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BACKGROUND: During the 3rd year of medical school, clerkships provide essential clinical experiences. However, other aspects of patient care may be overlooked during this critical phase of medical education. Faced with the challenge of integrating 'orphan' topics central to effective and compassionate medical practice, medical schools have begun to develop interclerkships or intersessions. DESCRIPTION: The Dimensions of Clinical Medicine (DCM) interclerkship series at Creighton University included evidence-based medicine, sexuality in clinical medicine, palliative care, professionalism, cultural sensitivity/awareness, complementary and alternative medicine, bioterrorism, and clinical ethics. Each interclerkship comprises 2 half-day sessions conducted at the end of each clerkship rotation. EVALUATION: Students approved of the interclerkship format and valued the active learning strategies employed in the course. Many students felt the time allotted for each program was excessive. We describe educational issues and practical concerns that are central to an effective intersession program. CONCLUSION: The interclerkship format is a viable approach for incorporating orphan topics into the clinical curriculum. [ABSTRACT FROM AUTHOR]

BACKGROUND: Pharmaceutical sales representatives and direct-to-consumer advertising may influence physician practices, particularly prescribing. Identifying the relevant knowledge and attitudes students possess about the pharmaceutical industry may help professional curricula address these influences. PURPOSES: To assess knowledge and attitudes toward pharmaceutical industry marketing, ethical principles guiding drug company interactions, pharmaceutical sales representatives as a source of drug information, and confidence level in addressing consumers seeking a prescription from a direct-to-consumer advertisement among senior-level medical, PharmD, and nurse practitioner students. METHODS: A cross-sectional survey design was used to assess student knowledge and attitudes of four domains associated with the pharmaceutical industry. RESULTS: Significant deficiencies were noted in student knowledge of pharmaceutical marketing expenditures, professional ethics regarding interactions with drug companies, and accuracy of drug information from sales representatives. CONCLUSIONS: Health professional students' knowledge and attitudes toward the pharmaceutical industry are formed prior to graduation. Professional curricula must address the influences of sales representatives before postgraduate training. [ABSTRACT FROM AUTHOR]

This article describes a study in process of a prospective, randomized, controlled trial of 80 physicians in primary care office-based practices to determine the impact of drug information sources and prescription printing using personal digital assistants (PDAs) on the frequency of potential medication errors generated during prescribing. The intervention involves training physicians through case-based simulation to use electronically available clinical drug information during the prescribing process and entering and printing the prescriptions to a local printer by means of the PDA. Human and environmental factor assessment will be conducted to optimize technology and applications incorporation into the office environment. Physician perceptions of point-of-care clinical drug information resources and hand-held technology interfaced in the office environment is described. Expected outcomes are to reduce medication errors and build capacity to further reduce errors in office-based practice. Copyright © 2002 by Aspen Publishers, Inc. [ABSTRACT FROM AUTHOR]

The purpose of this project was to assess if providing physicians (house staff) with routine comprehensive social history information on their patients will improve patient outcomes. Comprehensive social history information was gathered over a 5-month period on 134 consecutive patients. Patients were randomized to have social history information provided or not provided to the resident physician caring for them. Outcomes of interest were: patient satisfaction, length of stay, and early unplanned readmission. Analysis was with analysis of covariance, controlling for patient severity of illness and amount of social history information documented by the house officer. Outcomes were the same for patients for whom house staff were provided social history information versus those for whom the information was not provided. The authors conclude that providing house staff with routine comprehensive social history information did not influence patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: To test the reliability of Medicare claims in measuring vertical integration. We assess the accuracy of a commonly used measure of integration, primary care physician (PCP) practices billing Medicare as a hospital outpatient department (HOPD) in claims., Data Sources and Study Setting: Medicare fee-for-service claims, IQVIA, and CPC+ practice surveys for this study., Study Design: We compare measures of integration from Medicare claims to self-reported indicators of integration from IQVIA and a survey of CPC+ participating practice sites., Data Collection/extraction Methods: We measure integration by using site-of-service billing in the 100% sample of Medicare Carrier claims from 2017-2020. In the IQVIA SK&A (2017-2018), OneKey (2019-2020), and practice survey data (2017-2019), we use self-reported responses to measure integration., Principal Findings: We find that currently most PCP practices sites that report themselves as being integrated with a health system do not bill as an HOPD. In 2017, 11% of CPC+ practices were identified as being vertically integrated in claims, while the equivalent numbers in SK&A and surveys were 52% and 54% integration, respectively. A t-test found that both datasets significantly differed from claims (Survey: 41.3%-45.1%; SK&A: 45.3%-51.1%); this gap persists in 2018-2019., Conclusion: Measuring physician-hospital vertical integration accurately is integral to determining consolidation. The overwhelming majority of PCP practice sites not billing as an HOPD may reflect Medicare regulatory changes that have reduced the financial incentives for doing so. These findings have implications for researchers that study the growth in PCP-hospital integration in health care markets., (© 2024 Health Research and Educational Trust.)

