Dr. Mark L Diana

Goal:
The U.S. hospital sector is experiencing record levels of integration, with more than half of U.S. physicians and nearly three quarters of all hospitals affiliated with one of slightly more than 630 health systems. However, there is growing evidence to suggest that health system integration is associated with more expensive and lower quality care. The goal of this research is to explore the associations between forms of health system integration and hospital patient experience scores.

Methods:
A cross-section of data for the year 2019 was assembled and analyzed from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience survey. Data from the Compendium of US Health Systems, published by the Agency for Healthcare Research and Quality (AHRQ), and the American Hospital Association (AHA) Annual Survey were used to obtain independent variables and hospital-level covariates. A series of multivariable regressions was used to explore the associations between forms of health system integration and hospital patient experience scores across three domains: overall impression of the hospital; experiences with staff; and the hospital environment. Forms of both horizontal integration (i.e., number of hospitals owned by hospital-based health systems) and vertical integration (i.e., physician-hospital integration, nursing home ownership, accountable care organization [ACO] participation, group purchasing, contract management, offering insurance products, and investor ownership) were explored.

Principal Findings:
Although horizontal integration was not associated with any meaningful differences in patient experience scores, health systems with physician–hospital integration were associated with overall impression scores that were 2 percentage points higher than systems without physician integration. Similarly, contract management and membership in a group purchasing organization were associated with overall impression and environment scores that were 2 to 3 percentage points higher than hospitals that did not engage in those forms of integration. By contrast, investor ownership was associated with a 5% lower score for overall patient experience compared with other forms of ownership.

Practical Applications:
The findings of this study suggest that hospitals in more vertically integrated systems may have higher patient experience scores than independent hospitals and those that belong exclusively to horizontally integrated systems. Thus, there are elements of vertical integration that could benefit patients and be worth pursuing. Conversely, higher degrees of horizontal integration in the form of multi-hospital ownership may not be of any benefit to patients and should be pursued with caution.

We examined changes in hospital uncompensated care costs in the context of Louisiana's Medicaid expansion. Louisiana remains the only state in the Deep South to have expanded Medicaid under the Affordable Care Act and can serve as a model for states that have not adopted expansion, many of which are located in the South census region. We found that Medicaid expansion was associated with a 33 percent reduction in the share of total operating expenses attributable to uncompensated care costs for general medical and surgical hospitals in Louisiana in the first three years after expansion. Reductions varied by hospital type, with larger effects found for rural and public hospitals versus urban and for-profit or private nonprofit hospitals. As hospital operating expenses consistently increased during the sample period, our results imply that hospitals in Louisiana are treating fewer patients for whom no reimbursement was provided since the state expanded Medicaid.

Background: Accountable care organizations (ACOs) are being implemented rapidly across the Unites States. Previous studies indicated an increasing number of hospitals have participated in ACOs. However, little is known about how ACO participation could influence hospitals' performance.
Purpose: This study aims to examine the impact of Medicare ACO participation on hospitals' patient experience.
Methodology/Approach: Difference-in-difference analyses were conducted to compare 10 patient experience measures between hospitals participating in Medicare ACOs and those not participating.
Results: In general, hospitals participating in Pioneer ACOs had significantly improved scores on nursing communication and doctor communication. Shared Savings Program (SSP) ACO participation did not show significant improvement of patient experience. Subgroup analyses indicate that, for hospitals in the middle and top tertile groups in terms of baseline experience, Pioneer ACO and SSP ACO participation was associated with better patient experience. For hospitals in the bottom tertile, Pioneer ACO and SSP ACO participation had no association with patient experience. Conclusion: ACO participation improved some aspects of patient experience among hospitals with prior good performance. However, hospitals with historically poor performance did not benefit from ACO participation.
Practice Implications: Prior care coordination and quality improvement experience position Medicare ACOs for greater success in terms of patient experience. Hospital leaders need to consider the potential negative consequences of ACO participation and the hospital's preparedness for care coordination.

