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BACKGROUND AND OBJECTIVES Physician management companies (PMCs) acquire physician practices and contract with hospitals to provide physician management services. We evaluated the association between PMC-NICU affiliations and prices, spending, utilization, and clinical outcomes. METHODS We linked commercial claims to PMC-NICU affiliations and conducted difference- in-differences analyses comparing changes in prices paid for physician services per critical or intensive care NICU day, length of the NICU stay, physician spending (total paid amount for physician services during stay), spending on hospital services (total paid amount for hospital services during stay), and clinical outcomes in PMC-affiliated versus non-PMC–affiliated NICUs. The study included 2858 infants admitted to 34 PMC-affiliated NICUs and 92 461 infants admitted to 2348 NICUs without an affiliation. RESULTS PMC affiliation was associated with a differential increase in the mean price of the 5 most common types of critical and intensive care days in NICU admissions by $313 per day (95% confidence interval, $207–$419) for PMC-affiliated versus non- PMC-affiliated NICUs. This represents a 70.4% increase in prices, relative to the preaffiliation period PMC and non- PMC-affiliated NICU means. PMC-NICU affiliation was also associated with a differential increase in physician spending by $5161 per NICU stay (95% confidence interval, $3062–$7260), a 56.4% increase. There was no significant association between PMC-NICU affiliation and changes in length of stay, clinical outcomes, or hospital spending. CONCLUSIONS PMC affiliation was associated with large increases in prices and total spending for NICU services, but not with changes in length of stay or adverse clinical outcomes.

Physician management companies (PMCs), often backed by private equity (PE), are increasingly providing staffing and management services to health care facilities, yet little is known of their influence on prices.To study changes in prices paid to practitioners (anesthesiologists and certified registered nurse anesthetists) before and after an outpatient facility contracted with a PMC.This retrospective cohort study used difference-in-differences methods to compare price changes before and after a facility contracted with a PMC with facilities that did not and to compare differences between PMCs with and without PE investment. Commercial claims data (2012-2017) from 3 large national insurers in the Health Care Cost Institute database were combined with a novel data set of PMC facility contracts to identify prices paid to anesthesia practitioners in hospital outpatient departments and ambulatory surgery centers. The cohort included 2992 facilities that never contracted with a PMC and 672 facilities that contracted with a PMC between 2012 and 2017, collectively representing 2 255 933 anesthesia claims.Temporal variation in facility-level exposure to PMC contracts for anesthesia services.Main outcomes were (1) allowed amounts and the unit price (allowed amounts standardized per unit of service) paid to anesthesia practitioners; and (2) the probability that a practitioner was out of network.From before to after the PMC contract period, allowed amounts increased by 16.5% (+$116.39; 95% CI, $76.11 to $156.67; P .001), and the unit price increased by 18.7% (+$18.79; 95% CI, $12.73 to $24.84; P .001) in PMC facilities relative to non-PMC facilities. Results did not show evidence that anesthesia practitioners were moved out of network (+2.25; 95% CI, -2.56 to 7.06; P .36). In subsample analyses, PMCs without PE investment increased allowed amounts by 12.9% (+$89.88; 95% CI, $42.07 to $137.69; P .001), while PE-backed PMCs (representing half of the PMCs in the sample) increased allowed amounts by 26.0% ($187.06; 95% CI, $133.59 to $240.52; P .001). Similar price increases were observed for unit prices.In this cohort study, prices paid to anesthesia practitioners increased after hospital outpatient departments and ambulatory surgery centers contracted with a PMC and were substantially higher if the PMC received PE investment. This research provides insights into the role of corporate ownership in health care relevant to policy makers, payers, practitioners, and patients.

Physicians’ professional ethics require that they put patients’ interests ahead of their own and that they should allocate limited medical resources efficiently. Understanding physicians’ extent of adherence to these principles requires understanding the social preferences that lie behind them. These social preferences may be divided into two qualitatively different trade-offs: the trade-off between self and other (altruism) and the trade-off between reducing differences in payoffs (equality) and increasing total payoffs (efficiency). We experimentally measure social preferences among a nationwide sample of practicing physicians in the United States. Our design allows us to distinguish empirically between altruism and equality–efficiency orientation and to accurately measure both trade-offs at the level of the individual subject. We further compare the experimentally measured social preferences of physicians with those of a representative sample of Americans, an “elite” subsample of Americans, and a nationwide sample of medical students. We find that physicians’ altruism stands out. Although most physicians place a greater weight on self than on other, the share of physicians who place a greater weight on other than on self is twice as large as for all other samples—32% as compared with 15 to 17%. Subjects in the general population are the closest to physicians in terms of altruism. The higher altruism among physicians compared with the other samples cannot be explained by income or age differences. By contrast, physicians’ preferences regarding equality–efficiency orientation are not meaningfully different from those of the general sample and elite subsample and are less efficiency oriented than medical students.

