Are physician executive pay-for-performance programs the future of physician leader compensation in Canada?

This article explores the growing trend of physician executive pay-for-performance plans in the U.S. and Canada and discusses the underlying principles of incentive-based compensation models. Pay-for-performance plans are becoming increasingly popular with boards of many healthcare organizations across the country. They may offer an opportunity for increased accountability in the context of the 2003 Health Accord. Although there is little current evidence to support the notion that incentive-based compensation has long-term implications for quality improvement, their popularity continues to increase.     

Does investor-ownership of nursing homes compromise the quality of care?

Quality problems have long plagued the nursing home industry. While two-thirds of U.S. nursing homes are investor-owned, few studies have examined the impact of investor-ownership on the quality of care. The authors analyzed 1998 data from inspections of 13,693 nursing facilities representing virtually all U.S. nursing homes. They grouped deficiency citations issued by inspectors into three categories ("quality of care," "quality of life," and "other") and compared deficiency rates in investor-owned, nonprofit, and public nursing homes. A multivariate model was used to control for case mix, percentage of residents covered by Medicaid, whether the facility was hospital-based, whether it was a skilled nursing facility for Medicare only, chain ownership, and location by state. The study also assessed nurse staffing. The authors found that investor-owned nursing homes provide worse care and less nursing care than nonprofit or public homes. Investor-owned facilities averaged 5.89 deficiencies per home, 46.5 percent higher than nonprofit and 43.0 percent higher than public facilities, and also had more of each category of deficiency. In the multivariate analysis, investor-ownership predicted 0.679 additional deficiencies per home; chain-ownership predicted an additional 0.633 deficiencies per home. Nurse staffing ratios were markedly lower at investor-owned homes.     

Does Medicaid managed care affect access to care for the uninsured?

This study investigates whether the implementation of Medicaid managed care from 1994 to 2001 was associated with changes in access to care for the uninsured. We used regression analysis to examine relationships between changes in county-level Medicaid managed care activity over time and changes in four measures of perceived access to care. After we controlled for sex, race, ethnicity, poverty, age, health, and education and included county fixed effects to account for unobserved county characteristics that are potentially associated with the implementation of Medicaid managed care and outcome measures, we found that Medicaid managed care has had no consistent effect on access.     

Does investor ownership of nursing homes compromise the quality of care?

OBJECTIVES: Two thirds of nursing homes are investor owned. This study examined whether investor ownership affects quality. METHODS: We analyzed 1998 data from state inspections of 13,693 nursing facilities.We used a multivariate model and controlled for case mix, facility characteristics, and location. RESULTS: Investor-owned facilities averaged 5.89 deficiencies per home, 46.5% higher than nonprofit facilities and 43.0% higher than public facilities. In multivariate analysis, investor ownership predicted 0.679 additional deficiencies per home; chain ownership predicted an additional 0.633 deficiencies. Nurse staffing was lower at investor-owned nursing homes. CONCLUSIONS: Investor-owned nursing homes provide worse care and less nursing care than do not-for-profit or public homes.     

Does quality improvement implementation affect hospital quality of care?

The authors examined how the association between quality improvement (QI) implementation in hospitals and hospital clinical quality is moderated by hospital organizational and environmental context. The authors used Ordinary Least Squares regression analysis of 1,784 community hospitals to model seven quality indicators as a function of four measures of QI implementation and a variety of control variables. They found that forces that are external and internal to the hospital condition the impact of particular QI activities on quality indicators: specifically data use, statistical tool use, and organizational emphasis on Continuous Quality Improvement (CQI). Results supported the proposition that QI implementation is unlikely to improve quality of care in hospital settings without a commensurate fit with the financial, strategic, and market imperatives faced by the hospital.     

Does continuity of care with a family physician reduce hospitalizations among older adults?

OBJECTIVE: To examine the relation between continuity of primary care and hospitalizations. METHODS: Survey data from a representative sample of older adults aged 67 or over living in the province of Manitoba (n = 1863) were linked to administrative data, which provide complete records of physician visits and hospitalizations. A visit-based measure of continuity of care was derived using a majority-of-care definition, whereby individuals who made 75% of all their visits to family physicians (FPs) to the same FP were classified as having high continuity of care, and those with less than 75% of their visits to the same FP as having low continuity of care. Whether individuals were hospitalized (for either ambulatory care-sensitive conditions or all conditions) was also determined from administrative records. RESULTS: High continuity of care was associated with reduced odds of ambulatory care-sensitive hospitalizations (adjusted odds ratio = 0.67, confidence interval 0.51-0.90) controlling for demographic and self-reported, health-related measures. It was not related to hospitalizations for all conditions, however. CONCLUSIONS: The study highlights the importance of continuity of primary care in reducing potentially avoidable hospitalizations.     

