172 results on '"J. Michael McWilliams"'
Search Results
2. Risk Adjustment And Promoting Health Equity In Population-Based Payment: Concepts And Evidence
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J. Michael McWilliams, Gabe Weinreb, Lin Ding, Chima D. Ndumele, and Jacob Wallace
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Health Policy - Published
- 2023
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3. Difference‐in‐differences for categorical outcomes
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John A. Graves, Carrie Fry, J. Michael McWilliams, and Laura A. Hatfield
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Medically Uninsured ,Insurance, Health ,Medicaid ,Methods Corner ,Patient Protection and Affordable Care Act ,Health Policy ,Humans ,Insurance Coverage ,United States - Abstract
OBJECTIVE: To discuss and develop difference‐in‐difference estimators for categorical outcomes and apply them to estimate the effect of the Affordable Care Act's Medicaid expansion on insurance coverage. DATA SOURCES: Secondary analysis of Survey on Income and Program Participation (SIPP) data on health insurance coverage types before (January 2013) and after (December 2015) Medicaid expansion in 39 US states (19 expansion and 20 non‐expansion). STUDY DESIGN: We develop difference‐in‐difference methods for repeated measures (panel data) of categorical outcomes. We discuss scale‐dependence of DID assumptions for marginal and transition effect estimates and specify a new target estimand: the difference between outcome category transitions under treatment versus no treatment. We establish causal assumptions about transitions that are sufficient to identify this and a marginal target estimand. We contrast the marginal estimands identified by the transition approach versus an additive assumption only about marginal evolution. We apply both the marginal and transition approaches to estimate the effects of Medicaid expansion on health insurance coverage types (employer‐sponsored; other private, non‐group; public; and uninsured). DATA EXTRACTION: We analyzed 16,027 individual survey responses from people aged 18–62 years in the 2014 SIPP panel. PRINCIPAL FINDINGS: We show that the two identifying assumptions are equivalent (on the scale of the marginals) if either the baseline marginal distributions are identical or the marginals are constant in both groups. Applying our transitions approach to the SIPP data, we estimate a differential increase in transitions from uninsured to public coverage and differential decreases in transitions from uninsured to private, non‐group coverage and in remaining uninsured. CONCLUSIONS: By comparing the assumption that marginals are evolving in parallel to an assumption about transitions across outcome values, we illustrate the scale‐dependence of difference‐in‐differences. Our application shows that studying transitions can illuminate nuances obscured by changes in the marginals.
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- 2022
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4. Racial and Ethnic Disparities in Health Care Use and Access Associated With Loss of Medicaid Supplemental Insurance Eligibility Above the Federal Poverty Level
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Eric T. Roberts, Youngmin Kwon, Alexandra G. Hames, J. Michael McWilliams, John Z. Ayanian, and Renuka Tipirneni
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Internal Medicine - Abstract
ImportanceMedicaid supplemental insurance covers most cost sharing in Medicare. Among low-income Medicare beneficiaries, the loss of Medicaid eligibility above this program’s income eligibility threshold (100% of federal poverty level [FPL]) may exacerbate racial and ethnic disparities in Medicare beneficiaries’ ability to afford care.ObjectiveTo examine whether exceeding the income threshold for Medicaid, which results in an abrupt loss of Medicaid eligibility, is associated with greater racial and ethnic disparities in access to and use of care.Design, Setting, and ParticipantsThis cross-sectional study used a regression discontinuity design to assess differences in access to and use of care associated with exceeding the income threshold for Medicaid eligibility. We analyzed Medicare beneficiaries with incomes 0% to 200% of FPL from the 2008 to 2018 biennial waves of the Health and Retirement Study linked to Medicare administrative data. To identify racial and ethnic disparities associated with the loss of Medicaid eligibility, we compared discontinuities in outcomes among Black and Hispanic beneficiaries (n = 2885) and White beneficiaries (n = 5259). Analyses were conducted between January 1, 2022, and October 1, 2022.Main outcome measuresPatient-reported difficulty accessing care due to cost and outpatient service use, medication fills, and hospitalizations measured from Medicare administrative data.ResultsThis cross-sectional study included 8144 participants (38 805 person-years), who when weighted represented 151 282 957 person-years in the community-dwelling population of Medicare beneficiaries aged 50 years and older and incomes less than 200% FPL. In the weighted sample, the mean (SD) age was 75.4 (9.4) years, 66.1% of beneficiaries were women, 14.8% were non-Hispanic Black, 13.6% were Hispanic, and 71.6% were White. Findings suggest that exceeding the Medicaid eligibility threshold was associated with a 43.8 percentage point (pp) (95% CI, 37.8-49.8) lower probability of Medicaid enrollment among Black and Hispanic Medicare beneficiaries and a 31.0 pp (95% CI, 25.4-36.6) lower probability of Medicaid enrollment among White beneficiaries. Among Black and Hispanic beneficiaries, exceeding the threshold was associated with increased cost-related barriers to care (discontinuity: 5.7 pp; 95% CI, 2.0-9.4), lower outpatient use (−6.3 services per person-year; 95% CI, −10.4 to −2.2), and fewer medication fills (−6.9 fills per person-year; 95% CI, −11.4 to −2.5), but it was not associated with a statistically significant discontinuity in hospitalizations. Discontinuities in these outcomes were smaller or nonsignificant among White beneficiaries. Consequently, exceeding the threshold was associated with widened disparities, including greater reductions in outpatient service use (disparity: −6.2 services per person-year; 95% CI, −11.7 to −0.6; P = .03) and medication fills (disparity: −7.2 fills per person-year; 95% CI, −13.4 to −1.0; P = .02) among Black and Hispanic vs White beneficiaries.Conclusions and RelevanceThis cross-sectional study found that loss of eligibility for Medicaid supplemental insurance above the federal poverty level, which increases cost sharing in Medicare, was associated with increased racial and ethnic health care disparities among low-income Medicare beneficiaries. Expanding eligibility for Medicaid supplemental insurance may narrow these disparities.
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- 2023
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5. Professional Backgrounds of Board Members at Top-Ranked US Hospitals
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Suhas Gondi, Sanjay Kishore, and J. Michael McWilliams
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Internal Medicine - Published
- 2023
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6. ACO Investment Model Produced Savings, But The Majority Of Participants Exited When Faced With Downside Risk
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Matthew J. Trombley, J. Michael McWilliams, Betty Fout, and Brant Morefield
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Health Policy - Published
- 2022
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7. Coding-Driven Changes In Measured Risk In Accountable Care Organizations
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Michael E. Chernew, Jessica Carichner, Jeron Impreso, J. Michael McWilliams, Thomas G. McGuire, Sartaj Alam, Bruce E. Landon, and Mary Beth Landrum
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Health Policy - Published
- 2021
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8. Pay for Performance: When Slogans Overtake Science in Health Policy
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J Michael, McWilliams
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General Medicine ,Original Investigation - Abstract
IMPORTANCE: The Medicare Merit-based Incentive Payment System (MIPS) influences reimbursement for hundreds of thousands of US physicians, but little is known about whether program performance accurately captures the quality of care they provide. OBJECTIVE: To examine whether primary care physicians’ MIPS scores are associated with performance on process and outcome measures. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 80 246 US primary care physicians participating in the MIPS program in 2019. EXPOSURES: MIPS score. MAIN OUTCOMES AND MEASURES: The association between physician MIPS scores and performance on 5 unadjusted process measures, 6 adjusted outcome measures, and a composite outcome measure. RESULTS: The study population included 3.4 million patients attributed to 80 246 primary care physicians, including 4773 physicians with low MIPS scores (≤30), 6151 physicians with medium MIPS scores (>30-75), and 69 322 physicians with high MIPS scores (>75). Compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly worse mean performance on 3 of 5 process measures: diabetic eye examinations (56.1% vs 63.2%; difference, −7.1 percentage points [95% CI, −8.0 to −6.2]; P
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- 2022
9. 340B Drug Pricing Program and hospital provision of uncompensated care
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Sunita Desai and J. Michael McWilliams
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Pharmacies ,medicine.medical_specialty ,business.industry ,Health Policy ,Uncompensated Care ,Pharmacy ,Hospital cost ,medicine.disease ,Drug Costs ,Hospitals ,Article ,Incentive ,Acute care ,Costs and Cost Analysis ,medicine ,Humans ,Medical emergency ,business ,Drug pricing - Abstract
OBJECTIVE: To evaluate whether hospital entry into the 340B Drug Pricing Program - which entitles eligible hospitals to discounts on drug purchases and intends for hospitals to use associated savings to devote more resources to the care of low-income populations - is associated with changes in hospital provision of uncompensated care. STUDY DESIGN: We analyzed secondary data on 340B participation and uncompensated care provision among general acute care hospitals and critical access hospitals from 2003–2015. We constructed an annual, hospital-level dataset on hospital 340B participation from the Office of Pharmacy Information Systems and on uncompensated care provision from the Hospital Cost Reporting Information System. METHODS: Focusing on two periods of Program expansion, we separately analyzed trends in uncompensated care costs for 340B-eligible general acute-care hospitals and critical access hospitals, stratified by year of 340B Program entry, including a stratum of eligible hospitals that never participated. We used a differences-in-differences approach to quantify whether there were differential changes in provision of uncompensated care after hospitals enter the 340B Program relative to hospitals that did not participate or had not yet entered. RESULTS: We do not find evidence that hospitals increased provision of uncompensated care after entry into the 340B Program differentially more than hospitals that never entered or had not yet entered the Program. CONCLUSIONS: Relying on hospitals to invest surplus into care for the underserved without marginal incentives to do so or strong oversight may not be an effective strategy to expand safety net care.
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- 2021
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10. National Trends In ED Visits, Hospital Admissions, And Mortality For Medicare Patients During The COVID-19 Pandemic
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Bruce E. Landon, Hazar H. Khidir, Peter B. Smulowitz, A. James O'Malley, J. Michael McWilliams, and Lawrence Zaborski
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medicine.medical_specialty ,Coronavirus disease 2019 (COVID-19) ,business.industry ,Health Policy ,Medicare beneficiary ,Retrospective cohort study ,Emergency department ,Relative risk ,Emergency medicine ,Pandemic ,medicine ,National trends ,business ,National data - Abstract
Concerns about avoidance or delays in seeking emergency care during the COVID-19 pandemic are widespread, but national data on emergency department (ED) visits and subsequent rates of hospitalization and outcomes are lacking. Using data on all traditional Medicare beneficiaries in the US from October 1, 2018, to September 30, 2020, we examined trends in ED visits and rates of hospitalization and thirty-day mortality conditional on an ED visit for non-COVID-19 conditions during several stages of the pandemic and for areas that were considered COVID-19 hot spots versus those that were not. We found reductions in ED visits that were largest by the first week of April 2020 (52 percent relative decrease), with volume recovering somewhat by mid-June (25 percent relative decrease). These reductions were of similar magnitude in counties that were and were not designated as COVID-19 hot spots. There was an early increase in hospitalizations and in the relative risk for thirty-day mortality, starting with the first surge of the pandemic, peaking at just over a 2-percentage-point increase. These results suggest that patients were presenting with more serious illness, perhaps related to delays in seeking care.