Background:The Affordable Care Act introduced a major systematic change aimed to promote coordination across the care continuum. Yet, it remains unknown the extent to which hospital system structures have changed following the Affordable Care Act. The structure of hospital systems has important implications for the cost, quality, and accessibility of health services.
Objectives:To assess trends in the structures of hospital systems.
Research Design:We aggregated data from the American Hospital Association (AHA) Annual Survey to the system level. Using a panel of hospital systems from 2008 to 2015, we assessed trends in the number of hospital systems, their size, ownership characteristics, geospatial arrangements, and integration with outpatient services.
Results:In the period 2008-2015, there was an increasing percentage of hospitals that were system affiliated as well as growth in the number of hospital systems. A greater percentage of hospital systems that were organized as moderately centralized systems transitioned to centralized systems than to decentralized systems (19.8% vs. 4.7%; P<0.001). In terms of geospatial arrangement, a greater percentage of hub-and-spoke systems moved to a regional design than to national systems (20.0% vs. 8.2%; P<0.05). An increasing trend over time toward greater integration with outpatient services was found in a measure of total system level integration with outpatient services.
Conclusions:Our findings suggest that hospital systems may be moving toward more regional designs. In addition, the trend of increasing integration offered across hospital systems overall, and as portion of total integration, suggests that systems may be increasing their services along the continuum of care.

Accountable care organizations (ACOS) were established as part of the Affordable Care Act to reduce costs, improve the patient experience, and increase the quality of care. While previous studies have examined the quality, costs, and patient experience among ACOs, the relationship between hospitals' ACO participation and its effects on hospitals' performance have been incompletely characterized. The main purpose of this study is to measure the association between hospitals' participation in Medicare Pioneer and Shared Savings Program (SSP) ACOs and readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. We employed a cross-sectional design using hospital readmission data from Hospital Compare, hospital characteristics data from the American Hospital Association Annual Survey, and market environmental data from Area health Resource Files. We employed a descriptive analysis and linear regressions to examine how ACO participation is associated with readmission rates in these three conditions.
Overall, we found that SSP ACO participation is significantly associated with a decrease in the HF readmission rate (beta = 0.320, p < .05), while Pioneer ACO participation is not associated with a decrease in the HF readmission rate. In addition, we found no evidence that Pioneer ACO or SSP ACO participation is associated with reduced readmission rates for AMI or pneumonia. This study concluded that Medicare ACO programs have limited effects on readmission rates. Policy makers should consider adjusting the accountable care model to improve the quality of care.

Objective
To examine the effects of the penetration of dual‐eligible special needs plans (D‐SNPs) on health care spending.
Data Sources/Study Setting
Secondary state‐level panel data from Medicare‐Medicaid Linked Enrollee Analytic Data Source (MMLEADS) public use file and Special Needs Plan Comprehensive Reports, Area Health Resource Files, and Medicaid Managed Care Enrollment Report between 2007 and 2011.
Study Design
A difference‐in‐difference strategy that adjusts for dual‐eligibles’ demographic and socioeconomic characteristics, state health resources, beneficiaries’ health risk factors, Medicare/Medicaid enrollment, and state‐ and year‐fixed effects.
Data Collection/Extraction Methods
Data from MMLEADS were summarized from Centers for Medicare and Medicaid Services (CMS)'s Chronic Conditions Data Warehouse, which contains 100 percent of Medicare enrollment data, claims for beneficiaries who are enrolled in the fee‐for‐service (FFS) program, and Medicaid Analytic Extract files. The MMLEADS public use file also includes payment information for managed care. Data in Special Needs Plan Comprehensive Reports were from CMS's Health Plan Management System.
Principal Findings
Results indicate that D‐SNPs penetration was associated with reduced Medicare spending per dual‐eligible beneficiary. Specifically, a 1 percent increase in D‐SNPs penetration was associated with 0.2 percent reduction in Medicare spending per beneficiary. We found no association between D‐SNPs penetration and Medicaid or total spending.
Conclusion
Involving Medicaid services in D‐SNPs may be crucial to improve coordination between Medicare and Medicaid programs and control Medicaid spending among dual‐eligible beneficiaries. Starting from 2013, D‐SNPs were mandated to have contracts with state Medicaid agencies. This change may introduce new effects of D‐SNPs on health care spending. More research is needed to examine the impact of D‐SNPs on dual‐eligible spending.

