A quality-driven physician compensation model: four-year follow-up study.

Pay-for-Performance Programs Show Positive Impact on Low-Performing Physicians

While Preferred Provider Organizations (PPOs) are designed to contain the costs of health care, they may not be able to do so if sicker individuals opt not to use PPO providers. This study examined how level of mental health status and prior use of mental health services affected the decision to use or not use PPO providers for mental health care for employees enrolled in fee-for-service plans with a PPO option. Data were obtained from an employee survey and claims data on three large employee groups. It was not possible to examine effects of sickliness on the intent to select PPO providers for mental health care directly because about one half of employees could not identify who they would visit for mental health care or even how they would select a provider for such care. The intent to use PPO or non-PPO providers for general medical care, however, was not significantly associated with mental health status when other factors were controlled. Furthermore, among persons who used mental health services after implementation of the PPO option, those who had previously visited providers who were to become part of the PPO panel tended to stay with PPO providers, while those who previously visited providers who were not to enter the PPO panel subsequently selected away from PPO providers for mental health care. This pattern of results suggests that established individual patient-provider relationships, rather than sickliness, determined the selection of PPO versus non-PPO providers for mental health care for employees enrolled in these optional PPO fee-for-service plans.

The organization of the delivery of health care can have significant cost-saving implications, but few of the available studies have made adequate comparisons of costs across plans. Furthermore, new organizational types such as independent practice associations and preferred provider organizations have not yet been studied in detail. This paper examines ambulatory utilization in a preferred provider organization (PPO) for Uniformed Services beneficiaries at Pacific Medical Center (PMC) in Seattle. The utilization in the PPO is compared with the results of a recently reported study of three other organizationally different Seattle plans: a Blue Cross/Blue Shield plan (BC), a closed-panel health maintenance organization (HMO), and an independent practice association (IPA). The PPO was similar to the IPA and the HMO in having a high percent of patients with any ambulatory use and had standardized ambulatory costs per user which were lower than BC but higher than the HMO. Thus, this particular type of PPO may have cost-saving features, particularly because the Uniformed Services population is known to use more health services than the general population. Methodological issues for future utilization research across organizations are also discussed.

Nurse Practitioners in Emergency Care

Are physicians assistants the answer to a shortage of nephrologists?

Hawaii Medical Service Association (HMSA), the Blue Cross Blue Shield of Hawaii, introduced Population-based Payments for Primary Care (3PC), a new capitation-based primary care payment system, in 2016. The effect of this system on quality measures has not been evaluated. To evaluate whether the 3PC system was associated with changes in quality, utilization, or spending in its first year. Observational study using HMSA claims and clinical registry data from January 1, 2012, to December 31, 2016, and a propensity-weighted difference-in-differences method to compare 77 225 HMSA members in Hawaii attributed to 107 primary care physicians (PCPs) and 4 physician organizations participating in the first wave of the 3PC and 222 233 members attributed to 312 PCPs and 14 physician organizations that continued in a fee-for-service model in 2016 but had 3PC start dates thereafter. Participation in the 3PC system. The primary outcome was the change in a composite measure score reflecting the probability that a member achieved an eligible measure out of 13 pooled Healthcare Effectiveness Data and Information Set quality measures. Primary care visits and total cost of care were among 15 secondary outcomes. In total, the study included 299 458 HMSA members (mean age, 42.1 years; 51.5% women) and 419 primary care physicians (mean age, 54.9 years; 34.8% women). The risk-standardized composite measure scores for 2012 to 2016 changed from 75.1% to 86.6% (+11.5 percentage points) in the 3PC group and 74.3% to 83.5% (+9.2 percentage points) in the non-3PC group (differential change, 2.3 percentage points [95% CI, 2.1 to 2.6 percentage points]; P < .001). Of 15 prespecified secondary end points for utilization and spending, 11 showed no significant difference. Compared with the non-3PC group, the 3PC system was associated with a significant reduction in the mean number of primary care visits (3.3 to 3.0 visits vs 3.3 to 3.1 visits; adjusted differential change, -3.9 percentage points [95% CI, -4.6 to -3.2 percentage points]; P < .001), but there was no significant difference in mean total cost of care ($3344 to $4087 vs $2977 to $3564; adjusted differential change, 1.0% [95% CI, -1.3% to 3.4%]; P = .39). In its first year, the 3PC population-based primary care payment system in Hawaii was associated with small improvements in quality and a reduction in PCP visits but no significant difference in the total cost of care. Additional research is needed to assess longer-term outcomes as the program is more fully implemented and to determine whether results are generalizable to other health care markets.

