Medical care research and review : MCRR, Jan 2, 2015
Accountable care organizations (ACOs) have incentives to meet quality and cost targets to share i... more Accountable care organizations (ACOs) have incentives to meet quality and cost targets to share in any resulting savings. Achieving these goals will require ACOs to engage more actively with patients and their families. The extent to which ACOs do so is currently unknown. Using mixed methods, including a national survey, phone interviews, and site-visits, we examine the extent to which ACOs actively engage patients and their families, explore challenges involved, and consider approaches for dealing with those challenges. Results indicate that greater ACO use of patient activation and engagement (PAE) activities at the point-of-care may be related to positive perceptions among ACO leaders of the impact of PAE investments on ACO costs, quality, and outcomes of care. We identify a number of important practices associated with greater PAE, including high-level leadership commitment, goal-setting supported by adequate resources, extensive provider training, use of interdisciplinary care ...
The extent to which physicians lead, own, and govern accountable care organizations (ACOs) is unk... more The extent to which physicians lead, own, and govern accountable care organizations (ACOs) is unknown. However, physicians' involvement in ACOs will influence how clinicians and patients perceive the ACO model, how effective these organizations are at improving quality and costs, and how future ACOs will be organized. From October 2012 to May 2013 we fielded the National Survey of Accountable Care Organizations, the first such survey of public and private ACOs. We found that 51 percent of ACOs were physician-led, with another 33 percent jointly led by physicians and hospitals. In 78 percent of ACOs, physicians constituted a majority of the governing board, and physicians owned 40 percent of ACOs. The broad reach of physician leadership has important implications for the future evolution of ACOs. It seems likely that the challenge of fundamentally changing care delivery as the country moves away from fee-for-service payment will not be accomplished without strong, effective leade...
The accountable care organization (ACO) model is currently being pursued by private insurers, as ... more The accountable care organization (ACO) model is currently being pursued by private insurers, as well as federal and state governments. Little is known, however, about the prevalence of private payer ACO contracts and the characteristics of contract structures or how these compare with public ACO contracts. and Methods Cross-sectional analysis of the National Survey of Accountable Care Organizations (n=173) on ACO contracts with public and private payers and private payer contract characteristics. Most ACOs had only 1 ACO contract (57%). About half of ACOs had a contract with a private payer. The single most common private payer ACO contract was an upside-only shared savings model (41%), although the majority of private contracts included some form of downside risk (56%). A large majority of contracts made shared savings contingent upon quality performance (79%), and some included bonus payments for quality performance (39%). Most private payer contracts included upfront payments, s...
Accountable care organizations (ACOs) may be well positioned to increase the focus on managing be... more Accountable care organizations (ACOs) may be well positioned to increase the focus on managing behavioral health conditions (mental health and substance abuse) through the integration of behavioral health treatment and primary care. We used a mixed-methods research design to examine the extent to which ACOs are clinically, organizationally, and financially integrating behavioral health care and primary care. We used data from 257 respondents to the National Survey of Accountable Care Organizations, a nationally representative survey of ACOs. The data were supplemented with semistructured, in-depth interviews with clinical leaders at sixteen ACOs purposively sampled to represent the spectrum of behavioral health integration. We found that most ACOs hold responsibility for some behavioral health care costs, and 42 percent include behavioral health specialists among their providers. However, integration of behavioral health care and primary care remains low, with most ACOs pursuing tra...
Safety net primary care providers, including as community health centers, have long been isolated... more Safety net primary care providers, including as community health centers, have long been isolated from mainstream health care providers. Current delivery system reforms such as Accountable Care Organizations (ACOs) may either reinforce the isolation of these providers or may spur new integration of safety net providers. This study examines the extent of community health center involvement in ACOs, as well as how and why ACOs are partnering with these safety net primary care providers. Mixed methods study pairing the cross-sectional National Survey of ACOs (conducted 2012 to 2013), followed by in-depth, qualitative interviews with a subset of ACOs that include community health centers (conducted 2013). One hundred and seventy-three ACOs completed the National Survey of ACOs. Executives from 18 ACOs that include health centers participated in in-depth interviews, along with leadership at eight community health centers participating in ACOs. Key survey measures include ACO organization...