Background: Broader primary care practice range of services (ROS), defined as the diversity of professional services delivered, is associated with lower utilization. ROS provided by individual primary care physicians (PCPs) varies considerably with unclear implications for patients., Objectives: Create a PCP-ROS measure covering six categories of outpatient services, including expanded codes for mental health counseling services and point of care ultrasound (POCUS) technology in physician offices. Determine whether PCP-ROS is associated with total Medicare expenditures, inpatient admissions, acute hospital utilization (AHU), and emergency department (ED) visits. Examine physician and practice characteristics associated with PCP-ROS., Design: Retrospective cohort study., Participants: 4,569,711 Medicare fee-for-service beneficiaries and 27,008 PCPs observed during the evaluation of the Comprehensive Primary Care Plus (CPC +) initiative., Measurements: PCP-ROS, hospitalizations, AHU (includes observation stays as well as inpatient admissions), ED visits, and total Medicare expenditures., Results: Physicians varied substantially in the range of services provided. Broader PCP-ROS was significantly, independently associated with 1 - 3% lower Medicare expenditures (p ≤ 0.01), inpatient admissions (p ≤ 0.027), AHU (p ≤ 0.025), and ED visit rates (p ≤ 0.000). PCP-ROS score was associated with improved patient outcomes, independent of physician provision of procedures (such as laceration repair or skin excisions). Physicians in practice sites affiliated with a hospital or health system had narrower PCP-ROS than independent physicians by 0.3 to 0.4 (p < 0.001). Internal medicine specialty was associated with narrower PCP-ROS than family medicine by 0.3 (p < 0.001)., Conclusions: Patients cared for by primary care physicians who provide a broader range of services subsequently experience lower acute care utilization and expenditures than do those cared for by physicians with narrower ROS. Practice leaders and professional associations should consider how best to ensure that primary care physicians efficiently and effectively provide the office-based professional services most needed by their patients., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Purpose: Despite evidence suggesting that high-quality primary care can prevent unnecessary hospitalizations, many primary care practices face challenges in achieving this goal, and there is little guidance identifying effective strategies for reducing hospitalization rates. We aimed to understand how practices in the Comprehensive Primary Care Plus (CPC+) program substantially reduced their acute hospitalization rate (AHR) over 2 years., Methods: We used Bayesian analyses to identify the CPC+ practice sites having the highest probability of achieving a substantial reduction in the adjusted Medicare AHR between 2016 and 2018 (referred to here as AHR high performers). We then conducted telephone interviews with 64 respondents at 14 AHR high-performer sites and undertook within- and cross-case comparative analysis., Results: The 14 AHR high performers experienced a 6% average decrease (range, 4% to 11%) in their Medicare AHR over the 2-year period. They credited various care delivery activities aligned with 3 strategies for reducing AHR: (1) improving and promoting prompt access to primary care, (2) identifying patients at high risk for hospitalization and addressing their needs with enhanced care management, and (3) expanding the breadth and depth of services offered at the practice site. They also identified facilitators of these strategies: enhanced payments through CPC+, prior primary care practice transformation experience, use of data to identify high-value activities for patient subgroups, teamwork, and organizational support for innovation., Conclusions: The AHR high performers observed that strengthening the local primary care infrastructure through practice-driven, targeted changes in access, care management, and comprehensiveness of care can meaningfully reduce acute hospitalizations. Other primary care practices taking on the challenging work of reducing hospitalizations can learn from CPC+ practices and may consider similar strategies, selecting activities that fit their context, personnel, patient population, and available resources., (© 2023 Annals of Family Medicine, Inc.)