Does Medicaid coverage of Medicare cost sharing affect physician care for dual‐eligible Medicare beneficiaries?

ObjectiveTo assess changes in physicians’ provision of care to duals (low‐income individuals with Medicare and Medicaid) in response to a policy that required Medicaid to fully pay Medicare''s cost sharing for office visits with these patients. This policy—a provision of the Affordable Care Act—effectively increased payments for office visits with duals by 0%‐20%, depending on the state, in 2013 and 2014.Data SourcesFee‐for‐service claims for a 5% random sample of Medicare beneficiaries in 2010‐2016.Study DesignWe conducted a difference‐in‐differences analysis to compare changes in office visits among Qualified Medicare Beneficiaries (QMBs)—the largest subpopulation of duals for whom payment rates were affected by this policy—to changes among other low‐income Medicare beneficiaries for whom payment rates were unaffected (pooled across all states). Next, we conducted a triple‐differences analysis that compared changes between QMBs and other low‐income beneficiaries in 33 states with payment rate increases of approximately 20% to analogous changes in 14 states without payment increases.Data CollectionThe study included administrative Medicare enrollment and claims data for QMBs and a comparison group of other low‐income Medicare beneficiaries (1 914 073 beneficiary‐years from 2010 to 2016).Principal FindingsNationally, we did not find a differential increase in office visits among QMBs versus other low‐income beneficiaries that coincided with this payment change. In the triple‐differences analysis, we did not observe a greater increase in visits among QMBs vs other low‐income beneficiaries in states where the policy resulted in large (approximately 20%) increases in payment rates vs states where payment rates were unaffected (triple‐differences estimate: −0.12 annual visits, 95% CI: −0.28, 0.04; P = 0.15).ConclusionsPhysicians’ provision of care to low‐income Medicare beneficiaries may not be responsive to short‐run payment changes.     

Medicaid managed care: the last bastion of the HMO?

States rely on health maintenance organizations (HMOs) for their Medicaid beneficiaries because they offer guaranteed access to comprehensive benefits at a predictable cost. This is true despite movement away from HMOs, or at least the more restrictive variants, in the private sector. Plans that focus on Medicaid are becoming more central to states' programs as commercial plans exit. Publicly traded, Medicaid-focused plans are also emerging. Medicaid participating plans are aggressively managing costs and care, contrasting sharply with commercial insurance where the trend is toward less intrusive managed care. In this context, state Medicaid managed care programs are facing important policy challenges related to plan participation, mainstreaming, and product design.     

How does the quality of care compare in five countries?

International data on quality of medical care allow countries to compare their performance to that of other countries. The Commonwealth Fund International Working Group on Quality Indicators collected data on twenty-one indicators that reflect medical care in Australia, Canada, New Zealand, England, and the United States. The indicators include five-year cancer relative survival rates, thirty-day case-fatality rates after acute myocardial infarction and stroke, breast cancer screening rates, and asthma mortality rates. No country scores consistently the best or worst overall. Each country has at least one area of care where it could learn from international experiences and one area where its experiences could teach others.     

Does the planned long-term care policy in Taiwan meet the needs of people with disabilities?

The long-term care (LTC) insurance policy will be enacted in Taiwan. Under the proposed policy, people with disabilities will have priority in receiving insurance. The aim of this study was to compare the functional statuses of 3 disability groups and to investigate the coverage provided by the planned LTC insurance in Taiwan.     

Does substituting home care for institutional care lead to a reduction in Medicaid expenditures?

In 1981 Congress introduced Home and Community Based Services (HCBS) waivers in an attempt to contain Medicaid long-term care expenditures. This paper analyzes the efficacy of the waiver program. To date, little is known about its impact on cost containment. Using state-level Medicaid data on expenditures and the number of individuals participating in HCBS waivers between 1992 and 2000, this study estimates the impact of HCBS waivers on total Medicaid expenditures as well as on Medicaid institutional, home health and pharmaceutical expenditures. A fixed effects model is used to analyze Medicaid expenditures using variation in the size of HCBS waiver programs across states and over time. The results, robust across multiple specifications, show increases rather than decreases in total Medicaid spending as well as increases in the other Medicaid spending categories analyzed. This implies that there is no evidence of substitution from institutional care to the HCBS waiver program or that cost-shifting is occurring. In fact, the large magnitude of the estimated spending increases suggests the waivers may induce more people to enter the Medicaid program.     

Does the Belgian diabetes type 2 care trajectory improve quality of care for diabetes patients?

