Informal Physician Interaction Could Result in Lower Payments for Surgery, AHRQ Study Finds

Increased informal interaction among primary- and specialty-care physicians within health systems was associated with lower Medicare payments for surgery, according to AHRQ-funded research in JAMA Surgery. Researchers analyzed the records of about 253,000 Medicare beneficiaries who underwent coronary artery bypass graft surgeries. They concluded that increased interactions among physicians — defined as “informal integration” — were associated with lower payments due to fewer duplicate tests, treatments or other services. Such informal integration could provide a model to reduce surgery costs nationally, researchers said. Savings were greatest for reduced hospital readmissions (13 percent) and post-acute care (5.8 percent). The authors concluded that increasing informal interactions may be a promising method to lower surgery payments, in addition to formal integration, such as that from accountable care organizations. Access the abstract.

2017 Dec 27. doi: 10.1001/jamasurg.2017.5150. [Epub ahead of print]

Association of Informal Clinical Integration of Physicians With Cardiac Surgery Payments.

Funk RJ1, Owen-Smith J2, Kaufman SA3, Nallamothu BK4,5, Hollingsworth JM3.

Author information

Abstract

IMPORTANCE:

To reduce inefficiency and waste associated with care fragmentation, many current programs target greater clinical integration among physicians. However, these programs have led to only modest Medicare spending reductions. Most programs focus on formal integration, which often bears little resemblance to actual physician interaction patterns.

OBJECTIVES:

To examine how physician interaction patterns vary between health systems and to assess whether variation in informal integration is associated with care delivery payments.

DESIGN, SETTING, AND PARTICIPANTS:

National Medicare data from January 1, 2008, through December 31, 2011, identified 253 545 Medicare beneficiaries (aged ≥66 years) from 1186 health systems where Medicare beneficiaries underwent coronary artery bypass grafting (CABG) procedures. Interactions were mapped between all physicians who treated these patients-including primary care physicians and surgical and medical specialists-within a health system during their surgical episode. The level of informal integration was measured in these networks of interacting physicians. Multivariate regression models were fitted to evaluate associations between payments for each surgical episode made on a beneficiary's behalf and the level of informal integration in the health system where the patient was treated.

EXPOSURES:

The informal integration level of a health system.

MAIN OUTCOMES AND MEASURES:

Price-standardized total surgical episode and component payments.

RESULTS:

The total 253 545 study participants included 175 520 men (69.2%; mean [SD] age, 74.51 [5.75] years) and 78 024 women (34.3%; 75.67 [5.91] years). One beneficiary of the 253 545 participants did not have sex information. The low level of informal clinical integration included 84 598 patients (33.4%; mean [SD] age, 75.00 [5.93] years); medium level, 84 442 (33.30%; 74.94 [5.87] years); and high level, 84 505 (33.34%; 74.66 [5.72] years) (P < .001). Informal integration levels varied across health systems. After adjusting for patient, health-system, and community factors, higher levels of informal integration were associated with significantly lower total episode and component payments (β coefficients for informal integration were -365.87 [95% CI, -451.08 to -280.67] for total episode payments, -182.63 [-239.80 to -125.46] for index hospitalization, -43.13 [-55.53 to -30.72] for physician services, -74.48 [-103.45 to -45.51] for hospital readmissions, and -62.04 [-88.00 to -36.07] for postacute care; P < .001 for each association). When beneficiaries were treated in health systems with higher informal integration, the greatest savings of lower estimated payments were from hospital readmissions (13.0%) and postacute care services (5.8%).

CONCLUSIONS AND RELEVANCE:

Informal integration is associated with lower spending. Although most programs that seek to promote clinical integration are focused on health systems' formal structures, policy makers may also want to address informal integration.