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Background: Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail. Methods: This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~ 43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~ 6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data. Conclusions: This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk. Trial registration: The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023. [ABSTRACT FROM AUTHOR]

Over the past 20 years, much attention has been paid to health care prices and the role they play in driving high health care spending in the US.[1] This is in no small part due to the 2003 paper by Anderson et al. entitled "It's the Prices, Stupid: Why the United States is So Different from Other Countries",[2] and the follow-up paper in 2019 entitled "It's Still The Prices, Stupid: Why The US Spends So Much On Health Care, And A Tribute To Uwe Reinhardt".[3] In this issue, Mehrotra et al.[4] take on the issue of how differences in prices I at the medical group level i may contribute to differences in spending using data for the non-elderly population commercially insured by the United Health Group. With relatively limited cost sharing,[11] patients may be using other criteria to make decisions about whether and where to get inpatient and specialty care. [Extracted from the article]

Introduction: This paper describes the development of "Swedish Guidelines for OSA treatment" and the underlying managed care process. The Apnea Hypopnea Index (AHI) is traditionally used as a single parameter for obstructive sleep apnea (OSA) severity classification, although poorly associated with symptomatology and outcome. We instead implement a novel matrix for shared treatment decisions based on available evidence. Methods: A national expert group including medical and dental specialists, nurses, and patient representatives developed the knowledge-driven management model. A Delphi round was performed amongst experts from all Swedish regions (N = 24). Evidence reflecting treatment effects was extracted from systematic reviews, meta-analyses, and randomized clinical trials. Results: The treatment decision in the process includes a matrix with five categories from a "very weak"" to "very strong" indication to treat, and it includes factors with potential influence on outcome, including (A) OSA-related symptoms, (B) cardiometabolic comorbidities, (C) frequency of respiratory events, and (D) age. OSA-related symptoms indicate a strong incitement to treat, whereas the absence of symptoms, age above 65 years, and no or well-controlled comorbidities indicate a weak treatment indication, irrespective of AHI. Conclusions: The novel treatment matrix is based on the effects of treatments rather than the actual frequency of respiratory events during sleep. A nationwide implementation of this matrix is ongoing, and the outcome is monitored in a prospective evaluation by means of the Swedish Sleep Apnea Registry (SESAR). [ABSTRACT FROM AUTHOR]

Many developed countries rely, to varying degrees, on competition among private health plans to obtain affordable and high-quality health insurance for their residents. Incorporating beneficiary-level competitive bidding into these healthcare systems can better align the incentives of these health plans, increase their willingness to enroll, and serve the sickest and most vulnerable patients while keeping costs manageable. We identify two digitally enabled program designs that allow private insurance plans to competitively bid to enroll individual beneficiaries. Compared with those used in existing entitlement programs, these designs always make a larger share of the beneficiary population profitable to enroll, thereby increasing willingness of the plans to enroll the most costly beneficiaries and improving access to care. On simulating the conditions of existing real-word healthcare entitlement programs, we found that these new designs actually tend to lower the tax burden in up to 83% of simulations. The research findings suggest that these new designs hold great promise in achieving the dual aim of improved access and lower costs. We believe that findings from this research can guide policymakers implement policies that will enroll more beneficiaries and cost the taxpayers less. Healthcare entitlement programs in the United States represent a large and growing financial outlay for taxpayers. In the pursuit of operational efficiencies, program administrators often contract with private managed care organizations (MCOs) to procure insurance for beneficiaries. This, however, encourages MCOs to attract the healthiest beneficiaries and avoid the sickest, a phenomenon known as risk selection. This paper investigates whether risk selection can be mitigated with a mechanism where MCOs bid to enroll each individual beneficiary. Although procurement auctions have been studied extensively in the literature, extant research has rarely discussed individual-level bidding. Digitization can contribute to the development and introduction of efficient market structures and mechanisms for matching beneficiaries with appropriate MCOs. We model demand- and supply-side aspects in a two-sided insurance marketplace to examine three mechanisms, risk adjustment, bidding, and a mix of prospective payment and bidding, with and without reserve prices. Analytical results show that traditional risk adjustment cannot optimally be used to eliminate risk selection, whereas the bidding mechanisms eliminate it entirely. Mixed bidding eliminates risk selection at a strictly lower cost than pure bidding. The proposed mixed bidding approach is a new type of mechanism with preauction offers that strictly dominates the second-price auction without requiring additional assumptions. Numerical analysis shows bidding dominates risk adjustment in 75.1% of simulated parameter sets. Compared with risk adjustment, bidding secures coordinated care for 12.1% more allocated beneficiaries while lowering program costs by 9.2% and largely preserving MCO profits. This would amount to approximately $27.2 billion in Medicaid program savings. Sensitivity analysis reveals that the proposed bidding mechanism dominates in scenarios that closely resemble real-world healthcare entitlement environments. These results show that digital markets that enable individual-level auctions are a promising approach for achieving the dual aim of financial sustainability and expanded access to care for the most vulnerable. History: This paper has been accepted by Ravi Bapna, Martin Bichler, Bob Day, and Wolfgang Ketter, Senior Editors; and Liangfei Qiu, Associate Editor, for the Information Systems Research Special Section on Market Design and Analytics. Supplemental Material: The online appendix is available at https://doi.org/10.1287/isre.2021.1062. [ABSTRACT FROM AUTHOR]