Although accountable care organizations (ACOs) are rapidly being deployed in Medicare, little is ... more Although accountable care organizations (ACOs) are rapidly being deployed in Medicare, little is known about how the model might affect high-risk, high cost groups such as cancer patients. The Physician Group Practice Demonstration, which ran from 2005 to 2010 in 10 physician groups, provides the best current evidence on the likely effectiveness of accountable care organizations for Medicare beneficiaries. Changes in cancer treatment and spending under this program may be indicative of cancer treatment under ACO payment reform. Using Medicare fee-for-service claims data, regression analysis was used to estimate changes in payments for cancer patients using a difference-in-difference design comparing pre- (2001-2004) and post-intervention (2005-2009) trends in spending on cancer patients in PGPD participants to local control groups. Regression models indicate the Physician Group Practice Demonstration was associated with average Medicare spending reductions per cancer patient of $721...
Accountable care organizations (ACOs) seek to reduce growth in healthcare spending while ensuring... more Accountable care organizations (ACOs) seek to reduce growth in healthcare spending while ensuring high-quality care. We hypothesized that accountable care organization implementation would selectively limit the use of discretionary cardiovascular care (defined as care occurring in the absence of indications such as myocardial infarction or stroke), while maintaining high-quality care, such as nondiscretionary cardiovascular imaging and procedures. The intervention group was composed of fee-for-service Medicare patients (n=819 779) from 10 groups participating in a Medicare pilot accountable care organization, the Physician Group Practice Demonstration (PGPD). Matched controls were patients (n=934 621) from nonparticipating groups in the same regions. We compared use of cardiovascular care before (2002-2004) and after (2005-2009) PGPD implementation, studying both discretionary and nondiscretionary carotid and coronary imaging and procedures. Our main outcome measure was the differen...
ABSTRACT Scholarly and public discourses on Muslim immigrants in Europe have questioned if Islam ... more ABSTRACT Scholarly and public discourses on Muslim immigrants in Europe have questioned if Islam is an impediment to sociocultural adaptation and whether Muslims are a distinctive group in their religiosity and social values. We use a new survey of 480 British Muslims in conjunction with the British Social Attitudes Survey to examine differences between Muslim and non-Muslim Britons on religiosity (practice, belief, salience) and moral and social issues regarding gender, abortion, and homosexuality. Muslims are more religious than other Britons, including both British Christians and religious “nones.” Muslims also are more conservative than other Britons across the range of social and moral attitudes. Multivariate analysis shows, however, that much of the difference on moral issues is due to socioeconomic disadvantage and high religiosity among Muslims. Although being a highly religious group in an otherwise secular country renders Muslims distinctive, factors that predict social conservatism among all Britons—high religiosity and low SES—apply similarly to Muslims.
ABSTRACT While in the American context religion is seen to facilitate immigrant incorporation by ... more ABSTRACT While in the American context religion is seen to facilitate immigrant incorporation by providing both spiritual and socioeconomic resources, in Europe high levels of religiosity are theorized as a barrier for immigrant incorporation into the secular mainstream. This is particularly salient for Islam, Europe's largest minority religion. In this study, we use the 2008–2009 England and Wales Citizenship Survey to compare levels and predictors of religiosity between Muslim and non‐Muslim first‐generation immigrants and their native‐born counterparts. Overall, Muslims are more religious than non‐Muslims. The results show that among non‐Muslims, the foreign‐born are significantly more religious than the native‐born; among Muslims, however, nativity has no impact on religiosity, indicating the native‐born are as highly religious as the foreign‐born. Additionally, although education is associated with reduced religiosity among non‐Muslim immigrants and native‐born, for Muslims it has no significant impact. Muslims across diverse ethnic and socioeconomic backgrounds show strong religious adherence. Results suggest that pathways to secular, mainstream norms do not operate in the same manner across Muslim and non‐Muslim immigrant groups.
