Genevra Murray
Genevra Murray
Scroll
Assistant Professor of Public Health Policy and Management
-
Professional overview
-
Genevra F. Murray, PhD is an Assistant Professor in the Department of Public Health Policy and Management. Her research and teaching focus is on the organization and management of health care services, examining the organizational dimensions of payment and delivery system reform and its impact on racial, ethnic and socioeconomic disparities.
Dr. Murray’s current projects are focused on primary care delivery, with an emphasis on the health care safety net; the social determinants of health, particularly the integration of social services and medical care; advance care planning and palliative care integration; and global health systems and governance, particularly related to sexual and reproductive health care. She uses a mix of research methods with expertise in longitudinal qualitative methods.
Prior to joining the faculty at GPH, Dr. Murray was a fellow at Boston Medical Center and a research scientist at The Dartmouth Institute for Health Policy and Clinical Practice. She has published in leading journals such as Health Affairs, Milbank Quarterly and Health Care Management Review.
Dr. Murray received her PhD in medical anthropology from the University of Pennsylvania, having graduated from there summa cum laude with a BA in anthropology.
-
Education
-
PhD Anthropology, University of PennsylvaniaBA Anthropology, University of Pennsylvania
-
Honors and awards
-
Ruth L. Kirschstein National Research Service Award Recipient (202020212022)Fulbright Scholar (20052006)William Penn Fellowship (2002200320042005)Summa Cum Laude, University of Pennsylvania (2001)Phi Beta Kappa, University of Pennsylvania (2001)Valedictorian, Department of Anthropology, University of Pennsylvania (2001)
-
Publications
Publications
Advancing equity in challenging times: A qualitative study of telehealth expansion and changing patient–provider relationships in primary care settings during the COVID-19 pandemic
AbstractAijaz, M., Lewis, V. A., & Murray, G. F. (n.d.).Publication year
2024Journal title
Digital HealthVolume
10AbstractObjective: The patient–provider relationship is critical for achieving high-quality care and better health outcomes. During the COVID-19 pandemic, primary care practices rapidly transitioned to telehealth. While telehealth provided critical access to services for many, not all patients could optimally utilize it, raising concerns about its potential to exacerbate inequities in patient–provider relationships. We investigated technical and workforce-related barriers to accessing telehealth and the impacts on patient–provider relationships for vulnerable populations. Methods: Qualitative, semi-structured interviews from May 2021 to August 2021 with 31 individuals (medical directors, physicians, and medical assistants) working at 20 primary care practices in Massachusetts, North Carolina, and Texas. Thematic analysis to better understand how barriers to using telehealth complicated patient–provider relationships. Results: Interviewees shared challenges for providers and patients that had a negative effect on patient–provider relationships, particularly for vulnerable patients, including older adults, lower socio-economic status patients, and those with limited English proficiency. Providers faced logistical challenges and disruptions in team-based care, reducing care coordination. Patients experienced technological challenges that made accessing and engaging in telehealth difficult. Interviewees shared challenges for patient–provider relationships as commonly used telephone-only telehealth reduced channels for non-verbal communication. Conclusion: This study indicates that barriers to virtual interaction with patients compared to in-person care likely led to weaker personal relationships that may have longer-term effects on engagement with and trust in the healthcare system, particularly among vulnerable patient groups. Additional support and resources should be available to primary care providers to optimize telehealth utilization.Enrollment Patterns of Medicare Advantage Beneficiaries by Dental, Vision, and Hearing Benefits
AbstractGupta, A., Silver, D., Meyers, D. J., Murray, G., Glied, S., & Pagán, J. A. (n.d.).Publication year
2024Journal title
JAMA Health ForumVolume
5Issue
1Page(s)
E234936AbstractImportance: Most Medicare beneficiaries now choose to enroll in Medicare Advantage (MA) plans. Racial and ethnic minority group and low-income beneficiaries are increasingly enrolling in MA plans. Objective: To examine whether dental, vision, and hearing supplemental benefits offered in MA plans are associated with the plan choices of traditionally underserved Medicare beneficiaries. Design, Setting, and Participants: This exploratory observational cross-sectional study used data from the 2018 to 2020 Medicare Current Beneficiary Survey linked to MA plan benefits. The nationally representative sample comprised primarily community-dwelling MA beneficiaries enrolled in general enrollment MA plans. Data analysis was performed between April and October 2023. Exposures: Beneficiary self-identified race and ethnicity and combined individual and spouse income and educational attainment. Main Outcomes and Measures: Binary indicators were developed to determine whether beneficiaries were enrolled in a plan offering any dental, comprehensive dental, any vision, eyewear, any hearing, or hearing aid benefit. Mixed-effects logistic regression models were estimated to report average marginal effects adjusted for beneficiary-level demographic and health characteristics, plan attributes, and plan availability. Results: This study included 8139 (weighted N = 31 million) eligible MA beneficiaries, with a mean (SD) age of 77.7 (7.5) years. More than half of beneficiaries (54.9%) were women; 9.8% self-identified as Black, 2.0% as Hispanic, 83.9% as White, and 4.2% as other or multiple races or ethnicities. Plan choices by dental benefits were examined among 7516 beneficiaries who were not enrolled in any dental standalone plan, by vision benefits for 8026 beneficiaries not enrolled in any vision standalone plan, and by hearing benefits for 8131 beneficiaries not enrolled in any