This paper examines how the managerial labor market in nonprofit hospitals has adjusted to the financial pressures induced by HMO penetration. Using a panel of about 1,500 nonprofit hospitals over the period 1992-96, the authors find that top executive turnover increased following an increase in HMO penetration. Moreover, the increase in turnover was concentrated among the hospitals that had lower levels of economic profitability. While the link between top executive pay and for-profit performance measures was on average very weak, HMO penetration tightened that link: as HMO penetration increased, top executives were compensated more for improving the profitability of their hospitals. These results, while of limited economic magnitude, are qualitatively consistent with the view that HMO penetration has increased the weight assigned to for-profit performance in the management of not-for-profit hospitals. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to assess the organizational effectiveness of the introduction of a healthcare information system (electronic medical records and databases) in healthcare in Kazakhstan. Methods: The authors used a combination of 2 methods: expert assessment and strengths, weaknesses, opportunities, and threats (SWOT) analysis. SWOT analysis is a necessary element of research, constituting a mandatory preliminary stage both when drawing up strategic plans and for taking corrective measures in the future. The expert survey was conducted using 2 questionnaires. Results: The study involved 40 experts drawn from specialists in primary healthcare in Aktobe: 15 representatives of administrative and managerial personnel (chief doctors and their deputies, heads of medical statistics offices, organizational and methodological offices, and internal audit services) and 25 general practitioners. Conclusions: The following functional indicators of the medical and organizational effectiveness of the introduction of information systems in polyclinics were highlighted: first, improvement of administrative control, followed in descending order by registration and movement of medical documentation, statistical reporting and process results, and the cost of employees’ working time. There has been no reduction in financial costs, namely in terms of the costs of copying, delivery of information in paper form, technical equipment, and paper.

Objectives: We conducted a systematic review of studies reporting the direct healthcare costs of treating older adults with diagnosed Alzheimer disease and related dementias (ADRD) within private Medicare managed care plans., Study Design: A systematic review of all studies published in English reporting original empirical analyses of direct costs for older adults with ADRD in Medicare managed care., Methods: All papers indexed in PubMed or Web of Science reporting ADRD costs within Medicare managed care plans from 1983 through 2018 were identified and reviewed., Results: Despite the growth in Medicare managed care enrollment, only 9 papers report the costs of care for individuals with ADRD within these plans, and only 1 study reports data less than 10 years old. This limited literature reports wide ranges for ADRD-attributable costs, with estimates varying from $3738 to $8726 in annual prevalent costs and $8938 to $38,794 in 1-year immediate postdiagnosis incident costs. Reviewed studies also used varied study populations, case and cost ascertainment methods, and analytic methods, making cross-study comparisons difficult., Conclusions: The expected continued growth in Medicare managed care enrollment, coupled with the large and growing impact of ADRD on America's healthcare delivery and finance systems, requires more research on the cost of ADRD within managed care. This research should use more consistent approaches to identify ADRD prevalence and provide more detail regarding which components of care are included in analyses and how the costs of care are captured and measured.