Private equity firms have increasingly acquired physician practices, and particularly dermatology practices. Analyzing commercial claims from the Health Care Cost Institute (2012–17), we used a dif...

Background Medicare’s Merit-based Incentive Payment System (MIPS) is a major value-based purchasing program. Little is known about how physician practice leaders view the program and its benefits and challenges. Objective To understand practice leaders’ perceptions of MIPS. Design and Participants Interviews were conducted from December 12, 2019, to June 23, 2020, with leaders of 30 physician practices of various sizes and specialties across the USA. Practices were randomly selected using the Medical Group Management Association’s membership database. Practices included small primary care and general surgery practices (1–9 physicians); medium primary care and general surgery practices (10–25 physicians); and large multispecialty practices (50 or more physicians). Participants were asked about their perceptions of MIPS measures; the program’s effect on patient care; administrative burden; and rationale for participation. Main Measures Major themes related to practice participation in MIPS. Key Results Interviews were conducted with 30 practices representing all US census regions. Six major themes emerged: (1) MIPS is understood as a continuation of previous value-based payment programs and a precursor to future programs; (2) measures are more relevant to primary care practices than other specialties; (3) leaders are conflicted on whether the program improves patient care; (4) MIPS creates a substantial administrative burden, exacerbated by annual programmatic changes; (5) incentives are small relative to the effort needed to participate; and (6) external support for participation can be helpful. Many participants indicated that their practice only participated in MIPS to avoid financial penalties; some reported that physicians cared for fewer patients due to the program’s administrative burden. Conclusions Practice leaders reported several challenges related to MIPS, including irrelevant measures, administrative burden, frequent programmatic changes, and small incentives. They held mixed views on whether the program improves patient care. These findings may be useful to policymakers hoping to improve MIPS. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-021-06758-w.

Background More fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with more subsequent healthcare utilization (such as more tests, procedures, emergency department visits, and hospitalizations) than less fragmented ambulatory care. It is not known if race and socioeconomic status are associated with fragmented ambulatory care. Methods We conducted a longitudinal analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, using the REGARDS baseline visit plus the first year of follow-up. We included participants ≥65 years old, who had linked fee-for-service Medicare claims, and ≥ 4 ambulatory visits in the first year of follow-up. We used Tobit regression to determine the associations between race, annual household income, and educational attainment at baseline and fragmentation score in the subsequent year (as measured with the reversed Bice-Boxerman Index). Covariates included other demographic characteristics, medical conditions, medication use, health behaviors, and psychosocial variables. Additional analyses categorized visits by the type of provider (primary care vs. specialist). Results The study participants (N = 6799) had an average age of 73.0 years, 53% were female, and 30% were black. Nearly half had low annual household income (p Conclusions Among Medicare beneficiaries, blacks had less fragmented ambulatory care than whites, due to lower utilization of specialty care. Future research is needed to determine the effect of fragmented care on health outcomes for blacks and whites.

Background Previous studies have suggested that highly fragmented ambulatory care increases the risk of subsequent hospitalization, but those studies used claims only and were not able to adjust for many clinical potential confounders. Objective The objective of this study was to determine the association between fragmented ambulatory care and subsequent hospitalization, adjusting for demographics, medical conditions, medications, health behaviors, psychosocial variables, and physiological variables. Design Longitudinal analysis of data (2003-2016) from the nationwide REasons for Geographic And Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims. Subjects A total of 12,693 Medicare beneficiaries 65 years and older from the REGARDS study who had at least 4 ambulatory visits in the first year of observation and did not have a hospitalization in the prior year. Measures We defined high fragmentation as a reversed Bice-Boxerman score above the 75th percentile. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and incident hospitalization in the 3 months following each exposure period. Results The mean age was 70.4 years; 54% were women, and 33% were African American. During the first year of observation, participants with high fragmentation had a median of 8 ambulatory visits with 6 providers, whereas participants with low fragmentation had a median of 7 visits with 3 providers. Over 11.8 years of follow-up, 6947 participants (55%) had a hospitalization. High fragmentation was associated with an increased hazard of hospitalization (adjusted hazard ratio=1.18; 95% confidence interval: 1.12, 1.24). Conclusion Highly fragmented ambulatory care is an independent risk factor for hospitalization.