Collaborating With NPs and PAs: Best Practices for Comanagement of Patient Care

What Acute Care Nurse Practitioners Should Understand About Reimbursement

BackgroundIn 2018, Palliative Care Australia issued a report outlining nine standards which intended to guide and support the delivery of high-quality palliative care in Australia. Standard 8 encouraged services to...

Back to table of contents Previous article Next article ColumnFull AccessDatapoints: Internet-Based Behavioral Health Services in Health PlansConstance M. Horgan Sc.D.Elizabeth L. Merrick Ph.D., M.S.W.Sharon Reif Ph.D.Maureen Stewart M.A.Constance M. Horgan Sc.D.Search for more papers by this authorElizabeth L. Merrick Ph.D., M.S.W.Search for more papers by this authorSharon Reif Ph.D.Search for more papers by this authorMaureen Stewart M.A.Search for more papers by this authorPublished Online:1 Mar 2007AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Forty percent of individuals with Internet access use it to obtain health information ( 1 ). Despite the increasing salience of the Internet, little systematic information exists on the prevalence of health plan-sponsored online resources for behavioral health. Data presented are from a nationally representative survey of commercial health plans sampled from 60 nationally representative market areas. A total of 368 of 441 eligible plans (83%) responded to a survey on alcohol, drug abuse, and mental health services in 2003. Medical directors indicated whether each of their three largest products offered Internet-based resources via e-mail, Web sites, or Internet-based videoconferencing. Data are weighted to reflect national estimates. We examined differences by three product types (health maintenance organization [HMO], preferred provider organization [PPO], and point-of-service plan [POS]) and three behavioral health contracting arrangements (specialty managed behavioral health care organization, comprehensive contracting with a single vendor for general medical and behavioral health, and internal behavioral health services provided by plan employees or a network administered by the plan). Analyses were conducted at the product level. Most products offered online provider directories and educational information ( Figure 1 ). Two-thirds offered behavioral health self-assessment tools, and almost one-half provided online referral. About one-third provided personalized responses to problems. Only 2% offered online counseling. Products with specialty contracting were the most likely to offer online services. Products with comprehensive contracting rarely offered most online services. HMO and POS products were more likely to offer online services than PPOs (data not shown). For example, about a third of HMOs and half of POS products offered personalized responses online, compared with less than 10% of PPOs. Figure 1 Internet-based behavioral health information and services offered by health plansFor-profit plans were more likely to offer online patient self-assessment, referral, and personal response to questions. Products in the Northeast were more likely than those in other regions to have online directories, self-assessment, educational information, and online referral (data not shown.)The survey found that health plans frequently used the Internet to provide information but used it less often to provide clinical services directly. Delivering behavioral health services, such as counseling, via the Internet certainly raises more complex clinical, professional, privacy, and legal issues than, for example, offering educational information. At least in the short term, increasing use of Internet-based tools designed to facilitate and complement traditional clinical services seems likely.Acknowledgments and disclosuresFunding was provided by grant R01-DA-10915 from the National Institute on Drug Abuse and grant R01-AA-10869 from the National Institute on Alcohol Abuse and Alcoholism. The authors thank Deborah Garnick, Sc.D., Dominic Hodgkin, Ph.D., and Frank Potter, Ph.D., for their contributions.The authors report no competing interests.The authors are affiliated with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, MS 035, 415 South St., Waltham, MA 02454 (e-mail: [email protected]). Harold Alan Pincus, M.D., Terri L. Tanielian, M.A., and Amy M. Kilbourne, Ph.D., M.P.H., are editors of this column.Reference1. Baker L, Wagner TH, Singer S, et al: Use of the Internet and e-mail for health care information. JAMA 289:2400–2406, 2003Google Scholar FiguresReferencesCited byDetailsCited byWhat Is the Role of e-Technology in Mental Health Services and Psychiatric Research?Journal of Psychosocial Nursing and Mental Health Services, Vol. 46, No. 4 Volume 58Issue 3 March, 2007Pages 307-307PSYCHIATRIC SERVICES March 2007 Volume 58 Number 3 Metrics PDF download History Published online 1 March 2007 Published in print 1 March 2007