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- 2021
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11. Soft Consolidation In Medicare ACOs: Potential For Higher Prices Without Mergers Or Acquisitions
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Peter Lyu, J. Michael McWilliams, and Michael E. Chernew
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Consolidation (business) ,business.industry ,Health Policy ,Accountable care ,MEDLINE ,Accounting ,business - Abstract
Antitrust guidance specifies that participation in Medicare accountable care organizations (ACOs) is sufficient to meet clinical integration standards for separately owned providers to jointly nego...
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- 2021
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12. Outcomes After Shortened Skilled Nursing Facility Stays Suggest Potential For Improving Postacute Care Efficiency
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David C. Grabowski, Brian E McGarry, Lin Ding, and J. Michael McWilliams
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Patient discharge ,medicine.medical_specialty ,business.industry ,030503 health policy & services ,Health Policy ,Medicare beneficiary ,Skilled Nursing ,Postacute Care ,03 medical and health sciences ,Patient safety ,0302 clinical medicine ,Payment models ,Emergency medicine ,Medicine ,Cost sharing ,030212 general & internal medicine ,Skilled Nursing Facility ,0305 other medical science ,business - Abstract
Reducing postacute care in skilled nursing facilities (SNFs) in favor of home-based care is a leading cost-saving strategy in new payment models. Yet the extent to which SNF stays can be safely shortened remains unclear. We leveraged the exposure of fee-for-service Medicare beneficiaries without supplemental coverage to cost sharing after SNF benefit day 20 as a cause of shortened stays. Marked reductions in length-of-stay because of cost sharing shifted patients to home more than a week earlier than expected without cost sharing, producing a discharge spike. These reductions were not associated with clear evidence of compromised patient safety as measured by death, hospitalization for fall-related injuries, or all-cause hospitalization within nine days of the spike. Adverse consequences requiring hospitalization could not be excluded for a small proportion of shortened stays. These findings suggest potential for improving postacute care efficiency, as SNF stays may be unnecessarily long to ensure safety.
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- 2021
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13. Risk Adjustment And Health Equity: The Authors Reply
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J. Michael McWilliams, Gabe Weinreb, Chima D. Ndumele, and Jacob Wallace
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Health Policy - Published
- 2023
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14. Medicaid Coverage ‘Cliff’ Increases Expenses And Decreases Care For Near-Poor Medicare Beneficiaries
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Julie M. Donohue, Walid F. Gellad, Eric T. Roberts, J. Michael McWilliams, Lindsay M. Sabik, Alexandra Glynn, and Noelle Cornelio
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Medigap ,Prescription drug ,Poverty ,business.industry ,Health Policy ,Health care ,Cost sharing ,Subsidy ,Business ,Medical prescription ,Medicaid ,health care economics and organizations ,Demography - Abstract
Cost sharing in traditional Medicare can consume a substantial portion of the income of beneficiaries who do not have supplemental insurance from Medicaid, an employer, or a Medigap plan. Near-poor Medicare beneficiaries (with incomes more than 100 percent but less than 200 percent of the federal poverty level) are ineligible for Medicaid but frequently lack alternative supplemental coverage, resulting in a supplemental coverage "cliff" of 25.8 percentage points just above the eligibility threshold for Medicaid (100 percent of poverty). We estimated that beneficiaries affected by this supplemental coverage cliff incurred an additional $2,288 in out-of-pocket spending over the course of two years, used 55 percent fewer outpatient evaluation and management services per year, and filled fewer prescriptions. Lower prescription drug use was partly driven by low take-up of Part D subsidies, which Medicare beneficiaries automatically receive if they have Medicaid. Expanding eligibility for Medicaid supplemental coverage and increasing take-up of Part D subsidies would lessen cost-related barriers to health care among near-poor Medicare beneficiaries.
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- 2021
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15. Variation In Emergency Department Admission Rates Among Medicare Patients: Does The Physician Matter?
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Bruce E. Landon, Peter B. Smulowitz, Lawrence Zaborski, J. Michael McWilliams, and A. James O'Malley
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Variation (linguistics) ,business.industry ,Payment models ,Health Policy ,Health care ,MEDLINE ,Medicine ,Emergency department ,Medical emergency ,business ,medicine.disease ,humanities - Abstract
Hospitalizations account for the largest share of health care spending. New payment models increasingly encourage health care providers to reduce hospital admissions. Although emergency department ...
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- 2021
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16. The merits of administrative benchmarks for population-based payment programs
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Michael E, Chernew, Jermaine, Heath, and J Michael, McWilliams
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Benchmarking ,Humans ,Medicare ,United States - Abstract
The different approaches to setting benchmarks for population-based payment models (empirical, bidding based, and administratively set) have unique advantages and challenges.
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- 2022
17. Performance on Patient Experience Measures of Former Chief Medical Residents as Physician Exemplars Chosen by the Profession
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Lucy Chen and J. Michael McWilliams
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Internal Medicine - Abstract
ImportancePhysicians’ knowledge about each other’s quality is central to clinical decision-making, but such information is not well understood and is rarely harnessed to identify exemplars for disseminating best practices or quality improvement. One exception is chief medical resident selection, which is typically based on interpersonal, teaching, and clinical skills.ObjectiveTo compare care for patients of primary care physicians (PCPs) who were former chiefs with care for patients of nonchief PCPs.Design, Setting, and ParticipantsUsing 2010 to 2018 Medicare Fee-For-Service Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data (response rate, 47.6%), Medicare claims for random 20% samples of fee-for-service beneficiaries, and medical board data from 4 large US states, we compared care for patients of former chief PCPs with care for patients of nonchief PCPs in the same practice using linear regression. Data were analyzed from August 2020 to January 2023.ExposuresReceiving the plurality of primary care office visits from a former chief PCP.Main Outcomes and MeasuresComposite of 12 patient experience items as primary outcome and 4 spending and utilization measures as secondary outcomes.ResultsThe CAHPS samples included 4493 patients with former chief PCPs and 41 278 patients with nonchief PCPs. The 2 groups were similar in age (mean [SD], 73.1 [10.3] years vs 73.2 [10.3] years), sex (56.8% vs 56.8% female), race and ethnicity (1.2% vs 1.0% American Indian or Alaska Native, 1.3% vs 1.9% Asian or Pacific Islander, 4.8% vs. 5.6% Hispanic, 7.3% vs 6.6% non-Hispanic Black, and 81.5% vs. 80.0% non-Hispanic White), and other characteristics. The Medicare claims for random 20% samples included 289 728 patients with former chief PCPs and 2 954 120 patients with nonchief PCPs. Patients of former chief PCPs rated their care experiences significantly better than patients of nonchief PCPs (adjusted difference in composite, 1.6 percentage points; 95% CI, 0.4-2.8; effect size of 0.30 standard deviations (SD) of the physician-level distribution of performance; P = .01), including markedly higher ratings of physician-specific communication and interpersonal skills typically emphasized in chief selection. Differences were large for patients of racial and ethnic minority groups (1.16 SD), dual-eligible patients (0.81 SD), and those with less education (0.44 SD) but did not vary significantly across groups. Differences in spending and utilization were minimal overall.Conclusions and RelevanceIn this study, patients of PCPs who were former chief medical residents reported better care experiences than patients of other PCPs in the same practice, especially for physician-specific items. The study results suggest that the profession possesses information about physician quality, motivating the development and study of strategies for harnessing such information to select and repurpose exemplars for quality improvement.
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- 2023
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18. Care Experiences and Visit Use of Physician and Nonphysician Medicare Patients
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Annabel Z. Wang and J. Michael McWilliams
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Pharmacology (medical) - Abstract
This cross-sectional study compares care experiences and outpatient visit use between physician-patients and nonphysician-patients.
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- 2023
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19. Physician-Peer Relationships and Patient Experiences With Specialist Care
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Maximilian J, Pany and J Michael, McWilliams
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Internal Medicine - Abstract
ImportancePeer relationships may motivate physicians to aspire to high professional standards but have not been a major focus of quality improvement efforts.ObjectiveTo determine whether peer relationships between primary care physicians (PCPs) and specialists formed during training motivate improved specialist care for patients.Design, Setting, and ParticipantsIn this quasi-experimental study, difference-in-differences analysis was used to estimate differences in experiences with specialist care reported by patients of the same PCP for specialists who did vs did not co-train with the PCP, controlling for any differences in patient ratings of the same specialists in the absence of co-training ties. Specialist visits resulting from PCP referrals from 2016 to 2019 in a large health system were analyzed, including a subset of undirected referrals in which PCPs did not specify a specialist. Data were collected from January 2016 to December 2019 and analyzed from March 2020 to October 2022.ExposureThe exposure was PCP-specialist overlap in training (medical school or postgraduate medical) at the same institution for at least 1 year (co-training).Main Outcomes and MeasuresComposite patient experience rating of specialist care constructed from Press Ganey’s Medical Practice Survey.ResultsOf 9920 specialist visits for 8655 patients (62.9% female; mean age, 57.4 years) with 502 specialists in 13 specialties, 3.1% (306) involved PCP-specialist dyads with a co-training tie. Co-training ties between PCPs and specialists were associated with a 9.0 percentage point higher adjusted composite patient rating of specialist care (95% CI, 5.6-12.4 percentage points; P Conclusions and RelevanceIn this quasi-experimental study, PCP-specialist co-training elicited changes in specialist care that substantially improved patient experiences, suggesting potential gains from strategies encouraging the formation of stronger physician-peer relationships.
