Medicare Fee Cuts and Cardiologist-Hospital Integration

Song, Zirui; Wallace, Jacob; Neprash, Hannah T.; McKellar, M. Richard; Chernew, Michael E.; McWilliams, J. Michael

doi:10.1001/jamainternmed.2015.2017

Cited by 27 publications

(32 citation statements)

References 3 publications

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“…This form of consolidation has increased prices and spending without ostensibly improving quality. 17,25–28 Building on previous evidence, 29,30 our study more generally underscores the importance of differences in profitability between hospital-owned and independent outpatient settings in encouraging hospital–physician consolidation. Thus, our findings support broader proposals to make payments and discounts for care delivery setting-neutral.…”

Section: Discussionsupporting

confidence: 74%

Consequences of the 340B Drug Pricing Program

Desai

McWilliams

2018

N Engl J Med

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BACKGROUND The 340B Drug Pricing Program entitles qualifying hospitals to discounts on outpatient drugs, increasing the profitability of drug administration. By tying the program eligibility of hospitals to their Disproportionate Share Hospital (DSH) adjustment percentage, which reflects the proportion of hospitalized patients who are low-income, the program is intended to expand resources for underserved populations but provides no direct incentives for hospitals to use financial gains to enhance care for low-income patients. METHODS We used Medicare claims and a regression-discontinuity design, taking advantage of the threshold for program eligibility among general acute care hospitals (DSH percentage, >11.75%), to isolate the effects of the program on hospital–physician consolidation (i.e., acquisition of physician practices or employment of physicians by hospitals) and on the outpatient administration of parenteral drugs by hospitalowned facilities in three specialties in which parenteral drugs are frequently used. For low-income patients, we also assessed the effects of the program on the provision of care by hospitals and on mortality. RESULTS Hospital eligibility for the 340B Program was associated with 2.3 more hematologist–oncologists practicing in facilities owned by the hospital, or 230% more hematologist–oncologists than expected in the absence of the program (P = 0.02), and with 0.9 (or 900%) more ophthalmologists per hospital (P = 0.08) and 0.1 (or 33%) more rheumatologists per hospital (P = 0.84). Program eligibility was associated with significantly higher numbers of parenteral drug claims billed by hospitals for Medicare patients in hematology–oncology (90% higher, P = 0.001) and ophthalmology (177% higher, P = 0.03) but not rheumatology (77% higher, P = 0.12). Program eligibility was associated with lower proportions of low-income patients in hematology–oncology and ophthalmology and with no significant differences in hospital provision of safety-net or inpatient care for low-income groups or in mortality among low-income residents of the hospitals’ local service areas. CONCLUSIONS The 340B Program has been associated with hospital–physician consolidation in hematology–oncology and with more hospital-based administration of parenteral drugs in hematology–oncology and ophthalmology. Financial gains for hospitals have not been associated with clear evidence of expanded care or lower mortality among low-income patients. (Funded by the Agency for Healthcare Research and Quality and others.)

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Section: Discussionsupporting

confidence: 74%

Consequences of the 340B Drug Pricing Program

Desai

McWilliams

2018

N Engl J Med

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“…Employment also frees physicians from the task of attracting new clients, developing relationships with other physicians for referrals, and other administrative burdens. At the same time, physician integration helps hospitals through referrals and bargaining power with insurers . This last statement does not apply to hospitalists though since hospitalists do not have a relationship with the patients before they are admitted to the hospital.…”

Section: Theoretical Frameworkmentioning

confidence: 99%

Hospitalists staffing levels and hospital performance

Al‐Amin

2019

Health Services Research

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| INTRODUC TI ONUnderstanding appropriate staffing levels and skill mix is an essential prerequisite in the quest for better quality, patient safety, patient experience, and efficiency. Most of the literature on staffing levels has focused on the nursing staff. Registered nurse (RN) staffing levels are associated with lower readmission rates, 1 lower mortality rates, 2 lower hospital-acquired infections rates, 3 and higher patient satisfaction. 4 Kane et al performed a meta-analysis on RN staffing levels and concluded that higher RN staffing levels are associated with better patient outcomes and quality. 5 Little, however, is known on the association between physician staffing Abstract Objective (or Study Question): To examine the association between hospitalists staffing levels and contract type with CMS Total Performance Score (TPS). Data Sources/Study Setting: Total performance scores were obtained from CMS, hospital-level data from the 2015 American Hospital Association Annual Survey Database, and unemployment rates from the Area Resource Health File. Study Design: We used cluster analysis to classify hospitals based on the distribution of various hospitalist contracts, and we used regression analysis to examine the association between TPS and hospitalist staffing levels and contract distributions. Hospital-level predictors included hospitalists staffing levels, RN staffing levels, and Magnet status. Market-level variables were unemployment rates and competition. Principal Findings: Higher staffing levels of employed hospitalists or hospitalists with a group contract are associated with higher TPS (with coefficient estimates of 0.85 and 0.83, respectively, and the same standard error of 0.22). Higher staffing levels of hospitalists under individual contract are negatively associated with TPS (with coefficient estimate of −0.43 and standard error of 0.21). Based on the regression analysis using hospital clusters as independent variables, hospitals with individual contractsor without hospitalists providing care had significantly worse TPS compared to hospitals that predominantly employ hospitalists (with coefficient estimate of −1.80 and standard error of 0.61). Magnet status, RN staffing levels, and small and medium size were positively associated with TPS. Medicare share of inpatient days, teaching status, AMCs, and for-profit and public nonfederal ownership were negatively associated with TPS. Conclusions:Adequate hospitalist staffing level is important for hospitals to achieve better performance. Hospitals need to consider the mix of arrangements or contracts that they have with hospitalists. K E Y W O R D Shospitalists, hospitals, staffing, total performance score, value-based purchasing | 45Health Services Research

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“…Hospitals and physicians also may consolidate to take advantage of Medicare payment rules that favor provision of services in hospital outpatient departments, rather than physician offices. [12]…”

Section: Potential Reasons For Consolidationmentioning

confidence: 99%

Little Evidence Exists To Support The Expectation That Providers Would Consolidate To Enter New Payment Models

Neprash

Chernew

McWilliams³

2017

Health Affairs

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Provider consolidation has been associated with higher health care prices and spending. Prevailing wisdom assumes that payment reform will accelerate consolidation, especially between physicians and hospitals and among physician groups, as providers position themselves to bear financial risk for the full continuum of patient care. Drawing from a number of data sources from 2008 onward, we examined the relationship between Medicare’s Accountable Care Organization (ACO) programs and provider consolidation. According to multiple measures, consolidation was underway in 2008–2010, before the Affordable Care Act (ACA) established the ACO programs. While the number of hospital mergers and specialty-oriented physician group size increased after the ACA, we found minimal evidence associating consolidation with ACO penetration at a market level or with ACO participation by physicians within markets. We conclude that payment reform has been associated with little acceleration in consolidation apart from trends already underway, but with some evidence of potential defensive consolidation in response to new payment models.

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Medicare Fee Cuts and Cardiologist-Hospital Integration

Cited by 27 publications

References 3 publications

Consequences of the 340B Drug Pricing Program

Consequences of the 340B Drug Pricing Program

Hospitalists staffing levels and hospital performance

Little Evidence Exists To Support The Expectation That Providers Would Consolidate To Enter New Payment Models

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