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Importance: Increasing integration across medical services may have important implications for health care quality and spending. One major but poorly understood dimension of integration is between physician organizations and pharmacies for self-administered drugs or in-house pharmacies., Objective: To describe trends in the use of in-house pharmacies, associated physician organization characteristics, and associated drug prices., Design, Setting, and Participants: A cross-sectional study was conducted from calendar years 2011 to 2019. Participants included 20% of beneficiaries enrolled in fee-for-service Medicare Parts A, B, and D. Data analysis was performed from September 15, 2020, to December 20, 2023., Exposures: Prescriptions filled by in-house pharmacies., Main Outcomes and Measures: The share of Medicare Part D spending filled by in-house pharmacies by drug class, costliness, and specialty was evaluated. Growth in the number of physician organizations and physicians in organizations with in-house pharmacies was measured in 5 specialties: medical oncology, urology, infectious disease, gastroenterology, and rheumatology. Characteristics of physician organizations with in-house pharmacies and drug prices at in-house vs other pharmacies are described., Results: Among 8 020 652 patients (median age, 72 [IQR, 66-81] years; 4 570 114 [57.0%] women), there was substantial growth in the share of Medicare Part D spending on high-cost drugs filled at in-house pharmacies from 2011 to 2019, including oral anticancer treatments (from 10% to 34%), antivirals (from 12% to 20%), and immunosuppressants (from 2% to 9%). By 2019, 63% of medical oncologists, 20% of urologists, 29% of infectious disease specialists, 21% of gastroenterologists, and 22% of rheumatologists were in organizations with specialty-relevant in-house pharmacies. Larger organizations had a greater likelihood of having an in-house pharmacy (0.75 percentage point increase [95% CI, 0.56-0.94] per each additional physician), as did organizations owning hospitals enrolled in the 340B Drug Discount Program (10.91 percentage point increased likelihood [95% CI, 6.33-15.48]). Point-of-sale prices for high-cost drugs were 1.76% [95% CI, 1.66%-1.87%] lower at in-house vs other pharmacies., Conclusions and Relevance: In this cross-sectional study of physician organization-operated pharmacies, in-house pharmacies were increasingly used from 2011 to 2019, especially for high-cost drugs, potentially associated with organizations' financial incentives. In-house pharmacies offered high-cost drugs at lower prices, in contrast to findings of integration in other contexts, but their growth highlights a need to understand implications for patient care.

Importance: Vertical relationships (eg, ownership or affiliations, including joint contracting) between physicians and health systems are increasing in the US., Objective: To analyze how vertical relationships between primary care physicians (PCPs) and large health systems are associated with changes in ambulatory and acute care utilization, referral patterns, readmissions, and total medical spending for commercially insured individuals., Design, Setting, and Participants: This case-control study with a repeated cross-section, stacked event design analyzed outcomes of patients whose attributed PCP entered a vertical relationship with a large health care system in 2015 or 2017 compared with patients whose attributed PCP was either never or always in a vertical relationship with a large health system from 2013 to 2017 in the state of Massachusetts. The sample consisted of commercially insured patients who met enrollment criteria and who were attributed to PCPs who were included in the Massachusetts Provider Database in 2013, 2015, and 2017 and for whom vertical relationships were measured. Enrollee and claims data were obtained from the 2013 to 2017 Massachusetts All-Payer Claims Database. Statistical analyses were conducted between January 5, 2021, and June 5, 2023., Exposure: Evaluation-and-management visit with attributed PCP in 2015 to 2017., Main Outcomes and Measures: Outcomes (which were measured per patient-year [ie, per patient per year from January to December] in this sample) were utilization (count of specialist physician visits, emergency department [ED] visits, and hospitalizations overall and within attributed PCP's health system), spending (total medical expenditures and use of high-price hospitals), and readmissions (readmission rate and use of hospitals with a low readmission rate)., Results: The sample of 4 030 224 observations included 2 147 303 females (53.3%) and 1 881 921 males (46.7%) with a mean (SD) age of 35.07 (19.95) years. Vertical relationships between PCPs and large health systems were associated with an increase of 0.69 (95% CI, 0.34-1.04; P < .001) in specialist visits per patient-year, a 22.64% increase vs the comparison group mean of 3.06 visits, and a $356.67 (95% CI, $77.16-$636.18; P = .01) increase in total medical expenditures per patient-year, a 6.26% increase vs the comparison group mean of $5700.07. Within the health care system of the attributed PCPs, the number of specialist visits changed by 0.80 (95% CI, 0.56-1.05) per patient year (P < .001), a 29.38% increase vs the comparison group mean of 2.73 specialist visits per patient-year. The number of ED visits changed by 0.02 (95% CI, 0.01-0.03) per patient year (P = .001), a 14.19% increase over the comparison group mean of 0.15 ED visits per patient-year. The number of hospitalizations changed by 0.01 (95% CI, 0.00-0.01) per patient-year (P < .001), a 22.36% increase over the comparison group mean of 0.03 hospitalizations per patient-year. There were no differences in readmission outcomes., Conclusions: Results of this case-control study suggest that vertical relationships between PCPs and large health systems were associated with steering of patients into health systems and increased spending on patient care, but no difference in readmissions was found.