hearing standalone plan. Black beneficiaries were more likely to enroll in plans with any dental benefit (9.0 percentage points [95% CI, 3.4-14.4]; P <.001), any comprehensive dental benefit (11.2 percentage points [95% CI, 5.7-16.7]; P <.001), any eye benefit (3.0 percentage points [95% CI, 1.0 to 5.0]; P =.004), or any eyewear benefit (6.0 percentage points [95% CI, 0.6-11.5]; P =.03) compared with White beneficiaries. Lower-income individuals (earning ≤200% of the federal poverty level) were more likely to enroll in a plan with a comprehensive dental benefit (4.4 percentage-point difference [95% CI, 0.1-7.9]; P =.01) compared with higher-income beneficiaries. Beneficiaries without a college degree were more likely to enroll in a plan with a comprehensive dental benefit (4.7 percentage-point difference [95% CI, 1.4-8.0]; P =.005) compared with those with higher educational attainment. Conclusions and Relevance: The results of this study suggest that racial and ethnic minority individuals and those with lower income or educational attainment are more likely to choose MA plans with dental or vision benefits. As the federal government prepares to adjust MA plan star ratings for health equity, implements MA payment cuts, and allows increasing flexibility in supplemental benefit offerings, these findings may inform benefit monitoring for MA.."I'm in My Feelings Now": Examination of Advance Care Planning Video Declarations by People with Advanced Cancer from a Safety Net Hospital
AbstractQuintiliani, L. M., Murray, G. F., Waite, K., Salerno, K., Gignac, G. A., Yuh, D., Volandes, A., & Paasche-Orlow, M. K. (n.d.).Publication year
2023Journal title
Journal of palliative medicineVolume
26Issue
1Page(s)
28-34AbstractBackground: Advance care planning (ACP) is underutilized among those with advanced cancer, leading to the potential of not receiving goal-concordant care. Objectives: To understand the experience of patients in creating a video declaration (ViDec) of their ACP preferences and their family member/caregivers' perceptions after viewing their ViDec. Design: Qualitative study among patients and family members/caregivers. Setting/Subjects: Patients were recruited from a large safety net hospital in the United States. Patients with any type of advanced cancer were enrolled to create a ViDec and participate in an individual interview. Patients also identified a family member/caregiver to participate. Measurements: Content and perceptions of usefulness of ViDecs among patients and family members/caregivers. Results: In total, 32 patients participated. Patients had a mean age of 61 (10) years, 15 (47%) were women, 14 (44%) were Black or African American, and 12 (37%) had a high school education or less; 25 family members/caregivers participated. Across all ViDecs, the most common theme pertained to ACP for preferred medical treatments (97%). We describe three case studies of patient and caregiver pairs to represent salient dimensions of our data: (1) high perceived usefulness of ViDec, (2) populations at risk for not receiving goal-concordant care, and (3) varied responses to ViDec among family members/caregivers. Recommendations to improve the ViDec process included providing structured prompts to patients. Conclusions: These case studies highlight the potential high-perceived usefulness of ViDecs across patients and caregivers. ViDecs have the potential to improve care among patients with advanced cancer.A Decade of ACOs in Medicare: Have They Delivered on Their Promise?
AbstractSpivack, S. B., Murray, G. F., & Lewis, V. A. (n.d.).Publication year
2023Journal title
Journal of health politics, policy and lawVolume
48Issue
1Page(s)
63-92AbstractAccountable care organizations (ACOs) were envisioned as a way to address both health care cost growth and uneven quality in US health care. They emerged in the early 2000s, with the 2010 Affordable Care Act (ACA) establishing a Medicare ACO program. In the decade since their launch, ACOs have grown into one of Medicare’s flagship payment reform programs, with millions of beneficiaries receiving care from hundreds of ACOs. While great expectations surrounded ACOs’ introduction into Medicare, their impacts to date have been modest. ACOs have achieved some savings and improvements in measured quality, but disagreement persists over the meaning of those results: Do ACOs represent important, incremental steps forward on the path toward a more efficient, high-quality health care system? Or do their modest achievements signal a failure of large-scale progress despite the substantial investments of resources? ACOs have proven to be politically resilient, largely sidestepping the controversies and partisan polarization that have led to the demise of other ACA provisions. But the same features that have enabled ACOs to evade backlash have constrained their impacts and effectiveness. After a decade, ACOs’ long-term influence on Medicare and the US health care system remains uncertain.Evaluating a social risk screening and referral program in an urban safety-net hospital emergency department
AbstractLoo, S., Anderson, E., Lin, J. G., Smith, P., Murray, G. F., Hong, H., Jacquet, G. A., Koul, R., Rosenmoss, S., James, T., Shankar, K. N., & De La Vega, P. B. (n.d.).Publication year
2023Journal title
JACEP OpenVolume
4Issue
1AbstractObjective: The emergency department (ED) is an opportune venue to screen for unmet social needs and connect patients with social services. This quality improvement study incorporates both qualitative and quantitative data to examine unmet social needs among ED patients and program implementation. Methods: From September 2020 to December 2021, an urban safety-net hospital adult ED implemented a social needs screening and referral program. Trained emergency staff screened eligible patients for 5 social needs (housing, food, transportation, utilities, employment), giving resource guides to patients who screened positive (THRIVE+). We collected screening data from the electronic health record, conducted semi-structured interviews with THRIVE+ patients and clinical staff, and directly observed discharge interactions. Results: Emergency staff screened 58.5% of eligible patients for social risk. Of the screened patients, 27.0% reported