Managing a Solo Practice

APhA advances provider status initiative

Provider status effort engaged on Capitol Hill

This study examined physicians' propensity for caesarean deliveries at solo versus group practice obstetrics/gynaecology (ob/gyn) clinics in Taiwan. We used population-based (National Health Insurance) claims data covering all 253 618 singleton deliveries conducted at ob/gyn clinics, during 2000-02. The dependent variable, delivery mode, was treated as dichotomous [caesarean section (CS) = 1, vaginal delivery (VD) = 0]. The independent variable of interest was practice size, classified into four categories: 1, 2, 3 and 4+ physicians. Multilevel logistic regression modelling, accounting for clinic-level variation in CS rates, was used to examine CS likelihood by practice size, among the total delivery sample and among the sub-samples disaggregated by obstetric complication status. Solo practices have 7% excess caesarean cases relative to large group practices. After controlling for patient's age, physician demographics, the clinic's geographic location and size of delivery service, and clinic-level random effect, solo practice physicians were 5.38 times as likely as 4+ physician practices to provide caesarean delivery (CI = 4.18 approximately 6.93), 2-physician practices were 3.87 times (CI = 2.99 approximately 5.01) and 3-physician practices 2.72 times (CI = 2.06 approximately 3.59) as likely as 4+ physician practices to provide caesarean delivery. This effect is driven by higher CS propensity among solo and small groups among cases with obstetrically less salient complications and the 'no complications' subset of patients. Wide confidence intervals for odds ratios in these sub-samples also attest to wide variations in clinic-level CS rates among these patient groups. Solo physicians are the most likely to provide caesarean delivery, and CS likelihood decreases with increasing number of physicians in the practice. Group practice support may reduce the CS likelihood, when it is not clinically indicated. Policy makers should consider initiatives to limit full service delivery privileges to group practice obstetric clinics, in order to reduce unnecessary CS. Solo practice clinics should, at best, be licensed as birthing centres, required to transfer patients needing CS to a larger facility.

Are you ready for health care teams?

You have accessThe ASHA LeaderPolicy Analysis1 Nov 2011Rules Issued for Accountable Care Organizations Mark Kander Mark Kander Google Scholar More articles by this author https://doi.org/10.1044/leader.PA1.16152011.7 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In ASHA’s concerns about telepractice, access to speech-language and hearing services, and shared savings for speech-language and hearing professionals were not resolved in the Centers for Medicare and Medicaid Services’ (CMS) final rules for accountable care organizations (ACOs), a new model for providing health care services to Medicare beneficiaries under national health care reform law. An ACO is a network of physician group practices, hospitals, and others involved in patient care that share responsibility for providing care to Medicare patients. Much like health maintenance organizations, ACOs would bring together various health care components—primary care, specialists, hospitals, home health care, rehabilitation services—and offer providers and hospitals financial incentives (“shared savings”) for controlling costs and improving quality. However, Medicare patients will continue to have the ability to choose any provider inside or outside the ACO. ACOs are expected to create closer ties between hospitals and physicians and to be attractive to rehabilitation providers. CMS expects that ACOs typically will include primary care physicians, specialists, and a hospital. Rehabilitation services could be provided by in-house staff or by contracted rehabilitation provider organizations. ACOs would most likely contract with a single rehabilitation organization rather than increase administrative burdens by contracting separately with speech-language pathology, physical therapy, and occupational therapy providers. Audiology services could be incorporated into rehabilitation contracts through independent audiology contracts or ACO-participating otolaryngology practices. Shared savings payments would be distributed to physicians and hospitals participating in the ACO and to other providers based on individual contracts and the ACO’s determination of “how to equitably distribute shared savings or use the shared savings to meet the goals of the program,” according to the regulations. The ACO concept can be compared to a construction contract, with the ACO as general contractor and the providers as subcontractors. The final regulations released in October are less stringent than the proposed version. For example, prospective ACOs will not be required to assume financial risk during the first three years. Also, ACOs will be assessed on 33 quality measures (half the number initially proposed) divided into four domains: patient/caregiver experience, care coordination and patient safety, preventive health, and caring for at-risk populations. (Speech-language pathologists and audiologists already participate in the Medicare quality reporting process.) According to CMS, higher quality care will result in greater shared savings payments. Establishing an ACO typically will cost more than $3 million. The regulations create an assistance program—$170 million for up to 50 ACOs—for physicians and small hospitals that lack the requisite capital. In response to proposed ACO regulations issued in April, ASHA submitted comments suggesting that ACOs be required to: Ensure that speech-language pathology and audiology services are accessible to patients. CMS responded that market forces will determine the need for the range of services offered. Allocate an equitable portion of shared savings to speech-language pathologists and audiologists. CMS stated that it lacks legal authority to dictate this distribution. Encourage the use of telepractice services provided by audiologists and speech-language pathologists. In response, CMS announced that it is preparing a separate incentive package, not limited to ACOs, that expands Medicare-reimbursable telepractice services. ASHA will continue to analyze the impact and restrictions of ACOs, which are scheduled to begin operating in 2012. Author Notes Mark Kander, director of health care regulatory analysis, can be reached at[email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 16Issue 15November 2011 Get Permissions Add to your Mendeley library History Published in print: Nov 1, 2011 Metrics Downloaded 48 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2011 American Speech-Language-Hearing AssociationLoading ...

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Background Accountable care organizations (ACOs) aim to improve health care quality and reduce costs, including among patients with heart failure (HF). However, variation across ACOs in admission rates for patients with HF and associated factors are not well described. Methods and Results We identified Medicare fee-for-service beneficiaries with HF who were assigned to a Medicare Shared Savings Program ACO in 2017 and survived ≥30 days into 2018. We calculated risk-standardized acute admission rates across ACOs, assigned ACOs to 1 of 3 performance categories, and examined associations between ACO characteristics and performance categories. Among 1 232 222 beneficiaries with HF, 283 795 (mean age, 81 years; 54% women; 86% White; 78% urban) were assigned to 1 of 467 Medicare Shared Savings Program ACOs. Across ACOs, the median risk-standardized acute admission rate was 87 admissions per 100 people, ranging from 61 (minimum) to 109 (maximum) admissions per 100 beneficiaries. Compared to the overall average, 13% of ACOs performed better on risk-standardized acute admission rates, 72% were no different, and 14% performed worse. Most ACOs with better performance had fewer Black beneficiaries and were not hospital affiliated. Most ACOs that performed worse than average were large, located in the Northeast, had a hospital affiliation, and had a lower proportion of primary care providers. Conclusions Admissions are common among beneficiaries with HF in ACOs, and there is variation in risk-standardized acute admission rates across ACOs. ACO performance was associated with certain ACO characteristics. Future studies should attempt to elucidate the relationship between ACO structure and characteristics and admission risk.

Accountable care organizations agree to be accountable for the cost and outcomes of an attributed population. However, in many, no provisions have been made to account for oral health. There are several social, medical, and financial implications for health care provider and payer systems and health care outcomes when oral health is not accounted for in patient management. How can an organization strive to improve population health without including the oral health system? Total systemic health for a population must include oral health. Accountable care organizations are positioned to change the course of oral health in the United States and close the disparities that exist among vulnerable populations, including seniors. Such efforts will reduce health care costs. Opportunities abound to expand points of entry into the health care system via dental or medical care. Closing the great divide between 2 historically isolated professions will position the United States to make gains in true population health. I provide evidence of the need to mandate access to oral health care services for all Americans-specifically adults, because legislation currently exists for pediatric dental coverage.