Creating accountable care organizations: The extended hospital medical staff

Health Affairs

Volumn 26, Issue 1, 2007, Pages

  Fisher, Elliott S ^a,b   Staiger, Douglas O ^c,d,e   Bynum, Julie P W ^a   Gottlieb, Daniel J ^d  

^a DARTMOUTH MEDICAL SCHOOL   (United States)

^b VA MEDICAL CENTER   (United States)

^c Dartmouth College   (United States)

^d CECS ^*

^e NATIONAL BUREAU OF ECONOMIC RESEARCH   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

HEALTH CARE DELIVERY; HEALTH CARE POLICY; HEALTH CARE QUALITY; HEALTH INSURANCE; HUMAN; MEDICAL STAFF; MEDICARE; ORGANIZATION AND MANAGEMENT; REVIEW; SOCIAL BEHAVIOR; STANDARD; UNITED STATES;

DELIVERY OF HEALTH CARE; HEALTH CARE REFORM; HEALTH SERVICES ACCESSIBILITY; HUMANS; MANAGED COMPETITION; MEDICAL STAFF, HOSPITAL; MEDICARE; QUALITY ASSURANCE, HEALTH CARE; SOCIAL RESPONSIBILITY; UNITED STATES;

EID: 33846680355     PISSN: 02782715     EISSN: 02782715     Source Type: Journal    
DOI: 10.1377/hlthaff.26.1.w44     Document Type: Review

References (41)