Objective: Examine the relationship between patients' perceptions of quality and the objective level of quality at government health facilities, and determine whether the pre-existing attitudes and beliefs of patients regarding health services interfere with their ability to accurately assess quality of care.
Design: Cross-sectional, visit-level analysis.
Setting: Three regions (Nord-Ubangi, Kasai/Kasai-Central and Maniema/Tshopo) of the Democratic Republic of Congo.
Participants: Data related to the inpatient and outpatient visits to government health facilities made by all household members who were included in the survey was used for the analysis. Data were collected from patients and the facilities they visited.
Main Outcome Measures: Patients' perceptions of the level of quality related to availability of drugs and equipment; patient-centeredness and safety serve compared with objective measures of quality.
Results: Objective measures and patient perceptions of the drug supply were positively associated (beta = 0.16, 95% CI = 0.03, 0.28) and of safety were negatively associated (beta = -0.12, 95% CI = -0.23, -0.01). Several environmental factors including facility type, region and rural/peri-urban setting were found to be significantly associated with respondents' perceptions of quality across multiple outcomes.
Conclusions: Overall, patients are not particularly accurate in their assessments of quality because their perceptions are impacted by their expectations and prior experience. Future research should examine whether improving patients' knowledge of what they should expect from health services, and the transparency of the facility's quality data can be a strategy for improving the accuracy of patients' assessments of the quality of the health services, particularly in low-resourced settings.

Health information exchange (HIE) promises cost and utilization reductions. To date, only a small number of HIE studies have demonstrated benefits to patients, providers, public health, or payers. This may be because evaluations of HIE are methodologically challenging. Indeed, the quality of HIE evaluations is often limited and authors frequently note unmet evaluation objectives. We provide a systematic identification of HIE research challenges that can be used to inform strategies for higher quality scientific evidence.
We conducted qualitative interviews with 23 HIE researchers and leaders of HIE efforts representing experiences with more than 20 HIE efforts. We also conducted a six-person focus group to expand on and confirm individual interview findings. Qualitative analysis followed a grounded theory approach using multiple coders.
Participants experienced similar challenges across seven themes (i.e., HIE maturity, data quality, data availability, goal alignment, cooperation, methodology, and policy).
Several options may exist to improve HIE research, including developing better conceptual models and methodological approaches to HIE research; formal partnerships between researchers and HIE entities; and establishing a nationwide database of HIE information. Our proposed approaches of promoting data availability, resource sharing, and new partnerships can help to overcome existing barriers and facilitate HIE research.

Although approximately 82 percent of the US population was covered by some form of law that restricted smoking in public establishments as of 2014, most research examining the relationship between smoke-free laws and health has been focused at the state level.
To examine the effect of county workplace smoke-free laws over and above the effect of other (restaurant or bar) smoke-free laws on adult asthma.
The study estimated the effect of rates of adult asthma discharges before and after the implementation of county nonhospitality workplace smoke-free laws and county restaurant and bar smoke-free laws. Data were from 2002 to 2009, and all analyses were performed in 2011 through 2013.
A statistically significant relationship (-5.43,
< .05) was found between county restaurant or bar smoke-free laws and reductions in working age adult asthma discharges. There was no statistically significant effect of nonhospitality workplace smoke-free laws over and above the effect of county restaurant or bar laws.
This study suggests that further gains in preventable asthma-related hospitalizations in the US are more likely to be made by focusing on smoke-free laws in bars or restaurants rather than in nonhospitality workplaces.

There is a need to understand the costs associated with supporting, implementing, and maintaining the system redesign of small and medium-sized safety-net clinics. The authors aimed to understand the characteristics of clinics that transformed into patient-centered medical homes and the incremental cost for transformation.
The sample was 74 clinics in Greater New Orleans that received funds from the Primary Care Access and Stabilization Grant program between 2007 and 2010 to support their transformation. The study period was divided into baseline (September 21, 2007–March 21, 2008), transformation (March 22, 2008–March 21, 2009), and maintenance (March 22, 2009–September 20, 2010) periods, and data were collected at 6-month intervals. Baseline characteristics for the clinics that transformed were compared to those that did not. Fixed-effect models were conducted for cost estimation, controlling for baseline differences, using propensity score weights.
Half of the 74 primary care clinics achieved transformation by the end of the study period. The clinics that transformed had higher total cost, more clinic visits, and a larger female patient proportion at baseline. The estimated incremental cost for clinics that underwent transformation was $37.61 per visit per 6 months, and overall it cost $24.86 per visit per 6 months in grant funds to support a clinic's transformation.
Larger-sized clinics and those with a higher female proportion were more likely to transform. The Primary Care Access and Stabilization Grant program provided approximately $24.86 per visit over the 2 and 1/2 years. This estimated incremental cost could be used to guide policy recommendations to support primary care transformation in the United States.