Essays on Payment Reform, Physician Compensation and the Clinical Workforce
Garcia Mosqueira, Adrian
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CitationGarcia Mosqueira, Adrian. 2019. Essays on Payment Reform, Physician Compensation and the Clinical Workforce. Doctoral dissertation, Harvard University, Graduate School of Arts & Sciences.
AbstractThe purpose of this dissertation is to study specific policies within the recent wave of health care reform and their ground-level impacts on care delivery in the United States. This work analyzes changes in (i) the geographic distribution of the clinical workforce, (ii) the patterns of care-delivery by primary care physicians, and (iii) the collection and usage of information technology by medical practices that serve vulnerable populations.
The first chapter concerns itself with the Affordable Care Act (ACA) specifically the Medicaid expansion, and its effect on the concentrations of physicians and other clinicians in states that chose to expand Medicaid. Using a dataset containing counts of various health care professionals by county over six years, I find that states that expanded Medicaid had, on average significantly higher densities of all clinicians studied, including Primary Care Physicians (PCP), Nurse Practitioners, Physician Assistants, and M.D. Specialists. After accounting for the intensity of the expansion by including county-level measures of Expansion beneficiaries, there was no association with the concentration of clinicians, suggesting that previous research evidence showing increases in health care access and utilization post-Medicaid expansion were not a product of increased clinician headcounts.
Chapter 2 narrows in scope by looking only at PCPs, documenting the overall compensation landscape, as well as changes in care-delivery patterns due to reforms in physician compensation. Using a national dataset from 2012-2015 on ambulatory physician visits, this chapter uncovers evidence that system-level payment reform had little impact on front-line PCP compensation patterns, and that fee-for-service remains the dominant compensation model. Beyond compensation, I analyze whether physician compensation models are associated with delivery rates of some essential elements of primary care, such as nursing home visits, hospital visits, as well as a series of high and low value care measures. I find little evidence that payment reform and the resulting changes in compensation model impact rates of delivery of these types of care, prompting the need for further study on the topic as alternative payment models and value-based contracting programs take root and mature.
Chapter 3 broadens beyond clinicians by looking at other inputs of care delivery. The collection and use of physician performance on quality metrics and costs is a critical component of a practice’s ability to improve the value of care delivered. Safety-net practices (SNPs) face several challenges, including resource constraints, complex and vulnerable patient populations, suggesting that they might face difficulties in collecting these data for the purposes of physician evaluation and internal quality improvement relative to other practices. Moreover, as value-based contracting takes hold, SNPs are under pressure to collect these data and use it for quality and efficiency of care improvements, or risk financial penalties. Using an innovative national data source of primary care and multi-specialty practices, this study finds that SNPs do not have lower rates of physician performance data collection and use for the purposes of providing feedback, internal quality improvement, and physician compensation relative to other practices. Moreover, SNPs do not seem to possess lower health information technology capacities when compared to other sample practices. While SNPs do underperform in programs that provide economic incentives for improvement, these results suggest that these shortcomings are not due to deficits in information technology capabilities.
Citable link to this pagehttp://nrs.harvard.edu/urn-3:HUL.InstRepos:42029457
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