at least 1 unmet social need. Of those, 74.8% requested assistance. Screened patients reported housing insecurity (16.3%) as the most prevalent unmet social need followed by food insecurity (13.3%) and unemployment (8.7%). Among interviewed patients, 57.1% recalled being screened, but only 24.5% recalled receiving resource guides. Patients who received guides reported little success connecting with resources and supported universal guide dissemination. Staff expressed preference for warm handoff to social services. Of 13 observed discharge interactions, clinical staff only discussed guides with 2 patients, with no positive endorsement of the guides in any observed interactions. Conclusions: An ED social needs screening program can be moderately feasible and accepted. We identified housing as the most prevalent need. Significant gaps exist between screening and referral, with few patients receiving resources. Further training and workflow optimization are underway.Problematic Integration: Racial Discordance in End-of-Life Decision Making
AbstractDrummond, D. K., Kaur-Gill, S., Murray, G. F., Schifferdecker, K. E., Butcher, R., Perry, A. N., Brooks, G. A., Kapadia, N. S., & Barnato, A. E. (n.d.).Publication year
2023Journal title
Health CommunicationVolume
38Issue
12Page(s)
2730-2741AbstractWe describe racially discordant oncology encounters involving EOL decision-making. Fifty-eight provider interviews were content analyzed using the tenets of problematic integration theory. We found EOL discussions between non-Black providers and their Black patients were often complex and anxiety-inducing. That anxiety consisted of (1) ontological uncertainty in which providers characterized the nature of Black patients as distrustful, especially in the context of clinical trials; (2) ontological and epistemological uncertainty in which provider intercultural incompetency and perceived lack of patient health literacy were normalized and intertwined with provider assumptions about patients’ religion and support systems; (3) epistemological uncertainty as ambivalence in which providers’ feelings conflicted when deciding whether to speak with family members they perceived as lacking health literacy; (4) divergence in which the provider advised palliative care while the family desired surgery or cancer-directed medical treatment; and (5) impossibility when an ontological uncertainty stance of Black distrust was seen as natural by providers and therefore impossible to change. Some communication strategies used were indirect stereotyping, negotiating, asking a series of value questions, blame-guilt framing, and avoidance. We concluded that provider perceptions of Black distrust, religion, and social support influenced their ability to communicate effectively with patients.Structural Barriers to Well-grounded Advance Care Planning for the Seriously Ill: a Qualitative Study of Clinicians’ and Administrators’ Experiences During a Pragmatic Trial
AbstractMurray, G. F., Lakin, J. R., Paasche-Orlow, M. K., Tulsky, J. A., Volandes, A., Davis, A. D., Zupanc, S. N., Carney, M. T., Burns, E., Martins-Welch, D., LaVine, N., Itty, J. E., & Fix, G. M. (n.d.).Publication year
2023Journal title
Journal of general internal medicineVolume
38Issue
16Page(s)
3558-3565AbstractBackground: Advance Care Planning (ACP) comprises an iterative communication process aimed at understanding patients’ goals, values, and preferences in the context of considering and preparing for future medical treatments and decision making in serious illness. The COVID pandemic heightened patients’ and clinicians’ awareness of the need for ACP. Objective: Our goal was to explore the experiences of clinicians and administrators in the context of an intervention to improve ACP during the COVID pandemic. Design: Qualitative interview study. Participants: Clinicians and administrators across five sites that participated in the ACP-COVID trial. Approach: We conducted semi-structured, qualitative interviews examining the context and approach to ACP. Interviews were analyzed using template analysis to systematically organize the data and facilitate review across the categories and participants. Templates were developed with iterative input and line-by-line review by the analytic team, to reach consensus. Findings were then organized into emergent themes. Key Results: Across 20 interviews (4 administrators, 16 clinicians) we identified three themes related to how participants thought about ACP: (1) clinicians have varying views of what constitutes ACP; (2) the health system critically shapes ACP culture and norms; and (3) the centrality of clinicians’ affective experience and own needs related to ACP. Varying approaches to ACP include a forms-focused approach; a discussion-based approach; and a parental approach. System features that shape ACP norms are (1) the primacy of clinician productivity measures; (2) the role of the EHR; and (3) the culture of quality improvement. Conclusions: Despite high organizational commitment to ACP, we found that the health system channeled clinicians’ ACP efforts narrowly on completion of forms, in tension with the ideal of well-grounded ACP. This resulted in a state of moral distress that risks undermining confidence in the process of ACP and may increase risk of harm for patients, family/caregivers, and providers. Trial Registration: ClinicalTrials.gov Identifier: NCT04660422.Structure and integration of specialty palliative care in three NCI-designated cancer centers: a mixed methods case study
AbstractSchifferdecker, K. E., Butcher, R. L., Murray, G. F., Knutzen, K. E., Kapadia, N. S., Brooks, G. A., Wasp, G. T., Eggly, S., Hanson, L. C., Rocque, G. B., Perry, A. N., & Barnato, A. E. (n.d.).Publication year
2023Journal title
BMC Palliative CareVolume
22Issue
