Managing Risk: Evaluating Hospital Strategies for Value-based Payment Reform translation missing: zh.hyrax.visibility.toc_restricted.text

Jain, Sanjula (Summer 2018)

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A key factor underlying high health care spending in the United States is the structure of fee-for-service payment. In response, payers have begun to shift risk toward care providers through value-based payment models (Chapter 1). Among hospitals participating in these models, certain hospital characteristics (e.g., teaching status) have been associated with stronger performance. Further evidence suggests these characteristics explain some, but not all, of the variation in performance. This unexplained variation serves as the basis for this dissertation, which examines organizational strategies that facilitate the delivery of high-value care. 

In Chapter 2, I evaluate whether hospital implementation of care management practices, such as data sharing and care coordination, affect performance. I find early indications that care management practices can improve performance outcomes, but the magnitude of effects largely depends on internal organizational dynamics. Moreover, hospitals are more likely to invest in innovations such as care management if financial risk is involved. In Chapter 3, I assess trends in risk assumption and then determine which risk-related contracting arrangements contribute to more revenue at risk. I find that hospitals haven’t substantially changed their level of risk assumption in response to recent reforms, and yet are increasingly participating in risk-related contracting. Contracting through medical homes and physician employment are key drivers of risk assumption. This suggests that hospitals need to develop their internal capacity and infrastructure for value-based care delivery before assuming risk. Then, in Chapter 4, I conduct a case study of Emory Healthcare to evaluate the effectiveness of clinical and operational standardization strategies. Using a mixed-methods approach, I study whether implementation of sepsis standardization practices have an influence on clinical and financial outcomes. I find that adoption of such practices improves most clinical outcomes and results in cost savings. To further contextualize these findings, I interviewed hospital leaders to identify factors such as shared governance that underlie successful practice implementation. 

Together, this research conveys the importance of organizational strategies in understanding the variation in hospital performance under new payment schemes (Chapter 5). These findings not only have implications for providers participating in value-based models, but for policymakers designing future incentive structures. 

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