement a system for monitoring quality of care in its health plans. That system was based largely on a similar system in the United States that, until recently, was associated with steady improvements in performance. However, in recent years health plan quality in the United States appears to have reached a plateau.

Health plan resource use: bringing us closer to value-based decisions.

Objective: To examine commercial health plan variation in resource use for members with diabetes and its relationship to the quality of care for these members.

Study Design: Cohort study using National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set data submitted to the NCQA in 2007, reflecting 2006 health plan performance. Data are submitted to the NCQA by plans based on claim and administrative data; medical record data may be used to supplement missing claim data.

Exceptions to outpatient quality measures for coronary artery disease in electronic health records.

Background: Physicians report outpatient quality measures from data in electronic health records to facilitate care improvement and qualify for incentive payments.

Objective: To determine the frequency and validity of exceptions to quality measures and to test a system for classifying the reasons for these exceptions.

Design: Cross-sectional observational study.

Relationship of clinic medical home scores to quality and patient experience.

We tested the association between medical home characteristics and measures of technical quality and patient experience of care in the 21 clinics of a large medical group that had all achieved level III recognition from the National Committee for Quality Assurance. There was substantial variation among them in both scores on the recognition instrument and in clinic performance measures. However, the few statistically significant associations that were identified disappeared when correction for multiple analyses was applied.

Patient-centered medical homes in the United States.

The concept of a medical home is receiving increased attention as a potential means to improve care and reduce costs. This study describes the characteristics and capabilities of practices that have achieved recognition of National Committee for Quality Assurance as a "patient-centered medical home" (PCMH). Both small and large practices demonstrate capabilities related to the goals of PCMH of accessible, coordinated, and patient-centered care; however, practices affiliated with larger organizations achieve higher levels of PCMH recognition compared with unaffiliated small practices.

Adherence to standards of care by health maintenance organizations in Israel and the USA.

Background: The health-care systems in the USA and Israel differ in organization, financing and expenditure levels. However, managed care organizations play an important role in both countries, and a comparison of the performance of their community-based health plans could inform policymakers about ways to improve the quality of care.

Objective: To compare the adherence to standards of care in Israel and in the USA.

Leveraging improvement in quality and value in health care through a clinical performance measure framework: a recommendation of the American College of Physicians.

Policy maker efforts to evaluate the quality and costs of health care have stimulated a proliferation of disparate performance measures. This cacophony of performance measures creates confusion over which measures are applicable at which level of the health care system, limiting their effective application for accountability and improvements in patient care. The American College of Physicians (ACP) has created a clinical performance measurement framework to provide direction to policy makers and measure developers for future performance measure development and application.

Association of Health Plans' Healthcare Effectiveness Data and Information Set (HEDIS) performance with outcomes of enrollees with diabetes.

Background: Few quality of care evaluations examine the relationship between clinical processes and patient outcomes.

Objective: To determine the association between health plan performance on Healthcare Effectiveness Data and Information Set (HEDIS) clinical processes and intermediate outcome measures and Health Outcomes Survey (HOS) self-reported physical and mental health scores among Medicare plan enrollees with diabetes.

Research Design: Secondary data analysis of 2002 HEDIS and 2001-2003 HOS data.

The political economy of U.S. primary care.

Compelling evidence suggests that the United States lags behind other developed nations in the health of its population and the performance of its health care system, partly as a result of a decades-long decline in primary care. This paper outlines the political, economic, policy, and institutional factors behind this decline. A large-scale, multifaceted effort--a new Charter for Primary Care--is required to overcome these forces.

Is integration in large medical groups associated with quality?

Objective: To test the relationship between the presence of recommended chronic care model systems and the degree of integration among large medical groups.

Study Design: Cross-sectional survey in 2007 completed by medical directors of medical groups nationally with at least 100 physicians and a range of medical services and who had also participated in the National Survey of Physician Organizations.

Methods: We recruited 111 medical directors among 123 who were eligible.

Improving the reliability of physician performance assessment: identifying the "physician effect" on quality and creating composite measures.

Background: The proliferation of efforts to assess physician performance underscore the need to improve the reliability of physician-level quality measures.

Objective: Using diabetes care as a model, to address 2 key issues in creating reliable physician-level quality performance scores: estimating the physician effect on quality and creating composite measures.

Design: Retrospective longitudinal observational study.

Availability of data for measuring physician quality performance.

Objective: To evaluate measurement of physician quality performance, which is increasingly used by health plans as the basis of quality improvement, network design, and financial incentives, despite concerns about data and methodological challenges.

Study Design: Evaluation of health plan administrative claims and enrollment data.

Methods: Using administrative data from 9 health plans, we analyzed results for 27 well-accepted quality measures and evaluated how many quality events (patients eligible for a measure) were available per primary care physician and how different approaches for attributing patients to physicians affect the number of quality events per physician.

The potential effects of HEDIS performance measures on the quality of care.

We analyzed the potential effects of different levels of performance on eight Health Care Employer Data and Information Set (HEDIS) measures for cardiovascular disease and diabetes during 1995-2005. The measures targeted 3.3 million (25 percent) heart attacks.

Measuring practice systems for chronic illness care: accuracy of self-reports from clinical personnel.

Background: Purchasers, plans, and clinical practices involved in quality improvement initiatives are increasingly interested in measuring practice systems, particularly in relation to clinical quality and as part of pay-for-quality initiatives. The validity of self-reports of the use of practice systems was examined.

Methods: In 11 medical groups in Minnesota, the Physician Practice Connections Readiness Survey, which was developed on the basis of the concepts and evidence base of the Chronic Care Model, was used to survey office practice personnel about practice systems.