To assess the cross-sectional relationship between prices paid to physicians by commercial insurers and the provision of low-value services.Observational study design using Health Care Cost Institute claims representing 3 large national commercial insurers.The main outcome was count of 19 potential low-value services in 2014. The secondary outcome was total spending on the low-value services. Independent variables of interest were price quintiles based on each physician's mean geographically adjusted price of a mid-level office visit, the most commonly billed service by general internal medicine (GIM) physicians. We estimated the association between physician price quintile and provision of low-value services via negative binomial or generalized linear models with adjustments for measure, region, and patient and physician characteristics.This study included 750,452 commercially insured patients attributed to 28,951 GIM physicians. In 2014, the mean geographically adjusted price for physicians in the highest price quintile was $122.6 vs $54.7 for physicians in the lowest quintile ($67.9 difference; 95% CI, $67.5-$68.3). Relative to patients attributed to the lowest-priced physicians, those attributed to the highest-priced physicians received 3.6, or 22.9%, fewer low-value services per 100 patients (95% CI, 2.7-4.7 services per 100 patients). Spending on low-value services attributed to the highest-priced physicians was 10.9% higher ($520 difference per 100 patients; 95% CI, $167-$872).Commercially insured patients of high-priced physicians received fewer low-value services, although spending on low-value services was higher. More research is needed to understand why high-priced providers deliver fewer low-value services and whether physician prices are correlated with other measures of quality.

Primary care "teamlets" in which a staff member and physician consistently work together might provide a simple, cost-effective way to improve care, with or without insertion within a team.To determine the prevalence and performance of teamlets and teams.Cross-sectional observational study linking survey responses to Medicare claims.Six hundred eighty-eight general internists and family physicians.Based on survey responses, physicians were assigned to one of four teamlet/team categories (e.g., teamlet/no team) and, in secondary analyses, to one of eight teamlet/team categories that classified teamlets into high, medium, and low collaboration as perceived by the physician (e.g., teamlet perceived-high collaboration/no team).Descriptive: percentage of physicians in teamlet/team categories.physician burnout; ambulatory care sensitive emergency department and hospital admissions; Medicare spending.77.4% of physicians practiced in teamlets; 36.7% in teams. Of the four categories, 49.1% practiced in the teamlet/no team category; 28.3% in the teamlet/team category; 8.4% in no teamlet/team; 14.1% in no teamlet/no team. 15.7%, 47.4%, and 14.4% of physicians practiced in perceived high-, medium-, and low-collaboration teamlets. Physicians who practiced neither in a teamlet nor in a team had significantly lower rates of burnout compared to the three teamlet/team categories. There were no consistent, significant differences in outcomes or Medicare spending by teamlet/team or teamlet perceived-collaboration/team categories compared to no teamlet/no team, for Medicare beneficiaries in general or for dual-eligible beneficiaries.Most general internists and family physicians practice in teamlets, and some practice in teams, but neither practicing in a teamlet, in a team, or in the two together was associated with lower physician burnout, better outcomes for patients, or lower Medicare spending. Further study is indicated to investigate whether certain types of teamlet, teams, or teamlets within teams can achieve higher performance.

Despite reports of a physician burnout epidemic, there is little research on the relationship between burnout and objective measures of care outcomes and no research on the relationship between burnout and costs of care. Linking survey data from 1,064 family physicians to Medicare claims, we found no consistent statistically significant relationship between seven categories of self-reported burnout and measures of ambulatory care–sensitive admissions, ambulatory care–sensitive emergency department visits, readmissions, or costs. The coefficients for ambulatory care–sensitive admissions and readmissions for all burnout levels, compared with never being burned out, were consistently negative (fewer ambulatory care–sensitive admissions and readmissions), suggesting that, counterintuitively, physicians who report burnout may nevertheless be able to create better outcomes for their patients. Even if true, this hypothesis should not indicate that physician burnout is beneficial or that efforts to reduce physician burnout are unimportant. Our findings suggest that the relationship between burnout and outcomes is complex and requires further investigation.

To improve health care quality and decrease costs, both the public and private sectors continue to make substantial investments in the transformation of primary care. Central to these efforts is th...

The growth of private equity investment in health care has dramatically changed the landscape of health care delivery over the past decade. Private equity firms are rapidly acquiring physician prac...

We analyzed the relationship between prices paid to 30,549 general internal medicine physicians and the cost and quality of care for 769,281 commercially insured adults. The highest-price physician...

Managed care plans often attempt to control health care costs through strategies designed to decrease health care utilization. However, the extent to which the resulting patterns of utilization represent high-quality care (compared to fee-for-service products) remains controversial. The authors sought to compare patterns of ambulatory care (including how diffuse or fragmented the care patterns were) for Medicaid fee-for-service beneficiaries vs. Medicaid managed care beneficiaries. A serial cross-sectional study of adults (≥18 years old) was conducted using statewide Medicaid claims from New York State for calendar years 2010-2013. Beneficiaries were required to be continuously enrolled and have ≥4 ambulatory visits for each year they contributed data, yielding a sample of more than 1 million beneficiaries per year. Beneficiaries were characterized by age, sex, and case mix. For each year, ambulatory care patterns were compared across subgroups of beneficiaries using Poisson models (for numbers of visits and providers) and bounded Tobit models (for fragmentation scores). In 2010, among those who were not dual eligible, managed care beneficiaries had on average fewer visits (10.9 visits vs. 11.4 visits [

