Featured Publications

A Policy and Regulatory Framework to Promote Care Delivery Redesign and Production Efficiency In Health Care Markets

In this article, we discuss why reliance on transaction prices and market share alone is not sufficient for effective health policy development and regulatory enforcement in health care markets that are imperfectly competitive.

Dennis P. Scanlon, Jillian B. Harvey, Cheryl L. Damberg, Pratiksha Mahendra Bhagat, Yunfeng Shi

Health System Expansion and Changes in Medicare Beneficiary Utilization of Safety Net Providers

We examine whether market-level health system penetration is associated with Medicare beneficiaries' switching their usual source of care from federally qualified health centers to health systems and FQHCs' overall Medicare patient and visit volume.

Kun Li, José J. Escarce, Shiyuan Zhang, Denis Agniel, Maria DeYoreo, Justin W. Timbie

Higher Medicare Spending On Imaging And Lab Services After Primary Care Physician Group Vertical Integration

This study highlights how the growing trend of vertical integration, combined with differences in Medicare payment between hospitals and nonhospital providers, leads to higher Medicare spending.

Christopher M. Whaley, Xiaoxi Zhao, Michael R. Richards, Cheryl L. Damberg

Efficiency in Organizational Structure? Assessing Heterogeneous Effects in Hospital-Physician Integration

Using a 100% national sample of Medicare data, we estimate the impacts of hospital-physician integration using parametric and nonparametric quantile differences-in-differences approaches.

Cheryl L. Damberg, Michael R. Richards, Christopher M. Whaley

Market Landscape and Insurer-Provider Integration: The Case of Ambulatory Surgery Centers

Insurer-provider integration is a new form of vertical integration, with increasing prominence in health care markets. This paper documents the growth and geographic spread of a dominant insurer's acquisitions of ambulatory surgery centers.

Xiaoxi Zhao, Michael R. Richards, Cheryl L. Damberg, Christopher M. Whaley

Higher Medicare Spending On Imaging And Lab Services After Primary Care Physician Group Vertical Integration

This study highlights how the growing trend of vertical integration, combined with differences in Medicare payment between hospitals and nonhospital providers, leads to higher Medicare spending.

Christopher M. Whaley, Xiaoxi Zhao, Michael R. Richards, Cheryl L. Damberg

Consolidation by Any Other Name: The Emergence of Clinically Integrated Networks

In this report, the authors offer an initial assessment of clinically integrated networks (CINs), describe how health systems are using CINs strategically to compete in crowded health care markets, and identify why CINs require further study.

M. Susan Ridgely, Justin W. Timbie, Laura J. Wolf, Erin Lindsey Duffy, Christine Buttorff, Ashlyn Tom, Mary E. Vaiana

A Comprehensive Theory of Integration

This article presents a comprehensive theory describing how integrating structures, processes, and people within and across organizations might lead to integrated patient care and improved outcomes, including technical quality, efficiency, patient health, and both patient and provider experience.

Sara J. Singer, Michaela J. Kerrissey, Mark W. Friedberg, Russell S. Phillips

Alignment Between Objective and Subjective Assessments of Health System Performance: Findings From a Mixed-Methods Study

The article examines whether subjective performance assessments from health system executives match objective performance assessments and qualitatively explores ways to achieve high performance.

Dmitry Khodyakov, Christine Buttorff, Lea Xenakis, Cheryl L. Damberg, M. Susan Ridgely

Social Features of Integration in Health Systems and Their Relationship to Provider Experience, Care Quality and Clinical Integration

We developed and established the psychometric properties of survey measures describing normative and interpersonal integration.

Michaela J. Kerrissey, Maike V. Tietschert, Zhanna Novikov, Hassina Bahadurzada, Anna D. Sinaiko, Veronique Martin, Sara J. Singer

Are Health Systems Redesigning How Health Care Is Delivered?

An exploratory qualitative study to explore why and how health systems are engaging in care delivery redesign (CDR) activities.

Dennis P. Scanlon, Jillian B. Harvey, Laura J. Wolf, Jocelyn M. Vanderbrink, Bethany Shaw, Yunfeng Shi, Yasmin Mahmud, M. Susan Ridgely, Cheryl L. Damberg

The Importance of Understanding and Measuring Health System Structural, Functional, and Clinical Integration

We explore if there are ways to characterize health systems-not already revealed by secondary data-that could provide new insights into differences in health system performance.