Background

The Belgian care trajectory (CT) for diabetes mellitus type 2 (T2DM), implemented in September 2009, aims at providing integrated, evidence-based, multidisciplinary patient- centred care, based on the chronic care model.The research project ACHIL (Ambulatory Care Health Information Laboratory) studied the adherence of CT patients, in the early phases of CT programme implementation, with CT obligations, their uptake of incentives for self-management, whether the CT programme was targeting the appropriate group of patients, how care processes for these patients evolved over time and whether CT start led to better quality in the processes and outcomes of care.

Methods

This observational study took place in the period 2006–2011 and covered T2DM patients who started a CT between 01/09/2009 and 31/12/2011.Four data sources were used: outcome data, from electronic patient records (EPRs) on all CT patients, provided by general practitioners (GPs); reimbursement process data on all CT patients and clinically comparable patients; and data from a sample of CT patients and clinically comparable patients from an EPR-based regional GP network and a paper-based national GP network, respectively.Through multilevel analysis of cross-sectional and longitudinal data, the effect of CT inclusion on processes and outcome was estimated, controlling for potential confounders.

Results

By the end of 2011, data on 18,250 CT patients had been collected. Approximately 50 % of these CT patients had received reimbursement for a glucometer and nearly 60 % had had at least one encounter with a diabetes educator. The CT programme recruited T2DM patients who had been difficult to control in the past. In the years prior to CT start, there had been a gradual improvement in the follow up of these patients. Moreover, compared to non-CT patients, the proportion of CT patients adhering to the recommended frequency for monitoring of parameters, such as HbA1c, increased significantly around CT start. Some data sources, albeit not all, suggested there had been an improvement in certain outcomes, such as HbA1c, after CT inclusion.

Conclusions

According to this study, CT enrolment is associated with better quality of care processes compared to non-CT patients. This improvement was found in several of the data sources used in this study. However, results on outcome parameters remain inconclusive.

     

Does age influence the intensity of care in a managed care organization?

The primary objective of this study was to determine whether an inverse relationship between age and the intensity of care prevailed in an elderly, functionally impaired population enrolled in a managed care organization. The secondary objective was to determine whether those who died during the study were treated more intensively than the survivors. A total of 278 enrollees in a managed care organization who were 75 years and over, had a severe functional disability, excessive hospital or Emergency Department use, volunteered to take part in a 2-year study. Seventy-seven clients died during the study. We calculated indices of outpatient care intensity and hospital care intensity for the study period. With minor exceptions, the results clearly show that, for this group of clients, the intensity of outpatient care was clearly, inversely related to age. The intensity of hospital care was also inversely related to age, thereby ruling out the hypothesis that it was being substituted for outpatient care. The results also clearly show that, for this population, those who died during the study period were treated more intensively than the survivors. We found strong support for our hypotheses. An investigation of the reasons for these findings was beyond the scope of our data.     

Does quality of marital sex decline with duration?

Does the quality of marital sex increase or decrease with marital duration? Previous research assumes that it decreases; however, there is no empirical evidence of declining quality of marital sex with duration in the literature. This study theoretically and empirically examines how the quality of marital sex changes with duration. Theoretically, two effects may influence the change of quality of marital sex: the effect of diminishing marginal utility (the marginal utility of consuming a good or service diminishes as the consumption of that good or service increases) and the effect of the investment in the marriage-specific human capital (including the "partner specific" skills that enhance the enjoyment of marital sex and the knowledge about the spouse's sexual preferences, desires, and habits). The quality of marital sex could either increase or decrease depending on which effect is dominant. The multivariate analysis of the National Health and Social Life Survey data shows that marital duration has a small and negative effect on the quality of marital sex. The gender difference in the quality of marital sex is discussed.     

Does trust of patients in their physician predict loyalty to the health care insurer? The Israeli case study

ABSTRACT

This pioneer study tests the relationship between patients’ trust in their physicians and patients’ loyalty to their health care insurers. This is a cross-sectional study using a representative sample of patients from all health care insurers with identical health care plans. Regression analyses and Baron and Kenny’s model were used to test the study model. Patient trust in the physician did not predict loyalty to the insurer. Loyalty to the physician did not mediate the relationship between trust in the physician and loyalty to the insurer. Satisfaction with the physician was the only predictor of loyalty to the insurer.     

Realizing neighbourhood potential? The role of the availability of health care services on contact with a primary care physician

Access to health services research has traditionally focused on demographic, socioeconomic, and need-based factors, resulting in a relative lack of knowledge regarding place-based determinants. Further, much of what we know comes from international, national, and regional study. This study analyzes survey data (n=1635) to explore the relationship between neighbourhood-level potential access (i.e., availability) and realized access (i.e., use) in two Canadian cities. Controlling for predisposing, enabling and need factors, living in a well-served neighbourhood was a significant predictor of realized access, particularly in Saskatoon. This suggests that the relationship between potential and realized access may be modified by place-based factors.