Laborers Local 829 serves as a multi-employer health care provider for union construction members. The case focuses on accounting situations that might be faced on an audit engagement. The purpose of this case is to provide you with a realistic audit situation that requires you to think critically, plan and perform audit tests of investments and receivables, consider accounting issues related to receivables, and review and prepare audit working papers. Data for the case are based on an actual audit engagement performed by accounting practitioners. Names used, however, are fictitious. Investments consist of holdings similar to those of a mutual fund. Actual stock prices are used for the holdings. [ABSTRACT FROM AUTHOR]

This paper develops a multiple-period theoretical model of health maintenance organization (HMO) coverage of medical procedures as a function of HMO competition and a market's predisposition toward managed care. Previous empirical results regarding one laser procedure were not predicted by a single-period model. The new model predicts that more favorable predisposition toward managed care is positively associated with coverage of procedures for which coverage is discretionary. The empirical analysis in this paper focuses on 13 additional laser procedures. The new empirical findings are different from the previous findings and are more consistent with the hypotheses generated by the new theoretical model. (JEL Ill) [ABSTRACT FROM AUTHOR]

OBJECTIVES: This paper examines (1) the rate of plan switching among beneficiaries enrolled in a Medicaid managed long-term services and supports (MLTSS) program in Virginia, (2) barriers that prevent beneficiaries from changing plans, and (3) the extent to which a change in plans is associated with greater satisfaction with the current health plan. STUDY DESIGN: Survey data from a representative sample of 1048 members enrolled in Commonwealth Coordinated Care Plus, a Virginia Medicaid MLTSS program. METHODS: The survey ascertained whether beneficiaries changed plans at the previous open enrollment period, whether they wanted to change plans but did not, and reasons for not following through with a plan change. Logistic regression analysis examined the association between the intention to change plans and satisfaction with the current health plan. RESULTS: Seven percent of respondents changed plans during the previous open enrollment. However, twice as many respondents (15%) wanted to change plans but did not. The main reason for not changing plans was uncertainty about whether the new plan would meet their needs better than their current plan. Logistic regression analysis shows that an intention to change plans (realized or not) was associated with higher odds (3.5 times higher) of being dissatisfied with the current health plan compared with beneficiaries who had no intention to change plans. CONCLUSIONS: Greater dissatisfaction after a recent plan change may indicate that these members have specific needs beyond the scope of services offered by managed care organizations. [ABSTRACT FROM AUTHOR]

Policy makers (both public and private) are seeking ways to improve the value delivered within our health care system, that is, using fewer resources to provide the same benefit to patients, or using equivalent resources to provide more benefit. One strategy is to alter the predominant fee-for-service (FFS) economic incentives in the current system. To inform such policy changes, this paper identifies areas in which little is known about the effects of specific incentives (FFS, salary, etc.) on the two components of value: resource use and quality. Specific suggestions are offered regarding research that would be informative for policy makers, focusing on fundamental "building block" studies rather than overall evaluations of complex interventions, such as accountable care organizations. This research would better identify critical aspects of the FFS model and salary-based payments that are particularly problematic, as well as situations in which FFS or salary may be less problematic. The research would also explore when alternatives, such as episode-based payment might be feasible, or simply be hypothetical solutions. The availability of electronic health record-based data in various delivery systems would allow many of these studies to be accomplished in 3-5 years with budgets manageable by public and private funding sources. [ABSTRACT FROM AUTHOR]

Background: Ambulatory access to academic medical centers (AMCs) for patients insured with Medi-Cal (i.e., Medicaid in California) is understudied, particularly among the 85% of beneficiaries enrolled in managed care plans. As more AMCs develop partnerships with these plans, data on patient experiences of access to care and quality are needed to guide patient-centered improvements in care delivery. Methods: The authors conducted semi-structured, qualitative interviews with Medi-Cal-insured patients with initial visits at a large, urban AMC during 2022. Participant recruitment was informed by a database of ambulatory Medi-Cal encounters. The interview guide covered Medi-Cal enrollment, scheduling, and visit experience. Interviews were transcribed and inductively coded, then organized into themes across four domains: access, affordability, patient-provider interactions, and continuity. Results: Twenty participant interviews were completed (55% female, 85% English speaking, 80% self-identified minority or "other" race, and 30% Hispanic or Latino) with primary and/or specialty care visits. Within the access domain, participants reported delays with Medi-Cal enrollment and access to specialist care or testing, though appointment scheduling was reported to be easy. Affordability concerns included out-of-pocket medical and parking costs, and missed income when patients or families skipped work to facilitate care coordination. Participants considered clear, bilateral communication with providers fundamental to positive patient-provider interactions. Some participants perceived discrimination by providers based on their insurance status. Participants valued continuity, but experienced frustration arising from frequent and unexpected health plan changes that disrupted care with their established AMC providers. Conclusions: The missions of AMCs typically focus on clinical care, education, research, and equity. However, reports from Medi-Cal insured patients receiving care at AMCs highlight their stress and confusion related to inconsistent provider access, uncompensated costs, variability in perceptions of quality, and fragmented care. Recommendations based upon patient-reported concerns suggest opportunities for AMC health system-level improvements that are compatible with AMC missions. [ABSTRACT FROM AUTHOR]