Vertical integration in health care has recently garnered scrutiny by antitrust authorities and state regulators. We examined trends, geographic variation, and price effects of vertical integration and joint contracting between physicians and hospitals, using physician affiliations and all-payer claims data from Massachusetts from the period 2013-17. Vertical integration and joint contracting with small and medium health systems rose from 19.5 percent in 2013 to 32.8 percent in 2017 for primary care physicians and from 26.1 percent to 37.8 percent for specialists. Vertical integration and joint contracting with large health systems slightly declined, whereas geographic variation in these physician affiliations rose. We found that vertical integration and joint contracting led to price increases from 2013 to 2017, from 2.1 percent to 12.0 percent for primary care physicians and from 0.7 percent to 6.0 percent for specialists, with the greatest increases seen in large health systems. These findings can inform policy makers seeking to limit growth in health care prices.

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

Importance: Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally., Objective: To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians., Design, Setting, and Participants: Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019., Main Outcomes and Measures: Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades., Results: This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions., Conclusions and Relevance: The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.

With the Merit-Based Incentive Payment System, Medicare shifts from payment based on macroeconomic indicators to relying on physician- or group-level indicators of cost and quality--and could create a large fee differential between high- and low-performing physicians.

Objective: To assess whether patient choice of physician or health plan was affected by physician tier-rankings., Data Sources: Administrative claims and enrollment data on 171,581 nonelderly beneficiaries enrolled in Massachusetts Group Insurance Commission health plans that include a tiered physician network and who had an office visit with a tiered physician., Study Design: We estimate the impact of tier-rankings on physician market share within a plan of new patients and on the percent of a physician's patients who switch to other physicians with fixed effects regression models. The effect of tiering on consumer plan choice is estimated using logistic regression and a pre-post study design., Principal Findings: Physicians in the bottom (least-preferred) tier, particularly certain specialist physicians, had lower market share of new patient visits than physicians with higher tier-rankings. Patients whose physician was in the bottom tier were more likely to switch health plans. There was no effect of tier-ranking on patients switching away from physicians whom they have seen previously., Conclusions: The effect of tiering appears to be among patients who choose new physicians and at the lower end of the distribution of tiered physicians, rather than moving patients to the "best" performers. These findings suggest strong loyalty of patients to physicians more likely to be considered their personal doctor., (© Health Research and Educational Trust.)

Public report cards with quality and cost information on physicians, physician groups, and hospital providers have proliferated in recent years. However, many of these report cards are difficult for consumers to interpret and have had little impact on the provider choices consumers are making. To gain a more focused understanding of why these reports cards have not been more successful and what improvements could be made, we interviewed experts and surveyed registrants at the March 2011 AHRQ National Summit on Public Reporting for Consumers in Health Care. We found broad agreement that public reporting has been disconnected from consumer decisions about providers because of weaknesses in report card content, design, and accessibility. Policy makers have an opportunity to change the landscape of public reporting by taking advantage of advances in measurement, data collection, and information technology to deliver a more consumer-centered report card. Overcoming the constraint of limited public funding, and achieving the acceptance of providers, is critical to realizing future success.

Objective: To analyze consumer awareness, use, and trust of a tiered provider network, which differentiates copayments by provider cost-efficiency and quality., Study Design: Mail survey of a plan-stratified random sample of individuals in health plans offered by the Massachusetts Group Insurance Commission., Methods: Pearson's chi2 tests and multinomial logistic regression were used to analyze the effect of demographics and other characteristics on consumer awareness, understanding, trust, and use of a tiered provider network., Results: Half (49.5%) of respondents reported prior knowledge of the tiered networks in their health plan. Whites, respondents who saw a specialist in the last year, and respondents who used the Internet for health information were more likely to be aware of the tiers. A majority of respondents either did not trust (35.5%) or did not know whether they trusted (22.5%) the tiers to tell them which physicians were better than others. Nineteen percent of respondents reported knowing which tier one of their physicians was in; of this group, 50.1% learned this information at or after their first visit. Respondents who learned their physician's tier before the first visit were more likely to find this information important to their decision to see that physician (60.5% vs 39.5%; P <.01)., Conclusions: These findings suggest use of tiered networks to direct consumers to preferred providers requires increased consumer awareness and trust in the health plan as a source for provider rankings. Efforts targeting consumers before they decide to see a physician may be more successful.