Objective: To examine whether primary care physician (PCP) comprehensiveness is associated with Medicare beneficiaries' overall rating of care from their PCP and staff., Data Sources: We linked Medicare claims with survey data from Medicare beneficiaries attributed to Comprehensive Primary Care Plus (CPC+) physicians and practices., Study Design: We performed regression analyses of the associations between two claims-based measures of PCP comprehensiveness in 2017 and beneficiaries' rating of care from their PCP and practice staff in 2018., Data Collection/extraction Methods: The analytic sample included 6228 beneficiaries cared for by 3898 PCPs. Regressions controlled for beneficiary, physician, practice, and market characteristics., Principal Findings: Beneficiaries with more comprehensive PCPs rated care from their PCP and practice staff higher than did those with less comprehensive PCPs. For each comprehensiveness measure, beneficiaries whose PCP was in the 75th percentile were more likely than beneficiaries whose PCP was in the 25th percentile to rate their care highly (2 percentage point difference, p = 0.02)., Conclusions: Medicare beneficiaries with more comprehensive PCPs rate overall care from their PCPs and staff higher than those with less comprehensive PCPs., (© 2022 Health Research and Educational Trust.)

Objectives: To develop two practice-site-level measures of comprehensiveness and examine their associations with patient outcomes, and how their performance differs from physician-level measures., Data Sources: Medicare fee-for-service claims., Study Design: We calculated practice-site-level comprehensiveness measures (new problem management and involvement in patient conditions) across 5286 primary care physicians (PCPs) at 1339 practices in the Comprehensive Primary Care initiative evaluation in 2013. We assessed their associations with practices' attributed beneficiaries' 2014 total Medicare expenditures, hospitalization rates, ED visit rates. We also examined variation in PCPs' comprehensiveness across PCPs within practices versus between primary care practices. Finally, we compared associations of practice-site and PCP-level measures with outcomes., Principal Findings: The measures had good variation across primary care practices, strong validity, and high reliability. Receiving primary care from a practice at the 75th versus 25th percentile on the involvement in patient conditions measure was associated with $21.93 (2.8%) lower total Medicare expenditures per beneficiary per month (P < .01). Receiving primary care from a practice at the 75th versus 25th percentile on the new problem management measure was associated with $14.77 (1.9%) lower total Medicare expenditures per beneficiary per month (P < .05); 8.84 (3.0%) fewer hospitalizations (P < .001), and 21.27 (3.1%) fewer ED visits per thousand beneficiaries per year (P < .01). PCP comprehensiveness varied more within than between practices., Conclusions: More comprehensive primary care practices had lower Medicare FFS expenditures, hospitalization, and ED visit rates. Both PCP and practice-site level comprehensiveness measures had strong construct and predictive validity; PCP-level measures were more precise., (© Health Research and Educational Trust.)

Physician consolidation into health systems increased in nearly all metropolitan statistical areas (MSAs) from 2016 to 2018. Of the 382 US MSAs, 113 had more than half of their physicians in health systems in 2018. Consolidation of physicians was most notable in the Midwest and Northeast and in small-to-midsize MSAs.