To develop an exploratory taxonomy of Accountable Care Organizations (ACOs) to describe and under... more To develop an exploratory taxonomy of Accountable Care Organizations (ACOs) to describe and understand early ACO development and to provide a basis for technical assistance and future evaluation of performance. Data from the National Survey of Accountable Care Organizations, fielded between October 2012 and May 2013, of 173 Medicare, Medicaid, and commercial payer ACOs. Drawing on resource dependence and institutional theory, we develop measures of eight attributes of ACOs such as size, scope of services offered, and the use of performance accountability mechanisms. Data are analyzed using a two-step cluster analysis approach that accounts for both continuous and categorical data. We identified a reliable and internally valid three-cluster solution: larger, integrated systems that offer a broad scope of services and frequently include one or more postacute facilities; smaller, physician-led practices, centered in primary care, and that possess a relatively high degree of physician performance management; and moderately sized, joint hospital-physician and coalition-led groups that offer a moderately broad scope of services with some involvement of postacute facilities. ACOs can be characterized into three distinct clusters. The taxonomy provides a framework for assessing performance, for targeting technical assistance, and for diagnosing potential antitrust violations.
A substantial literature has found that religiosity is positively related to individuals&... more A substantial literature has found that religiosity is positively related to individuals' civic engagement and informal helping behavior. Concurrently, social networks as sources of information and encouragement have been suggested as the mechanism underlying phenomena including successful job searches, improved health and greater subjective well-being. In this paper we use data from the Portraits of American Life Study (PALS) to examine whether religiously based social networks explain the well-established relationship between religion and civic engagement. We test potential mechanisms including beliefs, affiliation, and social networks, and we find that having a strong network of religious friends explains the effect of church attendance for several civic and neighborly outcomes. We suggest this phenomenon may exist in other, non-religious, spheres that also produce strong friendship networks.
The Centers for Medicare &amp... more The Centers for Medicare & Medicaid Services (CMS) recently launched accountable care organization (ACO) programs designed to improve quality and slow cost growth. The ACOs resemble an earlier pilot, the Medicare Physician Group Practice Demonstration (PGPD), in which participating physician groups received bonus payments if they achieved lower cost growth than local controls and met quality targets. Although evidence indicates the PGPD improved quality, uncertainty remains about its effect on costs. To estimate cost savings associated with the PGPD overall and for beneficiaries dually eligible for Medicare and Medicaid. Quasi-experimental analyses comparing preintervention (2001-2004) and postintervention (2005-2009) trends in spending of PGPD participants to local control groups. We compared estimates using several alternative approaches to adjust for case mix. Ten physician groups from across the United States. The intervention group was composed of fee-for-service Medicare beneficiaries (n = 990,177) receiving care primarily from the physicians in the participating medical groups. Controls were Medicare beneficiaries (n = 7,514,453) from the same regions who received care largely from non-PGPD physicians. Overall, 15% of beneficiaries were dually eligible for Medicare and Medicaid. Annual spending per Medicare fee-for-service beneficiary. Annual savings per beneficiary were modest overall (adjusted mean $114, 95% CI, $12-$216). Annual savings were significant in dually eligible beneficiaries (adjusted mean $532, 95% CI, $277-$786), but were not significant among nondually eligible beneficiaries (adjusted mean $59, 95% CI, $166 in savings to $47 in additional spending). The adjusted mean spending reductions were concentrated in acute care (overall, $118, 95% CI, $65-$170; dually eligible: $381, 95% CI, $247-$515; nondually eligible: $85, 95% CI, $32-$138). There was significant variation in savings across practice groups, ranging from an overall mean per-capita annual saving of $866 (95% CI, $815-$918) to an increase in expenditures of $749 (95% CI, $698-$799). Thirty-day medical readmissions decreased overall (-0.67%, 95% CI, -1.11% to -0.23%) and in the dually eligible (-1.07%, 95% CI, -1.73% to -0.41%), while surgical readmissions decreased only for the dually eligible (-2.21%, 95% CI, -3.07% to -1.34%). Estimates were sensitive to the risk-adjustment method. Substantial PGPD savings achieved by some participating institutions were offset by a lack of saving at other participating institutions. Most of the savings were concentrated among dually eligible beneficiaries.
