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GoalThis study explored the use of a Lean daily management system (DMS) for COVID-19 response and recovery in U.S. hospitals and health systems. Originally developed in manufacturing, Lean is an evidence-based approach to quality and process improvement in healthcare. Although Lean has been studied in individual hospital units and outpatient practices, it has not been examined as a whole system response to crisis events.MethodsWe conducted qualitative interviews with 46 executive leaders, clinical leaders, and frontline staff in four hospitals and health systems across the United States. We developed a semistructured interview guide to understand DMS implementation in these care delivery organizations. As interviews took place 6-8 months following the onset of the pandemic, a subset of our interview questions centered on DMS use to meet the demands of COVID-19. Based on a deductive approach to qualitative analysis, we identified clusters of themes that described how DMS facilitated rapid system response to the public health emergency.Principal findingsThere were many important ways in which U.S. hospitals and health systems leveraged their DMS to address COVID-19 challenges. These included the use of tiered huddles to facilitate rapid communication, the creation of standard work for redeployed staff, and structured problem-solving to prioritize new areas for improvement. We also discovered ways that the pandemic itself affected DMS implementation in all organizations. COVID-19 universally created greater DMS visibility by opening lines of communication among leadership, strengthening measurement and accountability, and empowering staff to develop solutions at the front lines. Many lessons learned using DMS for crisis management will carry forward into COVID-19 recovery efforts. Lessons include expanding telehealth, reactivating incident command systems as needed, and efficiently coordinating resources amid potential future shortages.Practical applicationsOverall, the Lean DMS functioned as a robust property that enabled quick organizational response to unpredictable events. Our findings on the use of DMS are consistent with organizational resilience that emphasizes collective sense-making and awareness of incident status, team decision-making, and frequent interaction and coordination. These features of resilience are supported by DMS practices such as tiered huddles for rapid information dissemination and alignment across organizational hierarchies. When used in conjunction with plan-do-study-act methodology, huddles provide teams with enhanced feedback that strengthens their ability to make changes as needed. Moreover, gaps between work-as-imagined (how work should be done) and work-as-done (how work is actually done) may be exacerbated in the initial chaos of emergency events but can be minimized through the development of standard work protocols. As a facilitator of resilience, the Lean DMS may be used in a variety of challenging situations to ensure high standards of care.

Patient engagement strategies can equip patients with tools to navigate treatment decisions and improve patient-centered outcomes. Despite increased recognition about the importance of patient engagement, little is known about the extent of physician practice adoption of patient engagement strategies nationally.We analyzed data collected from the National Survey of Healthcare Organizations and Systems (NSHOS) on physician practice adoption of patient engagement strategies. Stratified-cluster sampling was used to select physician practices operating under different organizational structures. Multivariable linear regression models estimated the association of practice ownership, health information technology functionality, use of screening activities, patient responsiveness, chronic care management processes, and the adoption of patient engagement strategies, including shared decision-making, motivational interviewing, and shared medical appointments. All regression models controlled for participation in payment reforms, practice size, Medicaid revenue percentage, and geographic region.We found modest and varied adoption of patient engagement strategies by practices of different ownership types, with health system-owned practices having the lowest adoption of ownership types. Practice capabilities, including chronic care management processes, routine screening of medical and social risks, and patient care dissemination strategies were associated with greater practice-level adoption of patient engagement strategies.This national study is the first to characterize the adoption of patient engagement strategies by US physician practices. We found modest adoption of shared decision-making and motivational interviewing, and low adoption of shared medical appointments. Risk-based payment reform has the potential to motivate greater practice-level patient engagement, but the extent to which it occurs may depend on internal practice capabilities.

Background Graduate medical education (GME) program leaders struggle to incorporate quality measures in the ambulatory care setting, leading to knowledge gaps on how to provide feedback to residents and programs. While nationally collected quality of care data are available, their reliability for individual resident learning and for GME program improvement is understudied. Objective To examine the reliability of the Healthcare Effectiveness Data and Information Set (HEDIS) clinical performance measures in family medicine and internal medicine GME programs and to determine whether HEDIS measures can inform residents and their programs with their quality of care. Methods From 2014 to 2017, we collected HEDIS measures from 566 residents in 8 family medicine and internal medicine programs under one sponsoring institution. Intraclass correlation was performed to establish patient sample sizes required for 0.70 and 0.80 reliability levels at the resident and program levels. Differences between the patient sample sizes required for reliable measurement and the actual patients cared for by residents were calculated. Results The highest reliability levels for residents (0.88) and programs (0.98) were found for the most frequently available HEDIS measure, colorectal cancer screening. At the GME program level, 87.5% of HEDIS measures had sufficient sample sizes for reliable measurement at alpha 0.7 and 75.0% at alpha 0.8. Most resident level measurements were found to be less reliable. Conclusions GME programs may reliably evaluate HEDIS performance pooled at the program level, but less so at the resident level due to patient volume.

No research has considered a range of physician practice capabilities for managing patient care when examining practice-level influences on quality of care, utilization, and spending. Using data from the 2017 National Survey of Healthcare Organizations and Systems linked to 2017 Medicare fee-for-service claims data from attributed beneficiaries, we examined the association of practice-level capabilities with process measures of quality, utilization, and spending. In propensity score-weighted mixed-effects regression analyses, physician practice locations with "robust" capabilities had lower total spending compared to locations with "mixed" or "limited" capabilities. Quality and utilization, however, did not differ by practice-level capabilities. Physician practice locations with robust capabilities spend less on Medicare fee-for-service beneficiaries but deliver quality of care that is comparable to the quality delivered in locations with low or mixed capabilities. Reforms beyond those targeting practice capabilities, including multipayer alignment and payment reform, may be needed to support larger performance advantages for practices with robust capabilities.

ObjectiveTo assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes.Data sourcesMultiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data.Study designCross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse.Data collection/extraction methods1604580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414209 beneficiaries were considered clinically complex (frailty or 2+chronic conditions).Principal findingsFinancial integration and clinical integration were weakly correlated (correlation coefficient=0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76]).ConclusionsHigher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients.