Objective: To examine system integration with physician specialties across markets and the association between local system characteristics and their patterns of physician integration., Data Sources: Data come from the AHRQ Compendium of US Health Systems and IQVIA OneKey database., Study Design: We examined the change from 2016 to 2018 in the percentage of physicians in systems, focusing on primary care and the 10 most numerous nonhospital-based specialties across the 382 metropolitan statistical areas (MSAs) in the US. We also categorized systems by ownership, mission, and payment program participation and examined how those characteristics were related to their patterns of physician integration in 2018., Data Collection/extraction Methods: We examined local healthcare markets (MSAs) and the hospitals and physicians that are part of integrated systems that operate in these markets. We characterized markets by hospital and insurer concentration and systems by type of ownership and by whether they have an academic medical center (AMC), a 340B hospital, or accountable care organization., Principal Findings: Between 2016 and 2018, system participation increased for primary care and the 10 other physician specialties we examined. In 2018, physicians in specialties associated with lucrative hospital services were the most commonly integrated with systems including hematology-oncology (57%), cardiology (55%), and general surgery (44%); however, rates varied substantially across markets. For most specialties, high market concentration by insurers and hospital-systems was associated with lower rates of physician integration. In addition, systems with AMCs and publicly owned systems more commonly affiliated with specialties unrelated to the physicians' potential contribution to hospital revenue, and investor-owned systems demonstrated more limited physician integration., Conclusions: Variation in physician integration across markets and system characteristics reflects physician and systems' motivations. These integration strategies are associated with the financial interests of systems and other strategic goals (eg, medical education, and serving low-income populations)., (© 2020 The Author. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Objective: We aim to assess whether system providers perform better than nonsystem providers under an alternative payment model that incentivizes high-quality, cost-efficient care. We posit that the payment environment and the incentives it provides can affect the relative performance of vertically integrated health systems. To examine this potential influence, we compare system and nonsystem hospitals participating in Medicare's Comprehensive Care for Joint Replacement (CJR) model., Data Sources: We used hospital cost and quality data from the Centers for Medicare & Medicaid Services linked to data from the Agency for Healthcare Research and Quality's Compendium of US Health Systems and hospital characteristics from secondary sources. The data include 706 hospitals in 67 metropolitan areas., Study Design: We estimated regressions that compared system and nonsystem hospitals' 2017 cost and quality performance providing lower joint replacements among hospitals required to participate in CJR., Principal Findings: Among CJR hospitals, system hospitals that provided comprehensive services in their local market had 5.8 percent ($1612) lower episode costs (P = .01) than nonsystem hospitals. System hospitals that did not provide such services had 3.5 percent ($967) lower episode costs (P = .14). Quality differences between system hospitals and nonsystem hospitals were mostly small and statistically insignificant., Conclusions: When operating under alternative payment model incentives, vertical integration may enable hospitals to lower costs with similar quality scores., (© Health Research and Educational Trust.)

Despite the prevalence of vertical integration, data and research focused on identifying and describing health systems are sparse. Until recently, we lacked an enumeration of health systems and an understanding of how systems vary by key structural attributes. To fill this gap, the Agency for Healthcare Research and Quality developed the Compendium of U.S. Health Systems, a data resource to support research on comparative health system performance. In this article, we describe the methods used to create the Compendium and present a picture of vertical integration in the United States. We identified 626 health systems in 2016, which accounted for 70% of nonfederal general acute care hospitals. These systems varied by key structural attributes, including size, ownership, and geographic presence. The Compendium can be used to study the characteristics of the U.S. health care system and address policy issues related to provider organizations.

Provider consolidation into vertically integrated health systems increased from 2016 to 2018. More than half of US physicians and 72 percent of hospitals were affiliated with one of 637 health systems in 2018. For-profit and church-operated systems had the largest increases in system size, driven in part by a large number of system mergers and acquisitions.

Purpose: Changing market forces increasingly are leading academic medical centers (AMCs) to form or join health systems. But it is unclear how this shift is affecting the tripartite academic mission of education, research, and high-quality patient care. To explore this topic, the authors identified and characterized the types of health systems that owned or managed AMCs in the United States in 2016., Method: The authors identified AMCs as any general acute care hospitals that had a resident-to-bed ratio of at least 0.25 and that were affiliated with at least one MD- or DO-granting medical school. Using the Agency for Healthcare Research and Quality 2016 Compendium of U.S. Health Systems, the authors also identified academic-affiliated health systems (AHSs) as those health systems that owned or managed at least one AMC. They compared AMCs and other general acute care hospitals, AHSs and non-AHSs, and AHSs by type of medical school relationship, using health system size, hospital characteristics, undergraduate and graduate medical education characteristics, services provided, and ownership., Results: Health systems owned or managed nearly all AMCs (361, 95.8%). Of the 626 health systems, 230 (36.7%) met the definition of an AHS. Compared with other health systems, AHSs included more hospitals, provided more services, and had a lower ratio of primary care doctors to specialists. Most AHSs (136, 59.1%) had a single, shared medical school relationship, whereas 38 (16.5%) had an exclusive medical school relationship and 56 (24.3%) had multiple medical school relationships., Conclusions: These findings suggest that several distinct types of relationships between AHSs and medical schools exist. The traditional vision of a medical school having an exclusive relationship with a single AHS is no longer prominent.