M. Susan Ridgely, Christine Buttorff, Laura J. Wolf, Erin Lindsey Duffy, Ashlyn Tom, Cheryl L. Damberg, Dennis P. Scanlon, Mary E. Vaiana

Understanding How Health Systems Facilitate Primary Care Redesign

The objectives of this study are to understand how health systems are facilitating primary care redesign (PCR), examine the PCR initiatives taking place within systems, and identify barriers to this work.

Jillian B. Harvey, Jocelyn M. Vanderbrink, Yasmin Mahmud, Erin Kitt-Lewis, Laura J. Wolf, Bethany Shaw, M. Susan Ridgely, Cheryl L. Damberg, Dennis P. Scanlon

Are Value-Based Incentives Driving Behavior Change to Improve Value?

Early indications suggest that value-based incentives are leading to changes; however, incentives remain small, potentially limiting their effectiveness in driving the significant changes needed to derive large improvements in performance.

Cheryl L. Damberg, Marissa Rose Silverman, Lane F. Burgette, Mary E. Vaiana, M. Susan Ridgely

Understanding U.S. Health Systems: Using Mixed Methods to Unpack Organizational Complexity

Researchers need qualitative data to understand how health systems actually work and influence clinical practice.

M. Susan Ridgely, Erin Lindsey Duffy, Laura J. Wolf, Mary E. Vaiana, Dennis P. Scanlon, Christine Buttorff, Brigitt Leitzell, Sangeeta C. Ahluwalia, Lara Hilton, Denis Agniel, Amelia Haviland, Cheryl L. Damberg

Regulating Quasi-Legal Markets: Evidence from Pain Management Clinic Laws

Using a difference-in-differences framework and Medicare claims data, we find that Pain Management Clinic Laws reduce problematic opioid prescribing and doctor shopping. We also estimate reductions in overdose death rates among the full population.

Yuji Mizushima, David Powell, Rahi Abouk, Cheryl L. Damberg

Implications of Missingness in Self-Reported Data for Estimating Racial and Ethnic Disparities in Medicaid Quality Measures

This study demonstrates the feasibility of using Bayesian Improved Surname Geocoding (BISG) in a Medicaid population, producing imputed estimates for more than 99% of beneficiaries.

Kimberly Yee, Megan Hoopes, Sophia Giebultowicz, Marc N. Elliott, K. John McConnell

The Perils Of PECOS: Using Medicare Administrative Data To Answer Important Policy Questions About Health Care Markets

We don’t know as much as we should about health systems, and our efforts are hampered by seriously flawed data.

M. Susan Ridgely, Cheryl L. Damberg, Mark E. Totten, José J. Escarce

Distinguishing High-Performing Health Systems Using a Composite of Publicly Reported Measures of Ambulatory Care

A composite measure that uses publicly reported data can produce valid, reliable, and stable rankings of quality of ambulatory care.

Denis Agniel, Amelia Haviland, Paul G. Shekelle, Adam Scherling, Cheryl L. Damberg

What Are the Determinants of Health System Performance? Findings from the Literature and a Technical Expert Panel

This study is part of an ongoing effort to discover how and why some health systems in the United States are high performing and others are not.

M. Susan Ridgely, Sangeeta C. Ahluwalia, Ashlyn Tom, Mary E. Vaiana, Aneesa Motala, Marissa Rose Silverman, Alice Y. Kim, Cheryl L. Damberg, Paul G. Shekelle

A Comprehensive Theory of Integration

This article presents a comprehensive theory describing how integrating structures, processes, and people within and across organizations might lead to integrated patient care and improved outcomes, including technical quality, efficiency, patient health, and both patient and provider experience.

Sara J. Singer, Michaela J. Kerrissey, Mark W. Friedberg, Russell S. Phillips

How Are Medical Groups Identified as High Performing? The Effect of Different Approaches to Classification of Performance

To accurately identify "high-performing providers", a standard definition of high-performance and an agreed-upon approach to measurement are necessary.

Sangeeta C. Ahluwalia, Cheryl L. Damberg, Ann C. Haas, Paul G. Shekelle

What Defines a High-Performing Health System: A Systematic Review

Lack of a consistent definition of a high-performing health system severely hampers our ability to compare delivery systems based on performance.