PURPOSE Despite the importance of training in ambulatory care settings for residents to acquire important competencies, little is known about the organizational and environmental factors influencing the relative amount of time primary care residents train in ambulatory care during residency. The authors examined factors associated with postgraduate year 1 (PGY-1) residents' ambulatory care training time in Accreditation Council for Graduate Medical Education (ACGME)-accredited primary care programs. METHOD U.S.-accredited family medicine (FM) and internal medicine (IM) programs' 2016-2017 National Graduate Medical Education (GME) Census data from 895 programs within 550 sponsoring institutions (representing 13,077 PGY-1s) were linked to the 2016 Centers for Medicare and Medicaid Services Cost Reports and 2015-2016 Area Health Resource File. Multilevel regression models examined the association of GME program characteristics, sponsoring institution characteristics, geography, and environmental factors with PGY-1 residents' percentage of time spent in ambulatory care. RESULTS PGY-1 mean (standard deviation, SD) percent time spent in ambulatory care was 25.4% (SD, 0.4) for both FM and IM programs. In adjusted analyses (% increase [standard error, SE]), larger faculty size (0.03% [SE, 0.01], P < .001), sponsoring institution's receipt of Teaching Health Center (THC) funding (6.6% (SE, 2.7), P < .01), and accreditation warnings (4.8% [SE, 2.5], P < .05) were associated with a greater proportion of PGY-1 time spent in ambulatory care. Programs caring for higher proportions of Medicare beneficiaries spent relatively less time in ambulatory care (< 0.5% [SE, 0.2], P < .01). CONCLUSIONS Ambulatory care time for PGY-1s varies among ACGME-accredited primary care residency programs due to the complex context and factors primary care GME programs operate under. Larger ACGME-accredited FM and IM programs and those receiving federal THC GME funding had relatively more PGY-1 time spent in ambulatory care settings. These findings inform policies to increase resident exposure in ambulatory care, potentially improving learning, competency achievement, and primary care access.

In May 2019, scholars in management and organization of health care organizations and systems met. The opening plenary was a moderated discussion with five distinguished scholars who have exemplified pushing the frontier of organizational theory and practice throughout their careers: Ann Barry Flood of Dartmouth College, John Kimberly of the University of Pennsylvania, Anthony (Tony) Kovner of New York University, Stephen (Steve) Shortell of University of California at Berkeley, and Jacqueline (Jackie) Zinn of Temple University. The discussion was moderated by Ingrid Nembhard of the University of Pennsylvania. The goal of the plenary was to provide an opportunity to hear from senior members of the health care management community how they think about organizational behavior and theory, changes that they have observed, research gaps that they see, and lessons for research and practice that they have learned. This article is the transcript of that plenary discussion. It is shared to capture the intellectual history of the field and help surface the critical advancements still needed in organizational theory and practice in health care. The closing remarks of the panelists summarize recommendations for both practice and scholarship in health care organization management.

Patient-reported outcome measures (PROs) can help clinicians adjust treatments and deliver patient-centered care, but organizational adoption of PROs remains low.This study examines the extent of PRO adoption among health systems and physician practices nationally and examines the organizational capabilities associated with more extensive PRO adoption.Two nationally representative surveys were analyzed in parallel to assess health system and physician practice capabilities associated with adoption of PROs of disability, pain, and depression.A total of 323 US health system and 2,190 physician practice respondents METHODS: Multivariable regression models separately estimated the association of health system and physician practice capabilities associated with system-level and practice-level adoption of PROs.Health system and physician practice adoption of PROs for depression, pain, and disability.Pain (50.6%) and depression (43.8%) PROs were more commonly adopted by all hospitals and medical groups within health systems compared to disability PROs (26.5%). In adjusted analyses, systems with more advanced health IT functions were more likely to use disability (p0.05) and depression (p0.01) PROs than systems with less advanced health IT. Practice-level advanced health IT was positively associated with use of depression PRO (p0.05), but not disability or pain PRO use. Practices with more chronic care management processes, broader medical and social risk screening, and more processes to support patient responsiveness were more likely to adopt each of the three PROs. Compared to independent physician practices, system-owned practices and community health centers were less likely to adopt PROs.Chronic care management programs, routine screening, and patient-centered care initiatives can enable PRO adoption at the practice level. Developing these practice-level capabilities may improve PRO adoption more than solely expanding health IT functions.

Background The Affordable Care Act and the introduction of accountable care organizations (ACOs) have increased the incentives for patients and providers to engage in preventive care, for example, through quality metrics linked to disease prevention. However, little is known about how ACOs deliver preventive care services. Objective To understand how Medicare ACOs provide preventive care services to their attributed patients. Design Mixed-methods study using survey data reporting Medicare ACO capabilities in patient care management and interviews with high-performing ACOs. Participants ACO executives completed survey data on 283 Medicare ACOs. These data were supplemented with 39 interviews conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff. Main Measures Survey measures included ACO performance, organizational characteristics, collaboration experience, and capabilities in care management and quality improvement. Telephone interviews followed a semi-structured interview guide and explored the mechanisms used, and motivations of, ACOs to deliver preventive care services. Key Results Medicare ACOs that reported being comprehensively engaged in the planning and management of patient care - including conducting reminders for preventive care services - had more beneficiaries and had a history of collaboration experience, but were not more likely to receive shared savings or achieve high-quality scores compared to other surveyed ACOs. Interviews revealed that offering annual wellness visits and having a system-wide approach to closing preventive care gaps are key mechanisms used by high-performing ACOs to address patients’ preventive care needs. Few programs or initiatives were identified that specifically target clinically complex patients. Aside from meeting patient needs, motivations for ACOs included increasing patient attribution and meeting performance targets. Conclusions ACOs are increasingly motivated to deliver preventive care services. Understanding the mechanisms and motivations used by high-performing ACOs may help both providers and payers to increase the use of preventive care.

Despite the prevalence of vertical integration, data and research focused on identifying and describing health systems are sparse. Until recently, we lacked an enumeration of health systems and an understanding of how systems vary by key structural attributes. To fill this gap, the Agency for Healthcare Research and Quality developed the Compendium of U.S. Health Systems, a data resource to support research on comparative health system performance. In this article, we describe the methods used to create the Compendium and present a picture of vertical integration in the United States. We identified 626 health systems in 2016, which accounted for 70% of nonfederal general acute care hospitals. These systems varied by key structural attributes, including size, ownership, and geographic presence. The Compendium can be used to study the characteristics of the U.S. health care system and address policy issues related to provider organizations.

Objective Building on the original taxonomy of hospital-based health systems from 20 years ago, we develop a new taxonomy to inform emerging public policy and practice developments. Data sources The 2016 American Hospital Association's (AHA) Annual Survey; the 2016 IQVIA Healthcare Organizations and Systems (HCOS) database; and the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS). Study design Cluster analysis of the 2016 AHA Annual Survey data to derive measures of differentiation, centralization, and integration to create categories or types of hospital-based health systems. Data collection Principal components factor analysis with varimax rotation generating the factors used in the cluster algorithms. Principal findings Among the four cluster types, 54% (N = 202) of systems are decentralized (-0.35) and relatively less differentiated (-0.37); 23% of systems (N = 85) are highly differentiated (1.28) but relatively decentralized (-0.29); 15% (N = 57) are highly centralized (2.04) and highly differentiated (0.65); and approximately 9 percent (N = 33) are least differentiated (-1.35) and most decentralized (-0.64). Despite differences in calculation, the Highly Centralized, Highly Differentiated System Cluster and the Undifferentiated, Decentralized System Cluster were similar to those identified 20 years ago. The other two system clusters contained similarities as well as differences from those 20 years ago. Overall, 82 percent of the systems remain relatively decentralized suggesting they operate largely as holding companies allowing autonomy to individual hospitals operating within the system. Conclusions The new taxonomy of hospital-based health systems bears similarities as well as differences from 20 years ago. Important applications of the taxonomy for addressing current challenges facing the healthcare system, such as the transition to value-based payment models, continued consolidation, and the growing importance of the social determinants of health, are highlighted.