1. For a summary of activities devoted to improving performance in health care, see Institute of Medicine, Performance Measurement: Accelerating Improvement (Washington: National Academies Press, 2006).
2. IOM, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academies Press, 2001);
3. E.A. Coleman and R.A. Berenson, "Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care," Annals of Internal Medicine 141, no. 7 (2004): 533-536;
4. and E.A. Coleman et al., "Posthospital Medication Discrepancies: Prevalence and Contributing Factors," Archives of Internal Medicine 165, no. 16 (2005): 1842-1847.
5. IOM, Performance Measurement.
6. Regarding the focus on physician groups, see F.J. Crosson, "The Delivery System Matters," Health Affairs 24, no. 6 (2005): 1543-1548;
7. and D.M. Lawrence, "Chronic Disease Care: Rearranging the Deck Chairs," Annals of Internal Medicine 143, no. 6 (2005): 458-459.
8. Regarding evidence of better performance, see S.M. Shortell et al., "An Empirical Assessment of High-Performing Medical Groups: Results from a National Study," Medical Care Research and Review 62, no. 4 (2005): 407-434.
9. Casalino reports that almost half of private practice physicians are in practiceswith one or two physicians, and 82 percent are in practices of nine or fewer. L.P. Casalino et al., "Benefits of and Barriers to Large Medical Group Practice in the United States," Archives of Internal Medicine 163, no. 16 (2003): 1958-1964.
10. The model was developed in pediatrics but has recently been extended to primary caremore generally. See B. Starfield and L. Shi, "The Medical Home, Access to Care, and Insurance: A Review of Evidence," Pediatrics 113, no. 5 Supp. (2004): 1493-1498;
11. and American College of Physicians, "The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care," 2006, http://www.acponline.org/hpp/adv_med.pdf (accessed 14 November 2006).
12. The idea of using the term "accountable care organizations" for the extended hospital medical staff or other organizations that could play similar roles (such as large multispecialty group practices) grew out of an exchange between Elliott Fisher and Glenn Hackbarth at a Medicare Payment Advisory Commission meeting in November 2006.
13. W.P. Welch, "Prospective Payment to Medical Staffs: A Proposal," Health Affairs 8, no. 1 (1989): 34-49;
14. W.P. Welch and M.E. Miller, "Proposals to Control High-Cost Hospital Medical Staffs," Health Affairs 13, no. 4 (1994): 42-57;
15. E.S. Fisher et al., "Hospital Readmission Rates for Cohorts of Medicare Beneficiaries in Boston and New Haven," New England Journal of Medicine 331, no. 15 (1994): 989-995;
16. J.E. Wennberg et al., "Use of Hospitals, Physician Visits, and Hospice Care during the Last Six Months of Life among Cohorts Loyal to Highly Respected Hospitals in the United States," British Medical Journal 328, no. 7440 (2004): 607;
17. and J.P.W. Bynum et al., "Assigning Ambulatory Patients and Their Physicians to Hospitals: A Method for Obtaining Population-Based Provider Performance Measurements," Health Services Research (published online 19 September 2006; 10.1111/j.1475-6773.2006.00633.x).
18. The assignment method draws on earlier efforts to assign patients to hospitals: See N.P. Roos, "Linking Patients to Hospitals: Defining Urban Hospital Service Populations," Medical Care 31, no. 5 Supp. (1993): YS6-YS15.
19. It was fully worked through using data from 1999 by Bynum and colleagues: See Bynum et al., "Assigning Ambulatory Patients." The methods presented here entail a slight modification that was found to improve the accuracy of assignment of physicians to hospitals: Instead of relying only on the admissions of assigned patients, we used all patients seen by a physician to determine the most likely hospital of admission.
20. Wennberg et al., "Use of Hospitals"; and J.E. Wennberg et al., "Evaluating the Efficiency of California Providers in Caring for Patients with Chronic Illnesses," Health Affairs 24 (2005): w526-w543 (published online 15 November 2005; 10.1377/hlthaff.w5.526).
21. For Exhibits 1-3, we restricted the analysis to the 4,163 hospitals with at least fifty ambulatory patients in 2003. For Exhibit 4, we included all physicians and hospitals with at least one assigned patient.
22. Although the figure of 62 percent might seem low to some, there is plausible variation across specialties - and many where outpatient practice is the rule. For example, 70 percent of 90,300 internists, but only 29 percent of 18,499 general practitioners, do inpatient work; 87 percent of 21,500 cardiologists do inpatient work, but only 16 percent of 29,900 psychiatrists do.
23. For this analysis, the proportion of work is defined based on the number of different individual patients for whom the physician bills.
24. E.S. Fisher et al., "The Implications of Regional Variations in Medicare Spending, Part 2: Health Outcomes and Satisfaction with Care," Annals of Internal Medicine 138, no. 4 (2003): 288-298;
25. E.S. Fisher et al., "Variations in the Longitudinal Efficiency of Academic Medical Centers," Health Affairs 23 (2004): VAR-19-VAR-32 (published online 7 October 2004; 10.1377/hlthaff.var.19);
26. and J.S. Skinner et al., "Is Technological Change in Medicine Always Worth It? The Case of Acute Myocardial Infarction," Health Affairs 25 (2006): w34-w47. Because many of the hospitals had small numbers of patients, we used empirical Bayes methods to reduce the impact of statistical noise on our 2000-02 measures and then ranked hospitals along each dimension.
27. To remove the effects on spending due to regional variations in policy payments (such as graduate medical education) and wages, we assigned a single national price to each diagnosis-related group (DRG). We used a similar process for physician services, based on the Medicare-assigned relative value unit for each procedure code on the physician claims.
28. See, for example, E.C. Schneider et al., "National Quality Monitoring of Medicare Health Plans: The Relationship between Enrollees' Reports and the Quality of Clinical Care," Medical Care 39, no. 12 (2001): 1313-1325;
29. and Shortell, "An Empirical Assessment."
30. T.P. Hofer et al., "The Unreliability of Individual Physician 'Report Cards' for Assessing the Costs and Quality of Care of a Chronic Disease," Journal of the American Medical Association 281, no. 22 (1999): 2098-2105.
31. J.E. Wennberg, E.S. Fisher, and J.S. Skinner, "Geography and the Debate over Medicare Reform," Health Affairs 21 (2002): w96-w114 (published online 13 February 2002; 10.1377/hlthaff.w2.96);
32. and Fisher et al., "Variations in the Longitudinal Efficiency."
33. Regarding patients' preferences, see R.S. Pritchard et al., "Influence of Patient Preferences and Local Health System Characteristics on the Place of Death," Journal of the American Geriatrics Society 46, no. 10 (1998): 1242-1250.
34. Regarding practice patterns, see B.E. Sirovich et al., "Variation in the Tendency of Primary Care Physicians to Intervene," Archives of Internal Medicine 165, no. 19 (2005): 2252-2256.
35. R.A. Berenson, P.B. Ginsburg, and J.H. May, "Hospital-Physician Relations: Cooperation, Competition, or Separation?" Health Affairs 26, no. 1 (2007): w31-w43 (published online 5 December 2006; 10.1377/hlthaff.26.1.w31).
36. Barriers to increased physician integration include both antitrust and physician self-referral regulations (Stark laws). See L.P. Casalino, "The Federal Trade Commission, Clinical Integration, and the Organization of Physician Practice," Journal of Health Politics, Policy and Law 31, no. 3 (2006): 569-585;
37. and M. Reynolds, "Stark Realities for Hospitals," Healthcare Financial Management 58, no. 9 (2004): 50-55.
38. J.E. Wennberg et al., The Care of Patients with Severe Chronic Illness: An Online Report on the Medicare Program by the Dartmouth Atlas Project, 2006, http://www.dartmouthatlas.org/atlases/ 2006_Chronic_Care_Atlas.pdf (accessed 14 November 2006).
39. Centers for Medicare and Medicaid Services, "Medicare Begins Performance-Based Payments for Physician Groups," Press Release, 31 January 2005, http://www.cms.hhs.gov/apps/media/press/release.asp? Counter=1341 (accessed 14 November 2006).
40. CMS, "CMS Demonstration Program Supports Physician-Hospital Collaborations to Improve Quality of Care while Getting Better Value," Press Release, 6 September 2006, http://www.cms.hhs.gov/apps/media/press/ release.asp?Counter=1957 (accessed 14 November 2006).
41. Deficit Reduction Act of 2005, P.L. 109-171 (8 February 2006).