Jessica I Billig, Yixin Tang, Michael Wu, Luyu Xie, Joshua M Liao
{"title":"Total Payments and Out-of-Pocket Expenses for Surgical Hand Trauma Episodes.","authors":"Jessica I Billig, Yixin Tang, Michael Wu, Luyu Xie, Joshua M Liao","doi":"10.7812/TPP/24.196","DOIUrl":"https://doi.org/10.7812/TPP/24.196","url":null,"abstract":"<p><strong>Purpose: </strong>Insight about episode spending after elective procedures has driven interest in bundling reimbursement for surgical procedures. However, little is known about episode spending for health systems (payments) and patients (out-of-pocket [OOP] expenses) after unplanned, nonelective procedures such as hand trauma.</p><p><strong>Methods: </strong>The authors used 2019-2022 national claims to conduct a cohort study of patients undergoing flexor tendon repair, open reduction internal fixation (ORIF) of a distal radius fracture, and replantation/revascularization. The authors constructed 90-day episodes spanning surgical procedures and postoperative care. The authors calculated episode spending from the perspectives of the health system (payments) and patients (OOP expenses). Multivariable regression models were used to examine the association between patient characteristics and spending.</p><p><strong>Results: </strong>Among 21,753 patients, 90-day postoperative spending varied by procedure type. Median payment was $14,263 for ORIF of distal radius fractures, $11,541 for flexor tendon repairs, and $25,700 for revascularization/replantation. Compared to ORIF of distal radius fractures, flexor tendon repairs were associated with 18% lower payments (cost ratio, 0.82; 95% confidence interval [CI], 0.80-0.83), while revascularization/replantation was associated with 7% lower payments (cost ratio, 0.93; 95% CI, 0.90-0.97). Patients with at least one comorbidity had 4% greater payments compared to patients with no comorbidities (cost ratio, 1.04; 95% CI, 1.03-1.06). However, inpatient procedures were 388% more expensive than outpatient procedures (cost ratio, 3.77; 95% CI, 3.77-3.99). The authors also found variation in patient OOP expenses based on procedure type.</p><p><strong>Conclusions: </strong>There was heterogeneity in health system and patient spending after hand trauma due to procedure type. This highlighted that any future payment or practice redesign for hand trauma episodes should be stratified by procedure type.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-9"},"PeriodicalIF":0.0,"publicationDate":"2025-08-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144970230","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Postpartum Phone Call Intervention to Improve Postpartum Breastfeeding, Support, and Outcomes.","authors":"Nikhita Ravikanti, Reece Burns, Jennifer Keomany, Hayrettin Okut, Jessica Kieffer, Holly Montgomery","doi":"10.7812/TPP/24.063","DOIUrl":"https://doi.org/10.7812/TPP/24.063","url":null,"abstract":"<p><strong>Introduction: </strong>Few studies have evaluated the utility of a postpartum phone call to assess patient status and improve outcomes. This study examined the effectiveness of a phone call intervention 1 week postpartum to evaluate and improve maternal support and outcomes, including breastfeeding, postpartum visit attendance, and intended contraception use.</p><p><strong>Methods: </strong>This retrospective cohort study included patients treated at a single obstetrical clinic. The intervention, a scripted, structured phone call performed 1 week postpartum by a nurse, asked about intended contraception use, postpartum depression risk factors, safe sleep practices, and gestational diabetes follow-up care, and also confirmed the postpartum visit. De-identified data were abstracted from electronic medical records to compare outcomes before and after the intervention was implemented.</p><p><strong>Results: </strong>A total of 653 postpartum patients with a mean age of 27 (standard deviation = 5.3). Exclusive breastfeeding rates were 74.4% pre-intervention vs 62.9% postintervention, exclusive formula feeding was 19.8% vs 18.5%, and mixed feeding rates were 4.3% vs 18% (<i>P</i> = .005). Clinic postpartum follow-up attendance rose from 73.7% to 86.8% (<i>P</i> = .007).</p><p><strong>Discussion: </strong>Mixed feeding rates were higher after the intervention was implemented, suggesting that patients who received the postpartum intervention were more likely to attempt mixed feeding.</p><p><strong>Conclusions: </strong>After implementing a structured postpartum phone call, mixed breastfeeding rates increased, in addition to postpartum visit attendance.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-7"},"PeriodicalIF":0.0,"publicationDate":"2025-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144970226","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Kaushalya Mendis, Veda Priya Puligundla, Myles Rosenzweig, Melissa Coffel, John Geracitano, Saif Khairat
{"title":"The Impact of Telehealth on Cost and Time Efficiency for Patients With Disabilities During Nonemergency Encounters: A Scoping Review.","authors":"Kaushalya Mendis, Veda Priya Puligundla, Myles Rosenzweig, Melissa Coffel, John Geracitano, Saif Khairat","doi":"10.7812/TPP/25.044","DOIUrl":"https://doi.org/10.7812/TPP/25.044","url":null,"abstract":"<p><strong>Background: </strong>Telehealth services have expanded in recent years, showing promising potential to improve health care access. This review examined the impact of telehealth on individuals of all ages living with chronic disabilities with a focus on cost, as well as other key outcomes such as time efficiency, clinical outcomes, and patient satisfaction.</p><p><strong>Methods: </strong>PRISMA guidelines were followed to examine US-based studies between 2018 and 2024 across 4 databases using keywords related to cost, telehealth, and disability. Studies were screened using Covidence software. Two reviewers independently assessed studies for inclusion. Data was extracted using a standardized form and thematically analyzed.