ImportanceThe 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.ObjectiveTo examine whether primary care physicians’ MIPS scores are associated with performance on process and outcome measures.Design, Setting, and ParticipantsCross-sectional study of 80 246 US primary care physicians participating in the MIPS program in 2019.ExposuresMIPS score.Main Outcomes and MeasuresThe association between physician MIPS scores and performance on 5 unadjusted process measures, 6 adjusted outcome measures, and a composite outcome measure.ResultsThe 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 1c screening (84.6% vs 89.4%; difference, −4.8 percentage points [95% CI, −5.4 to −4.2]; P P P = .045] and tobacco screening (95.0% vs 94.1%; difference, 0.9 percentage points [95% CI, 0.3 to 1.5]; P = .001). MIPS scores were inconsistently associated with risk-adjusted patient outcomes: compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly better mean performance on 1 outcome (307.6 vs 316.4 emergency department visits per 1000 patients; difference, −8.9 [95% CI, −13.7 to −4.1]; P P Conclusions and RelevanceAmong US primary care physicians in 2019, MIPS scores were inconsistently associated with performance on process and outcome measures. These findings suggest that the MIPS program may be ineffective at measuring and incentivizing quality improvement among US physicians.

Key Points Question Is private equity acquisition of nursing homes associated with the quality or cost of care for long-stay nursing home residents? Findings In this cohort study with difference-in-differences analysis of 9864 US nursing homes, including 9632 residents in 302 nursing homes acquired by private equity firms and 249 771 residents in 9562 other for-profit nursing homes without private equity ownership, private equity acquisition of nursing homes was associated with higher costs and increases in emergency department visits and hospitalizations for ambulatory sensitive conditions. Meaning This study suggests that more stringent oversight and reporting on private equity ownership of nursing homes may be warranted., Importance Private equity firms have been acquiring US nursing homes; an estimated 5% of US nursing homes are owned by private equity firms. Objective To examine the association of private equity acquisition of nursing homes with the quality and cost of care for long-stay residents. Design, Setting, and Participants In this cohort study of 302 private equity nursing homes with 9632 residents and 9562 other for-profit homes with 249 771 residents, a novel national database of private equity nursing home acquisitions was merged with Medicare claims and Minimum Data Set assessments for the period from 2012 to 2018. Changes in outcomes for residents in private equity–acquired nursing homes were compared with changes for residents in other for-profit nursing homes. Analyses were performed from March 25 to June 23, 2021. Exposure Private equity acquisitions of 302 nursing homes between 2013 and 2017. Main Outcomes and Measures This study used difference-in-differences analysis to examine the association of private equity acquisition of nursing homes with outcomes. Primary outcomes were quarterly measures of emergency department visits and hospitalizations for ambulatory care–sensitive (ACS) conditions and total quarterly Medicare costs. Antipsychotic use, pressure ulcers, and severe pain were examined in secondary analyses. Results Of the 259 403 residents in the study (170 687 women [65.8%]; 211 154 White residents [81.4%]; 204 928 residents [79.0%] dually eligible for Medicare and Medicaid; mean [SD] age, 79.3 [5.6] years), 9632 residents were in 302 private equity–acquired nursing homes and 249 771 residents were in 9562 other for-profit homes. The mean quarterly rate of ACS emergency department visits was 14.1% (336 072 of 2 383 491), and the mean quarterly rate of ACS hospitalizations was 17.3% (412 344 of 2 383 491); mean (SD) total quarterly costs were $8050.00 ($9.90). Residents of private equity nursing homes experienced relative increases in ACS emergency department visits of 11.1% (1.7 of 15.3; 1.7 percentage points; 95% CI, 0.3-3.0 percentage points; P = .02) and in ACS hospitalizations of 8.7% (1.0 of 11.5; 1.0 percentage point; 95% CI, 0.2-1.1 percentage points; P = .003) compared with residents in other for-profit homes; quarterly costs increased 3.9% (270.37 of 6972.04; $270.37; 95% CI, $41.53-$499.20; P = .02) or $1081 annually per resident. Private equity acquisition was not significantly associated with antipsychotic use (−0.2 percentage points; 95% CI, −1.7 to 1.4 percentage points; P = .83), severe pain (0.2 percentage points; 95% CI, −1.1 to 1.4 percentage points; P = .79), or pressure ulcers (0.5 percentage points; 95% CI, −0.4 to 1.3 percentage points; P = .30). Conclusions and Relevance This cohort study with difference-in-differences analysis found that private equity acquisition of nursing homes was associated with increases in ACS emergency department visits and hospitalizations and higher Medicare costs., This cohort study uses a national database of private equity nursing home acquisitions as well as Medicare data to examine the association of private equity acquisition of nursing homes with the quality and cost of care for long-stay residents.