The Lean management system is being adopted and implemented by an increasing number of US hospitals. Yet few studies have considered the impact of Lean on hospitalwide performance.A multivariate analysis was performed of the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals and 2018 publicly available data from the Agency for Healthcare Research and Quality and the Center for MedicareMedicaid Services on 10 quality/appropriateness of care, cost, and patient experience measures.Hospital adoption of Lean was associated with higher Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores (b = 3.35, p0.0001) on a scale of 100-300 but none of the other 9 performance measures. The degree of Lean implementation measured by the number of units throughout the hospital using Lean was associated with lower adjusted inpatient expense per admission (b = -38.67; p0.001), lower 30-day unplanned readmission rate (b = -0.01, p0.007), a score above the national average on appropriate use of imaging-a measure of low-value care (odds ratio = 1.04, p0.042), and higher HCAHPS patient experience scores (b = 0.12, p0.012). The degree of Lean implementation was not associated with any of the other 6 performance measures.Lean is an organizationwide sociotechnical performance improvement system. As such, the actual degree of implementation throughout the organization as opposed to mere adoption is, based on the present findings, more likely to be associated with positive hospital performance on at least some measures.

Health care systems continue to grow in size. Financial integration—the ownership of hospitals or physician practices—often has anticompetitive effects that contribute to the higher prices for health care seen in the US. To determine whether the potential harms of financial integration are counterbalanced by improvements in quality, we surveyed nationally representative samples of hospitals (n = 739) and physician practices (n = 2,189), stratified according to whether they were independent or were owned by complex systems, simple systems, or medical groups. The surveys included nine scales measuring the level of adoption of diverse, quality-focused care delivery and payment reforms. Scores varied widely across hospitals and practices, but little of this variation was explained by ownership status. Quality scores favored financially integrated systems for four of nine hospital and one of nine practice measures, but in no case favored complex systems. Greater financial integration was generally not associated with better quality.

Purpose Although much research has been done on accountable care organizations (ACOs), little is known about their impact on rural hospitals. We examine the association between rural hospitals' participation in an ACO and their performance on utilization and financial measures. Methods This quasi-experimental study estimates the relationship between voluntary ACO participation and hospital metrics using propensity score-matched, longitudinal regression models with year and hospital fixed effects. Regression models controlled for secular trends and time-varying hospital and county characteristics. Hospital measures were from the American Hospital Association, RAND Hospital Data, and Leavitt Partners. The initial population comprises 643 rural hospitals that participated in an ACO for at least one year during the 2011 to 2018 study period and 1,541 rural hospitals that did not participate in an ACO. From this population we created a sample of propensity score-matched hospitals consisting of 525 ACO-participating and 525 comparable non-ACO hospitals. Results Rural hospitals' participation in an ACO is not associated with changes in hospital utilization or financial measures, nor is there an association between these performance metrics and whether another within-county hospital participated in an ACO. A secondary analysis limited to Critical Access Hospitals provides some evidence that inpatient utilization increases in the second year of ACO participation, though the increases are not significant in year 3 and beyond. Conclusion We find no evidence that rural hospitals experience substantive changes in outpatient visits, inpatient utilization, or operating margin in the years immediately after joining an ACO.

BACKGROUND Despite being adopted by a large number of hospitals, the relationship between Lean management and hospital performance is mixed and not well understood. PURPOSE We examined the relationships between Lean and hospital financial performance, patient outcomes, and patient satisfaction in a large national sample of hospitals, controlling for relevant organizational and market factors. METHODOLOGY/APPROACH A mixed effects linear regression analysis was performed to assess the relationships between adoption of Lean and 10 measures of hospital performance using data from 1,152 hospitals that responded to the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals. Hospital performance, organizational, and market data over the period 2011-2015 come from the 2015 American Hospital Association Annual Hospital Survey and the respective annual Centers for Medicare & Medicaid Services (CMS) Medicare Cost Report, CMS Hospital Compare, CMS MEDPAR, and the CMS Hospital Service Area File. RESULTS Lean adoption was significantly associated at alpha < .05, with lower Medicare spending per beneficiary (b = -.005, p = .027). None of the other nine associations were statistically significant, although eight of them were in the predicted direction. CONCLUSION Lean adoption is not associated with most measures of hospital performance. It is likely Lean implementation varies greatly across hospitals. Future research should examine the relationships among the various dimensions of Lean implementation and performance. PRACTICE IMPLICATIONS If Lean management is to contribute to hospital performance improvement, leaders must be highly cognizant of what "adoption of Lean" actually means in their hospital. Although limited, single-unit Lean initiatives in an emergency room or other patient care unit may improve performance on some unit-specific measures, improvement on hospital-wide measures of performance requires a broad, sustained commitment to the implementation of Lean practices and tools.

BackgroundShared decision-making (SDM) is widely recognized as a core strategy to improve patient-centered care. However, the implementation of SDM in routine care settings has been slow and its impact mixed.ObjectiveWe examine the temporal association of patient activation and patients' experience with the SDM process to assess the dominant directionality of this relationship.DesignPatient activation, or a patients' knowledge, skills, and confidence in self-management, was assessed using the 13-item Patient Activation Measure (PAM). Patient-reported assessment of the SDM process was assessed using the 3-item CollaboRATE measure. Patients at 16 adult primary care practices were surveyed in 2015 and 2016 on PAM (α = 0.92), CollaboRATE (α = 0.90), and demographics. The relationship between PAM and CollaboRATE was estimated using a cross-lagged panel model with clustered robust standard errors and practice fixed effects, controlling for patient characteristics.Participants1222 adult patients with diabetes and/or cardiovascular disease with survey responses at baseline (51% response rate) and a 1-year follow-up (73% response rate).ResultsPAM (mean 3.27 vs 3.28 on a range of 1 to 4; p = 0.082) and CollaboRATE (mean 3.62 vs 3.63 on a range of 1 to 5; p = 0.14) did not change significantly over time. In adjusted analyses, the path from baseline PAM to follow-up CollaboRATE (β = 0.35; p

The Centers for Medicare and Medicaid Services’ (CMS) State Innovation Models (SIMs) initiative funded 17 states to implement health care payment and delivery system reforms to improve health system performance. Whether SIM improved health information technology (HIT) and care management capabilities of physician practices, however, remains unclear. National surveys of physician practices ( N = 2,722) from 2012 to 2013 and 2017 to 2018 were linked. Multivariable regression estimated differential adoption of 10 HIT functions and chronic care management processes (CMPs) based on SIM award status (SIM Round 1, SIM Round 2, or non-SIM). HIT and CMP capabilities improved equally for practices in SIM Round 1 (5.3 vs. 6.8 capabilities, p < .001), SIM Round 2 (4.7 vs. 7.0 capabilities, p < .001), and non-SIM (4.2 vs. 6.3 capabilities, p < .001) states. The CMS SIM Initiative did not accelerate the adoption of ten foundational physician practice capabilities beyond national trends.