Cownose rays (Rhinoptera bonasus) are schooling rays commonly displayed in large groups in public aquariums. They are long-lived, have an annual reproductive cycle, and readily breed in managed care with most pregnancies culminating with the unaided and successful birth of a single neonate. Occasionally, females are observed to have prolonged pregnancies or suffer dystocia during parturition and intervention via a cesarian section (C-section) is required to deliver the neonate. Monthly reproductive monitoring at Ripley's Aquarium of the Smokies using ultrasound to stage pregnancies allows for the prediction of anticipated due dates and guides the decision to assist with delivery. Recognizing when to assist birth and best practices for performing C-section are important for the reproductive health, sustainability, and longevity of this species in managed care. This report describes a surgical technique for C-section in cownose rays and includes short-term complications and longterm outcomes for females. [ABSTRACT FROM AUTHOR]

Primary care is widely viewed as being in crisis despite its purported central role in addressing population issues related to healthcare cost, quality, access, and equity. Despite this pivotal role, the nature of the clinical practice today has largely emerged by default. We review the evolution of clinical practice in primary care from its genesis in small practices with paper charts and telephonic patient communication to managed care, pay-for-performance, and today's era of the electronic medical record, value-based payment, and consumerism. We suggest a necessary "reset" of expectations that focuses on today's practice structure and the historic face-to-face patient care expectations. Only by doing so can we successfully meet the demands of patients, society, and practicing internists. [ABSTRACT FROM AUTHOR]

Reports on the American Society of Internal Medicine's (ASIM) release of a series of white papers aimed at providing recommendations to reinvent managed care. Use of recommendations to influence managed-care organizations; Contact information.

OBJECTIVES: Emergency department (ED) crowding poses a severe public health threat, and identifying acceptable means of treating medical conditions in alternative sites of care is imperative. We compared patients' experiences with in-home urgent care via mobile integrated health (MIH) vs urgent care provided in EDs. STUDY DESIGN: Survey, completed on paper, online, or by telephone. We surveyed all patients who received MIH care for an urgent health problem (n = 443) and consecutive patients who visited EDs for urgent care (n = 1436). METHODS: Study participants were members of a managed care plan who were dually eligible for Medicare and Medicaid, 21 years or older, and treated either by MIH or in an ED for nonemergent conditions around Boston, Massachusetts, between February 2017 and June 2018. The survey assessed patients' perceptions of their urgent care experiences. RESULTS: A total of 206 patients treated by community paramedics and 718 patients treated in EDs completed surveys (estimated 66% and 62% response rates, respectively). Patients treated by MIH perceived higher- quality care, more frequently reporting "excellent" (54.7%) or "very good" (32.4%) care compared with ED patients (40.7% and 24.3%, respectively; P < .0001), and were significantly more likely to report that decisions made about their care were "definitely right" compared with patients treated in the ED (66.1% vs 55.6%; P = .02). CONCLUSIONS: Patients appear satisfied with receiving paramedic-delivered urgent care in their homes rather than EDs, perceiving higher-quality care. This suggests that in-home urgent care via MIH may be acceptable for patients with nonemergent conditions. [ABSTRACT FROM AUTHOR]

This document provides an overview of the negative consequences of the prior authorization process in healthcare, which prioritizes cost containment over patient well-being. It presents case studies where patients experienced delays in receiving necessary treatments due to prior authorization denials, resulting in adverse outcomes. The article argues for reforms to prioritize patient care and discusses the challenges and regulations associated with prior authorizations. It also discusses the history and development of managed care and utilization management in the United States, highlighting the growth of health maintenance organizations (HMOs) and preferred provider organizations (PPOs). The document explores the impacts of prior authorization on healthcare costs and quality, as well as the timeframes and delays associated with the process. It questions the prioritization of contractual obligations over human life in coverage denials and suggests potential solutions to improve the prior authorization process. [Extracted from the article]

This paper provides an overview of trends associated with global health care leadership development. Accompanying these trends are propositions based on current available evidence. These testable propositions should be considered when designing, implementing, and evaluating global health care leadership development models and programs. One particular leadership development model, a multilevel identity model, is presented as a potential model to use for leadership development. Other, complementary approaches, such as positive psychology and empowerment strategies, are discussed in relation to leadership identity formation. Specific issues related to global leadership are reviewed, including cultural intelligence and global mindset. An example is given of a nurse leadership development model that has been empirically tested in Canada. Through formal practice-academic-community collaborations, this model has been locally adapted and is being used for nurse leader training in Hong Kong, Taiwan, and Brazil. Collaborative work is under way to adapt the model for interprofessional health care leadership development. [ABSTRACT FROM AUTHOR]

Objective. This paper uses a unique database to examine premiums paid by beneficiaries for Medigap supplemental coverage. Average premiums charged by insurers are reported, as well as premiums by enrollee age and gender, and additional policy characteristics. Marginal prices for Medigap benefits are estimated using hedonic price regressions. In addition, the paper considers how additional policy characteristics and geographic differences in the use and cost of medical care affect premiums. Data Sources/Study Setting. A comprehensive database on premiums paid by beneficiaries for newly issued Medigap policies in the year 2000 along with state-level characteristics. Study Design. Hedonic pricing equations are used to estimate implicit prices for Medigap benefits. Data Collection/Extraction Methods. The Centers for Medicare & Medicaid Services contracted for the creation of a detailed database on Medigap premiums. Data were collected in three stages. First, letters were sent directly to insurers requesting premium data. Second, letters were directly to state insurance commissioner's offices requesting premium data. Last, each state insurance commissioner's office was visited to collect missing data. Principal Findings. With the exceptions of the part B deductible and drug benefit, Medigap supplemental insurance is priced consistent with the actuarial value of benefits offered under the standardized plans. Premiums vary substantially based on rating method, whether the policy is guaranteed issue, Medigap Select, or explicitly for smokers. Premiums increase with enrollee age, but do not vary between men and women. The relationship between premiums and enrollee age varies across rating methods. Attained-age policies show the strongest relationship between age and premiums, while community-rated premiums, by definition, do not vary with age. Medigap supplemental insurance premiums are higher in states with poorer health, greater utilization, and greater managed care penetration. Conclusions. Despite the high cost, Medigap plans are generally priced in accordance with the actuarial value of benefits. The primary exception is the drug benefit, which appears to be subject to substantial adverse selection. Benefits such as the part B deductible and at-home recovery benefit offer little value to consumers. Several states require insurers to community rate premiums. Such regulation has important implications for premiums, and research needs to consider the impact of such regulation on the Medigap market. [ABSTRACT FROM AUTHOR]

Over the last 25 years, national Health Maintenance Organization (HMO) and hospital firms attempted to enter local markets, either by acquiring formerly independent, locally based HMOs and hospitals or by directly entering local markets. While national HMOs have been relatively successful, national hospital firms have had much less success. This paper explores the reasons for this difference. It reviews changes in presence of national HMO and hospital firms in markets, discusses common conceptual lenses through which national entry into local markets typically has been viewed, and shows how social network theory can be used to develop a better understanding of why the entry experience of national HMO and hospital firms varies across markets. The paper concludes with a research agenda that addresses issues raised by social network theory and its application to national firm entry into local markets. [ABSTRACT FROM AUTHOR]

Introduces a series of papers on consumer-driven health care in the U.S. Emergence of consumer-driven health plans; State of the health care industry; Consumer response to the plan; Advantages over other managed care plans.