Importance: Consolidation among physician practices and between hospitals and physician practices has accelerated in the past decade, resulting in higher prices in commercial markets. The resulting integration of health care across clinicians and participation in alternative payment models (APMs), which aim to improve quality while constraining spending, are cited as reasons for consolidation, but little is known about the association between integration and APM participation., Objective: To examine the association of organizational characteristics, ownership, and integration with intensity of participation in APMs among physician practices., Design, Setting, and Participants: A cross-sectional descriptive study, adjusted for sampling and nonresponse weights, was conducted in US physician practice respondents to the National Survey of Healthcare Organizations and Systems conducted between June 16, 2017, and August 17, 2018; of 2333 responses received (response rate, 46.9%) and after exclusion of ineligible and incomplete responses, the number of practices included in the analysis was 2061. Data analysis was performed from April 1, 2019, to August 31, 2019., Exposures: Self-reported physician practice characteristics, including ownership, integration (clinical, cultural, financial, and functional), care delivery capabilities, activities, and environmental factors., Main Outcomes and Measures: Participation in APMs: (1) bundled payments, (2) comprehensive primary care and medical home programs, (3) pay-for-performance programs, (4) capitated contracts with commercial health plans, and (5) accountable care organization contracts., Results: A total of 49.2% of the 2061 practices included reported participating in 3 or more APMs; most participated in pay-for-performance and accountable care organization models. Covariate-adjusted analyses suggested that operating within a health care system (odds ratio [OR] for medical group: 2.35; 95% CI, 1.70-3.25; P < .001; simple health system: 1.46; 95% CI, 1.08-1.97; P = .02; and complex health system: 1.76; 95% CI, 1.25-2.47; P = .001 relative to independent practices), greater clinical (OR, 4.68; 95% CI, 2.28-9.59; P < .001) and functional (OR, 4.24; 95% CI, 2.00-8.97; P < .001) integration, and being located in the Northeast (OR for Midwest: 0.47; 95% CI, 0.34-0.65; P < .001; South: 0.47; 95% CI, 0.34-0.66; P < .001; and West: 0.64; 95% CI, 0.46-0.91; P = .01) were associated with greater APM participation., Conclusions and Relevance: Greater APM participation appears to be supported by integration and system ownership.

Providing high-quality primary care is key to improving health care in the United States. The Affordable Care Act sharpened the emerging focus on primary care as a critical lever to use in improving health care delivery, lowering costs, and improving the quality of care. We describe primary care delivery system reform models that were developed and tested over the past decade by the Center for Medicare and Medicaid Innovation-which was created by the Affordable Care Act-and reflect on key lessons and remaining challenges. Considerable progress has been made in understanding how to implement and support different approaches to improving primary care delivery in that decade, though evaluations showed little progress in spending or quality outcomes. This may be because none of the models was able to test substantial increases in primary care payment or strong incentives for other providers to coordinate with primary care to reduce costs and improve quality.

Objective: To develop claims-based measures of comprehensiveness of primary care physicians (PCPs) and summarize their associations with health care utilization and cost., Data Sources and Study Setting: A total of 5359 PCPs caring for over 1 million Medicare fee-for-service beneficiaries from 1404 practices., Study Design: We developed Medicare claims-based measures of physician comprehensiveness (involvement in patient conditions and new problem management) and used a previously developed range of services measure. We analyzed the association of PCPs' comprehensiveness in 2013 with their beneficiaries' emergency department, hospitalizations rates, and ambulatory care-sensitive condition (ACSC) admissions (each per 1000 beneficiaries per year), and Medicare expenditures (per beneficiary per month) in 2014, adjusting for beneficiary, physician, practice, and market characteristics, and clustering., Principal Findings: Each measure varied across PCPs and had low correlation with the other measures-as intended, they capture different aspects of comprehensiveness. For patients whose PCPs' comprehensiveness score was at the 75th vs 25th percentile (more vs less comprehensive), patients had lower service use (P < 0.05) in one or more measures: involvement with patient conditions: total Medicare expenditures, -$17.4 (-2.2 percent); hospitalizations, -5.5 (-1.9 percent); emergency department (ED) visits, -16.3 (-2.4 percent); new problem management: total Medicare expenditures, -$13.3 (-1.7 percent); hospitalizations, -7.0 (-2.4 percent); ED visits, -19.7 (-2.9 percent); range of services: ED visits, -17.1 (-2.5 percent). There were no significant associations between the comprehensiveness measures and ACSC admission rates., Conclusions: These measures demonstrate strong content and predictive validity and reliability. Medicare beneficiaries of PCPs providing more comprehensive care had lower hospitalization rates, ED visits, and total Medicare expenditures., (© Health Research and Educational Trust.)