Rapid changes in the health care marketplace are driving health care systems to modify operations by which the advanced practice registered nurse (APRN) and physician assistant (PA) clinicians serve patients. By identifying more effective and efficient utilization workflows, organizations can meet these demands resulting in high-functioning clinical teams. With the growing number of APRNs and PAs within a large academic medical center, there was a recognized need to establish effective and efficient utilization practices for these health care providers. Directors of the Advanced Practice Provider Best Practice Center developed an internal nurse practitioner (NP)/certified nurse midwife (CNM)/clinical nurse specialist (CNS)/PA assessment service in which evaluations were conducted to optimize APRN and PA practice at the clinical/department level. This assessment excluded certified registered nurse anesthetists. Thirty-two clinical areas were evaluated between September 2016 and May 2019. This included an NP/CNM/CNS/PA survey and over 200 individual NP/CNM/CNS and PA provider interviews. Assessments addressed utilization, billing practices, professional development, and communication among team members. Qualitative and quantitative reports were compiled. Many common themes were identified. These were broken down into three major categories: productivity, clinical operations, and professional development/support. Several recommendations were presented to department leaders regarding NP/CNM/CNS/PA practice. Those departments who implemented several of the recommendations showed positive outcomes. This was evidenced by increased financial gain (increased relative value units, increase in revenue generated), increased patient access (increased clinic densities), and overall NP/CNM/CNS/PA satisfaction.

