Effect of financial incentives on hospital-cardiologist integration and cardiac test location
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ABSTRACT:
SUBMITTER: Yuan A
PROVIDER: S-EPMC11343569 | biostudies-literature | 2023 Jul
REPOSITORIES: biostudies-literature
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Project description:ObjectiveTo describe how much of the recent increase in hospital-cardiologist integration has come from acquisitions of physician practices compared to individual employment decisions. While the role of physician practice acquisitions has received considerable attention in the news, integration may also be driven by individual physicians accepting employment at hospital-based practices.Data sourcesAmerican Medical Association Physician Masterfile and Medicare data.Study designAnalysis of changes in hospital-cardiologist integration from 2011 to 2018. We measured increases in integration and changes in the number of independent and hospital-owned practices.Data collection/extraction methodsNot applicable.Principal findingsIn 2011, 18% of cardiologists were integrated, rising to 25% in 2016. Of this rise, 48% occurred with no acquisitions. Physicians who had completed residencies in the past 5 years (early career physicians) had higher rates of integration that also increased over time: the percentage of early career physicians joining hospital systems rose from 25% to 32%, indicating rapid growth in the number of physicians who began their careers working in hospital-based sites.ConclusionsA large and growing portion of hospital-cardiologist integration came from hospital employment at the individual physician level. Future policies focused on preserving competition and affordability may benefit from better understanding this form of consolidation.
| S-EPMC8928021 | biostudies-literature
Project description:BackgroundCardiologists are increasingly moving from independent practice to direct employment by hospitals. Hospital employment has the potential to improve care coordination and delivery, but little is known about its effect on care quality and outcomes.ObjectivesIn this study, we sought to assess the association between hospital employment of cardiologists and patient outcomes, care quality, and utilization among patients hospitalized with incident acute myocardial infarction (AMI) or heart failure (HF).MethodsWe used a sample of Medicare fee-for-service beneficiaries hospitalized with incident AMI or HF from 2008 to 2019. We identified the accountable cardiologists that cared for these patients and determined their employment status by means of tax identification numbers. We used difference-in-differences methods to compare clinical outcomes, quality measures, and utilization for patients treated by hospital-employed cardiologists after switching from independent to hospital-employed practice, to outcomes for patients treated by cardiologists who remained independent. Models were adjusted for time trends and patient, hospital, and cardiologist characteristics. Patient outcomes were in-hospital mortality, 30-day mortality, and 30-day readmission. Quality measures were receipt of: 1) a guideline-recommended test to assess cardiac function; and 2) a 30-day follow-up clinic visit. Utilization measures were length of stay and, for AMI patients, the proportion receiving coronary revascularization.ResultsThe proportion of U.S. cardiologists employed by hospitals increased from 26% in 2008 to 63% in 2019. We identified 186,052 AMI and 259,849 HF patients cared for by cardiologists who switched to hospital employment and 168,052 AMI and 245,769 HF patients cared for by independent cardiologists. Patient characteristics were similar (mean age 80.8 years; 47% men). We found no significant differences in outcomes (eg, adjusted difference in 30-day mortality 0.03% [95% CI: -0.39% to 0.45%] for AMI patients and -0.05% [95% CI: -0.37% to 0.27%] for HF patients); no differences in most quality metrics except a small increase in the proportion of HF patients with 30-day follow-up (adjusted difference: 1.04%; 95% CI: 0.46%-1.62%); and no differences in utilization between patients treated by hospital-employed cardiologists (postswitch) vs independent cardiologists.ConclusionsAmong U.S. cardiologists, there has been a large shift from independent practice to direct employment by hospitals. We found minimal evidence that cardiologist employment by hospitals improves care quality or outcomes.
| S-EPMC11824900 | biostudies-literature
Project description:OBJECTIVEThe financial incentives for hospitals to improve care may be weaker if higher insurer payments for adverse conditions offset a portion of hospital costs. The purpose of this study was to simulate incentives for reducing hospital-acquired infections under various payment configurations by Medicare, Medicaid, and private payers.DESIGNMatched case-control study.SETTINGA large, urban hospital system with 1 community hospital and 2 tertiary-care hospitals.PATIENTSAll patients discharged in 2013 and 2014.METHODSUsing electronic hospital records, we identified hospital-acquired bloodstream infections (BSIs) and urinary tract infections (UTIs) with a validated algorithm. We assessed excess hospital costs, length of stay, and payments due to infection, and we compared them to those of uninfected patients matched by propensity for infection.RESULTSIn most scenarios, hospitals recovered only a portion of excess HAI costs through increased payments. Patients with UTIs incurred incremental costs of $6,238 (P<.01), while payments increased $1,901 (P<.05) at public diagnosis-related group (DRG) rates. For BSIs, incremental costs were $15,367 (P<.01), while payments increased $7,895 (P<.01). If private payers reimbursed a 200% markup over Medicare DRG rates, hospitals recovered 55% of costs from BSI and UTI among private-pay patients and 54% for BSI and 33% for UTI, respectively, across all patients. Under per-diem payment for private patients with no markup, hospitals recovered 71% of excess costs of BSI and 88% for UTI. At 150% markup and per-diem payments, hospitals profited.CONCLUSIONSHospital incentives for investing in patient safety vary by payer and payment configuration. Higher payments provide resources to improve patient safety, but current payment structures may also reduce the willingness of hospitals to invest in patient safety.Infect Control Hosp Epidemiol 2018;39:509-515.
