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Cited by 102Healthcare Policy and ManagementPrimary Care and Health OutcomesHealthcare Quality and Management

Delivery System Integration and Health Care Spending and Quality for Medicare Beneficiaries

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McWilliams, J. Michael, Chernew, Michael E., Zaslavsky, Alan M., Hamed, Pasha, Landon, Bruce E.·2013·JAMA Internal Medicine
DOI 10.1001/jamainternmed.2013.6886PMC PMC3800215
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Abstract

IMPORTANCE: The Medicare accountable care organization (ACO) programs rely on delivery system integration and health care provider risk sharing to lower spending while improving quality of care. OBJECTIVE: To compare spending and quality between larger and smaller provider groups and examine how size-related differences vary by 2 factors considered central to ACO performance: group primary care orientation and financial risk sharing by health care providers. EVIDENCE REVIEW: Using 2009 Medicare claims and linked American Medical Association Group Practice data, we assigned 4.29 million beneficiaries to health care provider groups based on primary care use. We categorized group size according to eligibility thresholds for the Shared Savings (≥5000 assigned beneficiaries) and Pioneer (≥15,000) ACO programs and distinguished hospital-based from independent groups. We assessed the primary care orientation of larger groups' specialty mix and used health maintenance organization market penetration and data from the Community Tracking Study to measure the extent of financial risk accepted by different types of provider groups in different areas for managed care patients. We estimated linear regression models comparing spending and quality between larger and smaller health care provider groups, allowing size-related differences to vary by measures of group primary care orientation and risk sharing. Spending and quality measures included total medical spending, spending by type of service, 5 process measures of quality, and 30-day readmissions, all adjusted for sociodemographic and clinical characteristics. FINDINGS: Compared with smaller groups, larger hospital-based groups had higher total per-beneficiary spending in 2009 (mean difference, +$849), higher 30-day readmission rates (+1.3 percentage points), and similar performance on 4 of 5 process measures of quality. In contrast, larger independent physician groups performed better than smaller groups on all process measures and exhibited significantly lower per-beneficiary spending in counties where risk sharing by these groups was more common (-$426). Among all groups sufficiently large to participate in ACO programs, a strong primary care orientation was associated with lower spending, fewer readmissions, and better quality of diabetes care. CONCLUSIONS AND RELEVANCE: Spending was lower and quality of care better for Medicare beneficiaries served by larger independent physician groups with strong primary care orientations in environments where health care providers accepted greater risk.

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  • Small, physician-owned practices have lower readmission rates than larger, independent- and hospital-owned practices.

    “and lower readmission rates than larger, independent- and hospital-owned practices. 8”

    From The Paradox of Size: How Small, Independent Practices Can Thrive in Value-Based Care (2016) · cites this paper as [8]

    The Results section reports that 30-day readmission rates were higher for larger hospital-based groups than for small physician groups, and slightly higher for larger independent physician groups. The Methods section defines hospital-based groups by the location of practice sites, not hospital ownership, and does not establish that all small physician groups were physician-owned. The readmission comparison is supported, but the ownership labels are not. (LLM, conf=0.82)

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Authors
McWilliams, J. M., Chernew, M. E., Zaslavsky, A. M., Hamed, P., & Landon, B. E.
Affiliations
Brigham and Women's Hospital (US)
ORCID
Venue
JAMA Internal Medicine
Publisher
American Medical Association (AMA)
Published
2013-08-12
Volume
173
Issue
15
Pages
1447
ISSN
2168-6106 (ISSN-L)
DOI
10.1001/jamainternmed.2013.6886
PMC
PMC3800215
OpenAlex
W1990643273
Cited by
102
References
1
Citations by year
2026: 2 · 2025: 5 · 2024: 9 · 2023: 5 · 2022: 7 · 2021: 2 · 2020: 7 · 2019: 6 · 2018: 15 · 2017: 16 · 2016: 9 · 2015: 7 · 2014: 11 · 2013: 1
FWCI
21.91
Type
journal article
Language
en
Open access
Locations
  • JAMA Internal Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute on Aging (K08AG038354, P01AG032952)
Topics
  • Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
  • Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
  • Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
Keywords
financial risk sharing, health care spending, quality of care, 30-day readmission, diabetes management, Shared Savings Program, managed care
MeSH terms
Aged, Delivery of Health Care, Health Expenditures, Female, Group Practice, Medicare, Humans, Male, Physicians, Primary Health Care, Quality of Health Care, United States, Delivery of Health Care, Integrated

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