A 2016 survey from Deloitte found that half of physicians were unaware of important changes to the Medicare reimbursement policy that were set to begin on January 1, 2017, and thus questioned the readiness of hundreds of thousands of physicians expected to participate and meet certain performance criteria.1 For pathology, the Medicare reforms could have a $2 billion impact on the specialty during the next several years. All physicians will ease into the new requirements. For instance, with quality measures developed by the College of American Pathologists (CAP), pathologists can prevent a 2019 Medicare financial penalty by reporting on 1 quality measure in 2017. In future years, Medicare will require greater reporting and performance activity from all physicians and group practices in order to avoid decreases in reimbursement.With the expansion of health care fringe benefits during World War II, the advent of Medicare in 1965 under Title XVIII of the Social Security Act, and subsequent health care coverage programs under the control of the Centers of Medicare & Medicaid Services (CMS), the United States has seen a steep rise in health care expenditures. Currently, the CMS provides health care coverage for roughly 105 million beneficiaries at a cost of more than $1.1 trillion annually.2,3 In an effort to hold health care providers accountable for a portion of this increased cost, Congress created the Sustainable Growth Rate (SGR) formula in the Balanced Budget Act of 1997.4 Simplistically, the SGR was an adjustment factor applied to physician fee schedule (PFS) payments that was designed to ensure that the yearly expense per Medicare beneficiary did not exceed the growth in the Gross Domestic Product. However, implementation of this SGR-related PFS update was repeatedly delayed by Congress over the years (the "doc fix"), which eventually led to a potential 27.5–percentage point negative adjustment in PFS payment rates if an alternative to the SGR was not identified. These "doc fixes" also were a factor in the creation of quality pay for performance programs, the first being the Physician Quality Reporting System (PQRS). The PQRS, initially known as the Physician Quality Reporting Initiative, was created within the Tax Relief and Health Care Act of 2006 and made permanent within the Medicare Improvements for Patients and Providers Act of 2008.5,6 Subsequently, the Patient Protection and Affordable Care Act of 2010, commonly referred to as "Obamacare," established the Value-Based Payment Modifier (VBPM) program and the concept of Accountable Care Organizations (ACOs) through the Medicare Shared Savings Programs (MSSPs).7All of these programs had the intent of establishing accountability on the part of the health care provider for the quality and cost of care by linking these to payment. However, despite having these payment adjustment programs in place, the constant threat of a large SGR payment cut remained and made financial planning difficult for physician practices. Congress responded to this concern by passing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).8 This legislation was game-changing in that it terminated the never functionally implemented SGR formula, establishing a new framework for rewarding health care providers for better care, not merely more care, and made participation mandatory for all CMS-eligible clinicians (ECs) who wanted to avoid a negative adjustment to their Medicare Part B payments. Under MACRA, the last payment adjustment year related to the PQRS, VBPM, and Electronic Health Record Incentive program (Meaningful Use) will be in 2018, based on January 1, 2016, to December 31, 2016, reporting. In essence, this legislation has bundled all of the prior physician quality reporting programs into one, which the CMS has designated as its Quality Payment Program (QPP). More than 600 000 clinicians will now be reimbursed under the QPP. Initial reporting of metrics for this new program began January 1, 2017, and will close December 31, 2017, with payment adjustments related to this performance period starting in 2019.Within the QPP, there are 2 payment pathways—the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). An EC during the first 2 years is defined by law as any physician, physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, or any group that includes such professionals and bills CMS for those professional services. In future years, CMS has indicated it anticipates expanding this EC definition. Pathologists at independent laboratories are also considered ECs. This latter point is an important change from the previous quality reporting programs from which they had been excluded, because they were considered Medicare suppliers. Here, we will further describe the details of these 2 payment pathways, based on the CMS's final rule (81 FR 77008), and what you and/or your practice need to do to avoid a potential penalty in 2019.9According to CMS calculations, most ECs will fall into the MIPS pathway. The ECs can be excluded from MIPS by participating in a qualified APM, by not exceeding the low-volume threshold of seeing fewer than 100 Medicare patients or billing CMS less than $30 000 in a year in part B payments on the physician fee schedule, or by being a first-time enrollee in CMS. Based on an EC's or a group's performance within 4 categories, an overall composite performance score (CPS) will be calculated. This CPS is what will be used to compare the EC or the group to the rest of those within the MIPS and determine the potential bonus or penalty they will receive. The potential impact on CMS payments in 2019 from MIPS performance in 2017 is ±4%: this increases to ±5% in 2020, ±7% in 2021, and then ±9% in 2022 and beyond. The performance adjustments are budget neutral, such that the total amount of penalties and bonuses will equal zero.The 4 categories within MIPS are—Quality, Clinical Practice Improvement Activities (CPIAs), Advancing Care Information (ACI), and Resource Use. The requirements within each category can change depending on whether or not an EC is considered "patient facing" or "non–patient facing." This distinction is critical because performance requirements can differ between the 2 groups. According to the 2016 final rule, a non–patient facing EC must bill 100 or fewer patient-facing encounters in a calendar year. For those in a group, 75% of the ECs must fall within the above definition in order for the group to be considered non–patient facing. According to CMS, ECs and groups will be notified of their classification at the start of each performance year. A final list of what qualifies as