Adapted from Chan's (2000) model depicting success of litigation, this paper argues that with the application of various legislation, health maintenance organizations' (HMOs') violations of service fairness to each group: enrollees, physicians, and hospitals give rise to each group's lawsuits against the HMOs. Various authors (Bowen et al., 1999; Seiders and Berry, 1998) indicate that justice concepts such as distributive, procedural, and interactional justice can be applied to the area of service fairness. The violation of these underlying justice principles with HMOs' service unfairness to enrollees, physicians, and hospitals is examined. A general synopsis of the ethical issues in the managed care industry is provided. The various lawsuits launched by each group: enrollees, physicians, and hospitals together with the key statutes used are discussed. This paper also highlights the provisions and ramifications of the 11 April 2000 landmark agreement that Aetna made with Texas Attorney General John Cornyn to settle the 1998 lawsuit brought against the company. Lastly, the current ethical issues in the managed care industry are further discussed. The value of this paper can be adapted to the study of organizations' service fairness violations in other industries or in the educational, governmental, and not-for-profit sectors both nationally and internationally. [ABSTRACT FROM AUTHOR]

Within the past few years, managed care health insurance programs have become commonplace. With managed care programs, however, physicians are facing increasing ethical pressures. This paper examines the relationship between physicians' behavior intentions with respect to four managed care ethical scenarios and their responses to Forsyth's (1980) Ethics Position Questionnaire (EPQ). This is one of the first papers to compare this scale to behavioral intentions in the workplace. We provide a literature review of the ethical dilemmas that doctors face under a managed care system and conduct a national random sample of general practitioners and surgeons regarding the four managed care ethical dilemmas. The results show that the doctors surveyed are significantly more idealistic than relativistic. In relating the EPQ to the ethical scenarios, however, there was no support for the proposition that ethical ideology was related to the ethical behavioral intentions. This suggests more research is needed to establish the links between ethical positions, attitudes, and behavioral intentions. Finally, there were little differences in EPQ scores by practice or demographic variables, the only significant result being that general surgeons are significantly more idealistic than family practitioners. [ABSTRACT FROM AUTHOR]

Background: With declines in development assistance for health and growing interest in country ownership, donors are increasingly faced with the task of transitioning health programs to local actors towards a path to sustainability. Yet there is little available guidance on how to measure and evaluate the success of a transition and its subsequent effects. This study assesses the transition of the Avahan HIV/AIDS prevention program in India to investigate how preparations for transition affected continuation of program activities post-transition., Methods: Two rounds of two surveys were conducted and supplemented by data from government and Avahan Computerized Management Information Systems (CMIS). Exploratory factor analysis was used to develop two measures: 1) transition readiness pre-transition, and 2) institutionalization (i.e. integration of initial program systems into organizational procedures and behaviors) post-transition. A fixed effects model was built to examine changes in key program delivery outcomes over time. An ordinary least square regression was used to assess the relationship between transition readiness and sustainability of service outcomes both directly, and indirectly through institutionalization., Results: Transition readiness data revealed 3 factors (capacity, alignment and communication), on a 15-item scale with adequate internal consistency (alpha 0.73). Institutionalization was modeled as a unidimensional construct, and a 12-item scale demonstrated moderate internal consistency (alpha 0.60). Coverage of key populations and condom distribution were sustained compared to pre-transition levels (p<0.01). Transition readiness, but not institutionalization, predicted sustained outcomes post-transition. Transition readiness did not necessarily lead to institutionalization of key program elements one year after transition., Conclusion: Greater preparedness prior to transition is important to achieve better service delivery outcomes post-transition. This paper illustrates a methodology to measure transition readiness pre-transition to identify less ready organizations or program components in advance, improving the likelihood of service sustainability. Further research is needed around the conceptualization and development of measures of institutionalization and its effects on long-term program sustainability.

Objectives: Prior studies found that tiered provider networks channel patients to preferred providers in certain contexts. This paper evaluates whether the effects of tiered physician networks vary for different types of patients., Study Design: Cross-sectional analysis of fiscal year 2009 to 2010 administrative enrollment and claims data on nonelderly beneficiaries in Massachusetts Group Insurance Commission health plans., Methods: Main outcome measures are physician market share among new patients and the percent of physician's patients who switch away. We utilized estimated fixed effects linear regression models that were stratified by patient characteristics., Results: Physicians with the worst tier rankings had lower market share among new patients who are older and sicker, or male, representing losses in market share of 10% and 15%, respectively, than other tiered physicians. A poor tier ranking did not affect physician market share of new patients who are female or younger. There was no effect of a physician's tier ranking on the proportion of patients who switch to other doctors among any groups of patients., Conclusions: Loyalty to their own physicians is pervasive across groups of patients. Physicians with poor tier rankings lost market share among new patients who are older and sicker, and among new male patients. Together, these findings suggest that tiered network designs have the potential for the greatest impact on value in healthcare over time, as more patients seek new relationships with physicians.