Person: Landon, Bruce
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Landon, Bruce
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Publication Variation in Patient-Sharing Networks of Physicians Across the United States(American Medical Association (AMA), 2012) Landon, Bruce; Keating, Nancy; Barnett, Michael; Onnela, Jukka-Pekka; Paul, Sudeshna; O’Malley, A. James; Keegan, Thomas; Christakis, Nicholas A.Publication Patient-To-Physician Messaging: Volume Nearly Tripled As More Patients Joined System, But Per Capita Rate Plateaued(Health Affairs (Project Hope), 2014) Crotty, B. H.; Tamrat, Y.; Mostaghimi, Arash; Safran, Charles; Landon, BrucePatients want to be able to communicate with their physicians by e-mail. However, physicians are often concerned about the impact that such communications will have on their time, productivity, and reimbursement. Typically, physicians are not reimbursed for time spent communicating with patients electronically. But under federal meaningful-use criteria for information technology, physicians can receive a modest incentive for such communications. Little is known about trends in secure e-mail messaging between physicians and patients. To understand these trends, we analyzed the volume of messages in a large academic health care system’s patient portal in the period 2001–10. At the end of 2010, 49,778 patients (22.7 percent of all patients seen within the system) had enrolled in the portal, and 36.9 percent of enrolled patients (8.4 percent of all patients) had sent at least one message to a physician. Physicians in the aggregate saw a near tripling of e-mail messages during the study period. However, the number of messages per hundred patients per month stabilized between 2005 and 2010, at an average of 18.9 messages. As physician reimbursement moves toward global payments, physicians’ and patients’ participation in secure messaging will likely increase, and electronic communication should be considered part of physicians’ job descriptions.Publication Factors associated with geographic variation in cost per episode of care for three medical conditions(Springer, 2014) Hadley, Jack; Reschovsky, James D; O’Malley, James A; Landon, BruceObjective: To identify associations between market factors, especially relative reimbursement rates, and the probability of surgery and cost per episode for three medical conditions (cataract, benign prostatic neoplasm, and knee degeneration) with multiple treatment options. Methods: We use 2004–2006 Medicare claims data for elderly beneficiaries from sixty nationally representative communities to estimate multivariate models for the probability of surgery and cost per episode of care as a function local market factors, including Medicare physician reimbursement for surgical versus non-surgical treatment and the availability of primary care and specialty physicians. We used Symmetry’s Episode Treatment Groups (ETG) software to group claims into episodes for the three conditions (n = 540,874 episodes). Results: Higher Medicare reimbursement for surgical episodes and greater availability of the relevant specialists are significantly associated with more surgery and higher cost per episode for all three conditions, while greater availability of primary care physicians is significantly associated with less frequent surgery and lower cost per episode. Conclusion: Relative Medicare reimbursement rates for surgical vs. non-surgical treatments and the availability of both primary care physicians and relevant specialists are associated with the likelihood of surgery and cost per episode.Publication A Training Model for Implementing Hepatitis Prevention Services in Substance Use Disorder Clinics: A Qualitative Evaluation(Springer US, 2015) Hagedorn, Hildi J.; Rettmann, Nancy; Dieperink, Eric; Knott, Astrid; Landon, BrucePublication Emergency Department Use and Subsequent Hospitalizations Among Members of a High-Deductible Health Plan(American Medical Association (AMA), 2007) Wharam, James; Landon, Bruce; Galbraith, Alison; Kleinman, Kenneth Paul; Soumerai, Stephen; Ross-Degnan, DennisContext Patients evaluated at emergency departments often present with nonemergency conditions that can be treated in other clinical settings. High-deductible health plans have been promoted as a means of reducing overutilization but could also be related to worse outcomes if patients defer necessary care. Objectives To determine the relationship between transition to a high-deductible health plan and emergency department use for low- and high-severity conditions and to examine changes in subsequent hospitalizations. Design, Setting, and Participants Analysis of emergency department visits and subsequent hospitalizations among 8724 individuals for 1 year before and after their employers mandated a switch from a traditional health