Key Points Question How much variation in Medicare per beneficiary spending across counties was associated with social determinants of health (SDoH)? Findings In this cross-sectional study, SDoH were associated with 37.7% of variation in price-adjusted Medicare per beneficiary spending between counties in the highest and lowest quintiles of spending in 2017, including both direct contributions and indirect contributions through other factors. SDoH’s direct contribution accounted for 5.8% of the variation after controlling for patient demographic characteristics, clinical risk, and supply of health care resources. Meaning These findings suggest that addressing SDoH is important for reducing geographic spending variation and improving the value of health care., This cross-sectional study examines the association of social determinants of health with variation in Medicare per beneficiary spending at the county level., Importance Despite substantial geographic variation in Medicare per beneficiary spending in the US, little is known about the extent to which social determinants of health (SDoH) are associated with this variation. Objective To determine the associations between SDoH and county-level price-adjusted Medicare per beneficiary spending. Design, Setting, and Participants This cross-sectional study used county-level data on 2017 Medicare fee-for-service (FFS) spending, patient demographic characteristics (eg, age and gender) and clinical risk score, supply of health care resources (eg, number of hospital beds), and SDoH measures (eg, median income and unemployment rate) from multiple sources. Multivariable regressions were used to estimate the association of the variation in spending across quintiles with SDoH. Main Outcomes and Measures 2017 county-level price-adjusted Medicare Parts A and B spending per beneficiary. SDoH measures included socioeconomic position, race/ethnicity, social relationships, and residential and community context. Results Among 3038 counties with 33 495 776 Medicare FFS beneficiaries (18 352 336 [54.8%] women; mean [SD] age, 72 [1.5] years), mean Medicare price-adjusted per beneficiary spending for counties in the highest spending quintile was $3785 (95% CI, $3706-$3862) higher, or 49% higher, than spending for bottom-quintile counties (mean [SD] spending per beneficiary, $11 464 [735] vs $7679 [522]; P

Objective To quantify the impact of two approaches (directed and query-based) to health information exchange (HIE) on potentially avoidable use of health care services. Data sources/study setting Data on ambulatory care providers' adoption of HIE were merged with Medicare fee-for-service claims from 2008 to 2014. Providers were from 13 counties in New York served by the Rochester Regional Health Information Organization (RHIO). Study design Linear regression models with provider and year fixed effects were used to estimate changes in the probability of utilization outcomes for Medicare beneficiaries attributed to providers adopting directed and/or query-based HIE compared with beneficiaries attributed to providers who had not adopted HIE. Data collection Providers' HIE adoption status was determined through Rochester RHIO registration records. RHIO and claims data were linked via National Provider Identifiers. Principal findings Query-based HIE adoption was associated with a 0.2 percentage point reduction in the probability of an ambulatory care sensitive hospitalization and a 1.1 percentage point decrease in the likelihood of an unplanned readmission. Directed HIE adoption was not associated with any outcome. Conclusions The Centers for Medicare & Medicaid Services' (CMS) EHR certification criteria includes requirements for directed HIE, but not query-based HIE. Pending further research, certification criteria should place equal weight on facilitating query-based and directed exchange.

Background More fragmented ambulatory care (ie, care spread across many providers without a dominant provider) has been associated with excess emergency department and inpatient care. We sought to determine whether more fragmented ambulatory care is associated with an increase in the hazard of incident stroke, overall and stratified by health status and by race. Methods and Results We conducted a secondary analysis of data from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study (2003–2016), including participants aged ≥65 years who had linked Medicare fee‐for‐service claims and no history of stroke (N=12 510). We measured fragmentation of care with the reversed Bice‐Boxerman index. We used Poisson models to determine the association between fragmentation and adjudicated incident stroke. The average age of participants was 70.5 years; 53% were women, 32% were Black participants, and 16% were participants with fair or poor health. Overall, the adjusted rate of incident stroke was similar for high versus low fragmentation (8.2 versus 8.1 per 1000 person‐years, respectively; P =0.89). Among participants with fair or poor self‐rated health, having high versus low fragmentation was associated with a trend toward a higher adjusted rate of incident strokes (14.8 versus 10.4 per 1000 person‐years, respectively; P =0.067). Among Black participants with fair or poor self‐rated health, having high versus low fragmentation was associated with a higher adjusted rate of strokes (19.3 versus 10.3 per 1000 person‐years, respectively; P =0.02). Conclusions Highly fragmented ambulatory care is independently associated with incident stroke among Black individuals with fair or poor health.