Background: Small independent practices are increasingly giving way to more complex affiliations between provider organizations and hospital systems. There are several ways in which vertically integrated health systems could improve quality and lower the costs of care. But there are also concerns that integrated systems may increase the price and costs of care without commensurate improvements in quality and outcomes., Purpose: Despite a growing body of research on vertically integrated health systems, no systematic review that we know of compares vertically integrated health systems (defined as shared ownership or joint management of hospitals and physician practices) to nonintegrated hospitals or physician practices., Methods: We conducted a systematic search of the literature published from January 1996 to November 2016. We considered articles for review if they compared the performance of a vertically integrated health system and examined an outcome related to quality of care, efficiency, or patient-centered outcomes., Results: Database searches generated 7,559 articles, with 29 articles included in this review. Vertical integration was associated with better quality, often measured as optimal care for specific conditions, but showed either no differences or lower efficiency as measured by utilization, spending, and prices. Few studies evaluated a patient-centered outcome; among those, most examined mortality and did not identify any effects. Across domains, most studies were observational and did not address the issue of selection bias., Practice Implications: Recent evidence suggests the trend toward vertical integration will likely continue as providers respond to changing payment models and market factors. A growing body of research on comparative health system performance suggests that integration of physician practices with hospitals might not be enough to achieve higher-value care. More information is needed to identify the health system attributes that contribute to improved outcomes, as well as which policy levers can minimize anticompetitive effects and maximize the benefits of these affiliations.

Issue: New payment and care delivery models such as accountable care organizations (ACOs) have prompted health care delivery systems to better meet the requirements of their high-need, high-cost (HNHC) patients., Goal: To explore how a group of mature ACOs are seeking to match patients with appropriate interventions by segmenting HNHC populations with similar needs into smaller subgroups., Methods: Semistructured telephone interviews with 34 leaders from 18 mature ACOs and 10 national experts knowledgeable about risk stratification and segmentation., Key Findings and Conclusions: ACOs use a range of approaches to segment their HNHC patients. Although there was no consistent set of subgroups for HNHC patients across ACOs, there were some common ones. Respondents noted that when primary care clinicians were engaged in refining segmentation approaches, there was an increase in both the clinical relevance of the results as well as the willingness of frontline providers to use them. Population segmentation results informed ACOs’ understanding of program needs, for example, by helping them better understand what skill sets and staff were needed to deliver enhanced care management. Findings on how mature ACOs are segmenting their HNHC population can improve the future development of more systematic approaches.

We conduct a narrative literature review using four real-world cases of clinical decisions to show how barriers to the use of evidence-based medicine affect physician decision-making at the point of care, and where adjustments could be made in the healthcare system to address these barriers. Our four cases constitute decisions typical of the types physicians make on a regular basis: diagnostic testing, initial treatment and treatment monitoring. To shed light on opportunities to improve patient care while reducing costs, we focus on barriers that could be addressed through changes to policy and/or practice at a particular level of the healthcare system. We conclude by relating our findings to the passage of the Medicare Access and Children's Health Insurance Program Reauthorization Act in April 2015.