| S-EPMC6047523 | biostudies-literature
Project description:Importance:The strongest evidence for the effectiveness of Medicare's Hospital Readmissions Reduction Program (HRRP) involves greater reductions in readmissions for hospitals receiving penalties compared with those not receiving penalties. However, the HRRP penalty is an imperfect measure of hospitals' marginal incentive to avoid a readmission for HRRP-targeted diagnoses. Objectives:To assess the association between hospitals' condition-specific incentives and readmission performance and to examine the responsiveness of hospitals to condition-specific incentives compared with aggregate penalty amounts. Design, Setting, and Participants:This retrospective cohort analysis used Medicare readmissions data from 2823 US short-term acute care hospitals participating in HRRP to compare 3-year (fiscal years 2016-2019) follow-up readmission performance according to tertiles of hospitals' baseline (2016) marginal incentives for each of 5 HRRP-targeted conditions (acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, pneumonia, and hip and/or knee surgery). Main Outcomes and Measures:Linear regression models were used to estimate mean change in follow-up readmission performance, measured using the excess readmissions ratio, with baseline condition-specific incentives and aggregate penalty amounts. Results:Of 2823 hospitals that participated in the HRRP from baseline to follow-up, 2280 (81%) had more than 1 excess readmission for 1 or more applicable condition and 543 (19%) did not have any excess readmissions. The mean (SD) financial incentive to reduce readmissions for incentivized hospitals ranged from $8762 ($3699) to $58 158 ($26 198) per 1 avoided readmission. Hospitals with greater incentives for readmission avoidance had greater decreases in readmissions compared with hospitals with smaller incentives (45% greater for pneumonia, 172% greater for acute myocardial infarction, 40% greater for hip and/or knee surgery, 32% greater for chronic obstructive pulmonary disease, and 13% greater for heart failure), whereas hospitals with no incentives had increases in excess readmissions of 4% to 7% (median, 4% [percentage change for nonincentivized hospitals was 3.7% for pneumonia, 4.2% for acute myocardial infarction, 7.1% for hip and/or knee surgery, 3.7% for chronic obstructive pulmonary disease, and 3.7% for heart failure]; P < .001). During the study period, each additional $5000 in the incentive amount was associated with a 0.6- to 1.3-percentage point decrease, or up to a 26% decrease, in excess readmissions (P < .001). Regression to the mean explained approximately one-third of the results depending on the condition examined. Conclusions and Relevance:The findings suggest that improvements in readmission avoidance are more strongly associated with incentives from the HRRP than with aggregate penalty amounts, suggesting that the program has elicited sizeable changes. Worsened performance among hospitals with small or no incentives may indicate the need for reconsideration of the program's lack of financial rewards for high-performing hospitals.
| S-EPMC7125432 | biostudies-literature
Project description:Cellulosic biofuels are part of a portfolio of solutions to address climate change; however, their production remains expensive and federal policy interventions (e.g., Renewable Fuel Standard) have not spurred broad construction of cellulosic biorefineries. A range of state-level interventions have also been enacted, but their implications for the financial viability of biorefineries are not well understood. To address this gap, this study evaluated the efficacy of 20 state-level tax incentives from 14 states and their interactions with other location-specific economic parameters (e.g., state income tax rates, electricity prices). To characterize implications of location-specific policies and parameters on biorefinery cash flows, we developed a new BioSTEAM Location-Specific Evaluation (BLocS) module for the open-source software BioSTEAM. Leveraging BLocS and BioSTEAM, we characterized the minimum ethanol selling price (MESP) for a cellulosic biorefinery (using corn stover as feedstock) and two conventional biorefineries (using corn or sugarcane as feedstock) for comparison. Among state-specific scenarios, nonincentivized MESPs for the corn stover biorefinery ranged from 0.74 $·L-1 (4.20 $·gallon gasoline equivalent [gge]-1) [0.69-0.79 $·L-1; 3.91-4.48 $·gge-1; Oklahoma] to 1.02 $·L-1 (5.78 $·gge-1) [0.95-1.09 $·L-1; 5.39-6.18 $·gge-1; New York], while the tax incentive-induced MESP reduction ranged from negligible (Virginia) to 5.78% [5.43-6.20%; Iowa]. Ultimately, this work can inform the design of policy incentives for biorefineries under specific deployment contexts.