The growing use of artificial intelligence (AI) in health care has raised questions about who should be held liable for medical errors that result from care delivered jointly by physicians and algorithms. In this survey study comparing views of physicians and the U.S. public, we find that the public is significantly more likely to believe that physicians should be held responsible when an error occurs during care delivered with medical AI, though the majority of both physicians and the public hold this view (66.0% vs 57.3%; P = .020). Physicians are more likely than the public to believe that vendors (43.8% vs 32.9%; P = .004) and healthcare organizations should be liable for AI-related medical errors (29.2% vs 22.6%; P = .05). Views of medical liability did not differ by clinical specialty. Among the general public, younger people are more likely to hold nearly all parties liable.

IMPORTANCE: Several states have passed surprise-billing legislation to protect patients from unanticipated out-of-network medical bills, yet little is known about how state laws influence out-of-network prices and whether spillovers exist to in-network prices. OBJECTIVE: To identify any changes in prices paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists before and after states passed surprise-billing legislation. DESIGN, SETTING, AND PARTICIPANTS: This retrospective economic analysis used difference-in-differences methods to compare price changes before and after the passage of legislation in California, Florida, and New York, which passed comprehensive surprise-billing legislation between January 1, 2014, and December 31, 2017, to 45 states that did not. Commercial claims data from the Health Care Cost Institute were used to identify prices paid to anesthesiologists in hospital outpatient departments and ambulatory surgery centers. The final analytic sample comprised 2 713 913 anesthesia claims across the 3 treated states and the 45 control states. EXPOSURES: Temporal and state-level variation in exposure to surprise-billing legislation. MAIN OUTCOMES AND MEASURES: The unit price (allowed amounts standardized per unit of service) paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists. RESULTS: This retrospective economic analysis of 2 713 913 anesthesia claims found that after surprise-billing laws were passed in 3 states, the unit price paid to out-of-network anesthesiologists at in-network facilities decreased significantly in 2 of them: California, −$12.71 (95% CI, −$25.70 to −$0.27; P = .05) and Florida, −$35.67 (95% CI, −$46.27 to −$25.07; P

Key Points Question Compared with other nursing homes, are private equity (PE)–owned nursing homes associated with better or worse coronavirus disease 2019 (COVID-19) outcomes? Findings In this cross-sectional study of 11 470 US nursing homes, there were no statistically significant differences in staffing levels, COVID-19 cases or deaths, or deaths from any cause between PE nursing homes and facilities with other ownership types. Compared with PE, all other ownership types were more likely to have at least a 1-week supply of N95 masks and medical gowns. Meaning In this study, PE-owned nursing homes performed comparably with for-profit and nonprofit nursing homes based on COVID-19 cases and deaths and deaths by any cause but had less personal protective equipment than other nursing homes., This cross-sectional study evaluates the comparative performance of private equity–owned nursing homes on coronavirus disease 2019 (COVID-19) outcomes., Importance It is not known whether nursing homes with private equity (PE) ownership have performed better or worse than other nursing homes during the coronavirus disease 2019 (COVID-19) pandemic. Objective To evaluate the comparative performance of PE-owned nursing homes on COVID-19 outcomes. Design, Setting, and Participants This cross-sectional study of 11 470 US nursing homes used the Nursing Home COVID-19 Public File from May 17, 2020, to July 2, 2020, to compare outcomes of PE-owned nursing homes with for-profit, nonprofit, and government-owned homes, adjusting for facility characteristics. Exposure Nursing home ownership status. Main Outcomes and Measures Self-reported number of COVID-19 cases and deaths and deaths by any cause per 1000 residents; possessing 1-week supplies of personal protective equipment (PPE); staffing shortages. Results Of 11 470 nursing homes, 7793 (67.9%) were for-profit; 2523 (22.0%), nonprofit; 511 (5.3%), government-owned; and 543 (4.7%), PE-owned; with mean (SD) COVID-19 cases per 1000 residents of 88.3 [2.1], 67.0 [3.8], 39.8 [7.6] and 110.8 [8.1], respectively. Mean (SD) COVID-19 deaths per 1000 residents were 61.9 [1.6], 66.4 [3.0], 56.2 [7.3], and 78.9 [5.9], respectively; mean deaths by any cause per 1000 residents were 78.1 [1.3], 91.5 [2.2], 67.6 [4.5], and 87.9 [4.8], respectively. In adjusted analyses, government-owned homes had 35.5 (95% CI, −69.2 to −1.8; P = .03) fewer COVID-19 cases per 1000 residents than PE-owned nursing homes. Cases in PE-owned nursing homes were not statistically different compared with for-profit and nonprofit facilities; nor were there statistically significant differences in COVID-19 deaths or deaths by any cause between PE-owned nursing homes and for-profit, nonprofit, and government-owned facilities. For-profit, nonprofit, and government-owned nursing homes were 10.5% (9.1 percentage points; 95% CI, 1.8 to 16.3 percentage points; P = .006), 15.0% (13.0 percentage points; 95% CI, 5.5 to 20.6 percentage points; P

This cross-sectional study examines the clinical and societal implications of the exansion of private equity in women’s health care.