a patient-facing encounter is available at the CMS Web site (Quality Measure Encounter Codes; accessed January 24, 2017), but the ones most likely to affect pathologists include apheresis, bone marrow biopsy procedure, and evaluation and management CPT codes. Based on a preliminary analysis by CMS, most pathologists will be classified as non–patient facing.In order to ease transition into the new program, CMS has made several options available for reporting in 2017. In order to avoid a penalty in 2019, an EC or group simply must report something within one of the performance categories—for example, one quality measure, regardless of the number of cases—or attest to one CPIA, such as providing timely communication of test results. By simply reporting on one measure or activity, the EC and/or group will avoid the 4% downward payment adjustment in 2019. Other potential participation options include a partial year of reporting—meaning at least 90 days' worth of patient data—or a full year of reporting. Those that chose 1 of these 2 latter options would be eligible for a partial or a full bonus, respectively. The CMS has acknowledged that most small practices would be at a disadvantage and would likely have received a penalty in 2019 without these transition year rules.Within the Quality performance category, an EC or group must report on 6 applicable measures, or all that apply to them if they do not qualify for reporting 6 measures. Depending on the reporting mechanism, the reported data must be on at least 50% of their Medicare patients if done via claims reporting, or 50% of all their patients (regardless of payer) if using another reporting mechanism. For 2017, the CMS has maintained all 8 current CAP–developed quality measures (Table 1). There are other measures available that may apply to a limited number of pathologists and are only reported via a registry. If an EC is unsure if he or she qualifies for additional measures, the EC may contact CMS at the Quality Payment Program Service Center at 1-866-288-8292 or use the online measure tool on the CMS Web site (https://qpp.cms.gov/measures/quality; accessed January 4, 2017). Each applicable measure will receive a score ranging from 0 to 10 points depending on the EC's performance compared with others who reported on the same measure. If 6 measures were applicable to the EC, then a total of 60 points would therefore be available in this performance category. The CMS has classified the 2 lung cancer and the melanoma pathology reporting measures as "high-value" and outcome measures. There are potential bonus points available for reporting on the high-value measures.Of all of these performance categories, only the CPIA category represents a new pay-for-performance concept for CMS, where an EC is rewarded for activities such as care coordination, patient engagement, and safety. Within the final rule, there are 6 subcategories with a total of 92 medium- or high-weighted activities that could count toward obtaining the 40 points available in this performance category. As a non–patient facing EC, the EC or his or her group would need to attest to performing 2 medium-weighted or 1 high-weighted CPIA for a minimum of 90 days. In contrast, patient-facing ECs need to report 4 medium-weighted or 2 high-weighted CPIAs for full credit in this category. Some potential activities that pathologists may participate in are listed in Table 2. Reporting will be done via attestation, and future guidance is expected from the CMS regarding this process. Of importance is that those who report individually via claims will also have to attest individually for CPIA. This is in contrast to those reporting as a group, in which they would attest on 1 to 2 items as a group.The ACI performance category is, in essence, the Electronic Health Record Incentive Program (Meaningful Use). Historically, pathologists have been given an exemption from this program because the interoperability and information exchange measures within the program were not applicable to laboratory information systems (LISs). At least at the start of MIPS, it appears this exemption will continue, because non–patient facing clinicians will not be scored in this category. The CMS will reweight this category to zero for non–patient facing clinicians, and will reallocate the percentage value in this category to the Quality performance category in determining the CPS.Similarly, the Resource Use performance category will not be scored in 2017. Therefore, this category will be reweighted to zero for all ECs, with its percentage of the CPS also being reallocated to the Quality performance category. In the future, this performance category will be similar to the VBPM program but focused solely on claims-based cost calculation. The CMS will base the resource use score on the patients attributed to an EC. At least initially, it is anticipated that pathologists will not be eligible for patient attribution, and therefore would be ineligible for participation in this category.As previously mentioned, an overall CPS will be calculated based on the performance within each evaluable category and will range from 0 to 100. In 2019, those with a CPS higher than 70 will be eligible for a high-performance bonus. The initial proposed weighting of each category will be 60% of the CPS based on the Quality performance score, 15% based on the CPIA score, and 25% based on the ACI performance score. Resource use for the 2017 reporting year will be 0%. However, for non–patient facing ECs, the ACI category will not apply. Therefore, for most pathologists the CPS will be based solely on Quality (85%) and CPIA (15%).As a case example, a non–patient facing EC has 4 quality measures that apply to him or her, equating to 40 possible points within the Quality performance category. The EC reports on the 2 lung measures, the Barrett esophagus measure, and the colorectal cancer measure, and he or she receives a score of 36 out of 40 points. Plus, the EC receives 2 bonus points for the 2 high-value measures, for a final total of 38 out of 40 points. The Quality performance category would then contribute 81 points toward the CPS (38/40 × 85% = 81). Within the CPIA the EC reports on 1 high-weighted CPIA and receives the full 40 points within that performance category. This would lead to an additional 15 points (40/40 × 15%) toward the CPS, and a final CPS of 96 out of 100 points. In addition to likely doing well compared with other ECs, given a final CPS higher than 70, this EC would be eligible for a high-performance bonus as well.For the purpose of MIPS, there are several reporting options, which