</p><p><strong>Results: </strong>Out of 230 preliminary studies, 8 met the inclusion criteria. Telehealth interventions were found to be time and cost effective with comparable clinical outcomes and high patient satisfaction for individuals of all ages with disabilities. However, some challenges of integrating processes in emergency departments resulting in longer stays and implementation issues were noted.</p><p><strong>Discussion: </strong>Although cost benefits were evident for patients, programs, and health systems, successful implementation depends on resolving challenges related to digital infrastructure, equitable access, and patient-practitioner rapport.</p><p><strong>Conclusion: </strong>Telehealth represents a promising approach to improving health care access for individuals with disabilities, if implementation challenges are strategically addressed.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-9"},"PeriodicalIF":0.0,"publicationDate":"2025-08-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144970228","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Richard Frankel, Jordan Brogley Webb, John Bowen, Neil Mehta, J Harry Isaacson
{"title":"Back to the Future: Long-Term Leadership Lessons From the COVID-19 Pandemic.","authors":"Richard Frankel, Jordan Brogley Webb, John Bowen, Neil Mehta, J Harry Isaacson","doi":"10.7812/TPP/25.030","DOIUrl":"https://doi.org/10.7812/TPP/25.030","url":null,"abstract":"<p><strong>Introduction: </strong>The loss of 50,000,000 people during the 1918 influenza pandemic was blamed on war, unsanitary conditions, and lack of vaccines and preparation. Nine decades later, a similar virus (H1N1) killed 285,000 people, and again, the response was that preparation was ineffective, inefficient, and inequitable. Less than a decade later, preparedness for the coronavirus disease 2019 (COVID-19) outbreak revealed the United States was not prepared. This study's objectives were: 1) to develop a deeper understanding of leadership practices that led to successful responses to the COVID-19 pandemic, and 2) to learn about the underlying principles and practices that may help in preparing for the next pandemic.</p><p><strong>Methods: </strong>Senior leaders (14/23 or 61%) from across a multisite, multicountry integrated health system were recruited using maximum variation sampling. Individual recorded interviews (averaging 20 minutes) were based on principles of Appreciative Inquiry and critical incident reporting. Iterative consensus coding produced 6 major themes: self- and situation awareness, teamwork, readiness, inspirational leadership, internal communication, and external communication.</p><p><strong>Results: </strong>Beyond individual leadership decisions, organizational culture, shared cognition, and history may play a major role in shaping system-wide responses to catastrophic events like the COVID-19 pandemic.</p><p><strong>Discussion: </strong>Lack of preparation for dealing with novel events and one-way communication may be risk factors for chaotic and ineffective responses.</p><p><strong>Conclusion: </strong>Senior leaders must balance clinical necessity with humanistic values and purpose. Situation awareness and attention to organizational culture may improve the quality, timeliness, and effectiveness of responses to the next pandemic threat.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-9"},"PeriodicalIF":0.0,"publicationDate":"2025-08-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144970161","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Joseph H Joo, David H Au, Anna M Morenz, Michael Wu, Bethany Agusala, Joshua M Liao
{"title":"Informing Advanced Primary Care Management: Trends From Care Coordination Among Medicare Beneficiaries in 2020-2023.","authors":"Joseph H Joo, David H Au, Anna M Morenz, Michael Wu, Bethany Agusala, Joshua M Liao","doi":"10.7812/TPP/25.040","DOIUrl":"https://doi.org/10.7812/TPP/25.040","url":null,"abstract":"<p><strong>Background: </strong>Medicare recently began reimbursing for new advanced primary care management (APCM) services, which builds directly on the design of principal, chronic, and transitional care management. As APCM is anticipated to achieve similar goals and can be used similarly to predecessor services, practice and policy leaders would benefit from insight about collective use of principal, chronic, and transitional care management as APCM adoption begins in the United States.</p><p><strong>Methods: </strong>Using data encompassing 100% of professional services billed to and reimbursed by Medicare, the authors combined principal, chronic, and transitional care management together as coordination services for evaluation. The authors calculated cumulative sum of service counts and respective reimbursements overall and stratified by clinical specialty and place of service.</p><p><strong>Results: </strong>A total of 25,269,895 coordination services corresponding to $2,257,471,660 were provided by clinicians to Medicare beneficiaries between 2020 and 2023. Coordination services were most frequently delivered by primary care clinicians, which as a group accounted for 17,210,579 (68%) of services, compared to medical subspecialists, which accounted for 5,718,337 (23%) services, and other specialists, which accounted for 2,340,980 (9%) of services. With respect to place of service, most coordination services occurred in physician offices (21,895,715; 87%) as compared to hospital outpatient departments (757,571; 3%), homes (949,373; 4%), or other care sites (1,667,236; 6%).</p><p><strong>Conclusion: </strong>This study corroborated the potential benefit of policy decisions to target new coordination services (ie, APCM) toward primary care clinicians, while also highlighting the need to design policies in ways that engage non-primary care clinicians for common chronic conditions.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-4"},"PeriodicalIF":0.0,"publicationDate":"2025-08-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144875375","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Call for Papers: Improving Health Care Access.","authors":"","doi":"10.7812/TPP/25.098","DOIUrl":"10.7812/TPP/25.098","url":null,"abstract":"","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-2"},"PeriodicalIF":0.0,"publicationDate":"2025-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144333925","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Khang A Nguyen, Nicolaas Versteeg, Eleanor Morales, Rebecca Hilton