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- 2023
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20. Residual Confounding in Health Plan Performance Assessments: Evidence From Randomization in Medicaid
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Jacob Wallace, J. Michael McWilliams, Anthony Lollo, Janet Eaton, and Chima D. Ndumele
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Random Allocation ,Medicaid ,Internal Medicine ,Humans ,General Medicine ,United States - Abstract
Risk adjustment is used widely in payment systems and performance assessments, but the extent to which it distinguishes plan or provider effects from confounding due to patient differences is typically unknown.To assess the degree to which risk-adjusted measures of health plan performance adequately adjust for the variation across plans that arises because of differences in patient characteristics (residual confounding).Comparison between plan performance estimates based on enrollees who made plan choices (observational population) and estimates based on enrollees assigned to plans (randomized population).Natural experiment in which more than two thirds of a state's Medicaid population in 1 region was randomly assigned to 1 of 5 plans.137 933 enrollees in 2013 to 2014, of whom 31.1% selected a plan and 68.9% were randomly assigned to 1 of the same 5 plans.Annual total spending (that is, payments to providers), primary care use, dental care use, and avoidable emergency department visits, all scored as plan-specific deviations from the "average" plan performance within each population.Enrollee characteristics were appreciably imbalanced across plans in the observational population, as expected, but were not in the randomized population. Annual total spending varied across plans more in the observational population (SD, $147 per enrollee) than in the randomized population (SD, $70 per enrollee) after accounting for baseline differences in the observational and randomized populations and for differences across plans. On average, a plan's spending score (its deviation from the "average" performance) in the observational population differed from its score in the randomized population by $67 per enrollee in absolute value (95% CI, $38 to $123), or 4.2% of mean spending per enrollee (Potential heterogeneity in plan effects between the 2 populations.Residual confounding in risk-adjusted performance assessments can be substantial and should caution policymakers against assuming that risk adjustment isolates real differences in plan performance.Arnold Ventures.
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- 2022
21. An analysis of Medicare accountable care organization expense reports
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Catherine, Hersey, J Michael, McWilliams, Betty, Fout, Matthew J, Trombley, and Lauren, Scarpati
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Accountable Care Organizations ,Cost Savings ,Humans ,Health Expenditures ,Medicare ,United States ,Aged - Abstract
To understand the investments that Medicare Shared Savings Program accountable care organizations (ACOs) in the ACO Investment Model (AIM) made to participate in the program and the costs that they incurred as a result of their efforts to lower spending and improve quality.We conducted a systematic review and categorization of all available and approved quarterly expenses reported by AIM ACOs.We reviewed final approved quarterly expense reports submitted by ACOs detailing how they spent funds in the quarter. All distinct line-item descriptions were classified into a more informative and consistent set of categories. We then applied higher conceptual dimensions (type of care input and type of ACO strategy) to these newly categorized expenses to facilitate additional analysis of spending patterns.AIM ACOs reported expenses of $264.8 million over the 3 performance years (2016-2018). The majority of the $264.8 million in expenditures was incurred for personnel (55.5%), followed by infrastructure (22.3%), management firm expenses (15.3%), and internal programs and systems (6.9%). The dominant identifiable ACO strategy was care coordination and management, accounting for 52.9% of related ACO expenses.AIM ACOs invested most heavily in personnel, information technology, and care management, with less than half of the investments explicitly tied to a strategy for improving quality or reducing spending. Efforts to change clinician practice patterns, alter the way patients access the health care system, and institute other practice redesigns were not primary targets for investment.
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- 2021
22. Changes in patient experiences and assessment of gaming among large clinician practices in precursors of the Merit-Based Incentive Payment System
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Zirui Song, J. Michael McWilliams, Eric T. Roberts, and Lin Ding
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Male ,medicine.medical_specialty ,media_common.quotation_subject ,Pay for performance ,Medicare ,Incentive payment ,Article ,Patient experience ,Medicine ,Humans ,Quality (business) ,In patient ,Baseline (configuration management) ,Reimbursement, Incentive ,media_common ,Aged ,Motivation ,business.industry ,Payment ,United States ,Patient Outcome Assessment ,Video Games ,Family medicine ,Mandate ,Female ,business - Abstract
Importance Medicare’s Merit-Based Incentive Payment System (MIPS), a public reporting and pay-for-performance program, adjusts clinician payments based on publicly reported measures that are chosen primarily by clinicians or their practices. However, measure selection raises concerns that practices could earn bonuses or avoid penalties by selecting measures on which they already perform well, rather than by improving care—a form of gaming. This has prompted calls for mandatory reporting on a smaller set of measures including patient experiences. Objective To examine (1) practices’ selection of Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experience measures for quality scoring under the pay-for-performance program and (2) the association between mandated public reporting on CAHPS measures and performance on those measures within precursor programs of the MIPS. Design, Setting, and Participants This cross-sectional study included 2 analyses. The first analysis examined the association between the baseline CAHPS scores of large practices (≥100 clinicians) and practices’ selection of these measures for quality scoring under a pay-for-performance program up to 2 years later. The second analysis examined changes in patient experiences associated with a requirement that large practices publicly report CAHPS measures starting in 2014. A difference-in-differences analysis of 2012 to 2017 fee-for-service Medicare CAHPS data was conducted to compare changes in patient experiences between large practices (111-150 clinicians) that became subject to this reporting mandate and smaller unaffected practices (50-89 clinicians). Analyses were conducted between October 1, 2020, and July 30, 2021. Main Outcomes and Measures The primary outcomes of the 2 analyses were (1) the association of baseline CAHPS scores of large practices with those practices’ selection of those measures for quality scoring under a pay-for-performance program; and (2) changes in patient experiences associated with a requirement that large practices publicly report CAHPS measures starting in 2014. Results Among 301 large practices that publicly reported patient experience measures, the mean (IQR) age of patients at baseline was 71.6 (70.4-73.2 ) years, and 55.8% of patients were women (IQR, 54.3%-57.7%). Large practices in the top vs bottom quintile of patient experience scores at baseline were more likely to voluntarily include these scores in the pay-for-performance program 2 years later (96.3% vs 67.9%), a difference of 28.4 percentage points (95% CI, 9.4-47.5 percentage points;P = .004). After 2 to 3 years of the reporting mandate, patient experiences did not differentially improve in affected vs unaffected practices (difference-in-differences estimate: −0.03 practice-level standard deviations of the composite score; 95% CI, −0.64 to 0.58;P = .92). Conclusions and Relevance In this cross-sectional study of US physician practices that participated in precursors of the MIPS, large practices were found to select measures on which they were already performing well for a pay-for-performance program, consistent with gaming. However, mandating public reporting was not associated with improved patient experiences. These findings support recommendations to end optional measures in the MIPS but also suggest that public reporting on mandated measures may not improve care.
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- 2021
23. Organization and Performance of US Health Systems
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Nancy D. Beaulieu, Michael E. Chernew, J. Michael McWilliams, Mary Beth Landrum, Maurice Dalton, Angela Yutong Gu, Michael Briskin, Rachel Wu, Zakaria El Amrani El Idrissi, Helene Machado, Andrew L. Hicks, and David M. Cutler
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General Medicine - Abstract
ImportanceHealth systems play a central role in the delivery of health care, but relatively little is known about these organizations and their performance.ObjectiveTo (1) identify and describe health systems in the United States; (2) assess differences between physicians and hospitals in and outside of health systems; and (3) compare quality and cost of care delivered by physicians and hospitals in and outside of health systems.Evidence ReviewHealth systems were defined as groups of commonly owned or managed entities that included at least 1 general acute care hospital, 10 primary care physicians, and 50 total physicians located within a single hospital referral region. They were identified using Centers for Medicare & Medicaid Services administrative data, Internal Revenue Service filings, Medicare and commercial claims, and other data. Health systems were categorized as academic, public, large for-profit, large nonprofit, or other private systems. Quality of preventive care, chronic disease management, patient experience, low-value care, mortality, hospital readmissions, and spending were assessed for Medicare beneficiaries attributed to system and nonsystem physicians. Prices for physician and hospital services and total spending were assessed in 2018 commercial claims data. Outcomes were adjusted for patient characteristics and geographic area.FindingsA total of 580 health systems were identified and varied greatly in size. Systems accounted for 40% of physicians and 84% of general acute care hospital beds and delivered primary care to 41% of traditional Medicare beneficiaries. Academic and large nonprofit systems accounted for a majority of system physicians (80%) and system hospital beds (64%). System hospitals were larger than nonsystem hospitals (67% vs 23% with >100 beds), as were system physician practices (74% vs 12% with >100 physicians). Performance on measures of preventive care, clinical quality, and patient experience was modestly higher for health system physicians and hospitals than for nonsystem physicians and hospitals. Prices paid to health system physicians and hospitals were significantly higher than prices paid to nonsystem physicians and hospitals (12%-26% higher for physician services, 31% for hospital services). Adjusting for practice size attenuated health systems differences on quality measures, but price differences for small and medium practices remained large.Conclusions and RelevanceIn 2018, health system physicians and hospitals delivered a large portion of medical services. Performance on clinical quality and patient experience measures was marginally better in systems but spending and prices were substantially higher. This was especially true for small practices. Small quality differentials combined with large price differentials suggests that health systems have not, on average, realized their potential for better care at equal or lower cost.
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- 2023
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24. National Trends In ED Visits, Hospital Admissions, And Mortality For Medicare Patients During The COVID-19 Pandemic
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Peter B, Smulowitz, A James, O'Malley, Hazar, Khidir, Lawrence, Zaborski, J Michael, McWilliams, and Bruce E, Landon
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Hospitalization ,SARS-CoV-2 ,COVID-19 ,Humans ,Emergency Service, Hospital ,Medicare ,Pandemics ,Hospitals ,United States ,Aged ,Retrospective Studies - Abstract
Concerns about avoidance or delays in seeking emergency care during the COVID-19 pandemic are widespread, but national data on emergency department (ED) visits and subsequent rates of hospitalization and outcomes are lacking. Using data on all traditional Medicare beneficiaries in the US from October 1, 2018, to September 30, 2020, we examined trends in ED visits and rates of hospitalization and thirty-day mortality conditional on an ED visit for non-COVID-19 conditions during several stages of the pandemic and for areas that were considered COVID-19 hot spots versus those that were not. We found reductions in ED visits that were largest by the first week of April 2020 (52 percent relative decrease), with volume recovering somewhat by mid-June (25 percent relative decrease). These reductions were of similar magnitude in counties that were and were not designated as COVID-19 hot spots. There was an early increase in hospitalizations and in the relative risk for thirty-day mortality, starting with the first surge of the pandemic, peaking at just over a 2-percentage-point increase. These results suggest that patients were presenting with more serious illness, perhaps related to delays in seeking care.