are the same as what was available for PQRS. These include claims-based, traditional registry, group practice reporting option, Electronic Health Record, measure groups, and the Qualified Clinical Data Registry (QCDR). Historically, pathologists have primarily used claims-based reporting, with a smaller percentage using a traditional registry, a group practice reporting option, or the Electronic Health Record. Measure groups do not apply to pathology, and until recently a QCDR was not available. The group practice reporting option is available to multispecialty group practices and uses a Web interface for transmitting data for prepopulated quality measures.Other new payment pathways within the QPP are designated as APMs. These are advanced APMs and physician-focused payment models (PFPMs). The APMs are systems that are meant to promote accountability for a patient population, improving care coordination and encouraging the delivery of high-quality care in a cost-conscious manner. Currently, there are no pathology-specific advanced APMs or PFPMs; however, several pathology practices, especially those in some academic and large multi-institutional groups, are participating in this pathway through their involvement in a specific type of ACO. A potential advantage of participating through an advanced APM pathway is that you are excluded from MIPS, and from 2019 to 2024 your entity will receive an automatic 5% bonus. Additionally, starting in 2026, the physician fee schedule update will be 0.75%, as opposed to only 0.25% from those ECs in the MIPS pathway.Advanced APM encompasses MSSP tracks 2 and 3, Next Generation ACO model, Oncology Care model, Comprehensive End Stage Renal Disease model, and Comprehensive Primary Care+ in 2017. These models differ from some other traditional ACOs and MSSP track 1 in that there is substantial financial risk to the entity. These entities must report on measures that are comparable to MIPS, use certified Electronic Health Record technology, and carry substantial financial risk (8% or more of total Medicare revenue or 3% or more of expected Medicare expenditures). Additionally, these entities must meet a percent of revenue or patient threshold that increases each year (Table 3) in order to qualify as an advanced APM and therefore be exempt from MIPS. In 2018, the CMS may expand the program to include MSSP track 1+, a new voluntary bundled payment model, and the Comprehensive Care for Joint Replacement Payment model.The concept of PFPM was created within the MACRA legislation to foster the development of additional APMs for providers who might not be able to participate in existing pathways; however, no definition was provided. The CMS final rule first revealed the definition and fulfillment criteria. In a broad sense, a PFPM is an APM that must include Medicare beneficiaries, is anticipated to reduce cost and/or improve patient care, and closes an existing payment policy gap. The CMS did expand the definition to include nonphysician health care providers. Any group or entity may propose a PFPM by submitting a proposal to CMS with a projection of the anticipated size and scope of the PFPM; description of the burden of disease, illness, or disability on the target population; and an assessment of the financial opportunity. These proposals will be reviewed by the PFPM Technical Advisory Committee, which makes a recommendation to the Health and Human Services Secretary. The models accepted by the CMS will then undergo a process similar to that of other APMs, including public announcement, comment period, and request for applications.Additional information regarding the QPP can be found at https://qpp.cms.gov/ (accessed January 14, 2017). The history of such programs suggests that the MIPS requirements within each performance category will become more complex and demanding in future years. The thresholds have intentionally been set low at the start of the program to ease EC transition into the program and to minimize disruption to the delivery of health care. As ECs become more familiar with the program, reporting requirements will likely increase. Another potential threat to pathology is the retirement of our high-performing measures by the CMS. As a whole, pathology has done well within the PQRS program. The quality gaps initially seen at the time of creation of the measure have diminished, and therefore the need for those measures from the perspective of the CMS is less pronounced. However, CAP is striving to maintain these measures because they ensure that the quality of care that best serves Medicare beneficiaries will be promoted within the pathology community. However, additional measures need to be created to facilitate all pathologists' compliance with the MIPS program. The creation of a pathology-specific QCDR with a broader menu of measures is one potential way to help the pathology community succeed within MIPS. The CAP is currently in the process of introducing such a registry to the medical community.Participation in an APM by a large number of pathologists is not likely at this time. Similarly, pathology practice will not readily lend itself to the development of PFPM, given the broad range of services provided and specialties with which we interact. Although pathologists' services influence a large percentage of spending, we do not directly control a large portion of the total cost of care; therefore, the risk may seem too great for pathologists to participate in these models. However, pathologists must continuously reassess how to best position ourselves for the future.In the short term, it is essential for ECs and/or their groups to be aware that by simply reporting anything in 2017 they will avoid a 4% penalty to the PFS in 2019. For the Quality performance category, this can most easily be done via claims-based reporting, traditional registry, or, if the EC is part of a multispecialty group, the group reporting option Web interface. Information about the pathology-specific quality measures can be found on the CAP Web site within the advocacy pages (http://www.cap.org/web/home/involved/advocacy/physician-quality-reporting-system; accessed January 14, 2017), or on the CMS Web site (https://qpp.cms.gov/measures/quality; accessed January 14, 2017). An alternative way to participate in 2017 to avoid the MIPS negative payment adjustment is to attest to performing a CPIA. A full list of improvement activities can be found at https://qpp.cms.gov/measures/ia (accessed January 14, 2017).The authors would like to acknowledge and express our gratitude to Charles Fiegl, BA, for his expert review of the manuscript.