Sangeeta C. Ahluwalia, Cheryl L. Damberg, Marissa Rose Silverman, Aneesa Motala, Paul G. Shekelle

Stakeholder Input on the CAHPS Ambulatory Surveys

This study aimed to gather systematic stakeholder feedback to inform future revisions of CAHPS ambulatory surveys.

Ron D. Hays, Julie A. Brown, Emma Bianculli, Marc N. Elliott

Estimating an Intervention's Effects on Health Care Disparities Within and Between Physician Organizations: Decomposing the Effects of Health System Affiliation

This paper develops and interprets statistical models for estimating the longitudinal effects of an exposure, health system affiliation, on within- and between-group disparities.

Maria DeYoreo, Denis Agniel, Shiyuan Zhang, José J. Escarce, Justin W. Timbie

The Segregation of Physician Networks Providing Care to Black and White Patients with Heart Disease: Concepts, Measures, and Empirical Evaluation

Black-White disparities in cardiac care may be related to physician referral network segregation. We developed and tested new geographic physician network segregation measures.

Ioana Popescu, C. Ben Gibson, Luke J. Matthews, Shiyuan Zhang, José J. Escarce, Megan S. Schuler, Cheryl L. Damberg

Within‐Physician Differences in Patient Sharing Between Primary Care Physicians and Cardiologists Who Treat White and Black Patients With Heart Disease

Within-physician Black-White differences in patient sharing exist and may contribute to disparities in cardiac care.

Luke J. Matthews, Cheryl L. Damberg, Shiyuan Zhang, José J. Escarce, C. Ben Gibson, Megan S. Schuler, Ioana Popescu

A Formal Framework For Incorporating Equity Into Health Care Quality Measurement

We propose equity weighting, a new measurement framework to advance equity on multiple fronts that addresses the shortcomings of existing approaches and explicitly calibrates incentives to align with equity goals.

Denis Agniel, Irineo Cabreros, Cheryl L. Damberg, Marc N. Elliott, Rhianna C. Rogers

Access, Quality, And Financial Performance Of Rural Hospitals Following Health System Affiliation

Health system affiliation was associated with improved financial performance for rural hospitals but that it also could reduce local access to certain services and was not associated with improved health care quality for the two measures examined.

Claire E. O'Hanlon, Ashley M. Kranz, Maria DeYoreo, Ammarah Mahmud, Cheryl L. Damberg, Justin W. Timbie

Efficiency in Organizational Structure? Assessing Heterogeneous Effects in Hospital-Physician Integration

Cheryl L. Damberg, Michael R. Richards, Christopher M. Whaley

The Effects of Physician Vertical Integration on Referral Patterns, Patient Welfare, and Market Dynamics

Christopher M. Whaley, Xiaoxi Zhao

Market Landscape and Insurer-Provider Integration: The Case of Ambulatory Surgery Centers

Xiaoxi Zhao, Michael R. Richards, Cheryl L. Damberg, Christopher M. Whaley

Association Between Hospital-Physician Vertical Integration and Medication Adherence Rates

Jonathan S. Levin, Swad Komanduri, Christopher M. Whaley

Social Features of Integration in Health Systems and Their Relationship to Provider Experience, Care Quality and Clinical Integration

Michaela J. Kerrissey, Maike V. Tietschert, Zhanna Novikov, Hassina Bahadurzada, Anna D. Sinaiko, Veronique Martin, Sara J. Singer

Care Integration Within and Outside Health System Boundaries

Sara J. Singer, Anna D. Sinaiko, Maike V. Tietschert, Michaela J. Kerrissey, Russell S. Phillips, Veronique Martin, Grace Joseph, Hassina Bahadurzada, Denis Agniel

Evaluation of an Intervention to Reduce Low-Value Preoperative Care for Patients Undergoing Cataract Surgery at a Safety-Net Health System

To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives.

John N. Mafi, Patricia Godoy-Travieso, Eric Wei, Malvin Anders, Rodolfo Amaya, Carmen A. Carrillo, Jesse L. Berry, Laura Sarff, Lauren Patty Daskivich, Sitaram Vangala, Joseph A. Ladapo, Emmett B. Keeler, Cheryl L. Damberg, Catherine A. Sarkisian

Low-Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Older adults are particularly vulnerable to complications from proton pump inhibitor drugs. We sought to characterize the prevalence of potentially low-value PPI prescriptions among older adults to inform a quality improvement intervention.