Background The health care system in the United States is costly with high variance in quality. There is growing interest in transformational performance improvement initiatives, such as the Lean management system, to eliminate waste and inefficiency and improve quality of care for patients. Methods A national survey of all 4,500 short-term acute general medical/surgical and pediatric hospitals in the United States was fielded between May and September 2017 by the Survey Data Center of the American Hospital Association. Results Responses were received from 1,222 hospitals (27.3% response rate). Sixty-nine percent (69.3%) reported use Lean or related Lean plus Six Sigma or Robust Process Improvement approaches. Not-for-profit hospitals, hospitals located in metro/urban areas, those belonging to a system/network, and those with 100–399 beds were most likely to be engaged in these activities and for an average of 5.2 years. However, only 12.6% (n = 102) of hospitals reported being at a mature hospitalwide stage of implementation. The degree of maturity, leadership commitment, daily management system use, and training were each positively associated with reported positive performance outcomes. Conclusion A majority of hospitals have adopted Lean-based transformational performance improvement approaches but with wide variance in the degree of implementation. It takes time for Lean to gain traction. The length of time doing Lean is positively associated with implementation progress and reported positive performance impacts. The extent to which Lean has an organizationwide performance impact awaits further research that links the variables in this study with objective cost and quality measures.

IMPORTANCE: It is critical to develop a better understanding of the strategies provider organizations use to improve the performance of frontline clinicians and whether ACO participation is associated with differential adoption of these tools. OBJECTIVES: Characterize the strategies that physician practices use to improve clinician performance and determine their association with ACOs and other payment reforms. DATA SOURCES: The National Survey of Healthcare Organizations and the National Survey of ACOs fielded 2017‐2018 (response rates = 47 percent and 48 percent). STUDY DESIGN: Descriptive analysis for practices participating and not participating in ACOs among 2190 physician practice respondents. Linear regressions to examine characteristics associated with counts of performance domains for which a practice used data for feedback, quality improvement, or physician compensation as dependent variables. Logistic and fractional regression to examine characteristics associated with use of peer comparison and shares of primary care and specialist compensation accounted for by performance bonuses, respectively. PRINCIPAL FINDINGS: ACO‐affiliated practices feed back clinician‐level information and use it for quality improvement and compensation on more performance domains than non‐ACO‐affiliated practices. Performance measures contribute little to physician compensation irrespective of ACO participation. CONCLUSION: ACO‐affiliated practices are using more performance improvement strategies than other practices, but base only a small fraction of compensation on quality or cost.

EXECUTIVE SUMMARY Many public hospitals have adopted Lean management methodology, but little is known about the extent of Lean adoption or the relationship between Lean adoption and hospital performance. Using data from the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals, linked with data from the American Hospital Association 2015 Annual Hospital Survey and 2015 Centers for Medicare & Medicaid Services data on hospital performance, we compare public hospitals with nonprofit and for-profit hospitals on the rate of Lean adoption and the extent of Lean implementation. We also assess the associations between Lean adoption by the end of 2014 and measures of public hospital financial performance, patient outcomes, and patient satisfaction measured in 2015.Among the 288 public hospitals that responded to the survey, 54.2% reported that they had adopted Lean. The average length of time of Lean implementation was 4.58 years. The mean number of units in which Lean was implemented was 11.9 out of 29 possible hospital units, with the emergency department (ED) being the unit in which Lean was most frequently implemented. The most common Lean practices used were daily huddles, plan-do-study-act cycles, visual management, and use of standard work. Lean adoption by 2014 was significantly associated in the direction predicted with earnings before interest, taxes, depreciation, and amortization margin (b = .042, p < .020) and percentage of patients leaving the ED without being seen (b = -0.610, p < .068). No significant associations were found between Lean adoption and patient outcomes or patient satisfaction.

Accountable care organizations (ACOs) are a prominent payment and delivery model, often described and promoted as provider-driven organizations. However, because of the flexible nature of ACO contracts, management organizations may also become partners in ACOs. We use data from the National Survey of ACOs (N=276) to understand the prevalence of non-provider management partners’ involvement in ACOs, the services these partners provide, and the structure of ACOs with such partners. We find that 37% of ACOs reported having a management partner, and two-thirds of these reported that the partner shared financial risk or reward. Among ACOs with partners, ACOs reported that 94% provided data services, 66% care coordination, 68% education, and 84% administrative services; half received all four services from their partner. ACOs with partners were smaller and more primary care focused than other ACOs. Performance and cost and quality was similar between ACOs with and without partners. Our findings suggest that management partners play a central role in many ACOs, perhaps providing smaller or physician-run ACOs with capital and expertise perceived as necessary to launch an ACO. However, further research is needed to understand the nature of these relationships including both positive aspects (e.g. enabling participation) and negative aspects (e.g. value extracted compared to delivered).

Objective To examine the relationship of physician versus hospital ownership of small- and medium-sized practices with spending and utilization of care. Data Source/Study Setting/Data Collection Survey data for 1,045 primary care-based practices of 1–19 physicians linked to Medicare claims data for 2008 for 282,372 beneficiaries attributed to the 3,010 physicians in these practices. Study Design We used generalized linear models to estimate the associations between practice characteristics and outcomes (emergency department visits, index admissions, readmissions, and spending). Principal Findings Beneficiaries linked to hospital-owned practices had 7.3 percent more emergency department visits and 6.4 percent higher total spending compared to beneficiaries linked to physician-owned practices. Conclusions Physician practices are increasingly being purchased by hospitals. This may result in higher total spending on care.

Performance management systems (PMSYS) aid in improving the quality and efficiency of care, but little is known about factors that influence more robust PMSYS among physician organizations. Using a nationally representative survey of U.S. medical practices, we examined the extent to which organizational capabilities and external factors were associated with more developed PMSYS. Linear regression estimated the relative impact of these factors on PMSYS. On average, practices implemented a minority (32 points out of 100) of the PMSYS processes assessed. Practices evaluated ( p < .01) or financially incentivized by external entities ( p < .01), receiving data from health plans ( p < .01), participating in an accountable care organization ( p < .01), affiliating with an independent practice association and/or physician–hospital organization ( p < .01), and using health information technology ( p < .01) and chronic disease registries ( p < .01) to greater degrees had more robust PMSYS. PMSYS of medical practices are underdeveloped, although both external incentives and organizational capabilities may support PMSYS development.

Accountable care organizations (ACOs) are intended, in part, to improve health care quality. However, little is known about how ACOs may affect disparities or how providers serving disadvantaged patients perform under Medicare ACO contracts. We analyzed racial and ethnic disparities in health care outcomes among ACOs to investigate the association between the share of an ACO's patients who are members of racial or ethnic minority groups and the ACO's performance on quality measures. Using data from Medicare and a national survey of ACOs, we found that having a higher proportion of minority patients was associated with worse scores on twenty-five of thirty-three Medicare quality performance measures, two disease composite measures, and an overall quality composite measure. However, ACOs serving a high share of minority patients were similar to other ACOs in most observable characteristics and capabilities, including provider composition, services, and clinical capabilities. Our findings suggest that ACOs with a high share of minority patients may struggle with quality performance under ACO contracts, especially during their early years of participation-maintaining or potentially exacerbating current inequities. Policy makers must consider how to refine ACO programs to encourage the participation of providers that serve minority patients and to reward performance appropriately.