| S-EPMC9933530 | biostudies-literature
Project description:BackgroundIn 2012, the Ministry of Health in British Columbia, Canada, introduced a $75 incentive payment that could be claimed by hospital physicians each time they produced a written post-discharge care plan for a complex patient at the time of hospital discharge.ObjectiveTo examine whether physician financial payments incentivizing enhanced discharge planning reduce subsequent unplanned hospital readmissions.DesignInterrupted time series analysis of population-based hospitalization data.ParticipantsIndividuals with one or more eligible hospitalizations occurring in British Columbia between 2007 and 2017.Main measuresThe proportion of index hospital discharges with subsequent unplanned hospital readmission within 30 days, as measured each month of the 11-year study interval. We used interrupted time series analysis to determine if readmission risk changed after introduction of the incentive payment policy.Key resultsA total of 40,588 unplanned hospital readmissions occurred among 409,289 eligible index hospitalizations (crude 30-day readmission risk, 9.92%). Policy introduction was not associated with a significant step change (0.393%; 95CI, - 0.190 to 0.975%; p = 0.182) or change-in-trend (p = 0.317) in monthly readmission risk. Policy introduction was associated with significantly fewer prescription fills for potentially inappropriate medications among older patients, but no improvement in prescription fills for beta-blockers after cardiovascular hospitalization and no change in 30-day mortality. Incentive payment uptake was incomplete, rising from 6.4 to 23.5% of eligible hospitalizations between the first and last year of the post-policy interval.ConclusionThe introduction of a physician incentive payment was not associated with meaningful changes in hospital readmission rate, perhaps in part because of incomplete uptake by physicians. Policymakers should consider these results when designing similar interventions elsewhere.Trial registrationClinicalTrials.gov ID, NCT03256734.
| S-EPMC8606373 | biostudies-literature
Project description:In healthcare systems with a purchaser-provider split, contracts are an important tool to define the conditions for the provision of healthcare services. Financial risk allocation can be used in contracts as a mechanism to influence provider behavior and stimulate providers to provide efficient and high-quality care. In this paper, we provide new insights into financial risk allocation between insurers and hospitals in a changing contracting environment. We used unique nationwide data from 901 hospital-insurer contracts in The Netherlands over the years 2013, 2016, and 2018. Based on descriptive and regression analyses, we find that hospitals were exposed to more financial risk over time, although this increase was somewhat counteracted by an increasing use of risk-mitigating measures between 2016 and 2018. It is likely that this trend was heavily influenced by national cost control agreements. In addition, alternative payment models to incentivize value-based health care were rarely used and thus seemingly of lower priority, despite national policies being explicitly directed at this goal. Finally, our analysis shows that hospital and insurer market power were both negatively associated with financial risk for hospitals. This effect becomes stronger if both hospital and insurer have strong market power, which in this case may indicate a greater need to reduce (financial) uncertainties and to create more cooperative relationships.