The Accountable Care Organization (ACO) model is rapidly being implemented by Medicare, private p... more The Accountable Care Organization (ACO) model is rapidly being implemented by Medicare, private payers, and states, but little is known about the scope of ACO implementation. To determine the number of accountable care organizations in the United States, where they are located, and characteristics associated with ACO formation. Cross-sectional study of all ACOs in the United States as of August 2012. We identified ACOs from multiple sources; documented service locations (practices, clinics, hospitals); and linked service locations to local areas, defined as Dartmouth Atlas hospital service areas. We used multivariate analysis to assess what characteristics were associated with local ACO presence. We examined demographic characteristics (2010 American Community Survey) and health care system characteristics (2010 Medicare fee-for-service claims data). We identified 227 ACOs located in 27 percent of local areas. Fifty-five percent of the US population resides in these areas. HSA-level characteristics associated with ACO presence include higher performance on quality, higher Medicare per capita spending, fewer primary care physician groups, greater managed care penetration, lower poverty rates, and urban location. Much of the US population resides in areas where ACOs have been established. ACO formation has taken place where it may be easier to meet quality and cost targets. Wider adoption of the ACO model may require tailoring to local context.
Accountable care organizations (ACOs) are a promising payment model aimed at reducing costs while... more Accountable care organizations (ACOs) are a promising payment model aimed at reducing costs while also improving the quality of care. However, there is a risk that vulnerable populations may not be fully incorporated into this new model. We define two distinct vulnerable populations, clinically at-risk and socially disadvantaged, and we discuss how ACOs may benefit each group. We provide a framework to use in considering challenges for both vulnerable patients and health systems on the path to accountable care. We identify policies that can help overcome these obstacles: strategies that support ACO formation in diverse settings and that monitor, measure, and reward the performance of providers that reach all patients, including vulnerable populations.
ABSTRACT Much attention in popular discourse and academic, qualitative research has focused on st... more ABSTRACT Much attention in popular discourse and academic, qualitative research has focused on strengthening ‘fundamentalist’ religiosity among Muslim youth in Britain, and its impact on engendering politicized religious identities and conservative social attitudes. We use new survey data to empirically examine how Muslim youth differ from older Muslims and non-Muslim British peers on religiosity, Islam-specific and broader social attitudes. We find that young Muslims attribute a greater salience to Islam for their personal identity, even though they pray and read scripture less, and support plural interpretations of Islam more than their elders. Like other youth, Muslim youth show liberalizing social attitudes across generations on gay marriage and legal abortion. Notably, like Christian youth, Muslim youth express stronger support for including religion in public debates than their elders. Overall, Muslim youth religiosity although uniquely expressed, influences moral and social attitudes for Muslims similarly to that of Christian or other religious youth.
This study assesses how race/ethnicity and socio-economic status modify the relationship between ... more This study assesses how race/ethnicity and socio-economic status modify the relationship between exposure to movie smoking and having tried smoking in adolescents. Data come from a cross-sectional telephone survey and were analyzed using logistic regression models. A respondent reporting ever having tried smoking was regressed on exposure to movie smoking, race, socio-economic status, the interactions of these variables and family and background characteristics. National sample of US adolescents. A total of 3653 respondents aged 13-18 years. Outcome was if subjects reported ever having tried smoking. Movie smoking exposure was assessed through respondents' reporting having watched a set of movie titles, which were coded for smoking instances. The proportion having tried smoking was lower for blacks (32%) compared to Hispanics (41%) and whites (38%). The relationship between movie smoking and having tried smoking varied by race/ethnicity. Among whites and Hispanics exposure to movie smoking positively predicted smoking behavior, but movie smoking had no impact on blacks. Socio-economic status further modified the relation among whites; high socio-economic status white adolescents were more susceptible to movie smoking than low socio-economic status white adolescents. Exposure to movie smoking is not experienced uniformly as a risk factor for having ever tried smoking among US adolescents. Whites and Hispanics are more likely to try smoking as a function of increased exposure to movie smoking. In addition, higher socio-economic status increases susceptibility to movie smoking among whites. Youth with fewer risk factors may be more influenced by media messages on smoking.