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- 2021
25. Association of Shared Physician Training with Specialty Referral Networks and Patient Outcomes
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Maximilian J. Pany and J. Michael McWilliams
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medicine.medical_specialty ,Referral ,business.industry ,Special Issue Abstract ,Health Policy ,Family medicine ,Specialty ,Medicine ,business ,Association (psychology) - Abstract
RESEARCH OBJECTIVE: Specialty referrals are a key determinant of health care quality and a quintessential manifestation of physicians' agency on behalf of patients based on their unique knowledge as professionals and their intrinsic motivation to help. Yet we know surprisingly little about why physicians refer to the specialists they choose. Ideally, referrals by primary care physicians (PCPs) would be fully informed and made according to the expected benefits to patients of specialist attributes. However, referrals may also be influenced by professional or personal relationships among physicians, the implications of which are unclear. On one hand, such relationships may lead physicians to disproportionately refer to whom they know instead of who is best. On the other, PCPs may accumulate more information about the quality of specialists with whom they are more familiar, allowing them to better match their patients to specialists. With their actions subject to observation by friends or respected peers, referring PCPs may transmit more useful information and specialists may devote more effort to the patient's care. We leverage detailed EHR data to investigate whether training together influences referral decisions and the implications for patient care. In this abstract, we focus on preliminary analyses of the relationship between co‐training and referral preferences. STUDY DESIGN: Using the universe of EHR data from a large Boston‐area academic health system, we identified all referrals to five specialties (orthopedic surgery, general surgery, obstetrics, urology, and cardiology) initiated by system‐affiliated PCPs in 2018 and 2019. For each referral, we determined whether PCPs and specialists trained at the same medical school or post‐graduate institution at the same time using medical licensing data. We characterized how referral decisions and associated outcomes differed between PCP‐specialist pairs that trained together compared to pairs that did not. POPULATION STUDIED: 40,495 specialty referrals of 37,672 patients to 1273 specialists they had not seen before, initiated by 4890 primary care physicians in 2018 and 2019. Of these, 13,063 referrals were to orthopedic surgery, 8788 to general surgery, 3728 to obstetrics, 4205 to urology, and 10,846 to cardiology. PRINCIPAL FINDINGS: Overall, 22.5% (n = 9095) of referrals could have potentially been directed to co‐trainees. However, only 8.0% (n = 724) of these potential referrals (or 1.8% of all referrals) were directed to co‐trainees, ranging from 7.0% (n = 188) of general surgery referrals to 16.0% (n = 47) of obstetrics referrals. Among PCPs who co‐trained with specialists, a higher proportion of their referrals, on average, went to specialists they trained with compared to specialists they did not train with (26.2% vs. 21.4%, p
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- 2021
26. Changes in Quality of Care after Hospital Mergers and Acquisitions
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Bruce E. Landon, Jesse B. Dalton, Leemore S. Dafny, J. Michael McWilliams, Ifedayo O. Kuye, and Nancy Beaulieu
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business.industry ,Extramural ,media_common.quotation_subject ,MEDLINE ,General Medicine ,030204 cardiovascular system & hematology ,medicine.disease ,Article ,03 medical and health sciences ,0302 clinical medicine ,Health care ,Mergers and acquisitions ,medicine ,Hospital industry ,Quality (business) ,030212 general & internal medicine ,Medical emergency ,Quality of care ,business ,media_common ,Pace - Abstract
BACKGROUND: The hospital industry has consolidated substantially during the past two decades and at an accelerated pace since 2010. Multiple studies have shown that hospital mergers have led to higher prices for commercially insured patients, but research about effects on quality of care is limited. METHODS: Using Medicare claims and Hospital Compare data from 2007 through 2016 on performance on four measures of quality of care (a composite of clinical-process measures, a composite of patient-experience measures, mortality, and the rate of readmission after discharge) and data on hospital mergers and acquisitions occurring from 2009 through 2013, we conducted difference-in-differences analyses comparing changes in the performance of acquired hospitals from the time before acquisition to the time after acquisition with concurrent changes for control hospitals that did not have a change in ownership. RESULTS: The study sample included 246 acquired hospitals and 1986 control hospitals. Being acquired was associated with a modest differential decline in performance on the patient-experience measure (adjusted differential change, −0.17 SD; 95% confidence interval [CI], −0.26 to −0.07; P = 0.002; the change was analogous to a fall from the 50th to the 41st percentile) and no significant differential change in 30-day readmission rates (−0.10 percentage points; 95% CI, −0.53 to 0.34; P = 0.72) or in 30-day mortality (−0.03 percentage points; 95% CI, −0.20 to 0.14; P = 0.72). Acquired hospitals had a significant differential improvement in performance on the clinical-process measure (0.22 SD; 95% CI, 0.05 to 0.38; P = 0.03), but this could not be attributed conclusively to a change in ownership because differential improvement occurred before acquisition. CONCLUSIONS: Hospital acquisition by another hospital or hospital system was associated with modestly worse patient experiences and no significant changes in readmission or mortality rates. Effects on process measures of quality were inconclusive. (Funded by the Agency for Healthcare Research and Quality.)
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- 2020
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27. Did Hospital Readmissions Fall Because Per Capita Admission Rates Fell?
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J. Michael McWilliams, Pasha Hamed, Michael L. Barnett, Ateev Mehrotra, and Eric T. Roberts
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Hospital readmission ,medicine.medical_specialty ,Databases, Factual ,business.industry ,030503 health policy & services ,Health Policy ,Fee-for-Service Plans ,Patient Readmission ,Hospitals ,United States ,Article ,03 medical and health sciences ,0302 clinical medicine ,Emergency medicine ,medicine ,Per capita ,Humans ,030212 general & internal medicine ,Quality of care ,0305 other medical science ,business - Abstract
Recent reductions in readmission rates have been attributed to public reporting and pay-for-performance initiatives focused on readmissions. However, admission rates also declined during the same period. We demonstrate that, because the probability of an admission occurring soon after another is lower when there are fewer admissions per patient, the reduction in admission rates may have explained much of the reduction in readmission rates.
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- 2019
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28. Association Of Medicare’s Annual Wellness Visit With Cancer Screening, Referrals, Utilization, And Spending
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J. Michael McWilliams, Ishani Ganguli, Ateev Mehrotra, and Jeffrey Souza
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medicine.medical_specialty ,Office Visits ,Primary care ,Article ,Preventive care ,Insurance Claim Review ,03 medical and health sciences ,0302 clinical medicine ,Cancer screening ,Humans ,Medicine ,030212 general & internal medicine ,Annual wellness visit ,Referral and Consultation ,Early Detection of Cancer ,Health policy ,Aged ,business.industry ,030503 health policy & services ,Health Policy ,Fee-for-Service Plans ,Middle Aged ,Patient Acceptance of Health Care ,United States ,Family medicine ,Female ,Medicare Part B ,Medicare Part A ,Health Expenditures ,Emergency Service, Hospital ,0305 other medical science ,business - Abstract
Medicare's annual wellness visit was introduced in 2011 to promote evidence-based preventive care and identify risk factors and undiagnosed conditions in aging adults. Use of the visit has risen steadily since then, yet its benefits remain unclear. Using national Medicare data for 2008-15, we examined claims from fee-for-service Medicare beneficiaries attributed to practices that did or did not adopt the visit. We performed difference-in-differences analysis to compare differential changes in appropriate and low-value cancer screening, functional and neuropsychiatric care, emergency department visits, hospitalizations, and total spending. Examining 17.8 million beneficiary-years, we found modest differential improvements in rates of evidence-based screening and declines in emergency department visits. However, when we accounted for trends that predated the introduction of the visit, none of these benefits persisted. In sum, we found no substantive association between annual wellness visits and improvements in care.
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- 2019
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29. Early Effects of an Accountable Care Organization Model for Underserved Areas
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Betty Fout, Matthew J. Trombley, Sasha Brodsky, J. Michael McWilliams, Brant Morefield, and David J. Nyweide
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Male ,Organizational model ,MEDLINE ,Insurance Claim Review ,Medically Underserved Area ,030204 cardiovascular system & hematology ,Medicare ,03 medical and health sciences ,0302 clinical medicine ,Shared savings ,Cost Savings ,Humans ,Medicine ,030212 general & internal medicine ,health care economics and organizations ,Aged ,Aged, 80 and over ,Finance ,Accountable Care Organizations ,business.industry ,Health Care Costs ,General Medicine ,Middle Aged ,Investment (macroeconomics) ,United States ,Cost savings ,Medical Savings Accounts ,Accountable care ,Female ,Rural Health Services ,Health Expenditures ,business ,Medicaid - Abstract
The Centers for Medicare and Medicaid Services (CMS) developed the Accountable Care Organization (ACO) Investment Model (AIM) to encourage the growth of Medicare Shared Savings Program (MSSP) ACOs in rural and underserved areas. AIM provides financial support to eligible MSSP ACOs by means of prepayment of shared savings. Estimation of the performance of AIM ACOs on measures of spending and utilization in their first performance year would be useful for understanding the viability of ACOs located in these areas.We analyzed Medicare claims and enrollment data for a group of fee-for-service beneficiaries who had been attributed to 41 AIM ACOs and for a comparable group of beneficiaries who resided in the ACO markets but were served primarily by non-ACO providers. We used a difference-in-differences study design to compare changes in outcomes from the baseline period (2013 through 2015) to the performance period (2016) among beneficiaries attributed to AIM ACOs with concurrent changes among beneficiaries in the comparison group. The primary outcome of interest was total Medicare Part A and B spending.Provider participation in AIM was associated with a differential reduction in total Medicare spending of $28.21 per beneficiary per month relative to the comparison group, which amounted to an aggregate decrease of $131.0 million. Over the same period, CMS made $76.2 million in prepayments and paid an additional $6.2 million in shared savings to ACOs in which shared savings exceeded the prepayments. After we accounted for this $82.4 million in CMS spending, the aggregate net reduction was $48.6 million, which corresponded to a net reduction of $10.46 per beneficiary per month. Decreases in the number of hospitalizations and use of institutional post-acute care contributed to the observed reduction in overall spending.With up-front investments, participation in ACO shared savings contracts by providers serving rural and underserved areas was associated with lower Medicare spending than that among non-ACO providers. (Funded by the Centers for Medicare and Medicaid Services.).
