Organizational integration, practice capabilities, and outcomes in clinically complex medicare beneficiaries
Organizational integration, practice capabilities, and outcomes in clinically complex medicare beneficiaries
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DOI：
10.1111/1475-6773.13580
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发表时间：
2020-10-26
影响因子：
3.4
通讯作者：
Fisher, Elliott
中科院分区：
文献类型：
--
作者：
Colla, Carrie;Yang, Wendy;Fisher, Elliott
目的评估临床一体化与财务一体化、以质量为重点的医疗服务提供过程、受益者利用和结果之间的关系。数据来源2017-2018年全国医疗保健组织和系统调查(应答率47%)和2017年联邦医疗保险索赔数据中的多医生实践。研究设计将医疗保险受益者归因于医生实践的横断面研究，重点关注两个领域的一体化：临床(患者服务的协调、协议的使用、个人临床医生措施、信息获取)和财务(跨运营单位的财务管理和规划)。我们使用线性回归方法检验了整合领域、采用以质量为重点的医疗服务提供流程、受益人利用和健康相关结果以及价格调整支出之间的关联，使用线性回归调整实践和受益人特征，并考虑抽样和无响应的权重。数据收集/提取方法1 604 580个66岁或以上的按服务收费的联邦医疗保险受益人归因于2113个实践。其中，414 209名受益人被认为是临床复杂(虚弱或2+慢性疾病)。主要研究结果财务整合和临床整合弱相关(相关系数=0.19)。临床整合与更多地采用以质量为重点的护理交付流程相关，而财务整合与较少采用这些流程相关。整合通常与使用率降低或更好的受益者水平的健康相关结果无关，但临床整合和财务整合都与复杂和非复杂队列中的较低支出相关：(临床复杂队列：-2518美元，[95%CI：-3324，-1712]；临床非复杂队列：-255美元[95%CI：-413，-97]；财务复杂队列：-997美元[95%CI：-1320，-679]；和财务非复杂队列：-143美元[95%CI：-210，-76]。结论较高的财务整合水平与更好的医疗服务提供或更好的健康相关受益人结果无关。非财务形式的整合值得更多关注，因为在临床整合中得分较高的实践更有可能采用以质量为重点的护理交付流程，并在复杂患者的支出方面有更大的相关削减。
Objective To assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes.Data Sources Multiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data.Study Design Cross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse.Data Collection/Extraction Methods 1 604 580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414 209 beneficiaries were considered clinically complex (frailty or 2 + chronic conditions).Principal Findings Financial integration and clinical integration were weakly correlated (correlation coefficient = 0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76]).Conclusions Higher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients.