Physician Behavior In Accountable Care Organizations

This dissertation studies how performance risk-based (i.e., value-based) reimbursement over total costs of care in health insurance contracting affects how providers, specifically physician groups and health systems, determine marginal treatment choice and set the level of care provided to patients. Utilizing the widespread adoption of Accountable Care Organization (ACO) contracts by both commercial payers and Medicare, presented research explores changes in care delivery and health system organization when risks for total costs of care and satisfactory attainment of specific quality metrics (i.e. an ACO contract) are offered to providers. This dissertation proceeds in five parts. First, I review the substantial literatures related to the specific characteristics of ACO contracts in addition to the institutional details of such contracts themselves. Next, leveraging optimal procurement and auction theory, I present a theoretical foundation for considering ACOs as a form of incentive contract auction by Medicare and other insurers. This theoretical foundation motivates three principal empirical analyses of ACO contracts, each briefly explained in the preface, focused on changes in physician behavior following ACO contract adoption

Physicians’ Participation in ACOs is Lower in Places With Vulnerable Populations Than in More Affluent Communities

In 2013, physician participation in accountable care organizations (ACOs) was inversely related to the percentage of the local population that was black, living in poverty, uninsured, or disabled or that had less than a high school education. This risks exacerbating disparities in the quality of care received by these vulnerable populations

Accuracy of Emergency Medical Services Dispatcher and Crew Diagnosis of Stroke in Clinical Practice.

BACKGROUND: Accurate recognition of stroke symptoms by Emergency Medical Services (EMS) is necessary for timely care of acute stroke patients. We assessed the accuracy of stroke diagnosis by EMS in clinical practice in a major US city. METHODS AND RESULTS: Philadelphia Fire Department data were merged with data from a single comprehensive stroke center to identify patients diagnosed with stroke or TIA from 9/2009 to 10/2012. Sensitivity and positive predictive value (PPV) were calculated. Multivariable logistic regression identified variables associated with correct EMS diagnosis. There were 709 total cases, with 400 having a discharge diagnosis of stroke or TIA. EMS crew sensitivity was 57.5% and PPV was 69.1%. EMS crew identified 80.2% of strokes with National Institutes of Health Stroke Scale (NIHSS) ≥5 and symptom durationmodel, correct EMS crew diagnosis was positively associated with NIHSS (NIHSS 5-9, OR 2.62, 95% CI 1.41-4.89; NIHSS ≥10, OR 4.56, 95% CI 2.29-9.09) and weakness (OR 2.28, 95% CI 1.35-3.85), and negatively associated with symptom duration \u3e270 min (OR 0.41, 95% CI 0.25-0.68). EMS dispatchers identified 90 stroke cases that the EMS crew missed. EMS dispatcher or crew identified stroke with sensitivity of 80% and PPV of 50.9%, and EMS dispatcher or crew identified 90.5% of patients with NIHSS ≥5 and symptom duration \u3c6 \u3eh. CONCLUSION: Prehospital diagnosis of stroke has limited sensitivity, resulting in a high proportion of missed stroke cases. Dispatchers identified many strokes that EMS crews did not. Incorporating EMS dispatcher impression into regional protocols may maximize the effectiveness of hospital destination selection and pre-notification

Physicians’ Participation in ACOs is Lower in Places With Vulnerable Populations Than in More Affluent Communities

In 2013, physician participation in accountable care organizations (ACOs) was inversely related to the percentage of the local population that was black, living in poverty, uninsured, or disabled or that had less than a high school education. This risks exacerbating disparities in the quality of care received by these vulnerable populations

Accuracy of Emergency Medical Services Dispatcher and Crew Diagnosis of Stroke in Clinical Practice

BackgroundAccurate recognition of stroke symptoms by Emergency Medical Services (EMS) is necessary for timely care of acute stroke patients. We assessed the accuracy of stroke diagnosis by EMS in clinical practice in a major US city.Methods and resultsPhiladelphia Fire Department data were merged with data from a single comprehensive stroke center to identify patients diagnosed with stroke or TIA from 9/2009 to 10/2012. Sensitivity and positive predictive value (PPV) were calculated. Multivariable logistic regression identified variables associated with correct EMS diagnosis. There were 709 total cases, with 400 having a discharge diagnosis of stroke or TIA. EMS crew sensitivity was 57.5% and PPV was 69.1%. EMS crew identified 80.2% of strokes with National Institutes of Health Stroke Scale (NIHSS) ≥5 and symptom duration <6 h. In a multivariable model, correct EMS crew diagnosis was positively associated with NIHSS (NIHSS 5–9, OR 2.62, 95% CI 1.41–4.89; NIHSS ≥10, OR 4.56, 95% CI 2.29–9.09) and weakness (OR 2.28, 95% CI 1.35–3.85), and negatively associated with symptom duration >270 min (OR 0.41, 95% CI 0.25–0.68). EMS dispatchers identified 90 stroke cases that the EMS crew missed. EMS dispatcher or crew identified stroke with sensitivity of 80% and PPV of 50.9%, and EMS dispatcher or crew identified 90.5% of patients with NIHSS ≥5 and symptom duration <6 h.ConclusionPrehospital diagnosis of stroke has limited sensitivity, resulting in a high proportion of missed stroke cases. Dispatchers identified many strokes that EMS crews did not. Incorporating EMS dispatcher impression into regional protocols may maximize the effectiveness of hospital destination selection and pre-notification