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- 2019
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30. Using Consistently Low Performance to Identify Low-Quality Physician Groups
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Bruce E. Landon, Lauren Gilstrap, Christina A. Nguyen, J. Michael McWilliams, Mary Beth Landrum, and Michael E. Chernew
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Adult ,Male ,Adolescent ,MEDLINE ,Pharmacy ,Disease ,Glycemic Control ,Physicians, Primary Care ,Young Adult ,Diabetes mellitus ,Diabetes Mellitus ,Medicine ,Humans ,Practice Patterns, Physicians' ,Reimbursement, Incentive ,Work Performance ,Aged ,Original Investigation ,Lipid Regulating Agents ,Insurance, Health ,business.industry ,Research ,Health Policy ,Primary care physician ,Regression analysis ,General Medicine ,Middle Aged ,medicine.disease ,Hospitalization ,Online Only ,Hemoglobin A ,Cross-Sectional Studies ,Quartile ,Cardiovascular Diseases ,Linear Models ,Group Practice ,Female ,business ,Demography - Abstract
Key Points Question Can quality measures identify low-quality physician groups when performance is correlated across multiple measures or multiple years? Findings In this cross-sectional study of a commercially insured population with diabetes or cardiovascular disease, we found weak consistency of low performance scores across multiple measures but moderate to strong consistency of scores over multiple years. One percent or fewer of physician groups performed in the bottom quartile for all diabetes measures or all cardiovascular disease measures in any given year, while 4% to 11% were in the bottom quartile in all 4 years for most measures. Meaning These results suggest that consistency in poor performance depends on the statistical properties of the measures., This cross-sectional study assesses the use of consistently low performance scores for physician groups across multiple performance measures and over multiple years to identify low-quality physician groups., Importance There has been a growth in the use of performance-based payment models in the past decade, but inherently noisy and stochastic quality measures complicate the assessment of the quality of physician groups. Examining consistently low performance across multiple measures or multiple years could potentially identify a subset of low-quality physician groups. Objective To identify low-performing physician groups based on consistently low performance after adjusting for patient characteristics across multiple measures or multiple years for 10 commonly used quality measures for diabetes and cardiovascular disease (CVD). Design, Setting, and Participants This cross-sectional study used medical and pharmacy claims and laboratory data for enrollees ages 18 to 65 years with diabetes or CVD in an Aetna health insurance plan between 2016 and 2019. Each physician group’s risk-adjusted performance for a given year was estimated using mixed-effects linear probability regression models. Performance was correlated across measures and time, and the proportion of physician groups that performed in the bottom quartile was examined across multiple measures or multiple years. Data analysis was conducted between September 2020 and May 2021. Exposures Primary care physician groups. Main Outcomes and Measures Performance scores of 6 quality measures for diabetes and 4 for CVD, including hemoglobin A1c (HbA1c) testing, low-density lipoprotein testing, statin use, HbA1c control, low-density lipoprotein control, and hospital-based utilization. Results A total of 786 641 unique enrollees treated by 890 physician groups were included; 414 655 (52.7%) of the enrollees were men and the mean (SD) age was 53 (9.5) years. After adjusting for age, sex, and clinical and social risk variables, correlations among individual measures were weak (eg, performance-adjusted correlation between any statin use and LDL testing for patients with diabetes, r = −0.10) to moderate (correlation between LDL testing for diabetes and LDL testing for CVD, r = .43), but year-to-year correlations for all measures were moderate to strong. One percent or fewer of physician groups performed in the bottom quartile for all 6 diabetes measures or all 4 cardiovascular disease measures in any given year, while 14 (4.0%) to 39 groups (11.1%) were in the bottom quartile in all 4 years for any given measure other than hospital-based utilization for CVD (1.1%). Conclusions and Relevance A subset of physician groups that was consistently low performing could be identified by considering performance measures across multiple years. Considering the consistency of group performance could contribute a novel method to identify physician groups most likely to benefit from limited resources.
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- 2021
31. Early Hospital Compliance With Federal Requirements for Price Transparency
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Suhas Gondi, Adam L. Beckman, Philip Hinkes, J. Michael McWilliams, and Avery A. Ofoje
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business.industry ,010102 general mathematics ,Accounting ,Disclosure ,01 natural sciences ,Transparency (behavior) ,Insurance, Hospitalization ,United States ,Compliance (psychology) ,Access to Information ,03 medical and health sciences ,0302 clinical medicine ,Insurance carriers ,Internal Medicine ,Research Letter ,Government Regulation ,Medicine ,Humans ,030212 general & internal medicine ,0101 mathematics ,Ethics, Business ,Health Expenditures ,Hospital Costs ,business - Abstract
This cross-sectional study assesses compliance within a random sample of hospitals with a federal rule requiring hospitals to disclose the prices they negotiate with insurers.
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- 2021
32. Hospital Responses to Incentives in Episode-Based Payment for Joint Surgery
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Michael L. Barnett, Ateev Mehrotra, J. Michael McWilliams, David C. Grabowski, and Andrew D. Wilcock
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Male ,medicine.medical_specialty ,Joint replacement ,medicine.medical_treatment ,media_common.quotation_subject ,Population ,Medicare ,01 natural sciences ,Reimbursement Mechanisms ,03 medical and health sciences ,0302 clinical medicine ,Internal Medicine ,medicine ,Humans ,030212 general & internal medicine ,0101 mathematics ,Arthroplasty, Replacement, Knee ,education ,Aged ,Original Investigation ,media_common ,Aged, 80 and over ,Joint surgery ,education.field_of_study ,business.industry ,010102 general mathematics ,Payment ,United States ,Population based study ,Episode based payment ,Incentive ,Quartile ,Emergency medicine ,Female ,business - Abstract
Importance Medicare’s Comprehensive Care for Joint Replacement (CJR) model, initiated in 2016, is a national episode-based payment model for lower-extremity joint replacement (LEJR). Metropolitan statistical areas (MSAs) were randomly assigned to participation. In the third year of the program, Medicare made hospital participation voluntary in half of the MSAs and enabled LEJRs for knees to be performed in the outpatient setting without being subject to episode-based payment. How these changes affected program savings is unclear. Objective To estimate savings from the CJR program over time and assess how responses by hospitals to changing incentives were associated with those savings. Design, Participants, and Setting This controlled population-based study used Medicare claims data from January 1, 2014, to December 31, 2019, to analyze the spending for beneficiaries who received LEJR in 171 MSAs randomized to CJR vs typical payment. One-quarter of beneficiaries before and after the April 1, 2016, start date were excluded as a 6-month washout period (January 1 to June 30, 2016) to allow time in the evaluation period for hospitals to respond to the program rules. Main Outcomes and Measures The main outcomes were episode spending and, starting in year 3 of the program, the hospitals’ decision to no longer participate in CJR and perform LEJRs in the outpatient setting. Results Data from 1 087 177 patients (mean [SD] age, 74.4 [8.4] years; 692 604 women [63.7%]; 980 635 non-Hispanic White patients [90.2%]) were analyzed. Over the first 4 years of CJR, 321 038 LEJR episodes were performed at 702 CJR hospitals, and 456 792 episodes were performed at 826 control hospitals. From the second to the fourth year of the program, savings in CJR vs control MSAs diminished from −$976 per LEJR episode (95% CI, −$1340 to −$612) to −$331 (95% CI, −$792 to $130). In MSAs where hospital participation was made voluntary in the third year, more hospitals in the highest quartile of baseline spending dropped out compared with the lowest quartile (56 of 60 [93.3%] vs 29 of 56 [51.8%]). In MSAs where participation remained mandatory, CJR hospitals shifted fewer knee replacements to the outpatient setting in years 3 to 4 than controls (12 571 of 59 182 [21.2%] vs 21 650 of 68 722 [31.5%] of knee LEJRs). In these mandatory MSAs, 75% of the reduction in savings per episode from years 1 to 2 to years 3 to 4 of the program ($455; 95% CI, $137-$722) was attributable to CJR hospitals’ decision on which patients would undergo surgery or whether the surgical procedure would occur in the outpatient setting. Conclusions and Relevance This controlled population-based study found that savings observed in the second year of CJR largely dissipated by the fourth year owing to a combination of responses among hospitals to changes in the program. These results suggest a need for caution regarding the design of new alternative payment models.
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- 2021
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33. Medicaid Coverage 'Cliff' Increases Expenses And Decreases Care For Near-Poor Medicare Beneficiaries
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Eric T, Roberts, Alexandra, Glynn, Noelle, Cornelio, Julie M, Donohue, Walid F, Gellad, J Michael, McWilliams, and Lindsay M, Sabik
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Medicaid ,Humans ,Insurance, Medigap ,Cost Sharing ,Health Expenditures ,Medicare ,health care economics and organizations ,Insurance Coverage ,United States ,Article ,Aged - Abstract
Cost sharing in traditional Medicare can consume a substantial portion of the income of beneficiaries who do not have supplemental insurance from Medicaid, an employer, or a Medigap plan. Near-poor Medicare beneficiaries (with incomes more than 100 percent but less than 200 percent of the federal poverty level) are ineligible for Medicaid but frequently lack alternative supplemental coverage, resulting in a supplemental coverage "cliff" of 25.8 percentage points just above the eligibility threshold for Medicaid (100 percent of poverty). We estimated that beneficiaries affected by this supplemental coverage cliff incurred an additional $2,288 in out-of-pocket spending over the course of two years, used 55 percent fewer outpatient evaluation and management services per year, and filled fewer prescriptions. Lower prescription drug use was partly driven by low take-up of Part D subsidies, which Medicare beneficiaries automatically receive if they have Medicaid. Expanding eligibility for Medicaid supplemental coverage and increasing take-up of Part D subsidies would lessen cost-related barriers to health care among near-poor Medicare beneficiaries.
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- 2021
34. Impact of the Medicare Shared Savings Program on utilization of mental health and substance use services by eligibility and race/ethnicity
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Ana M. Progovac, Benjamin Lê Cook, Brian Mullin, Theodore L. Caputi, J. Michael McWilliams, and Andrea Acevedo
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Adult ,Mental Health Services ,Race ethnicity ,Prescription Drugs ,Population ,Ethnic group ,Comorbidity ,Medicare ,03 medical and health sciences ,Insurance Claim Review ,0302 clinical medicine ,Shared savings ,Sex Factors ,Residence Characteristics ,Outpatients ,Ethnicity ,Medicine ,Humans ,Disabled Persons ,030212 general & internal medicine ,education ,Depression (differential diagnoses) ,Aged ,education.field_of_study ,Inpatients ,Accountable Care Organizations ,business.industry ,030503 health policy & services ,Health Policy ,Racial Groups ,Age Factors ,Middle Aged ,Mental health ,Health quality ,United States ,Socioeconomic Factors ,Substance Abuse Treatment Centers ,Substance use ,0305 other medical science ,business ,Demography ,Antipsychotic Agents - Abstract
OBJECTIVE: To assess the impact of the Medicare Shared Savings Program (MSSP) ACOs on mental health and substance use services utilization and racial/ethnic disparities in care for these conditions. DATA SOURCES: Five percent random sample of Medicare claims from 2009 to 2016. STUDY DESIGN: We compared Medicare beneficiaries in MSSP ACOs to non‐MSSP beneficiaries, stratifying analyses by Medicare eligibility (disability vs age 65+). We estimated difference‐in‐difference models of MSSP ACOs on mental health and substance use visits (outpatient and inpatient), medication fills, and adequate care for depression adjusting for age, sex, race/ethnicity, region, and chronic medical and behavioral health conditions. To examine the differential impact of MSSP on our outcomes by race/ethnicity, we used a difference‐in‐difference‐in‐differences (DDD) design. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: MSSP ACOs were associated with small reductions in outpatient mental health (Coeff: −0.012, P
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- 2021
35. Variation In Emergency Department Admission Rates Among Medicare Patients: Does The Physician Matter?
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Peter B, Smulowitz, A James, O'Malley, Lawrence, Zaborski, J Michael, McWilliams, and Bruce E, Landon
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Hospitalization ,Patient Admission ,Physicians ,Humans ,Emergency Service, Hospital ,Medicare ,United States ,Aged - Abstract
Hospitalizations account for the largest share of health care spending. New payment models increasingly encourage health care providers to reduce hospital admissions. Although emergency department (ED) physicians play a major role in the decision to admit a patient, the extent to which admission rates vary among ED physicians even within the same hospital remains poorly understood. In this study we examined physician-level variation in ED admission rates for Medicare patients. We found meaningful variation in admission rates: The mean physician-level adjusted admission rate was 38.9 percent and ranged from 32.2 percent to 45.6 percent for physicians at the tenth and ninetieth percentiles, respectively, of the estimated distribution within the same hospital. In contrast, the predicted risk for admission based on patient characteristics varied little among these physicians, suggesting that the variation in admission rates was not due to differences in patients seen. Our results suggest that strategies targeting physician decision making could modify (by either increasing or decreasing when appropriate) rates of admissions.