Introduction: Physicians vary widely in how they treat some health conditions, despite strong evidence favoring certain treatments over others. We examined physicians' perspectives on factors that support or hinder evidence-based decisions and the implications for delivery systems, payers, and policymakers. Methods: We used Choosing Wisely ® recommendations to create four clinical vignettes for common types of decisions. We conducted semi-structured interviews with 36 specialists to identify factors that support or hinder evidence-based decisions. We examined these factors using a conceptual framework that includes six levels: patients, physicians, practice sites, organizations, networks and hospital affiliations, and the local market. In this model, population characteristics and payer and regulatory factors interact to influence decisions. Results: Patient openness to behavior modification and expectations, facilitated and hindered physicians in making evidence-based recommendations. Physicians' communication skills were the most commonly mentioned facilitator. Practice site, organization, and hospital system barriers included measures of emergency department throughput, the order in which test options are listed in electronic health records (EHR), lack of relevant decision support in EHRs, and payment incentives that maximize billing and encourage procedures rather than medical management or counseling patients on behavior change. Factors from different levels interacted to undermine evidence-based care. Most physicians received billing feedback, but quality metrics on evidence-based service use were nonexistent for the four decisions in this study. Conclusions and Implications: Additional research and quality improvement may help to modify delivery systems to overcome barriers at multiple levels. Enhancing provider communication skills, improving decision support in EHRs, modifying workflows, and refining the design and interpretation of some quality metrics would help, particularly if combined with concurrent payment reform to realign financial incentives across stakeholders., Competing Interests: The authors declare that they do not have any conflicts of interest.

The Medicare Access and CHIP Reauthorization Act (MACRA) introduces incentives for clinicians serving Medicare patients to move away from traditional "fee-for-service" and into alternative payment models (APMs) such as accountable care organizations and bundled payment arrangements. Thus, MACRA creates strong reasons for various teaching clinical services to participate in APMs, not only for Medicare patients but for other public and private payers as well. Unfortunately, different APMs may be more or less applicable to the diverse teaching physician roles, academic clinical programs, and patient populations served by medical schools and teaching hospitals. Therefore, this time of transition will complicate the work of academic clinical program leaders endeavoring to sustain the tripartite mission of patient care, health professional education, and research. Nonetheless, payment reforms promoted by MACRA can reward efforts to reinvent medical education to better incorporate value into medical decision making, as well as to give clinical learners the tools and insights needed to recognize their personal financial (and other) conflicts and navigate these to meet their patients' needs. This post-MACRA environment may intensify the need for researchers in academic medicine to stay independent of the short-term financial interests of affiliated clinical institutions. Health sciences scholars must be able to study effectively and speak forcefully regarding the actual benefits, risks, and costs of health care services so that educators and clinicians can identify high-value care and deliver it to their patients.

Background: Governments around the world exert a substantial degree of influence over physician reimbursement, but the structure and level of that influence varies greatly. This article defines and analyzes the role of government in physician reimbursement both internationally and in the United States., Analytical Framework: We create a typology for government involvement in physician reimbursement that divides intervention into either direct control or indirect control. Within those broad categories, we describe more specific forms of involvement including rate setting, operating as a public payer, employing physicians directly, providing a source of market discipline, regulating private insurance, and convening private participants in the market., Findings: We apply our framework to the modern healthcare systems of Germany, Sweden, Canada, and the United States, highlighting some of the implications of differences between the systems. Our central finding is that in contrast to other example healthcare systems, the United States system features a complex interplay of federal and state government influence, both direct and indirect, into physician reimbursement., Conclusion: We conclude the article by examining the ways in which recent legislation including the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act would likely change the role of government in physician reimbursement in the United States., (Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Comprehensiveness of primary care (the extent to which the clinician, as part of the primary care team, recognizes and meets the majority of each patient's physical and mental health care needs) is an important element of primary care, but seems to be declining in the U.S. This is concerning, because more comprehensive primary care is associated with greater equity and efficiency in health care, improved continuity, less care fragmentation and better health outcomes. Without measurement and support for its improvement, comprehensiveness may further decline as other measured aspects of primary care (e.g. access, coordination) improve. To track, support and improve comprehensiveness, it is useful to have valid and reliable ways to measure it. This paper discusses challenges to measuring comprehensiveness for a primary care team's patient panel, presents survey and claims-based measures of comprehensiveness, and provides suggestions for future research.