Medical care research and review : MCRR, Jan 2, 2015
Accountable care organizations (ACOs) have incentives to meet quality and cost targets to share i... more Accountable care organizations (ACOs) have incentives to meet quality and cost targets to share in any resulting savings. Achieving these goals will require ACOs to engage more actively with patients and their families. The extent to which ACOs do so is currently unknown. Using mixed methods, including a national survey, phone interviews, and site-visits, we examine the extent to which ACOs actively engage patients and their families, explore challenges involved, and consider approaches for dealing with those challenges. Results indicate that greater ACO use of patient activation and engagement (PAE) activities at the point-of-care may be related to positive perceptions among ACO leaders of the impact of PAE investments on ACO costs, quality, and outcomes of care. We identify a number of important practices associated with greater PAE, including high-level leadership commitment, goal-setting supported by adequate resources, extensive provider training, use of interdisciplinary care ...
The extent to which physicians lead, own, and govern accountable care organizations (ACOs) is unk... more The extent to which physicians lead, own, and govern accountable care organizations (ACOs) is unknown. However, physicians' involvement in ACOs will influence how clinicians and patients perceive the ACO model, how effective these organizations are at improving quality and costs, and how future ACOs will be organized. From October 2012 to May 2013 we fielded the National Survey of Accountable Care Organizations, the first such survey of public and private ACOs. We found that 51 percent of ACOs were physician-led, with another 33 percent jointly led by physicians and hospitals. In 78 percent of ACOs, physicians constituted a majority of the governing board, and physicians owned 40 percent of ACOs. The broad reach of physician leadership has important implications for the future evolution of ACOs. It seems likely that the challenge of fundamentally changing care delivery as the country moves away from fee-for-service payment will not be accomplished without strong, effective leade...
The accountable care organization (ACO) model is currently being pursued by private insurers, as ... more The accountable care organization (ACO) model is currently being pursued by private insurers, as well as federal and state governments. Little is known, however, about the prevalence of private payer ACO contracts and the characteristics of contract structures or how these compare with public ACO contracts. and Methods Cross-sectional analysis of the National Survey of Accountable Care Organizations (n=173) on ACO contracts with public and private payers and private payer contract characteristics. Most ACOs had only 1 ACO contract (57%). About half of ACOs had a contract with a private payer. The single most common private payer ACO contract was an upside-only shared savings model (41%), although the majority of private contracts included some form of downside risk (56%). A large majority of contracts made shared savings contingent upon quality performance (79%), and some included bonus payments for quality performance (39%). Most private payer contracts included upfront payments, s...
Accountable care organizations (ACOs) may be well positioned to increase the focus on managing be... more Accountable care organizations (ACOs) may be well positioned to increase the focus on managing behavioral health conditions (mental health and substance abuse) through the integration of behavioral health treatment and primary care. We used a mixed-methods research design to examine the extent to which ACOs are clinically, organizationally, and financially integrating behavioral health care and primary care. We used data from 257 respondents to the National Survey of Accountable Care Organizations, a nationally representative survey of ACOs. The data were supplemented with semistructured, in-depth interviews with clinical leaders at sixteen ACOs purposively sampled to represent the spectrum of behavioral health integration. We found that most ACOs hold responsibility for some behavioral health care costs, and 42 percent include behavioral health specialists among their providers. However, integration of behavioral health care and primary care remains low, with most ACOs pursuing tra...
Safety net primary care providers, including as community health centers, have long been isolated... more Safety net primary care providers, including as community health centers, have long been isolated from mainstream health care providers. Current delivery system reforms such as Accountable Care Organizations (ACOs) may either reinforce the isolation of these providers or may spur new integration of safety net providers. This study examines the extent of community health center involvement in ACOs, as well as how and why ACOs are partnering with these safety net primary care providers. Mixed methods study pairing the cross-sectional National Survey of ACOs (conducted 2012 to 2013), followed by in-depth, qualitative interviews with a subset of ACOs that include community health centers (conducted 2013). One hundred and seventy-three ACOs completed the National Survey of ACOs. Executives from 18 ACOs that include health centers participated in in-depth interviews, along with leadership at eight community health centers participating in ACOs. Key survey measures include ACO organization...