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- 2021
36. Hospital-Administered Cancer Therapy Prices for Patients With Private Health Insurance
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Roy, Xiao, Joseph S, Ross, Cary P, Gross, Stacie B, Dusetzina, J Michael, McWilliams, Rosh K V, Sethi, and Vinay K, Rathi
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Adult ,Cross-Sectional Studies ,Insurance, Health ,Neoplasms ,Internal Medicine ,Humans ,Medicare Part B ,Leuprolide ,Hospitals ,United States ,Aged ,Original Investigation - Abstract
IMPORTANCE: The federal Hospital Price Transparency final rule, which became effective in 2021, requires hospitals to publicly disclose payer-specific prices for drugs. However, little is known about hospital markup prices for parenterally administered therapies. OBJECTIVE: To assess the extent of price markup by hospitals on parenterally administered cancer therapies and price variation among hospitals and between payers at each hospital. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional analysis was conducted of private payer–specific negotiated prices for the top 25 parenteral (eg, injectable or infusible) cancer therapies by Medicare Part B spending in 2019 using publicly available hospital price transparency files. Sixty-one National Cancer Institute (NCI)–designated cancer centers providing clinical care to adults with cancer were included. The study was conducted from April 1 to October 15, 2021. EXPOSURES: Estimated hospital acquisition costs for each cancer therapy using participation data from the federal 340B Drug Pricing Program. MAIN OUTCOMES AND MEASURES: The primary outcome was hospital price markup for each cancer therapy in excess of estimated acquisition costs. Secondary outcomes were the extent of across-center price ratios, defined as the ratio between the 90th percentile and 10th percentile median prices across centers, and within-center price ratios, defined as the ratio between the 90th percentile and 10th percentile prices between payers at each center. RESULTS: Of 61 NCI-designated cancer centers, 27 (44.3%) disclosed private payer–specific prices for at least 1 top-selling cancer therapy as required by federal regulations. Median drug price markups across all centers and payers ranged between 118.4% (sipuleucel-T) and 633.6% (leuprolide). Across-center price ratios ranged between 2.2 (pertuzumab) and 15.8 (leuprolide). Negotiated prices also varied considerably between payers at the same center; median within-center price ratios for cancer therapies ranged from 1.8 (brentuximab) to 2.5 (bevacizumab). CONCLUSIONS AND RELEVANCE: Most NCI-designated cancer centers did not publicly disclose payer-specific prices for cancer therapies as required by federal regulation. The findings of this cross-sectional study suggest that, to reduce the financial burden of cancer treatment for patients, institution of public policies to discourage or prevent excessive hospital price markups on parenteral chemotherapeutics might be beneficial.
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- 2022
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37. Variation in Rates of Hospital Admission from the Emergency Department Among Medicare Patients at the Regional, Hospital, and Physician Levels
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Bruce E. Landon, A. James O'Malley, Lawrence Zaborski, J. Michael McWilliams, and Peter B. Smulowitz
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Percentile ,medicine.medical_specialty ,Referral ,Cross-sectional study ,Medicare ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Patient Admission ,medicine ,Humans ,030212 general & internal medicine ,Practice Patterns, Physicians' ,business.industry ,030208 emergency & critical care medicine ,Fee-for-Service Plans ,Emergency department ,Explained variation ,Confidence interval ,United States ,Hospitalization ,Cross-Sectional Studies ,Emergency medicine ,Emergency Medicine ,Observational study ,business ,Emergency Service, Hospital ,Cohort study - Abstract
Study objective Rates of admission from the emergency department (ED) vary widely across regions of the country, hospitals within regions, and physicians within hospitals. Our objective was to determine the extent to which variation in admission decisions was described by differences in admission rates at these 3 levels. This understanding will serve to better target interventions to modify rates of admission where appropriate. Methods In this cross-sectional observational cohort study, we analyzed Medicare fee-for-service claims for ED visits from 2012 to 2015 in a 20% random sample of beneficiaries. We first estimated the total regional-, hospital-, and physician-level variations in rates of admission and their proportions of the total variation after adjusting for patient and each level's covariates. We then estimated the extent to which each level's characteristics accounted for variation at that respective level. Results Our study sample included 5,778,218 visits with 45,491 physicians at 3,480 EDs across 306 hospital referral regions. The mean rate of admission was 38.9% and ranged from 21.4% to 53.0% for physicians at the 10th and 90th percentile of the distribution, respectively. The residual (unexplained) variations at the regional, hospital, and physician levels were 13.3% (95% confidence interval [CI], 11.2 to 15.5%), 60.1% (57.1 to 62.9%), and 26.7% (26.4 to 26.9%), respectively. Regional, hospital, and physician characteristics accounted for 9.1% (95% CI, -5.6 to 23.8%), 51.1% (48.8 to 53.5%), and 2.7% (1.3 to 4.1%), respectively, of the explained variation at their respective levels. Conclusion Within-area variation, both across hospitals within a region and across physicians within a hospital, is a more substantial component of observed variation in admission rates from the ED than regional level variation. These findings suggest that variation in admission rates is at least in part related to institutional norms and cultures as well as heterogeneity of physician decisionmaking within hospitals, both of which could be targets of interventions to modify rates of admission.
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- 2020
38. Consequences of Health Insurance Cost Sharing Among Low‐Income Medicare Beneficiaries: Evidence from Benefit Cliffs in Medicaid and Medicare’s Prescription Drug Subsidy Program
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Walid F. Gellad, J. Michael McWilliams, N. Cornelio, Lindsay M. Sabik, Julie M. Donohue, Alexandra Glynn, and Eric T. Roberts
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Actuarial science ,Prescription drug ,Ambulatory care ,Unintended consequences ,Moral hazard ,Health Policy ,Cost sharing ,Subsidy ,Business ,Medical prescription ,Special Issue Abstracts ,Medicaid ,health care economics and organizations - Abstract
RESEARCH OBJECTIVE: Cost sharing is intended to mitigate the effects of moral hazard in health insurance but can have unintended consequences if patients underuse medically beneficial care that is subject to out‐of‐pocket costs. The Medicare program requires substantial cost sharing, including deductibles and coinsurance for outpatient care and prescription drugs. However, little is known about the consequences of this benefit design for low‐income Medicare beneficiaries who do not qualify for Medicaid or Part D Low‐Income Subsidies (LIS), which defray these costs. In this study, we harnessed quasi‐random variation in exposure to Medicare cost sharing, resulting from “cliffs” in cost sharing subsidies above vs. below income eligibility thresholds for Medicaid and the LIS, to assess the effects of cost sharing on low‐income beneficiaries’ out‐of‐pocket spending and use of care. STUDY DESIGN: We conducted regression discontinuity analyses using detailed household income data from the Health and Retirement Study (HRS) linked to Medicare claims. Our study design compared Medicare beneficiaries with incomes above vs. below eligibility thresholds for the Qualified Medicare Beneficiary (QMB) program, a Medicaid benefit that eliminates cost sharing in Medicare Parts A and B for beneficiaries $2,000) out‐of‐pocket medical costs, relative to beneficiaries whose income was below this threshold. Beneficiaries whose income exceeded the LIS threshold had 17% fewer prescription drug claims and were 16% more likely to have high out‐of‐pocket costs. We found no discernable differences in inpatient utilization above vs. below either threshold. CONCLUSIONS: Our findings show how cost sharing obligations in the Medicare program affect low‐income beneficiaries’ use of care: beneficiaries whose income just exceeds thresholds at which these cost sharing obligations are eliminated or appreciably reduced use substantially fewer prescription drugs and, in some cases, outpatient care. IMPLICATIONS FOR POLICY OR PRACTICE: Medicare beneficiaries with minimally different incomes can face substantially different out‐of‐pocket costs that affect their use of care. Extending Medicaid and LIS cost sharing subsidies to additional near‐poor beneficiaries, and gradually tapering assistance for individuals with modestly higher incomes, could alleviate the impacts of Medicare’s cost sharing obligations on near poor beneficiaries’ use of care. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.