| S-EPMC9002227 | biostudies-literature
Project description:ImportanceAlthough breastfeeding has a positive effect on an infant's health and development, the prevalence is low in many communities. The effect of financial incentives to improve breastfeeding prevalence is unknown.ObjectiveTo assess the effect of an area-level financial incentive for breastfeeding on breastfeeding prevalence at 6 to 8 weeks post partum.Design, setting, and participantsThe Nourishing Start for Health (NOSH) trial, a cluster randomized trial with 6 to 8 weeks follow-up, was conducted between April 1, 2015, and March 31, 2016, in 92 electoral ward areas in England with baseline breastfeeding prevalence at 6 to 8 weeks post partum less than 40%. A total of 10 010 mother-infant dyads resident in the 92 study electoral ward areas where the infant's estimated or actual birth date fell between February 18, 2015, and February 17, 2016, were included. Areas were randomized to the incentive plus usual care (n = 46) (5398 mother-infant dyads) or to usual care alone (n = 46) (4612 mother-infant dyads).InterventionsUsual care was delivered by clinicians (mainly midwives, health visitors) in a variety of maternity, neonatal, and infant feeding services, all of which were implementing the UNICEF UK Baby Friendly Initiative standards. Shopping vouchers worth £40 (US$50) were offered to mothers 5 times based on infant age (2 days, 10 days, 6-8 weeks, 3 months, 6 months), conditional on the infant receiving any breast milk.Main outcomes and measuresThe primary outcome was electoral ward area-level 6- to 8-week breastfeeding period prevalence, as assessed by clinicians at the routine 6- to 8-week postnatal check visit. Secondary outcomes were area-level period prevalence for breastfeeding initiation and for exclusive breastfeeding at 6 to 8 weeks.ResultsIn the intervention (5398 mother-infant dyads) and control (4612 mother-infant dyads) group, the median (interquartile range) percentage of women aged 16 to 44 years was 36.2% (3.0%) and 37.4% (3.6%) years, respectively. After adjusting for baseline breastfeeding prevalence and local government area and weighting to reflect unequal cluster-level breastfeeding prevalence variances, a difference in mean 6- to 8-week breastfeeding prevalence of 5.7 percentage points (37.9% vs 31.7%; 95% CI for adjusted difference, 2.7% to 8.6%; P < .001) in favor of the intervention vs usual care was observed. No significant differences were observed for the mean prevalence of breastfeeding initiation (61.9% vs 57.5%; adjusted mean difference, 2.9 percentage points; 95%, CI, -0.4 to 6.2; P = .08) or the mean prevalence of exclusive breastfeeding at 6 to 8 weeks (27.0% vs 24.1%; adjusted mean difference, 2.3 percentage points; 95% CI, -0.2 to 4.8; P = .07).Conclusions and relevanceFinancial incentives may improve breastfeeding rates in areas with low baseline prevalence. Offering a financial incentive to women in areas of England with breastfeeding rates below 40% compared with usual care resulted in a modest but statistically significant increase in breastfeeding prevalence at 6 to 8 weeks. This was measured using routinely collected data.Trial registrationInternational Standard Randomized Controlled Trial Registry: ISRCTN44898617.
| S-EPMC5839268 | biostudies-literature
Project description:We revisit two fundamental motivations of dishonesty: financial incentives and probability of detection. We use an ability-based real effort task in which participants who are college students in India can cheat by over reporting the number of puzzles they could solve in a given period of time. The puzzles are all unsolvable and this fact is unknown to participants. This design feature allows us to obtain the distribution of cheating outcomes at the individual level. Controlling for participant attributes, we find that introducing piece-rate financial incentives lowers both the likelihood and magnitude of cheating only for individuals with a positive probability of detection. On the other hand, a decrease in the probability of detection to zero increases magnitude of cheating only for individuals receiving piece-rate incentives. Moreover, we observe that participants cheat significantly even in the absence of piece-rate incentives indicating that affective benefits may determine cheating. Finally, an increase in own perceived wealth status vis-à-vis one's peers is associated with a higher likelihood of cheating while feeling more satisfied with one's current economic state is associated with a lower magnitude of cheating.
| S-EPMC8854596 | biostudies-literature
Project description:Financial incentives have been used in a variety of settings to motivate behaviors that might not otherwise be undertaken. They have been highlighted as particularly useful in settings that require a single behavior, such as appointment attendance or vaccination. They also have differential effects based on socioeconomic status in some applications (e.g. smoking). To further investigate these claims, we tested the effect of providing different types of non-cash financial incentives on the return rates of chlamydia specimen samples amongst 16-24 year-olds in England. In 2011 and 2012, we ran a two-stage randomized experiment involving 2988 young people (1489 in Round 1 and 1499 in Round 2) who requested a chlamydia screening kit from Freetest.me, an online and text screening service run by Preventx Limited. Participants were randomized to control, or one of five types of financial incentives in Round 1 or one of four financial incentives in Round 2. We tested the effect of five types of incentives on specimen sample return; reward vouchers of differing values, charity donation, participation in a lottery, choices between a lottery and a voucher and including vouchers of differing values in the test kit prior to specimen return. Financial incentives of any type, did not make a significant difference in the likelihood of specimen return. The more deprived individuals were, as calculated using Index of Multiple Deprivation (IMD), the less likely they were to return a sample. The extent to which incentive structures influenced sample return was not moderated by IMD score. Non-cash financial incentives for chlamydia testing do not seem to affect the specimen return rate in a chlamydia screening program where test kits are requested online, mailed to requestors and returned by mail. They also do not appear more or less effective in influencing test return depending on deprivation level.
| S-EPMC3969100 | biostudies-literature