1AbstractIntroduction: Early access to specialty palliative care is associated with better quality of life, less intensive end-of-life treatment and improved outcomes for patients with advanced cancer. However, significant variation exists in implementation and integration of palliative care. This study compares the organizational, sociocultural, and clinical factors that support or hinder palliative care integration across three U.S. cancer centers using an in-depth mixed methods case study design and proposes a middle range theory to further characterize specialty palliative care integration. Methods: Mixed methods data collection included document review, semi-structured interviews, direct clinical observation, and context data related to site characteristics and patient demographics. A mixed inductive and deductive approach and triangulation was used to analyze and compare sites’ palliative care delivery models, organizational structures, social norms, and clinician beliefs and practices. Results: Sites included an urban center in the Midwest and two in the Southeast. Data included 62 clinician and 27 leader interviews, observations of 410 inpatient and outpatient encounters and seven non-encounter-based meetings, and multiple documents. Two sites had high levels of “favorable” organizational influences for specialty palliative care integration, including screening, policies, and other structures facilitating integration of specialty palliative care into advanced cancer care. The third site lacked formal organizational policies and structures for specialty palliative care, had a small specialty palliative care team, espoused an organizational identity linked to treatment innovation, and demonstrated strong social norms for oncologist primacy in decision making. This combination led to low levels of specialty palliative care integration and greater reliance on individual clinicians to initiate palliative care. Conclusion: Integration of specialty palliative care services in advanced cancer care was associated with a complex interaction of organization-level factors, social norms, and individual clinician orientation. The resulting middle range theory suggests that formal structures and policies for specialty palliative care combined with supportive social norms are associated with greater palliative care integration in advanced cancer care, and less influence of individual clinician preferences or tendencies to continue treatment. These results suggest multi-faceted efforts at different levels, including social norms, may be needed to improve specialty palliative care integration for advanced cancer patients.Cross-Sector Strategic Alliances Between Health Care Organizations and Community-Based Organizations: Marrying Theory and Practice
AbstractMurray, G. F., & Lewis, V. A. (n.d.).Publication year
2022Journal title
Advances in Health Care ManagementVolume
21AbstractWhile it has long been established that social factors, such as housing, transportation, and income, influence health and health care outcomes, over the last decade, attention to this topic has grown dramatically. Reforms that promote high-quality care as well as responsibility for total cost of care have shifted focus among health care providers toward upstream determinants of health care outcomes. As a result, there has been a proliferation of activity focused on integrating and aligning social and medical care, many of which depend critically on cross-sector alliances. Despite considerable activity in this area, cross-sector alliances in health care remain largely undertheorized. Both literatures stand to gain from more attention to carefully knitting together the theoretical and management literature on alliances with the empirical, health policy and health services literature on cross-sector alliances in health care. In this chapter, we lay out what exists in the current scientific literature as well as a framework for considering much needed work in this area. We organize the literature and our commentary around the lifecycle of alliances: alliance formation, including factors prompting alliance formation, partner selection, and alliance goals; alliance maturity, including the work of these cross-sector alliances, governance, finance and contracts, staffing structure, and rewards; and critical crossroads, including alliance timelines, definitions of success, and dissolution. We also lay out critical areas for future inquiry, including better theorizing on cross-sector alliances, developing typologies of these cross-sector health care alliances, and the role of policy in cross-sector alliances.Screening for Social Risk at Federally Qualified Health Centers: A National Study
AbstractCole, M. B., Nguyen, K. H., Byhoff, E., & Murray, G. F. (n.d.).Publication year
2022Journal title
American journal of preventive medicineVolume
62Issue
5Page(s)
670-678AbstractIntroduction: Federally Qualified Health Centers serve 29.8 million low-income patients across the U.S., many of whom have unaddressed social risks. In 2019, for the first time, data on social risk screening capabilities were collected from every U.S. Federally Qualified Health Center. The objectives of this study were to describe the national rates of social risk screening capabilities across Federally Qualified Health Centers, identify organizational predictors of screening, and assess between-state heterogeneity. Methods: Using a 100% sample of U.S. Federally Qualified Health Centers (N=1,384, representing 29.8 million patients) from the 2019 Uniform Data System, the primary outcome was whether a Federally Qualified Health Center collected data on patients’ social risk factors (yes/no). Summary statistics on the rates of social risk screening capabilities were generated in aggregate and by state. Linear probability models were then used to estimate the relationship between the probability of social risk screening and 7 key Federally Qualified Health Center characteristics (e.g., Federally Qualified Health Center size, Medicaid MCO contract, Medicaid accountable care organization presence). Data were analyzed in 2020‒2021. Results: Most (71%) Federally Qualified Health Centers collected social risk data, with a between-state variation. The most common screener was the Protocol for Responding to and Assessing Patients’ Assets Risks and Experiences (43% of Federally Qualified Health Centers that screened), whereas 22% collected social risk data using a nonstandardized screener. After adjusting for other characteristics, Federally Qualified Health Centers with social risk screening capabilities served more total patients, were more likely to be located in a state with a Medicaid accountable care organization, and were less likely to have an MCO contract. Conclusions: There has been widespread adoption of social risk screening tools across U.S. Federally Qualified Health Centers, but between-state disparities exist. Targeting social risk screening resources to smaller Federally Qualified Health Centers may increase the adoption of screening tools.Survey of Information Exchange and Advanced Use of Other Health Information Technology in Primary Care Settings Capabilities In and Outside of the Safety Net