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- 2020
39. Savings or Selection? Initial Spending Reductions in the Medicare Shared Savings Program and Considerations for Reform
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Michael E. Chernew, J. Michael McWilliams, Laura A. Hatfield, and Bruce E. Landon
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Male ,media_common.quotation_subject ,Original Scholarship ,Context (language use) ,Medicare ,03 medical and health sciences ,Insurance Claim Review ,0302 clinical medicine ,Cost Savings ,Humans ,030212 general & internal medicine ,Cost Sharing ,Baseline (configuration management) ,Selection (genetic algorithm) ,health care economics and organizations ,media_common ,Aged ,Selection bias ,Actuarial science ,Accountable Care Organizations ,030503 health policy & services ,Health Policy ,Public Health, Environmental and Occupational Health ,Payment ,United States ,Residual risk ,Incentive ,Organizational structure ,Female ,Business ,0305 other medical science - Abstract
Policy Points Concerns have been raised about risk selection in the Medicare Shared Savings Program (MSSP). Specifically, turnover in accountable care organization (ACO) physicians and patient panels has led to concerns that ACOs may be earning shared-savings bonuses by selecting lower-risk patients or providers with lower-risk panels. We find no evidence that changes in ACO patient populations explain savings estimates from previous evaluations through 2015. We also find no evidence that ACOs systematically manipulated provider composition or billing to earn bonuses. The modest savings and lack of risk selection in the original MSSP design suggest opportunities to build on early progress. Recent program changes provide ACOs with more opportunity to select providers with lower-risk patients. Understanding the effect of these changes will be important for guiding future payment policy. Context The Medicare Shared Savings Program (MSSP) establishes incentives for participating accountable care organizations (ACOs) to lower spending for their attributed fee-for-service Medicare patients. Turnover in ACO physicians and patient panels has raised concerns that ACOs may be earning shared-savings bonuses by selecting lower-risk patients or providers with lower-risk panels. Methods We conducted three sets of analyses of Medicare claims data. First, we estimated overall MSSP savings through 2015 using a difference-in-differences approach and methods that eliminated selection bias from ACO program exit or changes in the practices or physicians included in ACO contracts. We then checked for residual risk selection at the patient level. Second, we reestimated savings with methods that address undetected risk selection but could introduce bias from other sources. These included patient fixed effects, baseline or prospective assignment, and area-level MSSP exposure to hold patient populations constant. Third, we tested for changes in provider composition or provider billing that may have contributed to bonuses, even if they were eliminated as sources of bias in the evaluation analyses. Findings MSSP participation was associated with modest and increasing annual gross savings in the 2012-2013 entry cohorts of ACOs that reached $139 to $302 per patient by 2015. Savings in the 2014 entry cohort were small and not statistically significant. Robustness checks revealed no evidence of residual risk selection. Alternative methods to address risk selection produced results that were substantively consistent with our primary analysis but varied somewhat and were more sensitive to adjustment for patient characteristics, suggesting the introduction of bias from within-patient changes in time-varying characteristics. We found no evidence of ACO manipulation of provider composition or billing to inflate savings. Finally, larger savings for physician group ACOs were robust to consideration of differential changes in organizational structure among non-ACO providers (eg, from consolidation). Conclusions Participation in the original MSSP program was associated with modest savings and not with favorable risk selection. These findings suggest an opportunity to build on early progress. Understanding the effect of new opportunities and incentives for risk selection in the revamped MSSP will be important for guiding future program reforms.
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- 2020
40. Changes in Quality of Care after Hospital Mergers and Acquisitions. Reply
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Nancy D, Beaulieu, Leemore S, Dafny, and J Michael, McWilliams
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Health Facility Merger ,Quality of Health Care - Published
- 2020
41. Spending variation among ACOs in the Medicare Shared Savings Program
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Michael E. Chernew, Bruce E. Landon, Paul Trompke, David J. Nyweide, Michael Anne Kyle, J. Michael McWilliams, and Mary Beth Landrum
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Referral ,Cost Control ,media_common.quotation_subject ,Psychological intervention ,Medicare ,03 medical and health sciences ,0302 clinical medicine ,Cost Savings ,Medicine ,Humans ,030212 general & internal medicine ,Reimbursement, Incentive ,Reimbursement ,media_common ,Inpatient care ,Accountable Care Organizations ,business.industry ,030503 health policy & services ,Health Policy ,Fee-for-Service Plans ,United States ,Incentive ,Cross-Sectional Studies ,Quartile ,Service (economics) ,Liberian dollar ,Demographic economics ,Health Expenditures ,0305 other medical science ,business - Abstract
Objectives Understanding variation in spending across organizations, rather than across geographic areas, is important because care is delivered by organizations and interventions increasingly focus on organizations. Accountable care organizations (ACOs) are particularly important to study given their incentives to reduce spending. Analyzing spending differences across ACOs may help identify cost savings opportunities. Study design Cross-sectional analysis of Medicare claims. Methods We stratified ACOs into quartiles based on the deviation between each ACO's risk-adjusted spending and average risk-adjusted fee-for-service spending in the same market (hospital referral region). We compared spending between top- and bottom-quartile ACOs on each of 7 major service categories and 10 clinical condition groups to identify areas of potential savings. We simulated spending reductions if ACOs with high adjusted spending reduced spending to the levels of lower-spending ACOs. Results In 2016, geographically adjusted and risk-adjusted total per-beneficiary spending for the highest-spending quartile of ACOs was 14% higher than for ACOs in the lowest quartile. Variation between high- and low-spending ACOs was greatest, at 27%, in the use of skilled nursing facilities-a service category in which ACOs have reduced spending by the greatest percentage. Inpatient care was the largest driver of absolute dollar differences in spending, however, accounting for 37% of the total spread. If spending in ACOs above median adjusted spending were brought down to the median, savings would be 3% to 4%. Conclusions By extending the variations literature to focus on ACOs, we illustrated that meaningful further savings opportunities exist both within and across markets.
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- 2020
42. Getting Incentives Right in Payment Reform: Thinking Beyond Financial Risk
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Vinay K. Rathi, J. Michael McWilliams, and Eric T. Roberts
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Budgets ,Cost Control ,MEDLINE ,01 natural sciences ,Article ,03 medical and health sciences ,0302 clinical medicine ,Health care ,Internal Medicine ,Medicine ,Outpatient clinic ,Humans ,030212 general & internal medicine ,0101 mathematics ,Reimbursement, Incentive ,Reimbursement ,Finance ,Payment reform ,business.industry ,Financial risk ,010102 general mathematics ,General Medicine ,Benchmarking ,Quality Improvement ,United States ,Physician Incentive Plans ,Incentive ,business - Abstract
Successful payment reform requires strong incentives for provider organizations to limit health care spending. Often overlooked in the debate over how to strengthen global budget models is that inc...
- Published
- 2020
43. Health benefits of reduced patient cost sharing in Japan
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Akihiro Nishi, J Michael McWilliams, Haruko Noguchi, Hideki Hashimoto, Nanako Tamiya, and Ichiro Kawachi
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Public aspects of medicine ,RA1-1270 - Abstract
OBJECTIVE: To assess the effect on out-of-pocket medical spending and physical and mental health of Japan's reduction in health-care cost sharing from 30% to 10% when people turn 70 years of age. METHODS: Study data came from a 2007 nationally-representative cross-sectional survey of 10 293 adults aged 64 to 75 years. Physical health was assessed using a 16-point scale based on self-reported data on general health, mobility, self-care, activities of daily living and pain. Mental health was assessed using a 24-point scale based on the Kessler-6 instrument for nonspecific psychological distress. The effect of reduced cost sharing was estimated using a regression discontinuity design. FINDINGS: For adults aged 70 to 75 years whose income made them ineligible for reduced cost sharing, neither out-of-pocket spending nor health outcomes differed from the values expected on the basis of the trend observed in 64- to 69-year-olds. However, for eligible adults aged 70 to 75 years, out-of-pocket spending was significantly lower (P < 0.001) and mental health was significantly better (P < 0.001) than expected. These differences emerged abruptly at the age of 70 years. Moreover, the mental health benefits were similar in individuals who were and were not using health-care services (P = 0.502 for interaction). The improvement in physical health after the age of 70 years in adults eligible for reduced cost-sharing tended to be greater than in non-eligible adults (P = 0.084). CONCLUSION: Reduced cost sharing was associated with lower out-of-pocket medical spending and improved mental health in older Japanese adults.
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- 2012
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44. Changes In End-Of-Life Care In The Medicare Shared Savings Program
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Haiden A. Huskamp, J. Michael McWilliams, Lauren Gilstrap, David G. Stevenson, David C. Grabowski, and Michael E. Chernew
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Male ,Special populations ,Medicare ,01 natural sciences ,Article ,03 medical and health sciences ,0302 clinical medicine ,Shared savings ,Nursing ,Cost Savings ,Humans ,030212 general & internal medicine ,0101 mathematics ,Aged ,Terminal Care ,Accountable Care Organizations ,Health Policy ,010102 general mathematics ,Fee-for-Service Plans ,United States ,Accountable care ,Female ,Business ,Health Expenditures ,End-of-life care ,Health reform - Abstract
End-of-life care is often overly aggressive and inconsistent with patients' preferences. Although end-of-life care could therefore be a natural target for accountable care organizations (ACOs) in their efforts to reduce spending, identifying and curbing wasteful care for patients at high risk of death may be challenging. To date, the impact of ACOs on end-of-life care has not been quantified. Using fee-for-service Medicare claims through 2015 and a difference-in-differences approach, we found evidence of some changes in end-of-life care associated with providers' participation in the Medicare Shared Savings Program among both decedents and patients at high risk of death. Although generally suggestive of less aggressive care, most effects were small and inconsistent across cohorts of ACOs entering the program in different years. This suggests that ACOs have not yet substantially altered end-of-life care patterns and that additional incentives, time, or both may be needed. Alternatively, curbing wasteful end-of-life care might not be a viable source of substantial savings under population-based payment models.