Objectives: To assess the extent to which excluding physicians from a preferred provider organization (PPO) network causes patients to discontinue using their services and whether the associated changes will result in greater demand for emergency department or inpatient care., Study Design: Analysis of a natural experiment involving the narrowing of a PPO network operated by the Taft-Hartley Fund. The panel data analysis compared rates of patient discontinuation for excluded physicians before and after the change. The pre-post analysis used matched comparison groups for office visits, emergency department visits, inpatient admissions, and spending for affected patients., Methods: Claims data analysis used generalized estimating equations and controlled for patient age, sex, health status, and hourly wage. Models examining utilization and spending for 6187 patients who remained with excluded physicians also used a propensity score-matched comparison group identified from among patients who had never seen an excluded physician. Differential response to physician exclusion according to age, health status, and hourly wage was also examined through interaction terms., Results: The network narrowing reduced the odds of continuing to see an excluded physician (odds ratio, 0.18; P <.001). Patients who continued to see excluded physicians reduced their office visits by a mean of 0.9 visits per year, 0.8 visits more than comparison patients (P <.001). There were no significant changes in emergency department visits or admissions for patients of excluded physicians compared with a matched cohort., Conclusions: Substantial copayment differentials may be an effective means of encouraging patients to change physicians. Where they are based on reliable information about provider quality and cost, tiered networks may improve value.

Context: While there is debate over whether the U.S. is training too many physicians, many seem to agree that physicians are geographically maldistributed, with too few in rural areas., Objective: Official definitions of shortage areas assume the market for physician services is based on county boundaries. We wished to ascertain how the picture of a possible shortage changes using alternative measures of geographic access. We measure geographic access by the number of full-time equivalent physicians serving a community divided by the expected number of patients (possibly both from within the community and outside) receiving care from those physicians. Moreover, we wished to determine how the geographic distribution of physicians had changed since previous studies, in light of the large increase in physician numbers., Design: Cross-sectional data analyses of alternative measures of geographic access to physicians in 23 states with low physician-population ratios., Results: Between 1979 and 1999, the number of physicians doubled in the sample states. Although most specialties experienced greater diffusion everywhere, smaller specialties had not yet diffused to the smallest towns. Multiple measures of geographic access, including physician-to-population ratios, average distance traveled to the nearest physician, and projected average caseload per physician, confirm that residents of metropolitan areas have better geographic access to physicians. Physician-to-population ratios exhibit the largest degree of geographic disparity, but ratios in rural counties adjacent to metropolitan areas are smaller than in those not adjacent to metropolitan areas. Distance-traveled and caseload models that allow patients to cross county lines show less disparity and indicate that residents of isolated rural counties have less access than those living in counties adjacent to metropolitan areas., Conclusion: Geographic access to physicians has continued to improve over the past two decades, although some smaller specialties have not diffused to the most rural areas. While substantial variation in the supply of physicians across communities remains, current measures of geographic access to physicians overstate the extent of maldistribution and yield an incorrect ranking of areas according to geographic accessibility of physicians.

Why Do Physicians Pursue Cascades of Care After Incidental Findings? Census region data were not available for zip codes reported by 6 physicians in the sample SP ‡ sp Area-level education derived using the American Community Survey linked to physician-reported practice zip code. Of the remaining 41.4%, the most common reasons to pursue follow-up were practice/community norms (49.7%), concern about a lawsuit (35.7%), another doctor's advice (26.0%), and patient request (24.2%) (not mutually exclusive). [Extracted from the article]

