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The Chief Clinical Officer for Sound Physicians shares insights on coronavirus care from what he sees among the independent multispecialty group’s thousands of clinicians who partner with hospitals across 40 states., Summary Sound Physicians, which provides hospitalist, intensivist, and emergency medicine services nationwide, has admitted approximately 8,000 Covid-19 patients as of April 1, 2020. The organization’s Chief Clinical Officer notes that the impact of and response to the Covid-19 pandemic has been varied across the United States, with heightened demands in the hot spots. Despite the stresses — including long hours, short supplies, and, rarely, some uncooperative behavior — he expresses renewed faith and admiration in the sense of duty of physicians and what he sees as small acts of heroism.

The rising popularity of episode-based payment models for surgery underscores the need to better understand the drivers of variability in spending on postacute care. Examining postacute care spending for fee-for-service Medicare beneficiaries after three common surgical procedures in the period 2009-12, we found that it varied widely between hospitals in the lowest versus highest spending quintiles for postacute care, with differences of 129 percent for total hip replacement, 103 percent for coronary artery bypass grafting (CABG), and 82 percent for colectomy. Wide variation persisted after we adjusted for the intensity of postacute care. However, the variation diminished considerably after we adjusted instead for postacute care setting (home health care, outpatient rehabilitation, skilled nursing facility, or inpatient rehabilitation facility): It decreased to 16 percent for hip replacement, 4 percent for CABG, and 21 percent for colectomy. Health systems seeking to improve surgical episode efficiency should collaborate with patients to choose the highest-value postacute care setting.

There is wide variation in mortality across hospitals for cancer operations. While higher rates of mortality are commonly ascribed to high-risk resections, the impact on more common operations is unclear. We sought to evaluate causes of mortality following colon cancer operations across hospitals.Forty-nine American College of Surgeons Commission on Cancer hospitals were selected for participation in a Commission on Cancer special study. We ranked hospitals using a composite measure of mortality and performed onsite chart reviews. We examined patient characteristics and mortality following colon resections at very high-mortality and very low- mortality hospitals (2006-2007).We identified 3,025 patients who underwent an operation at 19 low-mortality (n = 1,006) and 30 high-mortality (n = 2,019) hospitals. There were wide differences in risk-adjusted mortality between high-mortality and low-mortality hospitals (9.3% vs 2.4%; P .001). Compared with low-mortality hospitals, high-mortality hospitals had more patients who were black (11.2% vs 6.5%; P .001), had ≥2 comorbidities (22.7% vs 18.9%; P .05), were categorized American Society of Anesthesiologists class 4-5 (11.9% vs 5.3%; P .001), and were functionally dependent (13.9% vs 8.8%; P .001). Rates of complication were similar in high-mortality versus low-mortality hospitals (odds ratio 1.29, 95% confidence interval, 0.85-1.95). For those experiencing complications, though, case fatality rates were significantly higher in high-mortality versus low-mortality hospitals (odds ratio 3.74, 95% confidence interval, 1.59-8.82).There is significant variation in mortality across hospitals for colon cancer operations, despite similar perioperative morbidity. This finding reflects a need for improved operative decision-making to enhance outcomes and quality of care at these hospitals.

In fiscal year 2015 the Centers for Medicare and Medicaid Services expanded its Hospital Value-Based Purchasing program by rewarding or penalizing hospitals for their performance on both spending and quality. This represented a sharp departure from the program's original efforts to incentivize hospitals for quality alone. How this change redistributed hospital bonuses and penalties was unknown. Using data from 2,679 US hospitals that participated in the program in fiscal years 2014 and 2015, we found that the new emphasis on spending rewarded not only low-spending hospitals but some low-quality hospitals as well. Thirty-eight percent of low-spending hospitals received bonuses in fiscal year 2014, compared to 100 percent in fiscal year 2015. However, low-quality hospitals also began to receive bonuses (0 percent in fiscal year 2014 compared to 17 percent in 2015). All high-quality hospitals received bonuses in both years. The Centers for Medicare and Medicaid Services should consider incorporating a minimum quality threshold into the Hospital Value-Based Purchasing program to avoid rewarding low-quality, low-spending hospitals.

Aiming to encourage care coordination and cost efficiency, the Center for Medicare and Medicaid Innovation (CMMI) launched the Bundled Payments for Care Improvement (BPCI) initiative in 2013. To help gauge the program's potential impact and generalizability, we describe early and current participants.We examined the cross-sectional association between BPCI participation and providers' structural and cost characteristics.Using data from October 2013 and June 2014, we quantified changes in BPCI participation. We described structural differences between participating and nonparticipating hospitals using t tests and χ2 tests, and we used the Cochrane-Armitage test to assess whether participants were more likely be in higher 90-day episode cost quintiles than their peers at baseline (2009-2010).Overall (risk-bearing and non-risk-bearing) participation in BPCI increased from about 400 in October 2013 to more than 2000 in June 2014-attributable, in part, to Model 2, the most comprehensive of the 4 models offered by CMMI for provider participation. Model 2 hospitals increasingly resemble eligible but nonparticipating hospitals. For the most commonly chosen condition of hip replacement, Model 2 hospitals were not costlier than their peers. Hospitals used to make up 97% of Model 2 participants, but physician practices now comprise a substantial number of Model 2 participants. However, most BPCI participants have not yet begun to bear financial risk. Risk-bearing Model 2 hospitals are a smaller and less representative group, with higher baseline costs for hip replacement than their peers.Growing participation in BPCI suggests strong interest in bundled payments. The long-term impact of BPCI will depend on CMMI's ability to persuade interested but non-risk-bearing participants to bear risk.