Identifying Key Areas for Delivery System Research
Appendix C: "Long List" of Delivery System Research Areas
This list is structured to correspond to the conceptual model suggested in the paper. It is intended to be illustrative and reasonably, but certainly not completely, comprehensive.
Each research area in the list can be studied in the context of: (1) a specific type of delivery system organization; and/or (2) a specific disease or area of preventive care.
Specific types of delivery system organizations include (this list is not intended to be comprehensive):
- Medical groups.
- Community health centers.
- Specialty hospitals.
- Integrated delivery systems (physicians + hospital(s) ± health plan ± …).
- Accountable care organizations.
- Long-term care facilities.
- Rehabilitation facilities.
- Home health care agencies.
- Retail clinics.
For each area, key questions are:
- What are alternative forms of the thing in question (e.g., alternative medical group structures, or alternative forms of nurse care management for patients with chronic illness)?
- What are the demographics of the alternative forms (i.e., What is the prevalence of each alternative? Where are these alternatives located? How if at all is the prevalence changing?)?
- What are the factors (e.g., external incentives, regulation) that affect the prevalence of the alternative forms?
- What are the effects, intended and unintended, of alternative forms on the outcomes of care?
|Research Area||Sample Research Questions|
|Size||Is the percentage of physicians who work in small medical practices/groups changing? Does it matter? Do large medical groups provide higher quality/lower cost care than small or medium-sized medical groups?|
|Specialty or staff mix||Do multispecialty medical groups provide higher quality/lower cost care than single specialty groups? Are new large multispecialty or single specialty medical groups being formed? What are the factors promoting or impeding group formation?|
|Ownership||Is physician employment by hospitals increasing? Do hospital-employed physicians provider higher quality/lower cost care than physician-owned medical practices?|
|Network or "single entity"||Do integrated delivery systems provide higher quality/lower cost care? Do large medical groups provide higher quality/lower cost care than independent practice associations (IPAs)?|
|Patient-centered medical home||To what extent are practices that have constituted themselves as patient-centered medical homes continuing to function as medical homes vs. abandoning the effort? What are the factors that influence this?|
|Accountable care organization||What types of organizations are constituting themselves as accountable care organizations? How does the quality/cost of care vary among the organizational types?|
|Type of culture||How can organizational culture be measured in health care delivery organizations? What are the distinct types of organizational culture and their prevalence? Do some types result in higher quality/lower cost care? What are the external and internal factors that promote particular types of organizational culture?|
|Type of leadership||Analogous questions as for culture.|
|Payment methods from payors||Are payments to medical homes sufficient to give practices a "business case" for investing in becoming a medical home? What are the effects of capitation payment plus a bonus for quality on provider organization performance compared to the effects of fee-for-service payment with bonuses for quality and for cost savings? What are unintended consequences of pay for performance programs? How can P4P programs be designed to minimize unintended consequences, such as increasing resource disparities between provider organizations located in advantaged vs. disadvantaged socioeconomic areas?|
|Public reporting of performance||What are the relative effects of pay for performance and public reporting on the quality and cost of care provided by different types of provider organization? Are both necessary? What are the factors promoting or impeding the use of public reporting information by patients and by physicians?|
|Negotiating leverage||Gaining increased negotiating leverage can result in higher payments from health plans for provider organizations. To what extent do attempts to gain increased leverage affect the structure of provider organizations? What are the effects of increased provider negotiating leverage on the quality and cost of health care?|
|Regulation||How do various regulations affect the structure of physician-hospital relationships? Do IPAs and physician-hospital organizations that are clinically integrated provide higher quality/lower cost care than those that are not?|
|Measurement issues||Can the quality and cost of care be reliably measured for individual primary care physicians? For physicians in other specialties? How large must a provider organization be for reliable measurement to be made of important measures of quality and cost (e.g., ambulatory-sensitive admissions are likely more important than process measures such as diabetic retinal exams; total cost of care is likely more important than attempts at measuring efficiency)? How can electronic medical records be used to complement or substitute for administrative claims data to make it possible to measure important areas of quality? How can patient experience surveys be structured to obtain information about important areas of quality?|
|Care of individuals, for example:
||How prevalent is the use of the process? What are its effects on the quality/cost of care? What factors encourage or discourage the use of the process? Are there unintended and undesirable consequences of the process?|
|Innovative approaches to hospital discharge||To what extent can discharge programs operated by hospitals, without involvement of outpatient physicians, reduce readmission rates?|
|Processes intended to improve patient safety—for example, to minimize falls in the hospital||How prevalent is the use of the process? What are its effects on the quality/cost of care? What factors encourage or discourage the use of the process? Are there unintended and undesirable consequences of the process?|
|Care of an organization's population of patients, for example:
||How prevalent is the use of the process? What are its effects on the quality/cost of care? What factors encourage or discourage the use of the process?|
|Use of clinical information technology, for example:
||What are the effects of the process on the quality/cost of care? What factors encourage or discourage the use of the process? What, if any, unintended consequences of the process are occurring? How might these be mitigated?|
|Internal incentives (within the provider organization), for example:|
||What external factors (e.g., payment methods from payors) drive organizations' internal incentives? What are the effects of different internal incentives on the quality/cost of care?|
||Is internal reporting of individuals' performance to peers sufficient to improve performance, or is internal pay for performance needed as well? What are unintended consequences of internal pay for performance and internal reporting of individuals' performance?|
|Types of patient engagement||How can types of patient engagement be categorized? What are the effects of different types of patient engagement on the quality/costs of care?|
|Factors promoting patient engagement||What organizational structural, cultural, and process factors promote patient engagement?|
|Inter-Relationships Among Key Elements of the Conceptual Model|
|How do the parts of the conceptual model interact? For example, what organizational structures and cultures are likely to result in the use of better processes for providing care and to result in better outcomes? How do external incentives affect organizational structures, cultures, and processes?|