Although accountable care organizations (ACOs) are rapidly being deployed in Medicare, little is ... more Although accountable care organizations (ACOs) are rapidly being deployed in Medicare, little is known about how the model might affect high-risk, high cost groups such as cancer patients. The Physician Group Practice Demonstration, which ran from 2005 to 2010 in 10 physician groups, provides the best current evidence on the likely effectiveness of accountable care organizations for Medicare beneficiaries. Changes in cancer treatment and spending under this program may be indicative of cancer treatment under ACO payment reform. Using Medicare fee-for-service claims data, regression analysis was used to estimate changes in payments for cancer patients using a difference-in-difference design comparing pre- (2001-2004) and post-intervention (2005-2009) trends in spending on cancer patients in PGPD participants to local control groups. Regression models indicate the Physician Group Practice Demonstration was associated with average Medicare spending reductions per cancer patient of $721...
Accountable care organizations (ACOs) seek to reduce growth in healthcare spending while ensuring... more Accountable care organizations (ACOs) seek to reduce growth in healthcare spending while ensuring high-quality care. We hypothesized that accountable care organization implementation would selectively limit the use of discretionary cardiovascular care (defined as care occurring in the absence of indications such as myocardial infarction or stroke), while maintaining high-quality care, such as nondiscretionary cardiovascular imaging and procedures. The intervention group was composed of fee-for-service Medicare patients (n=819 779) from 10 groups participating in a Medicare pilot accountable care organization, the Physician Group Practice Demonstration (PGPD). Matched controls were patients (n=934 621) from nonparticipating groups in the same regions. We compared use of cardiovascular care before (2002-2004) and after (2005-2009) PGPD implementation, studying both discretionary and nondiscretionary carotid and coronary imaging and procedures. Our main outcome measure was the differen...
ABSTRACT Scholarly and public discourses on Muslim immigrants in Europe have questioned if Islam ... more ABSTRACT Scholarly and public discourses on Muslim immigrants in Europe have questioned if Islam is an impediment to sociocultural adaptation and whether Muslims are a distinctive group in their religiosity and social values. We use a new survey of 480 British Muslims in conjunction with the British Social Attitudes Survey to examine differences between Muslim and non-Muslim Britons on religiosity (practice, belief, salience) and moral and social issues regarding gender, abortion, and homosexuality. Muslims are more religious than other Britons, including both British Christians and religious “nones.” Muslims also are more conservative than other Britons across the range of social and moral attitudes. Multivariate analysis shows, however, that much of the difference on moral issues is due to socioeconomic disadvantage and high religiosity among Muslims. Although being a highly religious group in an otherwise secular country renders Muslims distinctive, factors that predict social conservatism among all Britons—high religiosity and low SES—apply similarly to Muslims.
ABSTRACT While in the American context religion is seen to facilitate immigrant incorporation by ... more ABSTRACT While in the American context religion is seen to facilitate immigrant incorporation by providing both spiritual and socioeconomic resources, in Europe high levels of religiosity are theorized as a barrier for immigrant incorporation into the secular mainstream. This is particularly salient for Islam, Europe's largest minority religion. In this study, we use the 2008–2009 England and Wales Citizenship Survey to compare levels and predictors of religiosity between Muslim and non‐Muslim first‐generation immigrants and their native‐born counterparts. Overall, Muslims are more religious than non‐Muslims. The results show that among non‐Muslims, the foreign‐born are significantly more religious than the native‐born; among Muslims, however, nativity has no impact on religiosity, indicating the native‐born are as highly religious as the foreign‐born. Additionally, although education is associated with reduced religiosity among non‐Muslim immigrants and native‐born, for Muslims it has no significant impact. Muslims across diverse ethnic and socioeconomic backgrounds show strong religious adherence. Results suggest that pathways to secular, mainstream norms do not operate in the same manner across Muslim and non‐Muslim immigrant groups.