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- 2018
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45. Analysis of Consistency in Emergency Department Physician Variation in Propensity for Admission Across Patient Sociodemographic Groups
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Bruce E. Landon, A. James O'Malley, J. Michael McWilliams, Peter B. Smulowitz, Lawrence Zaborski, and Hazar Khidir
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Male ,medicine.medical_specialty ,Percentile ,Sociodemographic Factors ,Social Determinants of Health ,Ethnic group ,Medicare ,Racism ,Patient Admission ,Physicians ,Acute care ,Health care ,Humans ,Medicine ,Healthcare Disparities ,Practice Patterns, Physicians' ,Original Investigation ,Systemic Racism ,business.industry ,Research ,Health Policy ,General Medicine ,Emergency department ,humanities ,Bias, Implicit ,United States ,Health equity ,Online Only ,Cross-Sectional Studies ,Pacific islanders ,Female ,Emergency Service, Hospital ,business ,Medicaid ,Demography - Abstract
Key Points Question Are physician propensities to admit patients from the emergency department consistent across patient sociodemographic groups? Findings In this cross-sectional analysis of Medicare claims data from 2016 to 2019, the mean adjusted rates of hospital admission from the emergency department differed by patient sex, race and ethnicity, and Medicaid status. Individual physicians varied substantially within hospitals in the percentage of patients they admitted, and these differences in admission propensity were consistent across patient sociodemographic groups. Meaning The findings of this study suggest that physicians with higher or lower propensities to admit patients from the emergency department exhibit their relative propensity consistently across patient sociodemographic groups., Importance Sociodemographic disparities in health care and variation in physician practice patterns have been well documented; however, the contribution of variation in individual physician care practices to health disparities is challenging to quantify. Emergency department (ED) physicians vary in their propensity to admit patients. The consistency of this variation across sociodemographic groups may help determine whether physician-specific factors are associated with care differences between patient groups. Objective To estimate the consistency of ED physician admission propensities across categories of patient sex, race and ethnicity, and Medicaid enrollment. Design, Setting, and Participants This cross-sectional study analyzed Medicare fee-for-service claims for ED visits from January 1, 2016, to December 31, 2019, in a 10% random sample of hospitals. The allocation of patients to ED physicians in the acute care setting was used to isolate physician-level variation in admission rates that reflects variation in physician decision-making. Multi-level models with physician random effects and hospital fixed effects were used to estimate the within-hospital physician variation in admission propensity for different patient sociodemographic subgroups and the covariation in these propensities between subgroups (consistency), adjusting for primary diagnosis and comorbidities. Main Outcomes and Measures Admission from the ED. Results The analysis included 4 567 760 ED visits involving 2 334 361 beneficiaries and 15 767 physicians in 396 EDs. The mean (SD) age of the beneficiaries was 78 (8.2) years, 2 700 661 visits (59.1%) were by women, and most patients (3 839 055 [84.1%]) were not eligible for Medicaid. Of 4 473 978 race and ethnicity reports on enrollment, 103 699 patients (2.3%) were Asian/Pacific Islander, 421 588 (9.4%) were Black, 257 422 (5.8%) were Hispanic, and 3 691 269 (82.5%) were non-Hispanic White. Within hospitals, adjusted rates of admission were higher for men (36.8%; 95% CI, 36.8%-36.9%) than for women (33.7%; 95% CI, 33.7%-33.8%); higher for non-Hispanic White (36.0%; 95% CI, 35.9%-36.0%) than for Asian/Pacific Islander (33.6%; 95% CI, 33.3%-33.9%), Black (30.2%; 95% CI, 30.0%-30.3%), or Hispanic (31.1%; 95% CI, 30.9%-31.2%) beneficiaries; and higher for beneficiaries dually enrolled in Medicaid (36.3%; 95% CI, 36.2%-36.5%) than for those who were not (34.7%; 95% CI, 34.7%-34.8%). Within hospitals, physicians varied in the percentage of patients admitted, ranging from 22.4% for physicians at the 10th percentile to 47.6% for physicians at the 90th percentile of the estimated distribution. Physician admission propensities were correlated between men and women (r = 0.99), Black and non-Hispanic White patients (r = 0.98), and patients who were dually enrolled and not dually enrolled in Medicaid (r = 0.98). Conclusions and Relevance This cross-sectional study indicated that, although overall rates of admission differ systematically by patient sociodemographic factors, an individual physician’s propensity to admit relative to other physicians appears to be applied consistently across sociodemographic groups of patients., This cross-sectional study examines the consistency of variability in admission rates of patients presenting to the emergency department by sociodemographic factors.
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- 2021
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46. Medicare ACO Program Savings Not Tied To Preventable Hospitalizations Or Concentrated Among High-Risk Patients
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J. Michael McWilliams, Michael E. Chernew, and Bruce E. Landon
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Male ,medicine.medical_specialty ,Medicare ,Preventive care ,03 medical and health sciences ,0302 clinical medicine ,Shared savings ,Cost Savings ,Health spending ,Acute care ,medicine ,Humans ,030212 general & internal medicine ,Aged ,Risk Management ,High risk patients ,Accountable Care Organizations ,business.industry ,030503 health policy & services ,Health Policy ,Fee-for-Service Plans ,United States ,Hospitalization ,Accountable care ,Ambulatory ,Emergency medicine ,Female ,0305 other medical science ,business ,Health reform - Abstract
It has been widely assumed that better management and coordination of care for chronic conditions and high-risk patients would be the leading mechanisms for achieving savings in accountable care organizations (ACOs), specifically by reducing acute care needs through enhanced outpatient and preventive care. We examined the extent to which changes in spending and hospitalizations for ACO patients in the Medicare Shared Savings Program (MSSP) have been consistent with this expectation. By 2014, participation in the MSSP was associated with significant reductions in total Medicare fee-for-service spending for ACO patients but with proportionately smaller reductions in hospitalizations and some increases in hospitalizations for ambulatory care-sensitive conditions. In addition, spending reductions were not clearly concentrated among high-risk patients: Reductions for those patients accounted for only 38 percent of the total reduction among ACOs entering the MSSP in 2012, and reductions among 2013 MSSP entrants were almost entirely concentrated among lower-risk patients. These findings suggest that, on average, care coordination and management efforts focused on ambulatory care-sensitive conditions and high-risk patients have not been the major drivers of early savings in the MSSP.
- Published
- 2017
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47. Medicare Accountable Care Organizations and Antidepressant Use by Patients With Depression
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J. Michael McWilliams, Haiden A. Huskamp, Amanda R. Kreider, and Alisa B. Busch
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Adult ,medicine.medical_specialty ,Poison control ,Medicare ,Suicide prevention ,Article ,Occupational safety and health ,Medication Adherence ,03 medical and health sciences ,0302 clinical medicine ,Injury prevention ,medicine ,Humans ,030212 general & internal medicine ,Medical prescription ,Psychiatry ,Depression (differential diagnoses) ,Depressive Disorder ,Accountable Care Organizations ,business.industry ,030503 health policy & services ,Human factors and ergonomics ,Fee-for-Service Plans ,Antidepressive Agents ,United States ,Psychiatry and Mental health ,Antidepressant ,0305 other medical science ,business - Abstract
This study examined whether Medicare accountable care organization (ACO) programs were associated with early changes in antidepressant use or adherence among beneficiaries with depression.A difference-in-difference design was used to compare claims from Medicare fee-for-service beneficiaries (2009-2013) and ACO patients with those from local control groups. Outcome measures were total antidepressant days supplied, filling one or more antidepressant prescriptions, and proportion of days covered (PDC) by supply among antidepressant users (adherence).Among antidepressant users, ACO contracts were associated with slight differential increases in PDC (.4-.8 percentage point, p≤.03), depending on ACO program and entry year. The proportion of patients with one or more prescriptions was unchanged or decreased slightly for ACO patients with depression, such that total supply did not consistently increase.Medicare ACO programs were associated with early modest increases in antidepressant adherence but not with increases in the proportion of patients with depression who received antidepressants.
- Published
- 2017
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48. Little Evidence Exists To Support The Expectation That Providers Would Consolidate To Enter New Payment Models
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J. Michael McWilliams, Michael E. Chernew, and Hannah T. Neprash
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education ,Medicare ,Article ,03 medical and health sciences ,0302 clinical medicine ,Consolidation (business) ,Payment models ,Health spending ,Physicians ,Health care ,Health Facility Merger ,Humans ,030212 general & internal medicine ,health care economics and organizations ,Actuarial science ,Accountable Care Organizations ,Public economics ,business.industry ,Payment reform ,030503 health policy & services ,Health Policy ,United States ,Models, Economic ,Business ,Health Expenditures ,0305 other medical science - Abstract
Provider consolidation has been associated with higher health care prices and spending. The prevailing wisdom is that payment reform will accelerate consolidation, especially between physicians and hospitals and among physician groups, as providers position themselves to bear financial risk for the full continuum of patient care. Drawing on data from a number of sources from 2008 onward, we examined the relationship between Medicare's accountable care organization (ACO) programs and provider consolidation. We found that consolidation was under way in the period 2008-10, before the Affordable Care Act (ACA) established the ACO programs. While the number of hospital mergers and the size of specialty-oriented physician groups increased after the ACA was passed, we found minimal evidence that consolidation was associated with ACO penetration at the market level or with physicians' participation in ACOs within markets. We conclude that payment reform has been associated with little acceleration in consolidation in addition to trends already under way, but there is evidence of potential defensive consolidation in response to new payment models.
- Published
- 2017
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49. Factors Associated with Reduced Medicare Spending in the Accountable Care Organization (ACO) Investment Model
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Betty Fout, J. Michael McWilliams, Sasha Brodsky, Matthew J. Trombley, Chao Zhou, Brant Morefield, and David J. Nyweide
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Finance ,business.industry ,Health Policy ,Accountable care ,Business ,Special Issue Abstracts ,Investment (macroeconomics) - Abstract
RESEARCH OBJECTIVE: The ACO Investment Model (AIM) was designed to encourage providers in rural or underserved areas to participate in the Medicare Shared Savings Program (SSP) by providing up‐front financial support for care transformation. In the second performance year, there were 41 ACOs that continued participation in AIM, with 423,434 beneficiaries assigned them. Our research objective was to determine whether the significant reductions in total Medicare spending we found in the first performance year were sustained in the second year, and whether specific ACO or market characteristics were associated with spending in both performance years. STUDY DESIGN: We utilized a difference‐in‐differences evaluation design to estimate differences in total spending between Medicare fee‐for‐service (FFS) beneficiaries attributed to AIM ACOs and comparison beneficiaries, before versus after the start of AIM. The comparison group included beneficiaries residing in each AIM ACO’s market who were eligible but not attributed to an ACO. Regression and weighting were used to adjust for demographic characteristics and health status. We stratified first and second performance year results based on ACO and market characteristics, including whether an ACO used a management company; partnered with a hospital; had fewer than 6,500 enrolled beneficiaries; was in the top quartile of rurality among AIM markets; had a discontinuous market; or had total Medicare spending at baseline that was above the median among all AIM markets. POPULATION STUDIED: Medicare FFS beneficiaries attributed to ACOs in AIM, which targeted ACO formation in rural/underserved areas in 2016 and 2017. PRINCIPAL FINDINGS: Across all 41 AIM ACOs, we estimated a significant reduction in total spending of $36.94 per beneficiary per month (PBPM) in the second performance year—a reduction of 3.5% and similar to findings from the first performance year. There were no significant differences in AIM impacts based on any of our six stratifications, but results across the two performance years suggest that greater reductions were achieved by ACOs working with a management company. CONCLUSIONS: ACOs participating in AIM sustained reductions in total Medicare spending across the first two performance years and across diverse ACO and market characteristics. IMPLICATIONS FOR POLICY OR PRACTICE: Results from the second performance year strengthen the evidence that ACOs can help reduce Medicare spending in rural or underserved areas. Among AIM markets, variations in market‐level baseline spending, market dispersion, and high rurality were not barriers to achieving spending reductions. ACOs locating in rural or underserved areas may benefit through partnership with a management company. PRIMARY FUNDING SOURCE: Centers for Medicare and Medicaid Services.
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- 2020
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50. Physician Organization and the Role of Workforce Turnover
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Michael E. Chernew, J. Michael McWilliams, and Hannah T. Neprash
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medicine.medical_specialty ,Quality management ,business.industry ,Ownership ,Personnel Turnover ,General Medicine ,Medicare ,United States ,Anesthesiology ,Family medicine ,Physicians ,Workforce ,Internal Medicine ,medicine ,Outpatient clinic ,Group Practice ,Hospital-Physician Joint Ventures ,business - Published
- 2020
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