Medical ward care has been increasingly reallocated from medical doctors (MDs) to physician assistants (PAs). Insight into their roles and tasks is limited. This study aims to provide insight into different organizational models of medical ward care, focusing on the position, tasks and responsibilities of the involved PAs and MDs. In this cross-sectional descriptive study 34 hospital wards were included. Characteristics of the organizational models were collected from the heads of departments. We documented provider continuity by examination of work schedules. MDs and PAs in charge for medical ward care (n = 179) were asked to complete a questionnaire to measure workload, supervision and tasks performed. We distinguished four different organizational models for ward care: medical specialists in charge of admitted patients (100% MS), medical residents in charge (100% MR), PAs in charge (100% PA), both MRs and PAs in charge (mixed PA/MR). The wards with PAs had the highest provider continuity. PAs spend relatively more time on direct patient care; MDs spend relatively more time on indirect patient care. PAs spend more hours on quality projects (P = 0.000), while MDs spend more time on scientific research (P = 0.030). Across different organizational models for medical ward care, we found variations in time per task, time per bed and provider continuity. Further research should focus on the impact of these differences on outcomes and efficiency of medical ward care.

BackgroundThe physician assistant (PA) and the nurse practitioner (NP) were introduced into The Netherlands in 2001 and 1997 respectively. By the second decade, national policies had accelerated the acceptance and development of these professions. Since 2015, the PA and NP have full practice authority as independent health professionals. The aim of this research was to gain a better understanding of the tasks and responsibilities that are being shifted from Medical Doctors (MD) to PAs and NPs in hospitals. More specifically in what context and visibility are these tasks undertaken by hospital-based PAs and NPs in patient care. This will enable them to communicate their worth to the hospital management.Study designA descriptive, non-experimental research method design was used to collect and analyze both quantitative and qualitative data about the type of tasks performed by a PA or NP. Fifteen medical departments across four hospitals participated.MethodsThe patient scheduling system and hospital information system were probed to identify and characterize a wide variety of clinical tasks. The array of tasks was further verified by 108 interviews. All tasks were divided into direct and indirect patient care. Once the tasks were cataloged, then MDs and hospital managers graded the PA- or NP-performed tasks and assessed their contributions to the hospital management system.FindingsIn total, 2883 tasks were assessed. Overall, PAs and NPs performed a wide variety of clinical and administrative tasks, which differed across hospitals and medical specialties. Data from interviews and the hospital management systems revealed that over a third of the tasks were not properly registered or attributed to the PA or NP. After correction, it was found that the NP and PA spent more than two thirds of their working time on direct patient care.ConclusionsNPs and PAs performed a wide variety of clinical tasks, and the consistency of these tasks differed per medical specialty. Despite the fact that a large part of the tasks was not visible due to incorrect administration, the interviews with MDs and managers revealed that the use of an NP or PA was considered to have an added value at the quality of care as well to the production for hospital-based medical care in The Netherlands.

Children with medical complexity have high health service utilization and health expenditures that can impose significant financial burdens. This study examined these issues for families with children enrolled in US private health plans. Using IBM Watson/Truven Analytics℠ MarketScan® commercial claims and encounters data (2012-2014), we analyzed through regression models, the differences in health care utilization and spending of disaggregated health care services by health plan types and children's medical complexity levels. Children in consumer-driven and high-deductible plans had much higher out-of-pocket spending and cost shares than those in health maintenance organizations and preferred provider organizations (PPOs). Children with complex chronic conditions had higher service utilization and out-of-pocket expenditures while having lower cost shares on various categories of services than those without any chronic condition. Compared to families covered by PPOs, those with high-deductible or consumer-driven plans were 2.7 and 1.7 times more likely to spend over US$1000 out of pocket on their children's medical care, respectively. Families with higher complexity levels were more likely to experience financial burdens from expenditures on children's medical services. In conclusion, policymakers and families with children need to be cognizant of the significant financial burdens that can arise from children's complex medical needs and health plan demand-side cost sharing.