To develop an exploratory taxonomy of Accountable Care Organizations (ACOs) to describe and under... more To develop an exploratory taxonomy of Accountable Care Organizations (ACOs) to describe and understand early ACO development and to provide a basis for technical assistance and future evaluation of performance. Data from the National Survey of Accountable Care Organizations, fielded between October 2012 and May 2013, of 173 Medicare, Medicaid, and commercial payer ACOs. Drawing on resource dependence and institutional theory, we develop measures of eight attributes of ACOs such as size, scope of services offered, and the use of performance accountability mechanisms. Data are analyzed using a two-step cluster analysis approach that accounts for both continuous and categorical data. We identified a reliable and internally valid three-cluster solution: larger, integrated systems that offer a broad scope of services and frequently include one or more postacute facilities; smaller, physician-led practices, centered in primary care, and that possess a relatively high degree of physician performance management; and moderately sized, joint hospital-physician and coalition-led groups that offer a moderately broad scope of services with some involvement of postacute facilities. ACOs can be characterized into three distinct clusters. The taxonomy provides a framework for assessing performance, for targeting technical assistance, and for diagnosing potential antitrust violations.
A substantial literature has found that religiosity is positively related to individuals&... more A substantial literature has found that religiosity is positively related to individuals' civic engagement and informal helping behavior. Concurrently, social networks as sources of information and encouragement have been suggested as the mechanism underlying phenomena including successful job searches, improved health and greater subjective well-being. In this paper we use data from the Portraits of American Life Study (PALS) to examine whether religiously based social networks explain the well-established relationship between religion and civic engagement. We test potential mechanisms including beliefs, affiliation, and social networks, and we find that having a strong network of religious friends explains the effect of church attendance for several civic and neighborly outcomes. We suggest this phenomenon may exist in other, non-religious, spheres that also produce strong friendship networks.
The Centers for Medicare &amp... more The Centers for Medicare & Medicaid Services (CMS) recently launched accountable care organization (ACO) programs designed to improve quality and slow cost growth. The ACOs resemble an earlier pilot, the Medicare Physician Group Practice Demonstration (PGPD), in which participating physician groups received bonus payments if they achieved lower cost growth than local controls and met quality targets. Although evidence indicates the PGPD improved quality, uncertainty remains about its effect on costs. To estimate cost savings associated with the PGPD overall and for beneficiaries dually eligible for Medicare and Medicaid. Quasi-experimental analyses comparing preintervention (2001-2004) and postintervention (2005-2009) trends in spending of PGPD participants to local control groups. We compared estimates using several alternative approaches to adjust for case mix. Ten physician groups from across the United States. The intervention group was composed of fee-for-service Medicare beneficiaries (n = 990,177) receiving care primarily from the physicians in the participating medical groups. Controls were Medicare beneficiaries (n = 7,514,453) from the same regions who received care largely from non-PGPD physicians. Overall, 15% of beneficiaries were dually eligible for Medicare and Medicaid. Annual spending per Medicare fee-for-service beneficiary. Annual savings per beneficiary were modest overall (adjusted mean $114, 95% CI, $12-$216). Annual savings were significant in dually eligible beneficiaries (adjusted mean $532, 95% CI, $277-$786), but were not significant among nondually eligible beneficiaries (adjusted mean $59, 95% CI, $166 in savings to $47 in additional spending). The adjusted mean spending reductions were concentrated in acute care (overall, $118, 95% CI, $65-$170; dually eligible: $381, 95% CI, $247-$515; nondually eligible: $85, 95% CI, $32-$138). There was significant variation in savings across practice groups, ranging from an overall mean per-capita annual saving of $866 (95% CI, $815-$918) to an increase in expenditures of $749 (95% CI, $698-$799). Thirty-day medical readmissions decreased overall (-0.67%, 95% CI, -1.11% to -0.23%) and in the dually eligible (-1.07%, 95% CI, -1.73% to -0.41%), while surgical readmissions decreased only for the dually eligible (-2.21%, 95% CI, -3.07% to -1.34%). Estimates were sensitive to the risk-adjustment method. Substantial PGPD savings achieved by some participating institutions were offset by a lack of saving at other participating institutions. Most of the savings were concentrated among dually eligible beneficiaries.
