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Examples of Delivery System Structures

• Organizational structures (e.g., of a medical group, independent practice association [IPA], hospital):
  • Size.
  • Specialty mix.
  • Ownership (e.g., owned by physicians vs. owned by a hospital; for profit vs. not for profit).
  • Whether the organization is a network or a single entity (e.g., an IPA vs. a medical group, or a physician-hospital organization vs. a hospital and its employed physicians).
• Market structures:
  • Market concentration vs. fragmentation (e.g., among hospitals, health insurance plans, or physicians).

Examples of External Incentives

• Payment methods from payors (primarily commercial health insurance plans, Medicare, Medicaid), for example:
  • Fee for service.
  • Capitation (full or partial).
  • Bundled payments.
  • Episode-based payments.
  • Pay for performance.
• Public reporting of performance.
• Does negotiating leverage provide benefits to organizations that have it, e.g.:
  • Is negotiating leverage between health insurance plans and provider organizations important (e.g., can larger and/or more prestigious medical groups and hospitals negotiate higher payment rates)?
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  • Antitrust laws.
  • Stark law.
  • Civil monetary penalties.

Examples of Processes

• Processes aimed at discrete events, such as a surgical procedure or the generation of a prescription, for example:
  • Decision support.
  • Surgical checklists.
  • Electronic prescribing.
  • Disease-specific care pathways.
  • Innovative approaches to hospital discharge.
• Processes aimed at improving care of an organization's population of patients, for example:
  • Creation and use of registries of patients with chronic illnesses.
  • Care coordination—e.g., use of nurse care managers for patients with chronic illnesses.
  • Use of alternative providers—e.g., of pharmacists for hypertension management.
  • Programs intended to increase colon cancer screening.
• Internal incentives (within the provider organization), for example:
  • Basic internal payment method.
  • Bonuses (e.g., internal pay for performance).
  • Internal "public reporting" of individual physician performance.
• Use of clinical information technology to support the other processes used by the organization, for example:
  • Electronic medical records.
  • Patient portals.
  • Communication among providers.
• Other quality improvement processes.

Examples of Outcomes

• Quality of care.
• Cost of care.
• Patient experience and patient reported outcomes.
• Impact on disparities (socioeconomic and racial/ethnic).

It will be most desirable to measure outcomes for an organization's population of patients, for organizations large enough so that reliable measurement can be made of things like ambulatory sensitive admissions, readmissions, emergency department visits, and total cost of care per patient (risk adjusted).