AbstractCross, D. A., Stevens, M. A., Spivack, S. B., Murray, G. F., Rodriguez, H. P., & Lewis, V. A. (n.d.).Publication year
2022Journal title
Medical careVolume
60Issue
2Page(s)
140-148AbstractBackground: Advanced use of health information technology (IT) functionalities can support more comprehensive, coordinated, and patient-centered primary care services. Safety net practices may benefit disproportionately from these investments, but it is unclear whether IT use in these settings has kept pace and what organizational factors are associated with varying use of these features. Objective: The aim was to estimate advanced use of health IT use in safety net versus nonsafety net primary care practices. We explore domains of patient engagement, population health management (decision support and registries), and electronic information exchange. We examine organizational characteristics that may differentially predict advanced use of IT across these settings, with a focus on health system ownership and/or membership in an independent practice network as key factors that may indicate available incentives and resources to support these efforts. Research Design: We conduct cross-sectional analysis of a national survey of physician practices (n= 1776). We use logistic regression to predict advanced IT use in each of our domains based on safety net status and other organizational characteristics. We then use interaction models to assess whether ownership or network membership moderate the relationship between safety net status and advanced use of health IT. Results: Health IT use was common across primary care practices, but advanced use of health IT functionalities ranged only from 30% to 50% use. Safety net settings have kept pace with adoption of features for patient engagement and population management, yet lag in information exchange capabilities compared with nonsafety net practices (odds ratio= 0.52 for federally qualified health centers, P< 0.001; odds ratio =0.66 for other safety net, P=0.03). However, when safety net practices are members of a health system or practice network, health IT capabilities are comparable to nonsafety net sites. Conclusions: All outpatient settings would benefit from improved electronic health record usability and implementation support that facilitates advanced use of health IT. Safety net practices, particularly those without other sources of centralized support, need targeted resources to maintain equitable access to information exchange capabilities.Systemic Therapy Decision Making in Advanced Cancer: A Qualitative Analysis of Patient-Oncologist Encounters
AbstractWasp, G. T., Knutzen, K. E., Murray, G. F., Brody-Bizar, O. C., Liu, M. A., Pollak, K. I., Tulsky, J. A., Schenker, Y., & Barnato, A. E. (n.d.).Publication year
2022Journal title
JCO Oncology PracticeVolume
18Issue
8Page(s)
E1357-E1366AbstractPURPOSE:We sought to characterize patient-oncologist communication and decision making about continuing or limiting systemic therapy in encounters after an initial consultation, with a particular focus on whether and how oncologists foster shared decision making (SDM).METHODS:We performed content analysis of outpatient oncology encounters at two US National Cancer Institute-designated cancer centers audio recorded between November 2010 and September 2014. A multidisciplinary team used a hybrid approach of inductive and deductive coding and theme development. We used a combination of random and purposive sampling. We restricted quantitative frequency counts to the coded random sample but included all sampled encounters in qualitative thematic analysis.RESULTS:Among 31 randomly sampled dyads with three encounters each, systemic therapy decision making was discussed in 90% (84 of 93) encounters. Thirty-four (37%) broached limiting therapy, which 27 (79%) framed as temporary, nine (26%) as completion of a standard regimen, and five (15%) as permanent discontinuation. Thematic analysis of these 93 encounters, plus five encounters purposively sampled for permanent discontinuation, found that (1) patients and oncologists framed continuing therapy as the default, (2) deficiencies in the SDM process (facilitating choice awareness, discussing options, and incorporating patient preferences) contributed to this default, and (3) oncologists use persuasion rather than deliberation when broaching discontinuation.CONCLUSION:In this study of outpatient encounters between patients with advanced cancer and their oncologists, when discussing systemic therapy, there exists a default to continue systemic therapy, and deficiencies in SDM contribute to this default.Actual and Missed Opportunities for End-of-Life Care Discussions with Oncology Patients: A Qualitative Study
AbstractKnutzen, K. E., Sacks, O. A., Brody-Bizar, O. C., Murray, G. F., Jain, R. H., Holdcroft, L. A., Alam, S. S., Liu, M. A., Pollak, K. I., Tulsky, J. A., & Barnato, A. E. (n.d.).Publication year
2021Journal title
JAMA network openVolume
4Issue