The Accountable Care Organization (ACO) model is rapidly being implemented by Medicare, private p... more The Accountable Care Organization (ACO) model is rapidly being implemented by Medicare, private payers, and states, but little is known about the scope of ACO implementation. To determine the number of accountable care organizations in the United States, where they are located, and characteristics associated with ACO formation. Cross-sectional study of all ACOs in the United States as of August 2012. We identified ACOs from multiple sources; documented service locations (practices, clinics, hospitals); and linked service locations to local areas, defined as Dartmouth Atlas hospital service areas. We used multivariate analysis to assess what characteristics were associated with local ACO presence. We examined demographic characteristics (2010 American Community Survey) and health care system characteristics (2010 Medicare fee-for-service claims data). We identified 227 ACOs located in 27 percent of local areas. Fifty-five percent of the US population resides in these areas. HSA-level characteristics associated with ACO presence include higher performance on quality, higher Medicare per capita spending, fewer primary care physician groups, greater managed care penetration, lower poverty rates, and urban location. Much of the US population resides in areas where ACOs have been established. ACO formation has taken place where it may be easier to meet quality and cost targets. Wider adoption of the ACO model may require tailoring to local context.
Accountable care organizations (ACOs) are a promising payment model aimed at reducing costs while... more Accountable care organizations (ACOs) are a promising payment model aimed at reducing costs while also improving the quality of care. However, there is a risk that vulnerable populations may not be fully incorporated into this new model. We define two distinct vulnerable populations, clinically at-risk and socially disadvantaged, and we discuss how ACOs may benefit each group. We provide a framework to use in considering challenges for both vulnerable patients and health systems on the path to accountable care. We identify policies that can help overcome these obstacles: strategies that support ACO formation in diverse settings and that monitor, measure, and reward the performance of providers that reach all patients, including vulnerable populations.
ABSTRACT Much attention in popular discourse and academic, qualitative research has focused on st... more ABSTRACT Much attention in popular discourse and academic, qualitative research has focused on strengthening ‘fundamentalist’ religiosity among Muslim youth in Britain, and its impact on engendering politicized religious identities and conservative social attitudes. We use new survey data to empirically examine how Muslim youth differ from older Muslims and non-Muslim British peers on religiosity, Islam-specific and broader social attitudes. We find that young Muslims attribute a greater salience to Islam for their personal identity, even though they pray and read scripture less, and support plural interpretations of Islam more than their elders. Like other youth, Muslim youth show liberalizing social attitudes across generations on gay marriage and legal abortion. Notably, like Christian youth, Muslim youth express stronger support for including religion in public debates than their elders. Overall, Muslim youth religiosity although uniquely expressed, influences moral and social attitudes for Muslims similarly to that of Christian or other religious youth.
This study assesses how race/ethnicity and socio-economic status modify the relationship between ... more This study assesses how race/ethnicity and socio-economic status modify the relationship between exposure to movie smoking and having tried smoking in adolescents. Data come from a cross-sectional telephone survey and were analyzed using logistic regression models. A respondent reporting ever having tried smoking was regressed on exposure to movie smoking, race, socio-economic status, the interactions of these variables and family and background characteristics. National sample of US adolescents. A total of 3653 respondents aged 13-18 years. Outcome was if subjects reported ever having tried smoking. Movie smoking exposure was assessed through respondents' reporting having watched a set of movie titles, which were coded for smoking instances. The proportion having tried smoking was lower for blacks (32%) compared to Hispanics (41%) and whites (38%). The relationship between movie smoking and having tried smoking varied by race/ethnicity. Among whites and Hispanics exposure to movie smoking positively predicted smoking behavior, but movie smoking had no impact on blacks. Socio-economic status further modified the relation among whites; high socio-economic status white adolescents were more susceptible to movie smoking than low socio-economic status white adolescents. Exposure to movie smoking is not experienced uniformly as a risk factor for having ever tried smoking among US adolescents. Whites and Hispanics are more likely to try smoking as a function of increased exposure to movie smoking. In addition, higher socio-economic status increases susceptibility to movie smoking among whites. Youth with fewer risk factors may be more influenced by media messages on smoking.
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Papers by Valerie Lewis