BACKGROUND: Improving care for high-cost patients is increasingly important for improving the value of healthcare. Most prior research has focused on identifying patients with high costs, but the extent to which these costs are potentially preventable remains unclear. OBJECTIVE: To identify patients with persistent preventable utilization and compare their characteristics with high-cost patients. DESIGN: Descriptive analysis using Medicare claims data from 2013 to 2014. PARTICIPANTS: Medicare fee-for-service and dual-eligible beneficiaries (N = 515,689) from the New York metropolitan area who were continuously enrolled in Medicare Parts A and B in 2013 and 2014. MAIN MEASURES: The primary analysis focuses on patients with persistent preventable utilization (at least one preventable emergency department visit, hospitalization, or 30-day readmission in both 2013 and 2014) and high-cost patients in 2014 (top 10% of total annual spending). We compared demographic, medical, behavioral, and social characteristics and total and preventable healthcare utilization between these two groups. KEY RESULTS: Patients with persistent preventable utilization accounted for 4.8% of the overall patient population, 13.4% of overall costs, but 46.2% of preventable costs among all Medicare patients. Compared with high-cost patients, patients with persistent preventable utilization had lower median healthcare costs ($33,383 vs. $56,552), but their median potentially preventable costs were seven times higher ($7151 vs. $928). We also found that 1.9% of patients could be categorized in both the persistent preventable utilization group and the high-cost group. This subset of patients had the highest median Medicare costs and preventable costs and represented over 30% of total preventable spending and 9.4% of overall costs among all Medicare patients. CONCLUSION: Designing and targeting interventions for patients with persistent preventable utilization may offer an important opportunity to reduce unnecessary utilization and promote high-value care. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-06068-7) contains supplementary material, which is available to authorized users.

The growth of private equity investment in health care has dramatically changed the landscape of health care delivery over the past decade. Private equity firms are rapidly acquiring physician practices, with ophthalmology practices being one of the most frequently acquired types. We present perspectives from thirty-five semistructured interviews conducted with a wide range of knowledgeable people on private equity investment in physician practices, with a specific focus on ophthalmology. Acquisition by a private equity firm can be an attractive option for physicians, particularly older ones. However, interviewees had starkly conflicting perspectives on the likely impact of private equity acquisitions on the cost, quality, and use of medical care.

We analyzed the relationship between prices paid to 30,549 general internal medicine physicians and the cost and quality of care for 769,281 commercially insured adults. The highest-price physicians were paid more than twice as much per service, on average, as the lowest-price physicians were. Total annual costs for patients of the highest-price physicians were $996 (20 percent) higher than costs for patients of the lowest-price physicians were, and this variation was not explained by differences in use. Physician prices were not associated with quality: Among physicians in the same hospital referral region, we did not find significant differences between patients of the highest-price physicians and patients of lowest-price physicians in the likelihood of experiencing an ambulatory care-sensitive hospitalization or being readmitted within thirty days of hospital discharge. There were also no differences between the highest- and lowest-price physicians for these quality outcomes for high-need patients. Policy makers need more information on the causes and consequences of the large disparities in prices paid to physicians.

BACKGROUND: Whether patients’ reports of gaps in care coordination reflect clinically significant problems is unclear. OBJECTIVE: To determine any association between patient-reported gaps in care coordination and patient-reported preventable adverse outcomes. DESIGN AND PARTICIPANTS: We administered a cross-sectional survey on experiences with healthcare to participants in the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who were ≥ 65 years old. Of the 15,817 participants in REGARDS at the time of our survey (August 2017–November 2018), 11,138 completed the survey. We restricted the sample to participants who reported ≥ 2 ambulatory visits and ≥ 2 ambulatory providers in the past year (N = 7568). MAIN MEASURES: We considered 7 gaps in ambulatory care coordination, elicited with previously validated questions. We considered 4 outcomes: (1) a test that was repeated because the doctor did not have the result of the first test, (2) a drug-drug interaction that occurred due to multiple prescribers, (3) an emergency department visit that could have been prevented by better communication among providers, and (4) a hospital admission that could have been prevented by better communication among providers. We used logistic regression to determine the association between ≥ 1 gap in care coordination and ≥ 1 preventable outcome, adjusting for potential confounders. KEY RESULTS: The average age of the sample was 77.0 years; 55% were female, and 34% were African-American. More than one-third of participants (38.1%) reported ≥ 1 gap in care coordination and nearly one-tenth (9.8%) reported ≥ 1 preventable outcome. Having ≥ 1 gap in care coordination was associated with an increased odds of ≥ 1 preventable outcome (adjusted odds ratio 1.55; 95% confidence interval 1.33, 1.81). CONCLUSIONS: Participants’ reports of gaps in care coordination were associated with an increased odds of preventable adverse outcomes. Future interventions should leverage patients’ observations to detect and resolve gaps in care coordination. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-06047-y) contains supplementary material, which is available to authorized users.