6AbstractImportance: Early discussion of end-of-life (EOL) care preferences improves clinical outcomes and goal-concordant care. However, most EOL discussions occur approximately 1 month before death, despite most patients desiring information earlier. Objective: To describe successful navigation and missed opportunities for EOL discussions (eg, advance care planning, palliative care, discontinuation of disease-directed treatment, hospice care, and after-death wishes) between oncologists and outpatients with advanced cancer. Design, Setting, and Participants: This study is a secondary qualitative analysis of outpatient visits audio-recorded between November 2010 and September 2014 for the Studying Communication in Oncologist-Patient Encounters randomized clinical trial. The study was conducted at 2 US academic medical centers. Participants included medical, gynecological, and radiation oncologists and patients with stage IV malignant neoplasm, whom oncologists characterized as being ones whom they "...would not be surprised if they were admitted to an intensive care unit or died within one year." Data were analyzed between January 2018 and August 2020. Exposures: The parent study randomized participants to oncologist- and patient-directed interventions to facilitate discussion of emotions. Encounters were sampled across preintervention and postintervention periods and all 4 treatment conditions. Main Outcomes and Measures: Secondary qualitative analysis was done of patient-oncologist dyads with 3 consecutive visits for EOL discussions, and a random sample of 7 to 8 dyads from 4 trial groups was analyzed for missed opportunities. Results: The full sample included 141 patients (54 women [38.3%]) and 39 oncologists (8 women [19.5%]) (mean [SD] age for both patients and oncologists, 56.3 [10.0] years). Of 423 encounters, only 21 (5%) included EOL discussions. Oncologists reevaluated treatment options in response to patients' concerns, honored patients as experts on their goals, or used anticipatory guidance to frame treatment reevaluation. In the random sample of 31 dyads and 93 encounters, 35 (38%) included at least 1 missed opportunity. Oncologists responded inadequately to patient concerns over disease progression or dying, used optimistic future talk to address patient concerns, or expressed concern over treatment discontinuation. Only 4 of 23 oncologists (17.4%) had both an EOL discussion and a missed opportunity. Conclusions and Relevance: Opportunities for EOL discussions were rarely realized, whereas missed opportunities were more common, a trend that mirrored oncologists' treatment style. There remains a need to address oncologists' sensitivity to EOL discussions, to avoid unnecessary EOL treatment..Avoiding medicaid: Characteristics of primary care practices with no medicaid revenue
AbstractSpivack, S. B., Murray, G. F., Rodriguez, H. P., & Lewis, V. A. (n.d.).Publication year
2021Journal title
Health AffairsVolume
40Issue
1Page(s)
98-104AbstractPrimary care access for Medicaid patients is an ongoing area of concern. Most studies of providers’ participation in Medicaid have focused on factors associated with the Medicaid program, such as reimbursement rates. Few studies have examined the characteristics of primary care practices associated with Medicaid participation. We used a nationally representative survey of primary care practices to compare practices with no, low, and high Medicaid revenue. Seventeen percent of practices received no Medicaid revenue; 38 percent and 45 percent were categorized as receiving low and high Medicaid revenue, respectively. Practices with no Medicaid revenue were more often small, independent, and located in urban areas with higher household income. These practices also have lower population health capabilities.Critical issues in alliances between management partners and accountable care organizations
AbstractMurray, G. F., D’Aunno, T., & Lewis, V. A. (n.d.).Publication year
2021Journal title
Health Care Management ReviewVolume
46Issue
3Page(s)
237-247AbstractBackground Despite widespread engagement of accountable care organizations (ACOs) with management partners, little empirical evidence on these alliances exists to inform policymakers or payers. Management partners may be providing a valuable service in facilitating the transition to population health management. Alternately, in some cases, partners may be receiving high fees relative to the value of services provided. Purpose The aim of this study was to use qualitative data to identify motivations for and critical issues in alliances between ACOs and management partners. Methodology/Approach We used qualitative data collected from seven ACOs (193 semistructured interviews and observational data from 12 site visits) to characterize the alliances between management partners and providers in ACOs. Results We found that ACOs sought partners to provide financing, technical expertise, and risk bearing. Tensions in partnerships arose around resources (e.g., delivery on promised resources), control (e.g., who holds decision making authority), and values (e.g., commitment to safety net mission). Some partnerships persisted, whereas others dissolved. We found that there are two different underlying models of ACO-management partner alliances in our sample: (1) short-term partnerships aimed at organizational learning and (2) long-term partnerships based on complementarity. Conclusion Our results demonstrate how ACO alliances with management partners have unfolded as a kind of natural experiment in value-based payment reform. We expect that there is wide variation in quality, expertise, and delivery by management partners. Now multiple years into many of these alliances, we may address their value, strengths, and weaknesses from the perspective of providers as well as policy makers and payers. Practice Implications Accountable care organization providers must determine whether a management partner is the best solution to the challenges they face and, if so, which alliance model to pursue. Policymakers and payers should consider short- and long-term implications of ACO-management partner alliances, including considering changing the regulatory environment.FQHC Designation and Safety Net Patient Revenue Associated with Primary Care Practice Capabilities for Access and Quality
AbstractLewis, V. A., Spivack, S., Murray, G. F., & Rodriguez, H. P. (n.d.).Publication year
2021Journal title
Journal of general internal medicineVolume
36Issue
10Page(s)
