Closing the quality gap: revisiting the state of the science (vol. 1: bundled payment: effects on health care spending and quality).
ABSTRACT "Bundled payment" is a method in which payments to health care providers are related to the predetermined expected costs of a grouping, or "bundle," of related health care services. The intent of bundled payment systems is to decrease health care spending while improving or maintaining the quality of care.
To systematically review studies of the effects of bundled payment on health care spending and quality, and to examine key design and contextual features of bundled payment programs and their association with program effectiveness.
Electronic literature search of PubMed® and the Cochrane Library for studies published between 1985 and 2011.
Title and abstract review followed by full-text review to identify studies that assessed the effect of bundled payment on health care spending and/or quality.
Two authors independently abstracted data on study design, intervention design, context, comparisons, and findings. Reviewers rated the strength of individual studies as well as the strength and applicability of the body of evidence overall. Differences between reviewers were reconciled by consensus. Studies were categorized by bundled payment program and narratively summarized.
We reviewed 58 studies, excluding studies of the Medicare Inpatient Prospective Payment System, for which we reviewed 4 review articles. Most studies (57 of 58) were observational or descriptive; 1 study employed randomization of providers, and none employed random assignment of patients to treatment and control groups. The included studies examined 20 different bundled payment interventions, 16 of which focused on single institutional providers. The introduction of bundled payment was associated with: (1) reductions in health care spending and utilization, and (2) inconsistent and generally small effects on quality measures. These findings were consistent across different bundled payment programs and settings, but the strength of the body of evidence was rated as low, due mainly to concerns about bias and residual confounding. Insufficient evidence was available to identify the influence of key design factors and most contextual factors on bundled payment effects.
Most of the bundled payment interventions studied in reviewed articles (16/20) were limited to payments to single institutional providers (e.g., hospitals, skilled nursing facilities) and so have limited generalizability to newer programs including multiple provider types and/or multiple providers. Exclusion criteria and the search strategy we used may have omitted some relevant studies from the results. The review is limited by the quality of the underlying studies. The interventions studied were often incompletely described in the reviewed articles.
There is weak but consistent evidence that bundled payment programs have been effective in cost containment without major effects on quality. Reductions in spending and utilization relative to usual payment were less than 10 percent in many cases. Bundled payment is a promising strategy for reducing health spending. However, effects may not be the same in future programs that differ from those included in this review.
SourceAvailable from: Michel Wensing[Show abstract] [Hide abstract]
ABSTRACT: Background Practice accreditation is widely used to assess and improve quality of healthcare providers. Little is known about its effectiveness, particularly in primary care. In this study we examined the effect of accreditation on quality of care regarding diabetes, chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD).MethodsA comparative observational study with two cohorts was performed. We included 138 Dutch family practices that participated in the national accreditation program for primary care. A first cohort of 69 practices was measured at start and completion of a 3-year accreditation program. A second cohort of 69 practices was included and measured simultaneously with the final measurement of the first cohort. In separate multilevel regression analyses, we compared both within-group changes in the first cohort and between-groups differences at follow-up (first cohort) and start (second cohort). Outcome measures consisted of 24 systematically developed indicators of quality of care in targeted chronic diseases.ResultsIn the within-group comparison, we found improvements on 6 indicators related to diabetes (feet examination, cholesterol measurement, lipid lowering medication prescription) and COPD (spirometry performance, stop smoking advice). In the between-groups comparison we found that first cohort practices performed better on 4 indicators related to diabetes (cholesterol outcome) and CVD (blood pressure outcome, smoke status registration, glucose measurement).Conclusions Improvements of the quality of primary care for patients with chronic diseases were found, but few could be attributed to the accreditation program. Further development of accreditation is needed to enhance its effectiveness on chronic disease management.BMC Family Practice 11/2014; 15(1):179. DOI:10.1186/s12875-014-0179-4 · 1.74 Impact Factor
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ABSTRACT: The Closing the Quality Gap series from the Agency for Healthcare Research and Quality summarizes evidence for eight high-priority health care topics: outcomes used in disability research, bundled payment programs, public reporting initiatives, health care disparities, palliative care, the patient-centered medical home, prevention of health care-associated infections, and medication adherence. To distill evidence from this series and provide insight into the "state of the science" of quality improvement (QI). We provided common guidance for topic development and qualitatively synthesized evidence from the series topic reports to identify cross-topic themes, challenges, and evidence gaps as related to QI practice and science. Among topics that examined effectiveness of QI interventions, we found improvement in some outcomes but not others. Implementation context and potential harms from QI activities were not widely evaluated or reported, although market factors appeared important for incentive-based QI strategies. Patient-focused and systems-focused strategies were generally more effective than clinician-focused strategies, although the latter approach improved clinician adherence to infection prevention strategies. Audit and feedback appeared better for targeting professionals and organizations, but not patients. Topic reviewers observed heterogeneity in outcomes used for QI evaluations, weaknesses in study design, and incomplete reporting. Synthesizing evidence across topics provided insight into the state of the QI field for practitioners and researchers. To facilitate future evidence synthesis, consensus is needed around a smaller set of outcomes for use in QI evaluations and a framework and lexicon to describe QI interventions more broadly, in alignment with needs of decision makers responsible for improving quality.The Permanente journal 09/2013; DOI:10.7812/TPP/13-010
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ABSTRACT: The aim of this study was to research how the staff experience care expressed during the brief encounter with the patients in a diagnostic imaging department. This was a qualitative study with a phenomenological and hermeneutical frame of reference. The data were collected using field observations and semistructured interviews and analyzed according to the guidelines for meaning condensation by Giorgi. The imaging staff found that care is expressed in an administrative, an instrumental, and a compassionate sense. The imaging staff perceived care in a way that clearly differs from the traditional perception of care understood as the close relations between people. In their self-understanding, the staff found that care not only comprised the relational aspect but also that it was already delivered during the preparatory phases before the actual meeting with the patient and up until the image was electronically forwarded. And, care expressed in between was perceived as care in the traditional sense and termed as “patient care in radiology.”Journal of Radiology Nursing 03/2014; 33(1):23–29. DOI:10.1016/j.jradnu.2013.12.001