Objective To examine the effect of enrollee switching from a broad‐network accountable care organization (ACO) health maintenance organization (HMO) to a “high performance” ACO‐HMO with a selective narrow network and comprehensive patient navigation system on access, utilization, expenditures, and enrollee experiences. Data Sources Secondary administrative data were obtained for 2016–2020, and primary interview and survey data in 2021. Study Design Fixed‐effects instrumental variable analyses of administrative data and regression analyses of survey data. Outcomes included access, utilization, expenditures, and enrollee experience. Background information was gathered via interviews. Data Collection/Extraction Methods We obtained medical expenditure/enrollment and access data on continuously enrolled members in a broad‐network ACO‐HMO (n = 24,555), a subset of those who switched to a high‐performance ACO‐HMO in 2018 (n = 7664); interviews of organizational leaders (n = 13); and an enrollee survey (n = 512). Principal Findings Health care effectiveness data and information Set (HEDIS) access measures were not different across plans. However, annual utilization dropped by 15.5 percentage points (95% CI: 18.1, 12.9) more in the high‐performance ACO‐HMO, with relative annual expenditures declining by $1251 (95% CI: $1461, $1042) per person per year. High‐performance ACO‐HMO enrollees were 10.1 percentage points (95% CI 0.001, 0.201) more likely to access primary care usually or always as soon as needed and 11.2 percentage points (95% CI 0.007, 0.217) more likely to access specialty care usually or always as soon as needed. Plan satisfaction was 7.1 percentage points (95% CI: −0.001, 0.138) higher in the high‐performance ACO‐HMO. Interviewees noted the comprehensive patient navigation system was designed to ensure patients remained in the narrow network to receive care. Conclusions ACO and HMO contracts with selective narrow networks supported by comprehensive patient navigation can reduce expenditures and improve specialty access and patient satisfaction compared to broad‐network plans that lack these features. Payers should consider implementing narrow networks with comprehensive support systems.

Research Objective Over the past two decades, health care organizations have recognized the importance of physician feedback and data transparency for continuous performance improvement. Diffusion of innovation theory suggests that late‐adopting organizations face unique barriers to adoption, particularly of innovations that require infrastructure investments. This study aims to identify qualities associated with physician practices’ late or non‐adoption of unblinded peer comparisons for performance reporting. Study Design This research draws on the cross‐sectional 2017/2018 National Survey of Healthcare Organizations and Systems (NSHOS) practice‐level survey (response rate=47%) linked to 2017 IQVIA OneKey data on physician practices. Predictors of unblinded performance feedback include composites of organizational learning orientation, organizational capacity for innovation, health information technology (HIT capabilities), and participation in delivery reform initiatives. We perform a logistic regression to estimate the odds that a practice does not report using unblinded peer comparison feedback, controlling for reported practice ownership, a measure of physician influence on practice priorities and strategies, Medicaid revenue (less than 30% or ≥30%, as a proxy for financial resources and patient complexity), and practice size (physician count). Population Studied We study the population of practices with at least three primary care physicians using a nationally representative sample of 2,190 non‐federal physician practices. Practices are of diverse ownership, including primary care and multispecialty provider groups, those owned by healthcare systems, independent practices, and other arrangements. Principal Findings 27% of physician practices did not report using unblinded peer comparisons for performance feedback reports. These physician practices had lower organizational learning orientation (OR=0.689, p<0.001), lower HIT capabilities (OR = 0.725, P < .001), and less participation in delivery reform initiatives (OR = 0.740, P < .001). No significant association was found between organizational capacity for innovation and late adopter status. Of control variables, health care system ownership or ownership by some other entity, and “some” physician influence (compared to “little to none” or “a lot”) were found to be significantly associated with practice use of transparent performance comparisons. Our Medicaid revenue variable was not found to be significant. Conclusions Physician practices that do not use unblinded peer comparisons for performance feedback have lower organizational learning orientations, lower HIT capabilities, and participate in fewer delivery reform initiatives than adopters of transparent reporting. These findings indicate that late or non‐adopting practices may be less motivated toward learning, and external quality incentives may be less important influences on their innovation adoption. HIT capabilities and economies of scale related to practice ownership may also improve adoption of ...

Background: Increased integration of physician organizations and hospitals into health systems has not necessarily improved clinical integration or patient outcomes. However, federal regulators have issued favorable opinions for clinically integrated networks (CINs) as a way to pursue coordination between hospitals and physicians. Hospital organizational affiliations, including independent practice associations (IPA), physician-hospital organizations (PHOs), and accountable care organizations (ACOs), may support CIN participation. No empirical evidence, however, exists about factors associated with CIN participation. Methods: Data from the 2019 American Hospital Association survey (n = 4405) were analyzed to quantify hospital CIN participation. Multivariable logistic regression models were estimated to examine whether IPA, PHO, and ACO affiliations were associated with CIN participation, controlling for market factors and hospital characteristics. Results: In 2019, 34.6% of hospitals participated in a CIN. Larger, not-for-profit, and metropolitan hospitals were more likely to participate in CINs. In adjusted analyses, hospitals participating in CINs were more likely to have an IPA (9.5% points, P < 0.001), a PHO (6.1% points, P < 0.001), and ACO (19.3% points, P < 0.001) compared with hospitals not participating in a CIN. Conclusions: Over one-third of hospitals participate in a CIN, despite limited evidence about their effectiveness in delivering value. Results suggest that CIN participation may be a response to integrative norms. Future work should attempt to better define CIN participation and strive to disentangle overlapping organizational participation.