John N. Mafi, Folasade P. May, Katherine L. Kahn, Michelle Chong, Edgar Corona, Liu Yang, Margaret M. Mongare, Vishnu Nair, Courtney Reynolds, Reshma Gupta, Cheryl L. Damberg, Eric Esrailian, Catherine A. Sarkisian

Trends in Low-Value Health Service Use and Spending in the US Medicare Fee-for-Service Program, 2014–2018

Among individuals with fee-for-service Medicare receiving any of 32 measured services, low-value care use and spending decreased marginally from 2014 to 2018.

John N. Mafi, Rachel O. Reid, Lesley Baseman, Scot Hickey, Mark E. Totten, Denis Agniel, A. Mark Fendrick, Catherine A. Sarkisian, Cheryl L. Damberg

Waste in the Medicare Program: A National Cross-Sectional Analysis of 2017 Low-Value Service Use and Spending

In this analysis, we provide updated national estimates of low-value service use and spending in Medicare in 2017.

Rachel O. Reid, John N. Mafi, Lesley Baseman, A. Mark Fendrick, Cheryl L. Damberg

Primary Care Spending in the Fee-for-Service Medicare Population

Primary care spending represents a small percentage -- less than 3% -- of total fee-for-service Medicare spending, though it varies substantially across populations and states.

Rachel O. Reid, Cheryl L. Damberg, Mark W. Friedberg

Inpatient Care Experiences Are Better in Critical Access Hospitals Than in Other Hospitals

Critical access hospitals offer better patient experiences than larger hospitals, especially in responsiveness and cleanliness, despite serving sicker, older patients. For-profit and teaching CAHs may need quality improvements.

Megan K. Beckett, Christopher W. Cohea, Paul Cleary, Laura Giordano, Marc N. Elliott

Association Between Physician Age and Patterns of End-of-Life Care Among Older Americans

Using a nationally representative sample of Medicare beneficiaries, we examined the association between physician age and patterns of end of life (EOL) care with a broad range of EOL care measures.

Hiroshi Gotanda, Ryo Ikesu, Anne Walling, Jessica J. Zhang, Haiyong Xu, David Reuben, Neil S. Wenger, Cheryl L. Damberg, David Zingmond, Anupam B. Jena, Nate Gross, Yusuke Tsugawa

Barriers to Using Clinical Decision Support in Ambulatory Care: Do Clinics in Health Systems Fare Better?

We quantify the use of clinical decision support (CDS) and the specific barriers reported by ambulatory clinics and examine whether CDS utilization and barriers differed based on clinics' affiliation with health systems.

Yunfeng Shi, Alejandro Amill-Rosario, Robert S. Rudin, Shira H. Fischer, Paul G. Shekelle, Dennis P. Scanlon, Cheryl L. Damberg

Health System Affiliation of Physician Organizations and Quality of Care for Medicare Beneficiaries Who Have High Needs

This article tests the hypothesis that health systems provide better care to patients with high needs by comparing differences in quality between system-affiliated and nonaffiliated physician organizations.

Ashley M. Kranz, Maria DeYoreo, Blen Eshete-Roesler, Cheryl L. Damberg, Mark E. Totten, José J. Escarce, Justin W. Timbie

Racial and Ethnic Disparities in Care for Health System-Affiliated Physician Organizations and Non-Affiliated Physician Organizations

This article assesses racial and ethnic disparities in care for Medicare fee-for-service beneficiaries and whether disparities differ between health system-affiliated physician organizations (POs) and nonaffiliated POs.

Justin W. Timbie, Ashley M. Kranz, Maria DeYoreo, Blen Eshete-Roesler, Marc N. Elliott, José J. Escarce, Mark E. Totten, Cheryl L. Damberg

Health Information Technology for Ambulatory Care in Health Systems

The relatively low uptake of health IT functionalities important to care improvement suggests substantial opportunities for further improving adoption of ambulatory health IT even among the current EHR users.