While financial incentives to providers or patients are increasingly common as a quality improvement strategy, their impact on patient subgroups and health care disparities is unclear. To examine these patterns, we analyzed data from a randomized clinical trial of financial incentives to lower low-density lipoprotein (LDL) cholesterol levels in patients at risk for cardiovascular disease. Patients with higher baseline LDL experienced greater cholesterol reductions in the shared incentive arm (0.23 mg/dL per unit change in baseline LDL, 95% CI [-0.46, -0.00]) but were also less likely to have medication potency increases in the physician incentive arm ( OR = 0.98, 95% CI [0.97, 0.996]). Uninsured patients and those of race other than Black or White were less likely to have potency increases in the shared incentive arm ( OR = 0.15, 95% CI [0.03, 0.70] and OR = 0.09, 95% CI [0.01, 0.93], respectively). These findings suggest some differential response to incentives, particularly in the form of targeted medication changes. [ABSTRACT FROM AUTHOR]

Background: Team-based care is essential for delivering high-quality, comprehensive, and coordinated care. Despite considerable research about the effects of team-based care on patient outcomes, few studies have examined how team dynamics relate to provider outcomes. Purpose: The aim of this study was to examine relationships among team dynamics, primary care provider (PCP) clinical work satisfaction, and patient care coordination between PCPs in 18 Harvard-affiliated primary care practices participating in Harvard_s Academic Innovations Collaborative. Methodology: First, we administered a cross-sectional survey to all 548 PCPs (267 attending clinicians, 281 resident physicians) working at participating practices; 65% responded. We assessed the relationship of team dynamics with PCPs_ clinical work satisfaction and perception of patient care coordination between PCPs, respectively, and the potential mediating effect of patient care coordination on the relationship between team dynamics and work satisfaction. In addition, we embedded a qualitative evaluation within the quantitative evaluation to achieve a convergent mixed methods design to help us better understand our findings and illuminate relationships among key variables. Findings: Better team dynamics were positively associated with clinical work satisfaction and quality of patient care coordination between PCPs. Coordination partially mediated the relationship between team dynamics and satisfaction for attending clinicians, suggesting that higher satisfaction depends, in part, on better teamwork, yielding more coordinated patient care. We found no mediating effects for resident physicians. Qualitative results suggest that sources of satisfaction from positive team dynamics for PCPs may be most relevant to attending clinicians. Practice Implications: Improving primary care team dynamics could improve clinical work satisfaction among PCPs and patient care coordination between PCPs. In addition to improving outcomes that directly concern health care providers, efforts to improve aspects of team dynamics may also help resolve critical challenges in workforce planning in primary care. [ABSTRACT FROM AUTHOR]

Behavioral economics provides insights about the development of effective incentives for physicians to deliver high-value care. It suggests that the structure and delivery of incentives can shape behavior, as can thoughtful design of the decision-making environment. This article discusses several principles of behavioral economics, including inertia, loss aversion, choice overload, and relative social ranking. Whereas these principles have been applied to motivate personal health decisions, retirement planning, and savings behavior, they have been largely ignored in the design of physician incentive programs. Applying these principles to physician incentives can improve their effectiveness through better alignment with performance goals. Anecdotal examples of successful incentive programs that apply behavioral economics principles are provided, even as the authors recognize that its application to the design of physician incentives is largely untested, and many outstanding questions exist. Application and rigorous evaluation of infrastructure changes and incentives are needed to design payment systems that incentivize high-quality, cost-conscious care. [ABSTRACT FROM AUTHOR]

Despite more than a decade of benchmarking and public reporting of quality problems in the health care sector, changes in medical practice have been slow to materialize. To accelerate quality improvement, many private and public payers have begun to offer financial incentives to physicians and hospitals based on their performance on clinical and service quality measures. The authors review the empirical literature on paying for quality in health care and comparable interventions in other sectors. They find little evidence to support the effectiveness of paying for quality. The absence of findings for an effect may be attributable to the small size of the bonuses studied and the fact that payers often accounted for only a fraction of the targeted provider's panel. Even in nonhealth settings, however, where the institutional features are more favorable to a positive impact, the literature contains mixed results on the effectiveness of analogous pay-for-performance schemes. [ABSTRACT FROM AUTHOR]