BACKGROUND: Highly fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with excess tests, procedures, emergency department visits, and hospitalizations. Whether fragmented care is associated with worse health outcomes, or whether any association varies with health status, is unclear. OBJECTIVE: To determine whether fragmented care is associated with the risk of incident coronary heart disease (CHD) events, overall and stratified by self-rated general health. DESIGN AND PARTICIPANTS: We conducted a secondary analysis of the nationwide prospective Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study (2003–2016). We included participants who were ≥ 65 years old, had linked Medicare fee-for-service claims, and had no history of CHD (N = 10,556). MAIN MEASURES: We measured fragmentation with the reversed Bice-Boxerman Index. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and adjudicated incident CHD events in the 3 months following each exposure period. KEY RESULTS: The mean age was 70 years; 57% were women, and 34% were African-American. Over 11.8 years of follow-up, 569 participants had CHD events. Overall, the adjusted hazard ratio (HR) for the association between high fragmentation and incident CHD events was 1.14 (95% confidence interval (CI) 0.92, 1.39). Among those with very good or good self-rated health, high fragmentation was associated with an increased hazard of CHD events (adjusted HR 1.35; 95% CI 1.06, 1.73; p = 0.01). Among those with fair or poor self-rated health, high fragmentation was associated with a trend toward a decreased hazard of CHD events (adjusted HR 0.54; 95% CI 0.29, 1.01; p = 0.052). There was no association among those with excellent self-rated health. CONCLUSION: High fragmentation was associated with an increased independent risk of incident CHD events among those with very good or good self-rated health. SUPPLEMENTARY INFORMATION: The online version of this article (10.1007/s11606-020-06305-z) contains supplementary material, which is available to authorized users.

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

Nearly one-fifth of hospitalized Medicare fee-for-service beneficiaries are readmitted within 30 days. Participation in the Meaningful Use initiative among outpatient physicians may reduce readmissions.To evaluate the impact of outpatient physicians' participation in Meaningful Use on readmissions.The study population included 90,774 Medicare fee-for-service beneficiaries from New York State (2010-2012). We compared changes in the adjusted odds of readmission for patients of physicians who participated in Meaningful Use-stage 1, before and after attestation as meaningful users, with concurrent patients of matched control physicians who used paper records or electronic health records without Meaningful Use participation. Three secondary analyses were conducted: (1) limited to patients with 3+ Elixhauser comorbidities; (2) limited to patients with conditions used by Medicare to penalize hospitals with high readmission rates (acute myocardial infarction, congestive heart failure, and pneumonia); and (3) using only patients of physicians with electronic health records who were not meaningful users as the controls.Thirty-day readmission.Patients of Meaningful Use physicians had 6% lower odds of readmission compared with patients of physicians who were not meaningful users, but the estimate was not statistically significant (odds ratio: 0.94, 95% confidence interval, 0.88-1.01). Estimated odds ratios from secondary analyses were broadly consistent with our primary analysis.Physician participation in Meaningful Use was not associated with reduced readmissions. Additional studies are warranted to see if readmissions decline in future stages of Meaningful Use where more emphasis is placed on health information exchange and outcomes.

Structural integration is increasing among medical groups, but whether these changes yield care that is more integrated remains unclear. We explored the relationships between structural integration characteristics of 144 medical groups and perceptions of integrated care among their patients. Patients’ perceptions were measured by a validated national survey of 3,067 Medicare beneficiaries with multiple chronic conditions across six domains that reflect knowledge and support of, and communication with, the patient. Medical groups’ structural characteristics were taken from the National Study of Physician Organizations and included practice size, specialty mix, technological capabilities, and care management processes. Patients’ survey responses were most favorable for the domain of test result communication and least favorable for the domain of provider support for medication and home health management. Medical groups’ characteristics were not consistently associated with patients’ perceptions of integrate...

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) may accelerate the movement of physicians into corporate employment by hospitals and, to a lesser extent, by health insurers and other corporations. This article briefly summarizes the demographics of US physician practice, the potential advantages and disadvantages of physician employment by large corporations, and the evidence to date on the performance of large versus small physician practices and hospital-employed versus independent physicians. It describes the features of MACRA likely to lead physicians to seek corporate employment and the steps the Centers for Medicare and Medicaid Services has taken through MACRA to aid small independent physician practices. I conclude that MACRA's net effect is likely to be accelerated corporate employment of physicians and that there is an urgent need for more evidence on the impact of different types of provider organization on the quality and cost of care, and on patient, physician, and staff experience.