Yunfeng Shi, Alejandro Amill-Rosario, Robert S. Rudin, Shira H. Fischer, Paul G. Shekelle, Dennis P. Scanlon, Cheryl L. Damberg

Optimizing Health IT to Improve Health System Performance: A Work in Progress

We describe activities that health systems are pursuing to better leverage health IT to improve performance, in a qualitative thematic approach.

Robert S. Rudin, Shira H. Fischer, Cheryl L. Damberg, Yunfeng Shi, Paul G. Shekelle, Lea Xenakis, Dmitry Khodyakov, M. Susan Ridgely

Trends in the Use of Computerized Physician Order Entry by Health-System Affiliated Ambulatory Clinics in the United States, 2014–2016

Small practice size or not being part of a multi-hospital system are associated with lower use of computerized physician order entry. between 2014 and 2016. Less than optimal use in these environments may be harming patient outcomes.

Shira H. Fischer, Robert S. Rudin, Yunfeng Shi, Paul G. Shekelle, Alejandro Amill-Rosario, Dennis P. Scanlon, Cheryl L. Damberg

Trends in the Use of Clinical Decision Support by Health System–Affiliated Ambulatory Clinics in the United States, 2014–2016

Use of clinical decision support (CDS) in ambulatory clinics is increasing but remains modest. The CDS function with the greatest use is basic medication screening, which increased from 52% of clinics nationally in 2014 to 61% in 2016.

Robert S. Rudin, Shira H. Fischer, Yunfeng Shi, Paul G. Shekelle, Alejandro Amill-Rosario, M. Susan Ridgely, Dennis P. Scanlon, Cheryl L. Damberg

Electronic Health Record "Super-Users" and "Under-Users" in Ambulatory Care Practices

To achieve the broader benefits of electronic health records, health systems and policy makers need to identify and address barriers to full use of health IT functionalities.

Juliet Rumball-Smith, Paul G. Shekelle, Cheryl L. Damberg

Using Health IT to Coordinate Care and Improve Quality in Safety-Net Clinics

This study examined factors associated with use of health information technology (HIT) capabilities for improved care coordination and quality of care in U.S. health centers.

Ashley M. Kranz, Sarah Dalton, Cheryl L. Damberg, Justin W. Timbie

Physician Organizations' Use of Behavioral Nudges to Influence Physician Behavior

This paper investigates adoption of behavioral nudges by health system-affiliated physician organizations (POs), types of nudges being used, PO leader perceptions of nudge effectiveness, and implementation challenges.

Cheryl L. Damberg, Ashlyn Tom, Rachel O. Reid

Physician Compensation Arrangements and Financial Performance Incentives in US Health Systems

This study was a cross-sectional mixed-methods analysis of in-depth multimodal data from 31 POs affiliated with 22 purposefully selected health systems in 4 states. Data were analyzed from June 2019 to September 2020.

Rachel O. Reid, Ashlyn Tom, Rachel Ross, Erin Lindsey Duffy, Cheryl L. Damberg

Association of Primary and Specialty Care Integration on Physician Communication and Cancer Screening in Safety-Net Clinics

This study aimed to describe strategies CHCs use to integrate care with specialists and examine whether more strongly integrated CHCs have higher rates of screening for colorectal and cervical cancers and report better communication with specialists.

Ashley M. Kranz, Jamie L. Ryan, Ammarah Mahmud, Claude Messan Setodji, Cheryl L. Damberg, Justin W. Timbie

Provision of Social Services and Health Care Quality in US Community Health Centers, 2017

Some community health centers provide social services on-site and this was associated with better performance on measures of health care quality.

Ashley M. Kranz, Ammarah Mahmud, Denis Agniel, Cheryl L. Damberg, Justin W. Timbie

Federally Qualified Health Center Strategies for Integrating Care with Hospitals and Their Association with Measures of Communication

Health centers differ in the use of strategies to integrate care with hospitals. Overall, integration activity is associated with better communication.

Justin W. Timbie, Ashley M. Kranz, Ammarah Mahmud, Claude Messan Setodji, Cheryl L. Damberg

Specialty Care Access for Medicaid Enrollees in Expansion States

In a survey of community health center medical directors in 9 Medicaid expansion states and DC, nearly 60% reported difficulty obtaining new specialist visits and multiple access barriers on behalf of their patients.

Justin W. Timbie, Ashley M. Kranz, Ammarah Mahmud, Cheryl L. Damberg