Policy Points Accountable care organizations (ACOs) have incentives to promote the adoption of patient engagement strategies such as shared decision making and self-management support programs to improve patient outcomes and contain health care costs. High adoption of patient engagement strategies among ACO-affiliated practices did not improve patient-reported outcomes (PROs) of physical, emotional, and social function among adult patients with diabetes and/or cardiovascular disease over a one-year time frame, likely because implementing these strategies requires extensive clinician and staff training, workflow redesign, and patient participation over time. A dominant focus on improving clinical measures to meet external requirements may crowd out time needed for care team members to address other outcomes that matter to patients, including PROs. Payers and policy-makers should explicitly incentivize the collection and use of PROs when contracting with ACOs. Context Adult primary care practices of accountable care organizations (ACOs) are adopting a range of patient engagement strategies, but little is known about how these strategies are related to patient-reported outcomes (PROs) and how relational coordination among team members aids implementation. Methods We used a mixed-methods cohort study design integrating administrative and clinical data with two data collection waves (2014-2015 and 2016-2017) of clinician and staff surveys (n = 764), surveys of adult patients with diabetes and/or cardiovascular disease (CVD) (n = 1,276), and key informant interviews of clinicians, staff, and administrators (n = 103). Multivariable linear regression estimated the relationship of practice adoption of patient engagement strategies, relational coordination, and PROs of physical, social, and emotional function. The mediating role of patient activation was examined using cross-lagged panel models. Key informant interviews assessed how relational coordination influences the implementation of patient engagement strategies. Findings There were no differential improvements in PROs among patients of practices with high vs. low adoption of patient engagement strategies or among patients of practices with high vs. low relational coordination. The Patient Activation Measure (PAM) is strongly related to better physical, emotional, and social PROs over time. Relational coordination facilitated the implementation of patient engagement strategies, but key informants indicated that resources and systems to systematically track treatment preferences and goals beyond clinical indicators were needed to support effective implementation. Conclusions Adult patients with diabetes and/or CVD of ACO-affiliated practices with high adoption of patient engagement strategies do not have improved PROs of physical, emotional, and social function over a one-year time frame. Implementing patient engagement strategies increases task interdependence among primary care team members, which needs to be carefully managed. ACOs may need to make greater investment in collecting, monitoring, and analyzing PRO data to ensure that practice adoption and implementation of patient engagement strategies leads to improved physical, emotional, and social function among patients.

Shared decision-making (SDM) is widely recognized as a core strategy to improve patient-centered care. However, the implementation of SDM in routine care settings has been slow and its impact mixed.We examine the temporal association of patient activation and patients' experience with the SDM process to assess the dominant directionality of this relationship.Patient activation, or a patients' knowledge, skills, and confidence in self-management, was assessed using the 13-item Patient Activation Measure (PAM). Patient-reported assessment of the SDM process was assessed using the 3-item CollaboRATE measure. Patients at 16 adult primary care practices were surveyed in 2015 and 2016 on PAM (α = 0.92), CollaboRATE (α = 0.90), and demographics. The relationship between PAM and CollaboRATE was estimated using a cross-lagged panel model with clustered robust standard errors and practice fixed effects, controlling for patient characteristics.1222 adult patients with diabetes and/or cardiovascular disease with survey responses at baseline (51% response rate) and a 1-year follow-up (73% response rate).PAM (mean 3.27 vs 3.28 on a range of 1 to 4; p = 0.082) and CollaboRATE (mean 3.62 vs 3.63 on a range of 1 to 5; p = 0.14) did not change significantly over time. In adjusted analyses, the path from baseline PAM to follow-up CollaboRATE (β = 0.35; p 0.0001) was stronger than the path from baseline CollaboRATE to follow-up PAM (β = 0.04; p = 0.001).The relationship between patient activation and patients' experiences of the SDM process is bidirectional, but dominated by baseline patient activation. Rather than promoting the use of SDM for all patients, healthcare organizations should prioritize interventions to promote patient activation and engage patients with relatively high activation in SDM interventions.

INTRODUCTION: The adoption of advanced health information technology (HIT) capabilities, such as predictive analytic functions and patient access to records, remains variable among healthcare systems across the US. This study is the first to identify characteristics that may drive this variability among health systems. METHODS: Responses from the 2017/18 National Survey of Healthcare Organizations and Systems (NSHOS) were used to assess the extent to which health care system organizational structure, electronic health record (EHR) standardization, and resource allocation practices were associated with use of five advanced HIT capabilities. Of 732 systems surveyed, 446 responded (60.9%), 425 met sample inclusion criteria and 389 reported consistent EHR use. Multivariate linear regression with control variables estimated the relationships. RESULTS: Adoption of advanced HIT capabilities is low and variable, with a mean of 2.4 capabilities adopted and only 8.4% of systems reporting widespread adoption of all five capabilities. In adjusted analyses, EHR standardization (β= 0.76, p =0.001) was the strongest predictor of the number of advanced capabilities adopted, and ownership and management of medical groups (β= 0.32, p =0.04) was also a significant predictor. DISCUSSION: EHR standardization across organizations within a health care system appears to drive adoption of advanced HIT features. CONCLUSION: Health systems that standardize their EHRs and that own and manage hospitals and medical groups have higher rates of advanced health information technology capabilities features. System leaders looking to increase the use of advanced HIT capabilities should consider ways to better standardize their EHRs across organizations.

Physician practices have been growing in size, and becoming more commonly owned by hospitals, over time. We use survey data on physician practices surveyed at two points in time, linked to Medicare claims data, to investigate whether changes in practice size or ownership are associated with changes in the use of care management, health information technology (HIT), or quality improvement processes. We find that practice growth and becoming hospital-owned are associated with adoption of more quality improvement processes, but not with care management or HIT. We then investigate whether growth or becoming hospital-owned are associated with changes in Medicare spending, 30-day readmission rates, or ambulatory care sensitive admission rates. We find little evidence for associations with practice size and ownership, but the use of care management practices is associated with lower rates of ambulatory care sensitive admissions.