maintenance organization plan to a high-deductible health plan, compared with 59 557 contemporaneous controls who remained in the traditional plan. All persons were aged 1 to 64 years and insured by a Massachusetts health plan between March 1, 2001, and June 30, 2005. Main Outcome Measures Rates of first and repeat emergency department visits classified as low, indeterminate, or high severity during the baseline and follow-up periods, as well as rates of inpatient admission after emergency department visits. Results Between the baseline and follow-up periods, emergency department visits among members who switched to high-deductible coverage decreased from 197.5 to 178.1 per 1000 members, while visits among controls remained at approximately 220 per 1000 (−10.0% adjusted difference in difference; 95% confidence interval [CI], −16.6% to −2.8%; P = .007). The high-deductible plan was not associated with a change in the rate of first visits occurring during the study period (−4.1% adjusted difference in difference; 95% CI, −11.8% to 4.3%). Repeat visits in the high-deductible group decreased from 334.6 to 255.3 visits per 1000 members and increased from 321.1 to 334.4 per 1000 members in controls (−24.9% difference in difference; 95% CI, −37.5% to −9.7%; P = .002). Low-severity repeat emergency department visits decreased in the high-deductible group from 142.5 to 92.1 per 1000 members and increased in controls from 128.0 to 132.5 visits per 1000 members (−36.4% adjusted difference in difference; 95% CI, −51.1% to −17.2%; P<.001), whereas a small decrease in high-severity visits in the high-deductible group could not be excluded. The percentage of patients admitted from the emergency department in the high-deductible group decreased from 11.8 % to 10.9% and increased from 11.9% to 13.6% among controls (−24.7% adjusted difference in difference; 95% CI, −41.0% to −3.9%; P = .02). Conclusions Traditional health plan members who switched to high-deductible coverage visited the emergency department less frequently than controls, with reductions occurring primarily in repeat visits for conditions that were not classified as high severity, and had decreases in the rate of hospitalizations from the emergency department. Further research is needed to determine long-term health care utilization patterns under high-deductible coverage and to assess risks and benefits related to clinical outcomes.Publication Patient-Centered Medical Home Initiatives Expanded In 2009-13: Providers, Patients, And Payment Incentives Increased(Health Affairs (Project Hope), 2014) Edwards, S. T.; Bitton, Asaf; Hong, J.; Landon, BrucePatient-centered medical home initiatives are central to many efforts to reform the US health care delivery system. To better understand the extent and nature of these initiatives, in 2013 we performed a nationwide cross-sectional survey of initiatives that included payment reform incentives in their models, and we compared the results to those of a similar survey we conducted in 2009. We found that the number of initiatives featuring payment reform incentives had increased from 26 in 2009 to 114 in 2013. The number of patients covered by these initiatives had increased from nearly five million to almost twenty-one million. We also found that the proportion of time-limited initiatives—those with a planned end date—was 20 percent in 2013, a decrease from 77 percent in 2009. Finally, we found that the dominant payment model for patient-centered medical homes remained fee-for-service payments augmented by per member per month payments and pay-for-performance bonuses. However, those payments and bonuses were higher in 2013 than they were in 2009, and the use of shared-savings models was greater. The patient-centered medical home model is likely to continue both to become more common and to play an important role in delivery system reform.Publication Medicare Chronic Care Management Payments and Financial Returns to Primary Care Practices(American College of Physicians, 2015) Basu, Sanjay; Phillips, Russell; Bitton, Asaf; Song, Zirui; Landon, BruceBackground: Physicians have traditionally been reimbursed for face-to-face visits. A new non–visit-based payment for chronic care management (CCM) of Medicare patients took effect in January 2015. Objective: To estimate financial implications of CCM payment for primary care practices. Design: Microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements. Data Sources: National Ambulatory Medical Care Survey and other published sources. Target Population: Medicare patients. Time Horizon: 10 years. Perspective: Practice-level. Intervention: Comparison of CCM delivery approaches by staff and physicians. Outcome Measures: Net revenue per full-time equivalent (FTE) physician; time spent delivering CCM services. Results of Base-Case Analysis: If nonphysician staff were to deliver CCM services, net revenue to practices would increase despite opportunity and staffing costs. Practices could expect approximately $332 per enrolled patient per year (95% CI, $234 to $429) if CCM services were delivered by registered nurses (RNs), approximately $372 (CI, $276 to $468) if services were delivered by licensed practical nurses, and approximately $385 (CI, $286 to $485) if services were delivered by medical assistants. For a typical practice, this equates to more than $75 000 of net annual revenue per FTE physician and 12 hours of nursing service time per week if 50% of eligible patients enroll. At a minimum, 131 Medicare patients (CI, 115 to 140 patients) must enroll for practices to recoup the salary and overhead costs of hiring a full-time RN to provide CCM services. Results of Sensitivity Analysis: If physicians were to deliver all CCM services, approximately 25% of practices nationwide could expect net revenue losses due to opportunity costs of face-to-face visit time. Limitation: The CCM program may alter long-term primary care use, which is difficult to predict. Conclusion: Practices that rely on nonphysician team members to deliver CCM services will probably experience substantial net revenue gains but must enroll a sufficient number of eligible patients to recoup costs. Primary Funding Source: None.Publication Setting a research agenda for medical overuse(BMJ Publishing Group Ltd., 2015) Morgan, Daniel J; Brownlee, Shannon; Leppin, Aaron L; Kressin, Nancy; Dhruva, Sanket S; Levin, Les; Landon, Bruce; Zezza, Mark A; Schmidt, Harald; Saini, Vikas; Elshaug, Adam GAlthough overuse in medicine is gaining increased attention, many questions remain unanswered. Dan Morgan and colleagues propose an agenda for coordinated research to improve our understanding of the problemPublication Mammography Rates 3 Years After the 2009 US Preventive Services Task Force Guidelines Changes(American Society of Clinical Oncology (ASCO), 2015) Wharam, James; Landon, Bruce; Zhang, Fang; Xu, Xin; Soumerai, Stephen; Ross-Degnan, DennisPurpose In November 2009, the US Preventive Services Task Force (USPSTF) changed its mammography recommendations from every 1 to 2 years among women age ≥ 40 years to personalized screening decisions for women age 40 to 49 years and screening every 2 years for women age 50 to 74 years. Methods We studied mammography trends among 5.5 million women age 40 to 64 years enrolled in a large national health insurer. We used 2005 to 2009 mammography trends to predict 2012 rates. Our primary measure was the estimated difference between observed and predicted 2012 annual and biennial mammography rates. We stratified results by age group and race/ethnicity. Results Among women age 40 to 49 years, 2012 mammography rates declined by 9.9% (95% CI, −10.4% to −9.3%) relative to the predicted 2012 rate. Decreases were lowest among black women (−2.3%; 95% CI, −6.3% to 1.8%) and highest among Asian women (−17.4; 95% CI, −20.0 to −14.8). Annual mammography rates among women age 50 to 64 years declined by 6.1% (95% CI, −6.5% to −5.7%) by 2012. Regarding biennial mammography rates, women age 40 to 49 years experienced a 9.0% relative reduction (95% CI, −9.6% to −8.4%). White, Hispanic, and Asian women age 40 to 49 years demonstrated similar relative reductions of approximately 9% to 11%, whereas black women had no detectable changes (0.1%; 95% CI, −4.0% to 4.3%). Women age 50 to 64 years had a 6.2% relative reduction (95% CI, −6.6% to −5.7%) in biennial mammography that was similar among white, Hispanic, and Asian women. Black women age 50 to 64 years did not have changes in biennial mammography (0.4%; 95% CI, −2.6% to 3.5%). Conclusion Three years after publication of the 2009 USPSTF guidelines, mammography rates declined by 6% to 17% among white, Hispanic, and Asian women but not among black women. Small reductions in biennial mammography might be an unintended consequence of the updated guidelines.Publication Physicians’ Views of Performance Reports: Grading the Graders(BioMed Central, 2012) Landon, BruceQuality measurement and feedback programs have become widespread and are looked upon as a cornerstone of quality improvement efforts. Often, such programs are used to motivate consumer choice through public report cards or to reward high quality care through pay for performance programs. Physicians’ views on performance measurement and feedback programs, however, are rarely sought, despite the potential usefulness for improving the impact of such programs. The new IJHPR paper by Nissanholtz-Gannot and colleagues provides important data on physicians’ views of the Israeli quality measurement program that demonstrates strong support for the program among Israeli physicians while also identifying potential areas for improvement.