Context The adoption of pay-for-performance mechanisms for quality improvement is growing rapidly. Although there is intense interest in and optimism about pay-for-performance programs, there is little published research on pay-for-performance in health care. Objective To evaluate the impact of a prototypical physician pay-for-performance program on quality of care. Design, Setting, and Participants We evaluated a natural experiment with pay-for-performance using administrative reports of physician group quality from a large health plan for an intervention group (California physician groups) and a contemporaneous comparison group (Pacific Northwest physician groups). Quality improvement reports were included from October 2001 through April 2004 issued to approximately 300 large physician organizations. Main Outcome Measures Three process measures of clinical quality: cervical cancer screening, mammography, and hemoglobin A1c testing. Results Improvements in clinical quality scores were as follows: for cervical cancer screening, 5.3% for California vs 1.7% for Pacific Northwest; for mammography, 1.9% vs 0.2%; and for hemoglobin A1c, 2.1% vs 2.1%. Compared with physician groups in the Pacific Northwest, the California network demonstrated greater quality improvement after the pay-for-performance intervention only in cervical cancer screening (a 3.6% difference in improvement [P = .02]). In total, the plan awarded $3.4 million (27% of the amount set aside) in bonus payments between July 2003 and April 2004, the first year of the program. For all 3 measures, physician groups with baseline performance at or above the performance threshold for receipt of a bonus improved the least but garnered the largest share of the bonus payments. Conclusion Paying clinicians to reach a common, fixed performance target may produce little gain in quality for the money spent and will largely reward those with higher performance at baseline. [ABSTRACT FROM AUTHOR]

Examines the evolution of physician organizations relative to the managed medical care and market power in United States. Evaluation on the structure and functions of physician organizations; Importance of local market conditions on the development of physician organizations; Characteristics of the health care market.

Examines the scale and structure of capitated physician organizations in California. Acceptance of capitated contracts and utilization management functions; Shares of revenue derived by the group; Risk of sharing with health maintenance organization.

The author reflects on the increasing misuse of health care resources in the U.S. He states that despite such use of healthcare facilities, people in the U.S. are still not living any longer or better than their respective counterparts in industrialized countries. An overview of the Patient Protection and Affordable Care Act of 2010 is offered. The author suggests that spending and clinical care, patient experience, and outcomes must be monitored physicians and government.

Background: Pay for performance has increasingly become the subject of intense interest and debate, both of which have been heightened as the Centers for Medicare and Medicaid Services moves closer to adopting this approach for Medicare. Although many claims have been made for the effectiveness of this approach, the extent of its national penetration remains unknown. Methods: We surveyed a sample of 252 health maintenance organizations (HMOs) (response rate, 96%) drawn from 41 metropolitan areas across the nation about use of pay for performance. We determined the prevalence of pay-for-performance programs, detailed the features of such programs, and examined the adoption of pay for performance as a function of the characteristics of both the health plans and markets. Results: More than half the HMOs, representing more than 80% of persons enrolled, use pay for performance in their provider contracts. Of the 126 health plans with pay-for-performance programs, nearly 90% had programs for physicians and 38% had programs for hospitals. Use of pay for performance was statistically associated with geographic region, use of primary care providers (PCPs) as gatekeepers, use of capitation to pay PCPs, and whether the plans themselves received bonuses or penalties according to performance. Conclusions: Pay for performance is now commonly used by HMOs, especially those that are situated to assign responsibility for a particular patient to a PCP or medical group. As the design of Medicare with pay for performance moves forward, it will be important to leverage the early experience of pay for performance in the commercial market. N Engl J Med 2006;355:1895-902. [ABSTRACT FROM AUTHOR]

BACKGROUND ANO OBJECTIVES: Ordering rates for imaging studies and procedures may change if clinicians are shown the prices of those tests while they are ordering. We studied the effect of 2 forms of paid price information, single median price and paired internal/ external median prices, on how often pediatric-focused and adult-oriented clinicians (most frequently general pediatricians and adult specialists caring for pediatric-aged patients, respectively) order imaging studies and procedures for 0- to 21-year-olds. METHODS: In January 2014, we randomized 227 pediatric-focused and 279 adult-oriented clinicians to 1 of 3 study arms: Control (no price display), Single Median Price, or Paired Internal/External Median Prices (both with price display in the ordering screen of electronic health record). We used 1-way analysis of variance and paired t tests to examine how frequently clinicians (1) placed orders and (2) designated tests to be completed internally within an accountable care organization. RESULTS: For pediatric-focused clinicians, there was no significant difference in the rates at which orders were placed or designated to be completed internally across the study arms. For adult-oriented clinicians caring for children and adolescents, however, those in the Single Price and Paired Price arms placed orders at significantly higher rates than those in the Control group (Control 3.2 [SD 4.8], Single Price 6.2 [SD 6.8], P < .001 and Paired Prices 5.2 [SD 7.9], P = .04). The rate at which adult-oriented clinicians designated tests to be completed internally was not significantly different across arms. CONCLUSIONS: The effect of price information on ordering rates appears to depend on whether the clinician is pediatric-focused or adult-oriented. [ABSTRACT FROM AUTHOR]