Purpose – The purpose of this paper is to describe the current landscape of health information technology (HIT) in early accountable care organizations (ACOs), the different strategies ACOs are using to develop HIT-based capabilities, and how ACOs are using these capabilities within their care management processes to advance health outcomes for their patient population. Design/methodology/approach – Mixed methods study pairing data from a cross-sectional National Survey of ACOs with in-depth, semi-structured interviews with leaders from 11 ACOs (both completed in 2013). Findings – Early ACOs vary widely in their electronic health record, data integration, and analytic capabilities. The most common HIT capability was drug-drug and drug-allergy interaction checks, with 53.2 percent of respondents reporting that the ACO possessed the capability to a high degree. Outpatient and inpatient data integration was the least common HIT capability (8.1 percent). In the interviews, ACO leaders commented on different HIT development strategies to gain a more comprehensive picture of patient needs and service utilization. ACOs realize the necessity for robust data analytics, and are exploring a variety of approaches to achieve it. Research limitations/implications – Data are self-reported. The qualitative portion was based on interviews with 11 ACOs, limiting generalizability to the universe of ACOs but allowing for a range of responses. Practical implications – ACOs are challenged with the development of sophisticated HIT infrastructure. They may benefit from targeted assistance and incentives to implement health information exchanges with other providers to promote more coordinated care management for their patient population. Originality/value – Using new empirical data, this study increases understanding of the extent of ACOs’ current and developing HIT capabilities to support ongoing care management.

Background Multi-stakeholder alliances – groups of payers, purchasers, providers, and consumers that work together to address local health goals – are frequently used to improve health care quality within communities. Under the Aligning Forces for Quality (AF4Q) initiative, multi-stakeholder alliances were given funding and technical assistance to encourage the use of health information technology (HIT) to improve quality. We investigated whether HIT adoption was greater in AF4Q communities than in other communities. Methods Drawing upon survey data from 782 small and medium-sized physician practices collected as part of the National Study of Physician Organizations during July 2007 – March 2009 and January 2012—November 2013, we used weighted fixed effects models to detect relative changes in four measures representing three domains: use of electronic health records (EHRs), receipt of electronic information from hospitals, and patients’ online access to their medical records. Results Improvement on a composite EHR adoption measure was 7.6 percentage points greater in AF4Q communities than in non-AF4Q communities, and the increase in the probability of adopting all five EHR capabilities was 23.9 percentage points greater in AF4Q communities. There was no significant difference in improvement in receipt of electronic information from hospitals or patients’ online access to medical records between AF4Q and non-AF4Q communities. Conclusion By linking HIT to quality improvement efforts, AF4Q alliances may have facilitated greater adoption of EHRs in small and medium-sized physician practices, but not receipt of electronic information from hospitals or patients’ online access to medical records. Implications Multi-stakeholder alliances charged with promoting HIT to advance quality improvement may accelerate adoption of EHRs.

Primary care physicians play an important role in the diagnosis and management of depression. Yet little is known about their use of care management processes for depression. Using national survey data for the period 2006-13, we assessed the use of five care management processes for depression and other chronic illnesses among primary care practices in the United States. We found significantly less use for depression than for asthma, congestive heart failure, or diabetes in 2012-13. On average, practices used fewer than one care management process for depression, and this level of use has not changed since 2006-07, regardless of practice size. In contrast, use of diabetes care management processes has increased significantly among larger practices. These findings may indicate that US primary care practices are not well equipped to manage depression as a chronic illness, despite the high proportion of depression care they provide. Policies that incentivize depression care management, including additional quality metrics, should be considered.

To improve health care quality within communities, increasing numbers of multistakeholder alliances-groups of payers, purchasers, providers, and consumers-have been created. We used data from two rounds (conducted in July 2007-March 2009 and January 2012-November 2013) of a large nationally representative survey of small and medium-size physician practices. We examined whether the adoption of patient-centered medical home processes spread more rapidly in fourteen Robert Wood Johnson Foundation Aligning Forces for Quality communities, where multistakeholder health care alliances promoted their use, than in other communities. We found no difference in the overall growth of adoption of the processes between the two types of communities. However, improvement on a care coordination subindex was 7.17 percentage points higher in Aligning Forces for Quality communities than in others. Despite the enthusiasm for quality improvement led by multistakeholder alliances, such alliances may not be a panacea for spreading patient-centered medical home processes across a community.

To assess whether the characteristics and capabilities of individual practices intending to join the early Medicare accountable care organization (ACO) programs differed from those of practices not intending to join.Data from a 2012-2013 national survey of 1398 physician practices were linked to 2012 Medicare beneficiary claims data to examine differences between practices intending to join a Medicare ACO and practices not intending to join a Medicare ACO.Differences were examined with regard to patient sociodemographic characteristics and disease burden, practice characteristics and capabilities, and cost and quality measures. Logistic regression was used to examine the differences.Practices intending to join were more likely to have better care management capabilities (odds ratio [OR], 1.72; P.003), health information technology functionality (OR, 1.87; P.001), and use of quality improvement methods (OR, 1.52; P.04). They were also more likely to have had prior pay-for-performance experience (OR, 1.59; P.02) and less likely to be physician-owned (OR, 0.51; P.001). However, the practices with the greater capabilities still used half or less of them.Physician practices that intended to join the early ACO programs had greater capabilities and experience to manage risk than those practices that decided not to join. The early ACO programs thus attracted the more capable physician practices, but those practices still fell short of implementing key recommended behaviors. The findings have implications for future physician practice selection into ACOs.

Objective To examine the extent to which physician-to-system ownership transitions are associated with declines in practice-reported patient responsiveness (PRPR). Data Sources A longitudinal cohort of practices (n = 897) from the National Survey of Large Physician Organizations/National Survey of Small- and Medium-Sized Physician Organizations (2006/08) and the National Survey of All-Size Physician Organizations (2012/13). Study Design Multivariable regression estimated the effect of ownership on changes in PRPR, controlling for practice size, specialty composition, other practice, and market characteristics. Data Collection/Extraction Methods Data were collected from three nationally representative surveys of physician organizations consisting of 40-minute interviews with the medical director, president, or chief executive officer. Principal Findings Nine percent of organizations transitioned to system ownership. Compared to practices that were continuously physician-owned, practices that switched to system ownership did not have significantly lower PRPR at baseline but continuously system-owned practices did. Transitions to system ownership were associated with increased PRPR compared to continuously physician ownership. Increased practice size and changes in specialty composition, however, were associated with diminished PRPR. Conclusions Practices can maintain or improve strategies to address patient concerns when transferring ownership to systems with careful attention to the impact of increased size and changes in specialty composition.

OBJECTIVE:To examine whether an empirically derived taxonomy of Accountable Care Organizations (ACOs) is associated with quality and spending performance among patients of ACOs in the Medicare Shared Savings Program (MSSP). DATA SOURCES:Three waves of the National Survey of ACOs and corresponding publicly available Centers for Medicare & Medicaid Services performance data for NSACO respondents participating in the MSSP (N=204); SK&A Office Based Physicians Database from QuintilesIMS. STUDY DESIGN:We compare the performance of three ACO types (physician-led, integrated, and hybrid) for three domains: quality, spending, and likelihood of achieving savings. Sources of performance variation within and between ACO types are compared for each performance measure. PRINCIPAL FINDINGS:There is greater heterogeneity within ACO types than between ACO types. There were no consistent differences in quality by ACO type, nor were there differences in likelihood of achieving savings or overall spending per-person-year. There was evidence for higher spending on physician services for physician-led ACOs. CONCLUSIONS:ACOs of diverse structures perform comparably on core MSSP quality and spending measures. CMS should maintain its flexibility and continue to support participation of diverse ACOs. Future research to identify modifiable organizational factors that account for performance variation within ACO types may provide insight as to how best to improve ACO performance based on organizational structure and ownership.

