Palmira Santos

Medical Group Responses To Global Payment: Early Lessons From The ‘Alternative Quality Contract’ In Massachusetts

The largest insurer in Massachusetts, Blue Cross Blue Shield, began a new program in 2009 that combines global payments-fixed payments for the care of patient populations during a specified time period-with large potential quality bonuses for medical groups. In interviews with representatives of the participating medical groups, many of which could be considered prototype accountable care organizations, we found that most groups initially focused on two goals: building the infrastructure to help primary care providers earn quality bonuses; and managing referrals to direct patients to lower-cost settings. Groups are working to overcome numerous challenges, which include improving their data management capabilities; managing conflicting incentives in their fee-for-service contracts; and establishing cultures that emphasize teamwork, patient-centered care, and effective stewardship of medical resources. The participating medical groups are diverse in terms of size, organizational structure, and prior experience with managed care contracting. If the groups can succeed in reducing annual growth in health spending by half over the five-year contract, it could signal that even newly formed accountable care organizations can navigate a shift from fee-for-service to population-based payment models.

Early experience of a safety net provider reorganizing into an accountable care organization.

Although safety net providers will benefit from health insurance expansions under the Affordable Care Act, they also face significant challenges in the postreform environment. Some have embraced the concept of the accountable care organization to help improve quality and efficiency while addressing financial shortfalls. The experience of Cambridge Health Alliance (CHA) in Massachusetts, where health care reform began six years ago, provides insight into the opportunities and challenges of this approach in the safety net. CHAs strategies include care redesign, financial realignment, workforce transformation, and development of external partnerships. Early results show some improvement in access, patient experience, quality, and utilization; however, the potential efficiencies will not eliminate CHAs current operating deficit. The patient population, payer mix, service mix, cost structure, and political requirements reduce the likelihood of financial sustainability without significant changes in these factors, increased public funding, or both. Thus the future of safety net institutions, regardless of payment and care redesign success, remains at risk.

Decreasing intrapartum malpractice: Targeting the most injurious neonatal adverse events

Medical malpractice expenditures are mainly due to the occurrence of preventable harm with some of the highest liability rates in obstetrics. Establishing delivery system models which decrease preventable harm and malpractice risk have had varied results over the last decade. We conducted a case study of a risk reduction labor and delivery model at 5 demonstration sites. The model included standardized protocols for the most injurious events, training teams in labor and delivery emergencies, rapid reporting with cause analysis for all unplanned events, and disclosing unexpected occurrences to patients using coordinated communication and documentation. Each of the models components required buy in from the hospitals clinical and administrative leadership, and it also required collaboration, training, and continual feedback to labor and delivery nurses, doctors, midwives, and risk managers. The case study examined the key elements in the development of the model based on interviews of all team members and document review. We also completed data analysis pre and post implementation of the new model to assess the impact on event reporting and high liability occurrence rates. After 27 months post implementation, reporting of unintended events increased significantly (43 vs 84 per 1000 births, p < .01) while high-risk malpractice events decreased significantly (14 vs 7 per 1000 births, p < .01). This decrease enabled money allotted for malpractice claims to be reallocated for the implementation of the new model at 42 additional labor and delivery sites. Due to these results, this multilevel integrated model showed promise.

Population-Based Risk Factors for Shoulder Dystocia

Objective: To re‐examine the risk factors for shoulder dystocia given the increasing rates of obesity and diabetes in pregnant women. Design: Retrospective observational study. Setting: Five hospitals located in Wisconsin, Florida, Maryland, Michigan, and Alabama. Participants: We evaluated 19,236 births that occurred between April 1, 2011, and July 25, 2013. Methods: Data were collected from electronic medical records and used to evaluate the risk of shoulder dystocia. Data were analyzed using a generalized linear mixed model, which controlled for clustering due to site. Results: When insulin was prescribed, gestational diabetes was associated with an increased risk of shoulder dystocia (odds ratio = 2.10, 95% confidence interval [1.01, 4.37]); however, no similar association was found with regard to gestational diabetes treated with glycemic agents or through diet. Use of epidural anesthesia was associated with an increased risk for shoulder dystocia (odds ratio = 3.47, 95% confidence interval [2.72, 4.42]). Being Black or Hispanic, being covered by Medicaid or having no insurance, infant gestational age of 41 weeks or greater, and chronic diabetes were other significant risk factors. Conclusion: With the changing characteristics of pregnant women, labor and birth clinicians care for more pregnant women who have an increased risk for shoulder dystocia. Our findings may help prospectively identify women with the greatest risk.