Kyle L. Grazier

Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost

IMPORTANCE The value of integrated team delivery models is not firmly established. OBJECTIVE To evaluate the association of receiving primary care in integrated team-based care (TBC) practices vs traditional practice management (TPM) practices (usual care) with patient outcomes, health care utilization, and costs. DESIGN A retrospective, longitudinal, cohort study to assess the association of integrating physical and mental health over time in TBC practices with patient outcomes and costs. SETTING AND PARTICIPANTS Adult patients (aged ≥18 years) who received primary care at 113 unique Intermountain Healthcare Medical Group primary care practices from 2003 through 2005 and had yearly encounters with Intermountain Healthcare through 2013, including some patients who received care in both TBC and TPM practices. EXPOSURES Receipt of primary care in TBC practices compared with TPM practices for patients treated in internal medicine, family practice, and geriatrics practices. MAIN OUTCOMES AND MEASURES Outcomes included 7 quality measures, 6 health care utilization measures, payments to the delivery system, and program investment costs. RESULTS During the study period (January 2010-December 2013), 113,452 unique patients (mean age, 56.1 years; women, 58.9%) accounted for 163,226 person-years of exposure in 27 TBC practices and 171,915 person-years in 75 TPM practices. Patients treated in TBC practices compared with those treated in TPM practices had higher rates of active depression screening (46.1% for TBC vs 24.1% for TPM; odds ratio [OR], 1.91 [95% CI, 1.75 to 2.08), adherence to a diabetes care bundle (24.6% for TBC vs 19.5% for TPM; OR, 1.26 [95% CI, 1.11 to 1.42]), and documentation of self-care plans (48.4% for TBC vs 8.7% for TPM; OR, 5.59 [95% CI, 4.27 to 7.33]), lower proportion of patients with controlled hypertension (<140/90 mm Hg) (85.0% for TBC vs 97.7% for TPM; OR, 0.87 [95% CI, 0.80 to 0.95]), and no significant differences in documentation of advanced directives (9.6% for TBC vs 9.9% for TPM; OR, 0.97 [95% CI, 0.91 to 1.03]). Per 100 person-years, rates of health care utilization were lower for TBC patients compared with TPM patients for emergency department visits (18.1 for TBC vs 23.5 for TPM; incidence rate ratio [IRR], 0.77 [95% CI, 0.74 to 0.80]), hospital admissions (9.5 for TBC vs 10.6 for TPM; IRR, 0.89 [95% CI, 0.85 to 0.94]), ambulatory care sensitive visits and admissions (3.3 for TBC vs 4.3 for TPM; IRR, 0.77 [95% CI, 0.70 to 0.85]), and primary care physician encounters (232.8 for TBC vs 250.4 for TPM; IRR, 0.93 [95% CI, 0.92 to 0.94]), with no significant difference in visits to urgent care facilities (55.7 for TBC vs 56.2 for TPM; IRR, 0.99 [95% CI, 0.97 to 1.02]) and visits to specialty care physicians (213.5 for TBC vs 217.9 for TPM; IRR, 0.98 [95% CI, 0.97 to 0.99], P > .008). Payments to the delivery system were lower in the TBC group vs the TPM group (

Massachusetts’s Experience Suggests Coverage Alone Is Insufficient To Increase Addiction Disorders Treatment

3400.62 for TBC vs

Mental health carve-outs: effects and implications.

3515.71 for TPM; β, -

Effects of a mental health carve-out on use, costs, and payers: a four-year study.

115.09 [95% CI, -

Comparing Accuracy of Risk-Adjustment Methodologies Used in Economic Profiling of Physicians

199.64 to -

Translating Behavioral Health Services Research into Benefits Policy

30.54]) and were less than investment costs of the TBC program. CONCLUSIONS AND RELEVANCE Among adults enrolled in an integrated health care system, receipt of primary care at TBC practices compared with TPM practices was associated with higher rates of some measures of quality of care, lower rates for some measures of acute care utilization, and lower actual payments received by the delivery system.

Serious Mental Illness, Aging, and Utilization Patterns among Veterans

The Affordable Care Act is aimed at extending health insurance to more than thirty million Americans, including many with untreated substance use disorders. Will those who need addiction treatment receive it once they have insurance? To answer that question, we examined the experience of Massachusetts, which implemented its own universal insurance law in 2007. As did the Affordable Care Act, the Massachusetts reform incorporated substance abuse services into the essential benefits to be provided all residents. Prior to the laws enactment, the state estimated that a half-million residents needed substance abuse treatment. Our mixed-methods exploratory study thus asked whether expanded coverage in Massachusetts led to increased addiction treatment, as indicated by admissions, services, or revenues. In fact, we observed relatively stable use of treatment services two years before and two years after the state enacted its universal health care law. Among other factors, our study noted that the percentage of uninsured patients with substance abuse issues remains relatively high--and that when patients did become insured, requirements for copayments on their care deterred treatment. Our analysis suggests that expanded coverage alone is insufficient to increase treatment use. Changes in eligibility, services, financing, system design, and policy may also be required.

Under Pressure: Financial Effect of the Hospital-Acquired Conditions Initiative-A Statewide Analysis of Pressure Ulcer Development and Payment.

To control the rise in expenditures and to increase access to mental health and substance abuse (MH/SA) services, a growing number of employers and states are implementing a “carve-out.” Under this arrangement, the sponsor separates insurance benefits by disease or condition, service category, or population and contracts separately for the management of care and/or associated risks. A carve-out allows a unique set of managed care techniques to be applied to a subset of particularly costly or complex benefits. This article describes various carve-out models, discusses the potential advantages and disadvantages of a full carve-out, and summarizes recent public and private sector research regarding the strategy’s effects on access and use, cost savings and shifting, and quality of care. It concludes by discussing approaches to the assessment and monitoring of the processes and outcomes associated with a MH/SA carve-out.

Integration of Depression and Primary Care Barriers to Adoption

This study examines the effects of a mental health carve-out on a sample of continuously enrolled employees (N = 1,943) over a four-year time frame (1990–1994). The article presents a health care services utilization model of the effect of the carve-out on outpatient mental health use, cost, and source of payment in the three years post implementation relative to the year prior to the carve-out model. In the first three years of the carve-out, the likelihood of employees seeking mental health care increased in significant part because of the carve-out. For the outpatient mental health services user, the carve-out was not associated with the level of mental health services received. The carve-out was significantly associated over time with a reduction in the patients and employers mental health costs. This effect was more pronounced in the second and third years of the carve-out. The article explores the policy implications of these and other findings.

Estimating Return on Investment in Translational Research Methods and Protocols

This paper examines the relative accuracy of risk-adjustment methodologies used to profile primary care physician practice efficiency. Claims and membership data from an independent practice association health maintenance organization (HMO) were processed through risk-adjustment software of six different profiling methodologies. The Group R 2 statistic was used to measure, for simulated panels of HMO members, how closely each methodologys cost predictions matched the panels actual costs. All but one methodology explained at least 50% of panel cost variance with panels as small as 25 patients. Group R 2 performance tended to be better when high-cost cases were included rather than excluded from the analyses.