The effective management of patients with chronic illnesses is critical to bending the curve of health care spending in the United States and is a crucial test for health care reform. In this article we used data from three national surveys of physician practices between 2006 and 2013 to determine the extent to which practices of all sizes have increased their use of evidence-based care management processes associated with patient-centered medical homes for patients with asthma, congestive heart failure, depression, and diabetes. We found relatively large increases over time in the overall use of these processes for small and medium-size practices as well as for large practices. However, the large practices used fewer than half of the recommended processes, on average. We also identified the individual processes whose use increased the most and show that greater use of care management processes is positively associated with public reporting of patient experience and clinical quality and with pay-for-performance.

To be successful, accountable care organizations (ACOs) must effectively manage patient care. Health information technology (HIT) can support care delivery by providing various degrees of coordination. Few studies have examined the role of HIT functionalities or the role of different levels of coordination enabled by HIT on care management processes. We examine HIT functionalities in ACOs, categorized by the level of coordination they enable in terms of information and work flow, to determine which specific HIT functionalities and levels of coordination are most strongly associated with care management processes. Retrospective cross-sectional analysis was done using 2012 data from the National Survey of Accountable Care Organizations. HIT functionalities are categorized into coordination levels: information capture, the lowest level, which coordinates through standardization; information provision, which supports unidirectional activities; and information exchange, which reflects the highest level of coordination allowing for bidirectional exchange. The Care Management Process index (CMP index) includes 13 questions about the extent to which care is planned, monitored, and supported by providers and patients. Multiple regressions adjusting for organizational and ACO contractual factors are used to assess relationships between HIT functionalities and the CMP index. HIT functionality coordinating the most complex interdependences (information exchange) was associated with a 0.41 standard deviation change in the CMP index (β = .41, p < .001), but the associations for information capture (β = −.01, p = .97) and information provision (β = .15, p = .48) functionalities were not significant. The current study has shed some light on the relationship between HIT and care management processes by specifying the coordination roles that HIT may play and, in particular, the importance of information exchange functionalities. Although these represent early findings, further research can help policy makers and clinical leaders understand how to prioritize HIT development given resource constraints.

Background Theories, models, and frameworks used by implementation science, including Diffusion of Innovations, tend to focus on the adoption of one innovation, when often organizations may be facing multiple simultaneous adoption decisions. For instance, despite evidence that care management practices (CMPs) are helpful in managing chronic illness, there is still uneven adoption by physician organizations. This exploratory paper leverages this natural variation in uptake to describe inter-organizational patterns in adoption of CMPs and to better understand how adoption choices may be related to one another. Methods We assessed a cross section of national survey data from physician organizations reporting on the use of 20 CMPs (5 each for asthma, congestive heart failure, depression, and diabetes). Item response theory was used to explore patterns in adoption, first considering all 20 CMPs together and then by subsets according to disease focus or CMP type (e.g., registries, patient reminders). Mokken scale analysis explored whether adoption choices were linked by disease focus or CMP type and whether a consistent ordering of adoption choices was present. Results The Mokken scale for all 20 CMPs demonstrated medium scalability (H = 0.43), but no consistent ordering. Scales for subsets of CMPs sharing a disease focus had medium scalability (0.4 0.5). Scales for CMP type consistently ranked diabetes CMPs as most adoptable and depression CMPs as least adoptable. Within disease focus scales, patient reminders were ranked as the most adoptable CMP, while clinician feedback and patient education were ranked the least adoptable. Conclusions Patterns of adoption indicate that innovation characteristics may influence adoption. CMP dissemination efforts may be strengthened by encouraging traditionally non-adopting organizations to focus on more adoptable practices first and then describing a pathway for the adoption of subsequent CMPs. Clarifying why certain CMPs are “less adoptable” may also provide insights into how to overcome CMP adoption constraints. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0639-z) contains supplementary material, which is available to authorized users.

Objective Examine the extent to which physician organization participation in an accountable care organization (ACO) and electronic health record (EHR) functionality are associated with greater adoption of care transition management (CTM) processes. Data Sources/Study Setting A total of 1,398 physician organizations from the third National Study of Physician Organization survey (NSPO3), a nationally representative sample of medical practices in the United States (January 2012—May 2013). Study Design We used data from the third National Study of Physician Organization survey (NSPO3) to assess medical practice characteristics, including CTM processes, ACO participation, EHR functionality, practice type, organization size, ownership, public reporting, and pay-for-performance participation. Data Collection/Extraction Methods Multivariate linear regression models estimated the extent to which ACO participation and EHR functionality were associated with greater CTM capabilities, controlling for practice size, ownership, public reporting, and pay-for-performance participation. Principal Findings Approximately half (52.4 percent) of medical practices had a formal program for managing care transitions in place. In adjusted analyses, ACO participation (p

ObjectivesTo evaluate whether greater experience and success with performance incentives among physician practices are related to increased participation in Medicare's voluntary value-based payment reforms.Data sources/study settingPublicly available data from Medicare's Physician Compare (n=1,278; January 2012 to November 2013) and nationally representative physician practice data from the National Survey of Physician Organizations 3 (NSPO3; n=907,538; 2013).Study designWe used regression analysis to examine practice-level relationships between prior exposure to performance incentives and participation in key Medicare value-based payment reforms: accountable care organization (ACO) programs, the Physician Quality Reporting System ("Physician Compare"), and the Meaningful Use of Health Information Technology program ("Meaningful Use"). Prior experience and success with financial incentives were measured as (1) the percentage of practices' revenue from financial incentives for quality or efficiency; and (2) practices' exposure to public reporting of quality measures.Data collection/extraction methodsWe linked physician participation data from Medicare's Physician Compare to the NSPO3 survey.Principal findingsThere was wide variation in practices' exposure to performance incentives, with 64 percent exposed to financial incentives, 45 percent exposed to public reporting, and 2.2 percent of practice revenue coming from financial incentives. For each percentage-point increase in financial incentives, there was a 0.9 percentage-point increase in the probability of participating in ACOs (standard error [SE], 0.1, p&nbsp

Accountable care organizations (ACOs) and similar reforms aim to improve coordination between health care providers; however, due to the fragmented nature of the US health care system, successful coordination will hinge in large part on the ability of health care organizations to successfully partner across organizational boundaries. Little is known about new partnerships formed under the ACO model. We use mixed methods data from the National Survey of ACOs, Medicare ACO performance data and interviews with executive leaders across 31 ACOs to examine the prevalence, characteristics, and capabilities of partnership ACOs and why and how ACO partnerships form. We find that a striking percentage of ACOs - 81% - involve new partnerships between independent health care organizations. These "partnership ACOs" generally report lower capabilities on care management, care coordination, and health information technology. Additionally, under Medicare ACO programs partnership ACO achieved somewhat lower quality performance. Qualitative interviews revealed that providers are motivated to partner for resource complementarity, risk reduction, and legislative requirements, and are using a variety of formal and informal accountability mechanisms. Most partnership ACOs were formed out of existing, positive relationships, but a minority of ACOs formed out of previously competitive or conflictual relationships. Our findings suggests that the success of the ACO model will hinge in large part upon the success of new partnerships, with important implications for understanding ACO readiness and capabilities, the relatively small savings achieved to date by ACO programs, and the path to providers bearing more risk for population health management. In addition, ACO partnerships may provide an important window to monitor a potential wave of health care consolidation or, in contrast, a new model of independent providers successfully coordinating patient care.

