Lawrence P. Casalino

As good as it gets? Chronic care management in nine leading US physician organisations.

Innovations in care management processes have improved the care of patients with chronic illnesses, but many patients still do not receive these benefits. The authors have studied the barriers and facilitators to implementing these improvements in leading US physician practices About 125 million of the 276 million people living in the United States have some type of chronic illness (table 1).1 Four chronic conditions affect nearly half of Americans with a chronic disease: asthma, depression, and diabetes each affect about 15 million,2–4 while five million have congestive heart failure.5 In 1999 these four chronic diseases were directly responsible for 140 000 deaths in the United States6 and generated at least

Small And Medium-Size Physician Practices Use Few Patient-Centered Medical Home Processes

173bn (£108bn, €170bn) in medical and other costs. 5 7–9 Over the past decade the effectiveness of care for patients with these and other major chronic illnesses has been improved by innovations in care management processes such as the use of guidelines, disease management techniques, case management, and patient education to improve self management of chronic disease.10 However, many patients are not benefiting from these advances. Recent studies indicate that fewer than half of US patients with asthma, depression, and diabetes receive appropriate treatment.11–13 Organisational characteristics of physician practices associated with effective chronic disease care include the use of patient care teams, supportive information systems, and a high volume of patients.14 Hence, we expect that in the United States moderate and large sized, well organised, multispecialty practices are likely to offer chronic disease care that is as good as it gets and provide other physician organisations with benchmarks against which performance can be measured. #### Summary points

Health Care Reform Requires Accountable Care Systems

The patient-centered medical home has become a prominent model for reforming the way health care is delivered to patients. The model offers a robust system of primary care combined with practice innovations and new payment methods. But scant information exists about the extent to which typical US physician practices have implemented this model and its processes of care, or about the factors associated with implementation. In this article we provide the first national data on the use of medical home processes such as chronic disease registries, nurse care managers, and systems to incorporate patient feedback, among 1,344 small and medium-size physician practices. We found that on average, practices used just one-fifth of the patient-centered medical home processes measured as part of this study. We also identify internal capabilities and external incentives associated with the greater use of medical home processes.

Measuring The Medical Home Infrastructure In Large Medical Groups

is targeted. Many clinically proven interventions are relatively cost-effectivebutnotcost savingandmayaffectonlysmallportions of an overall population, and some clinically effective interventionsdonothavepositiveratesofreturnasinvestments. Also,manynonfinancialbarriers tohealth improvementmust beovercomeandothernonhealthproblemsmustbeaddressed forhealtheffects to translate intoeconomicgain.Theoutcome dependsonthepolitical commitment to improvinghealth, the political and policy decisions that are made, and the prioritization of needs and deployment of resources within a society. What is important is that the roleofhealthasaproductiveeconomic investment be captured and that focused efforts to improvehealthshouldbepartof theeconomicdevelopmentplan.

An Empirical Assessment of High-Performing Medical Groups: Results from a National Study:

The patient-centered medical home is taking center stage in discussions of primary care innovation as a new delivery model that provides comprehensive, coordinated care across the lifespan. Although the medical home is widely discussed by policymakers, payers, and other stakeholders, the extent to which physician practices have the infrastructure in place to function as medical homes is not known. Using data from the 2006-07 National Study of Physician Organizations, we examine the extent of adoption of medical home infrastructure components among large primary care and multispecialty medical groups and their association with medical group size and ownership.

What Does It Cost Physician Practices to Interact with Health Insurance Plans

The performance of medical groups is receiving increased attention. Relatively little conceptual or empirical work exists that examines the various dimensions of medical group performance. Using a national database of 693 medical groups, this article develops a scorecard approach to assessing group performance and presents a theory-driven framework for differentiating between high-performing versus low-performingmedical groups. The clinical quality of care, financial performance, and organizational learning capability of medical groups are assessed in relation to environmental forces, resource acquisition and resource deployment factors, and a quality-centered culture. Findings support the utility of the performance scorecard approach and identification of a number of key factors differentiating high-performing from low-performing groups including, in particular, the importance of a quality-centered culture and the requirement of outside reporting from third party organizations. The findings hold a number of important implications for policy and practice, and the framework presented provides a foundation for future research.

Barriers to Patient-physician Communication About Out-of-pocket Costs

Physicians have long expressed dissatisfaction with the time they and their staffs spend interacting with health plans. However, little information exists about the extent of these interactions. We conducted a national survey on this subject of physicians and practice administrators. Physicians reported spending three hours weekly interacting with plans; nursing and clerical staff spent much larger amounts of time. When time is converted to dollars, we estimate that the national time cost to practices of interactions with plans is at least

How The Center For Medicare And Medicaid Innovation Should Test Accountable Care Organizations

23 billion to

Paid Malpractice Claims for Adverse Events in Inpatient and Outpatient Settings

31 billion each year.

Continuity of Care and the Risk of Preventable Hospitalization in Older Adults

BACKGROUND: Though many patients and physicians believe that they should discuss out-of-pocket costs, research suggests that they infrequently do. OBJECTIVE: To examine barriers preventing patient-physician communication about out-of-pocket costs among study subjects recalling a time when they wanted to discuss these costs but did not do so. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional surveys of 133 general internists and 484 of their patients from 3 academic and 18 community practices in a large midwestern metropolitan region. MEASUREMENTS: Patient- and physician-reported barriers to discussing out-of-pocket costs. MAIN RESULTS: Overall, 54 patients (11%) and 27 physicians (20%) were able to recall a specific time when they wanted to discuss out-of-pocket costs but did not do so. Among patients, a wide variety of barriers were reported including their own discomfort (19%), insufficient time (13%), a belief that their physician did not have a viable solution (11%), and concerns about the impact of discussions on quality of care (9%). Among physicians, the most common barriers reported were insufficient time (67%) and a belief that they did not have a solution to offer (19%). CONCLUSIONS: Efforts to promote discussions of out-of-pocket costs should emphasize the legitimacy of patients’ concerns and brief actionable alternatives that physicians can take to address them.