{"title":"The Evolution of the Kaiser Permanente Southern California Regional Virtual Medical Center.","authors":"Khang A Nguyen, Nicolaas Versteeg, Eleanor Morales, Rebecca Hilton","doi":"10.7812/TPP/25.005","DOIUrl":"10.7812/TPP/25.005","url":null,"abstract":"","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"96-97"},"PeriodicalIF":0.0,"publicationDate":"2025-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12168037/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143664363","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jubi Yl Lin, Joseph H Joo, Lingmei Zhou, Rachna Goswami, Joshua M Liao
{"title":"The Impact of Payment Reform on Medicaid Access and Quality: A National Survey of Physicians.","authors":"Jubi Yl Lin, Joseph H Joo, Lingmei Zhou, Rachna Goswami, Joshua M Liao","doi":"10.7812/TPP/24.121","DOIUrl":"10.7812/TPP/24.121","url":null,"abstract":"<p><strong>Introduction: </strong>Addressing health inequity should involve improving access and quality of care for individuals with low income. In the United States, programs that involve accountable care incentives and broader risk adjustment are poised to help address these issues. However, there is limited understanding of perspectives among physicians as key stakeholders in determining access and quality.</p><p><strong>Methods: </strong>The authors surveyed physicians about how they perceived accountable care incentives and broader risk adjustment (greater inclusion of clinical, social, and behavioral risk factors) would impact access and quality for patients with low income insured through Medicaid.</p><p><strong>Results: </strong>Low Medicaid reimbursement rates and inadequate adjustment for patients' clinical, social, and behavioral risk factors were major factors why physicians reported not seeing Medicaid patients in their clinical practices. Many physicians believed that accountable care incentives and changes in risk adjustment would help facilitate higher quality of care for Medicaid patients, while the minority of physicians believed that accountable care organizations could ultimately improve the value of care beyond managed care organizations.</p><p><strong>Discussion: </strong>Policymakers could incorporate behavioral, social, and equity-related factors into risk adjustment and consider ways to incorporate accountable care incentives into existing and new entities in Medicaid.</p><p><strong>Conclusion: </strong>The majority of physicians believed that the care of Medicaid patients would improve under accountable care incentives and broader risk adjustment. Understanding physician perspectives is important for contextualizing policy about how payment reforms could affect access and quality of care for Medicaid patients.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"41-47"},"PeriodicalIF":0.0,"publicationDate":"2025-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12168033/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143796188","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Models of Care in Hospital Medicine: An Analysis of Advance Practitioner Utilization Using Monte Carlo Methods.","authors":"Rohit Sharma, Noora Akram, Michael Madden","doi":"10.7812/TPP/24.159","DOIUrl":"10.7812/TPP/24.159","url":null,"abstract":"<p><strong>Introduction: </strong>Physicians are facing a constant shortage, with market estimates of shortfalls only projected to increase as the population of the United States ages and health care employment needs increase. A lack of physicians has led to a steady increase in the number and scope of advanced practice practitioners (APPs) in the United States. Nurse practitioners and physician assistants have increased, in terms of percentage of the practitioner workforce, with varying degrees of autonomy. The authors describe a model of APPs to determine whether indirect supervision vs direct supervision is fiscally optimum in hospital medicine departments.</p><p><strong>Methods: </strong>The authors utilized R software in R Studio to simulate, via Monte Carlo methods, APP-independent and supervised models of care. Publicly available salary data were used as the foundation to generate the models. The data were then used to simulate typical care teams of APPs and physicians in hospital medicine, while utilizing typical billing practices.</p><p><strong>Discussion: </strong>Analysis of the models of care generated demonstrated that APPs, given the current payer reimbursements, are an integral part of the hospital medicine care team. A range of scenarios are accounted for. This research demonstrates that direct supervision has a lower cost per work relative value unit cost to the employer, as opposed to indirect supervision.</p><p><strong>Conclusion: </strong>APPs will only continue to increase their share of billed visits. In the setting of a hospital medicine workflow, given current payer and salary constraints, direct supervision is recommended to optimize the care team from a fiduciary perspective.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"48-53"},"PeriodicalIF":0.0,"publicationDate":"2025-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12168035/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144035714","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}