2922-2928AbstractBackground: Concerns exist about the ability of safety net health care organizations to participate in US health care reform. Primary care practices are key to several efforts, but little is known about how capabilities of primary care practices serving a high share of disadvantaged patients compare to other practices. Objective: To assess capabilities around access to and quality of care among primary care practices serving a high share of Medicaid and uninsured patients compared to practices serving a low share of these patients. Design: We analyzed data from the National Survey of Healthcare Organizations and Systems (response rate 46.8%), conducted 2017–2018. Participants: A total of 2190 medical practices with at least three adult primary care physicians. Main Measures: Our key exposures are payer mix and federally qualified health center (FQHC) designation. We classified practices as safety net if they reported a combined total of at least 25% of annual revenue from uninsured or Medicaid patients; we then further classified safety net practices into those that identified as an FQHC and those that did not. Key Results: FQHCs were more likely than other safety net practices and non-safety net practices to offer early or late appointments (79%, 55%, 62%; p=0.001) and weekend appointments (56%, 39%, 42%; p=0.03). FQHCs more often provided medication-assisted treatment for opioid use disorders (43%, 27%, 25%; p=0.004) and behavioral health services (82%, 50%, 36%; p<0.001). FQHCs were more likely to screen patients for social and financial needs. However, FQHCs and other safety net providers had more limited electronic health record (EHR) capabilities (61%, 71%, 80%; p<0.001). Conclusion: FQHCs were more likely than other types of primary care practices (both safety net practices and other practices) to possess capabilities related to access and quality. However, safety net practices were less likely than non-safety net practices to possess health information technology capabilities.Role of norms in variation in cancer centers' end-of-life quality: Qualitative case study protocol
AbstractKnutzen, K. E., Schifferdecker, K. E., Murray, G. F., Alam, S. S., Brooks, G. A., Kapadia, N. S., Butcher, R., & Barnato, A. E. (n.d.).Publication year
2020Journal title
BMC Palliative CareVolume
19Issue
1AbstractBackground: A critical barrier to improving the quality of end-of-life (EOL) cancer care is our lack of understanding of the mechanisms underlying variation in EOL treatment intensity. This study aims to fill this gap by identifying 1) organizational and provider practice norms at major US cancer centers, and 2) how these norms influence provider decision making heuristics and patient expectations for EOL care, particularly for minority patients with advanced cancer. Methods: This is a multi-center, qualitative case study at six National Comprehensive Cancer Network (NCCN) and National Cancer Institute (NCI) Comprehensive Cancer Centers. We will theoretically sample centers based upon National Quality Forum (NQF) endorsed EOL quality metrics and demographics to ensure heterogeneity in EOL intensity and region. A multidisciplinary team of clinician and non-clinician researchers will conduct direct observations, semi-structured interviews, and artifact collection. Participants will include: 1) cancer center and clinical service line administrators; 2) providers from medical, surgical, and radiation oncology; palliative or supportive care; intensive care; hospital medicine; and emergency medicine who see patients with cancer and have high clinical practice volume or high local influence (provider interviews and observations); and 3) adult patients with metastatic solid tumors and whom the provider would not be surprised if they died in the next 12 months and their caregivers (patient and caregiver interviews). Leadership interviews will probe about EOL institutional norms and organization. We will observe inpatient and outpatient care for two weeks. Provider interviews will use vignettes to probe explicit and implicit motivations for treatment choices. Semi-structured interviews with patients near EOL, or their family members and caregivers will explore past, current, and future decisions related to their cancer care. We will import transcribed field notes and interviews into Dedoose software for qualitative data management and analysis, and we will develop and apply a deductive and inductive codebook to the data. Discussion: This study aims to improve our understanding of organizational and provider practice norms pertinent to EOL care in U.S. cancer centers. This research will ultimately be used to inform a provider-oriented intervention to improve EOL care for racial and ethnic minority patients with advanced cancer. Trial registration: Clinicaltrials.gov; NCT03780816; December 19, 2018.The Role of Value-Based Payment in Promoting Innovation to Address Social Risks: A Cross-Sectional Study of Social Risk Screening by US Physicians
AbstractBrewster, A. L., Fraze, T. K., Gottlieb, L. M., Frehn, J., Murray, G. F., & Lewis, V. A. (n.d.).Publication year
2020Journal title
Milbank QuarterlyVolume
98Issue
4Page(s)
1114-1133AbstractPolicy Points One of the most important possibilities of value-based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. Screening patients for social risks such as housing instability and food insecurity represents an early step physician practices can take to address social needs. At present, adoption of social risk screening by physician practices is linked with having high innovation capacity and focusing on low-income populations, but not exposure to value-based payment. Expanding social risk screening by physician practices may require standardization and technical assistance for practices that have less innovative capacity. Context: One of the most important possibilities of value-based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. However, there is uncertainty about the conditions under which value-based payment will encourage health care providers to innovate to address upstream social risks. Methods: We used the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS), a nationally representative survey of physician practices (n = 2,178), to ascertain (1) the number of social risks for which practices systematically screen patients; (2) the extent of practices’ participation in value-based payment models; and (3) measures of practices’ capacity for innovation. We used multivariate regression models to examine predictors of social risk screening. Findings: On average, physician practices systematically screened for 2.4 out of 7 (34%) social risks assessed by the survey. In the fully adjusted model, implementing social risk screening