Objective To identify positive deviant (PD) physician organizations of Accountable Care Organizations (ACOs) with robust performance management systems (PMSYS). Data Source Third National Survey of Physician Organizations (NSPO3, n = 1,398). Study Design Organizational and external factors from NSPO3 were analyzed. Data Collection/Extraction Methods Linear regression estimated the association of internal and contextual factors on PMSYS. Two cutpoints (75th/90th percentiles) identified PDs with the largest residuals and highest PMSYS scores. Principal Findings A total of 65 and 41 PDs were identified using 75th and 90th percentiles cutpoints, respectively. The 90th percentile more strongly differentiated PDs from non-PDs. Having a high proportion of vulnerable patients appears to constrain PMSYS development. Conclusions Our PD identification method increases the likelihood that PD organizations selected for in-depth inquiry are high-performing organizations that exceed expectations.

Reports suggest a trend for physician practices to change ownership from physicians to hospitals. It remains unclear how this change affects quality of patient care. We report the effect of a change to hospital ownership on the use of care management processes (CMPs) and health information technology (IT) among practices in the United States.Trend analyses of 3 large national surveys of physician practices.We included 2 cohorts of practices: large practices with 20 or more physicians and small/medium practices with fewer than 20 physicians. The main outcomes were the changes in CMP and health IT indices among practices that were acquired by hospitals. We used multivariate logistic regression to assess these changes.Large practices acquired by hospitals had larger increases in their CMP index than those that remained physician-owned (11.0-point increase vs 7.0-point decrease; adjusted P = .03). Small/medium practices acquired by hospitals had smaller but significantly higher increases in their CMP score (3.8 points vs 2.6 points; adjusted P = .04). Among all practices, there were no significant differences in the change of the health IT index.We found a significant increase in the use of CMPs among practices that were acquired by hospitals and no difference in health IT use. These findings suggest that a trend for hospitals to own physician practices may have a positive effect on chronic disease management and quality of care.

PurposeImplementation and meaningful use of health information technology (HIT) has been shown to facilitate delivery system transformation, yet implementation is far from universal. This study examined correlates of greater HIT implementation over time among a national cohort of small primary care practices in the United States.MethodsWe used data from a 40-minute telephone panel survey of 566 small primary care practices having 8 or fewer physicians to investigate adoption and use of HIT in 2007-2010 and 2012-2013. We used generalized estimating equations (GEE) to estimate the association of practice characteristics and external incentives with the adoption and use of HIT. We studied 18 measures of HIT functionalities, including record keeping, clinical decision support, patient communication, and health information exchange with hospitals and pharmacies.ResultsOverall, use of 16 HIT functionalities increased significantly over time, whereas use of 2 decreased significantly. On average, compared with physician-owned practices, hospital-owned practices used 1.48 (95% CI, 1.07-1.88; P

Nearly two-thirds of US office-based physicians work in practices of fewer than seven physicians. It is often assumed that larger practices provide better care, although there is little evidence for or against this assumption. What is the relationship between practice size--and other practice characteristics, such as ownership or use of medical home processes--and the quality of care? We conducted a national survey of 1,045 primary care-based practices with nineteen or fewer physicians to determine practice characteristics. We used Medicare data to calculate practices' rate of potentially preventable hospital admissions (ambulatory care-sensitive admissions). Compared to practices with 10-19 physicians, practices with 1-2 physicians had 33 percent fewer preventable admissions, and practices with 3-9 physicians had 27 percent fewer. Physician-owned practices had fewer preventable admissions than hospital-owned practices. In an era when health care reform appears to be driving physicians into larger organizations, it is important to measure the comparative performance of practices of all sizes, to learn more about how small practices provide patient care, and to learn more about the types of organizational structures--such as independent practice associations--that may make it possible for small practices to share resources that are useful for improving the quality of care.

Purpose– Recognition of the importance and difficulty of engaging physicians in organisational change has sparked an explosion of literature. The social identity approach, by considering engagement in terms of underlying group identifications and intergroup dynamics, may provide a framework for choosing among the plethora of proposed engagement techniques. This paper seeks to address this issue.Design/methodology/approach– The authors examined how four disparate organisations engaged physicians in change. Qualitative methods included interviews (109 managers and physicians), observation, and document review.Findings– Beyond a universal focus on relationship-building, sites differed radically in their preferred strategies. Each emphasised or downplayed professional and/or organisational identity as befit the existing level of inter-group closeness between physicians and managers: an independent practice association sought to enhance members' identity as independent physicians; a hospital, engaging community physicians suspicious of integration, stressed collaboration among separate, equal partners; a developing integrated-delivery system promoted alignment among diverse groups by balancing “systemness” with subgroup uniqueness; a medical group established a strong common identity among employed physicians, but practised pragmatic co-operation with its affiliates.Research limitations/implications– The authors cannot confirm the accuracy of managers' perceptions of the inter-group context or the efficacy of particular strategies. Nonetheless, the findings suggested the fruitfulness of social identity thinking in approaching physician engagement.Practical implications– Attention to inter-group dynamics may help organisations engage physicians more effectively.Originality/value– This study illuminates and explains variation in the way different organisations engage physicians, and offers a theoretical basis for selecting engagement strategies.

Objective To compare early and later adopters of the accountable care organization (ACO) model, using the taxonomy of larger, integrated system; smaller, physician-led; and hybrid ACOs. Data sources The National Survey of ACOs, Waves 1 and 2. Study design Cluster analysis using the two-step clustering approach, validated using discriminant analysis. Wave 2 data analyzed separately to assess differences from Wave 1 and then data pooled across waves. Findings Compared to early ACOs, later adopter ACOs included a greater breadth of provider group types and a greater proportion self-reported as integrated delivery systems. When data from the two time periods were combined, a three-cluster solution similar to the original cluster solution emerged. Of the 251 ACOs, 31.1 percent were larger, integrated system ACOs; 45.0 percent were smaller physician-led ACOs; and 23.9 percent were hybrid ACOs—compared to 40.1 percent, 34.0 percent, and 25.9 percent from Wave 1 clusters, respectively. Conclusions While there are some differences between ACOs formed prior to August 2012 and those formed in the following year, the three-cluster taxonomy appears to best describe the types of ACOs in existence as of July 2013. The updated taxonomy can be used by researchers, policy makers, and health care organizations to support evaluation and continued development of ACOs.

The authors discuss what they believe to be the 5 core principles the next U.S. president should highlight to advance health care and improve the health of Americans.