Background: Databases of practicing physicians are important for studies that require sampling physicians or counting the physician population in a given area. However, little is known about how the three main sampling frames differ from each other., Objective: Our purpose was to compare the National Provider and Plan Enumeration System (NPPES), the American Medical Association Masterfile and the SK&A physician file., Methods: We randomly sampled 3000 physicians from the NPPES (500 in six specialties). We conducted two- and three-way comparisons across three databases to determine the extent to which they matched on address and specialty. In addition, we randomly selected 1200 physicians (200 per specialty) for telephone verification., Key Results: One thousand, six hundred and fifty-five physicians (55 %) were found in all three data files. The SK&A data file had the highest rate of missing physicians when compared to the NPPES, and varied by specialty (50 % in radiology vs. 28 % in cardiology). NPPES and SK&A had the highest rates of matching mailing address information, while the AMA Masterfile had low rates compared with the NPPES. We were able to confirm 65 % of physicians' address information by phone. The NPPES and SK&A had similar rates of correct address information in phone verification (72-94 % and 79-92 %, respectively, across specialties), while the AMA Masterfile had significantly lower rates of correct address information across all specialties (32-54 % across specialties)., Conclusions: None of the data files in this study were perfect; the fact that we were unable to reach one-third of our telephone verification sample is troubling. However, the study offers some encouragement for researchers conducting physician surveys. The NPPES and to a lesser extent, the SK&A file, appear to provide reasonably accurate, up-to-date address information for physicians billing public and provider insurers.

There is ample evidence that many clinical decisions made by physicians are inconsistent with current and generally accepted evidence. This leads to the underuse of some efficacious diagnostic, preventive or therapeutic services, and the overuse of others of marginal or no value to the patient. Evolving new payment and delivery models place greater emphasis on the provision of evidence-based services at the point of care. However, changing physician clinical behaviors is likely to be difficult and slow. Policy makers therefore need to design interventions that are most effective in promoting greater evidence-based care. To help identify modifiable factors that can influence clinical decisions at the point of care, we present a conceptual model and literature review of physician decision making. We describe the multitude of factors--drawn from different disciplines--that have been shown to influence physician point-of-care decisions. We present a conceptual framework for organizing these factors, dividing them into patient, physician, practice site, physician organization, network, market, and public policy influences. In doing so, we review some of the literature that speak to these factors. We then identify areas where additional research is especially needed, and discuss the challenges and opportunities for health services and policy researchers to gain a better understanding of these factors, particularly those that are potentially modifiable by policymakers and organizational leaders.

Primary care plays a central role in the provision of health care, and is an organizing feature for health care delivery systems in most Western industrialized democracies. For a variety of reasons, however, the practice of primary care has been in decline in the U.S. This paper reviews key primary care concepts and their definitions, notes the increasingly complex interplay between primary care and the broader health care system, and offers research priorities to support future measurement, delivery and understanding of the role of primary care features on health care costs and quality.

Congress is again attempting to repeal the Sustainable Growth Rate (SGR) formula. The formula is a failed mechanism intended to constrain Medicare Part B physician spending by adjusting annual physician fee updates. Congress has averted formula-driven physician fee cuts each year beginning in 2003 by overriding the SGR, usually accompanied with last-minute disputes about how these overrides should be paid for. Last year Congress achieved bipartisan and bicameral agreement on legislation to replace the SGR—the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, which we refer to as the "2014 SGR fix"—but was unable to find a way to pay for the legislation under current budget rules. Current congressional deliberations appear focused on how to pay for the fix, with wide consensus that the 2014 legislation should remain the basic model for reform. We describe key features of the 2014 SGR fix, place it in the context of both past and ongoing Medicare health policy, assess its strengths and weaknesses as a mechanism to foster improved care and lower costs in Medicare, and suggest further actions to ensure success in meeting these goals., (Project HOPE—The People-to-People Health Foundation, Inc.)

Aim: We conducted a midstream assessment of the comparative effectiveness research (CER) training programs funded by the American Recovery and Reinvestment Act (ARRA) by examining program characteristics, planned curriculum development activities and core competencies., Materials & Methods: We examined all 43 training projects funded by the US$46 million ARRA CER investment, collecting data from key informant discussions and a technical expert panel., Results: The majority of projects leveraged institutional resources to provide an individualized combination of didactic and experiential learning supported by strong mentorship. Core competencies included skills in statistical modeling, evidence synthesis (systematic reviews and meta-analysis) and general research design skills., Conclusion: ARRA-supported CER training programs enhanced workforce capacity by developing curricula and preparing CER researchers to apply emerging methods and utilize new CER infrastructure.