was not associated with the practices’ overall exposure to value-based payment. Being in the top quartile on any of three innovation capacity scales, however, was associated with screening for 0.95 to 1.00 additional social risk (p < 0.001 for all three results) relative to the bottom quartile. In subanalysis examining specific payment models, participating in a Medicaid accountable care organization was associated with screening for 0.37 more social risks (p = 0.015). Expecting more exposure to accountable care in the future was associated with greater social risk screening, but the effect size was small compared with practices’ capacity for innovation. Conclusions: Our results indicate that implementation of social risk screening—an initial step in enhancing awareness of social needs in health care—is not associated with overall exposure to value-based payment for physician practices. Expanding social risk screening by physician practices may require standardized approaches and implementation assistance to reduce the level of innovative capacity required.Upstream with a small paddle: How acos are working against the current to meet patients’ social needs
AbstractMurray, G. F., Rodriguez, H. P., & Lewis, V. A. (n.d.).Publication year
2020Journal title
Health AffairsVolume
39Issue
2Page(s)
199-206AbstractDespite interest in addressing social determinants of health to improve patient outcomes, little progress has been made in integrating social services with medical care. We aimed to understand how health care providers with strong motivation (for example, operating under new payment models) and commitment (for example, early adopters) fared at addressing patients’ social needs. We collected qualitative data from twenty-two accountable care organizations (ACOs). These ACOs were early adopters and were working on initiatives to address social needs, including such common needs as transportation, housing, and food. However, even these ACOs faced significant difficulties in integrating social services with medical care. First, the ACOs were frequently “flying blind,” lacking data on both their patients’ social needs and the capabilities of potential community partners. Additionally, partnerships between ACOs and community-based organizations were critical but were only in the early stages of development. Innovation was constrained by ACOs’ difficulties in determining how best to approach return on investment, given shorter funding cycles and longer time horizons to see returns on social determinants investments. Policies that could facilitate the integration of social determinants include providing sustainable funding, implementing local and regional networking initiatives to facilitate partnership development, and developing standardized data on community-based organizations’ services and quality to aid providers that seek partners.Care Transformation Strategies and Approaches of Accountable Care Organizations
AbstractLewis, V. A., Tierney, K. I., Fraze, T., & Murray, G. F. (n.d.).Publication year
2019Journal title
Medical Care Research and ReviewVolume
76Issue
3Page(s)
291-314AbstractAlthough accountable care organizations (ACOs) proliferate, little is known about the activities and strategies ACOs are pursuing to meet goals of reducing costs and improving quality. We use semistructured interviews with executives at 16 ACOs to understand ACO approaches. We identified two overarching ACO approaches to changing clinical care: a practice-based transformation approach, working to overhaul care processes and teams from the inside out; and an overlay approach, where ACO activities were centralized and delivered external to physician practices. We additionally identified four methods ACOs were using to achieve their aims: using patient support roles; targeted clinics, events, programs, and interventions; clinical process standardization; and tracking and identifying patients on which to focus resources. We expect that ACOs using either of the major approaches can succeed under current ACO programs, but that as value-based payment programs mature, ACOs will need to undertake practice-based approaches to be successful in the long term.Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals
AbstractFraze, T. K., Brewster, A. L., Lewis, V. A., Beidler, L. B., Murray, G. F., & Colla, C. H. (n.d.).Publication year
2019Journal title
JAMA network openVolume
2Issue
9AbstractImportance: Social needs, including food, housing, utilities, transportation, and experience with interpersonal violence, are linked to health outcomes. Identifying patients with unmet social needs is a necessary first step to addressing these needs, yet little is known about the prevalence of screening. Objective: To characterize screening for social needs by physician practices and hospitals. Design, Setting, and Participants: Cross-sectional survey analyses of responses by physician practices and hospitals to the 2017-2018 National Survey of Healthcare Organizations and Systems. Responses were collected from survey participants from June 16, 2017, to August 17, 2018. Exposures: Organizational characteristics, including participation in delivery and payment reform. Main Outcomes and Measures: Self-report of screening patients for food insecurity, housing instability, utility needs, transportation needs, and experience with interpersonal violence. Results: Among 4976 physician practices, 2333 responded, a response rate of 46.9%. Among hospitals, 757 of 1628 (46.5%) responded. After eliminating responses because of ineligibility, 2190 physician practices and 739 hospitals remained. Screening for all 5 social needs was reported by 24.4% (95% CI, 20.0%-28.7%) of hospitals and 15.6% (95% CI, 13.4%-17.9%) of practices, whereas 33.3% (95% CI, 30.5%-36.2%) of practices and 8.0% (95% CI, 5.8%-11.0%) of hospitals reported no screening. Screening for interpersonal violence was most common (practices: 56.4%; 95% CI, 53.3%-2 59.4%; hospitals: 75.0%; 95% CI, 70.1%-79.3%), and screening for utility needs was least common (practices: 23.1%; 95% CI, 20.6%-26.0%; hospitals: 35.5%; 95% CI, 30.0%-41.0%) among both hospitals and practices. Among practices, federally qualified health centers (yes: 29.7%; 95% CI, 21.5%-37.8% vs no: 9.4%; 95% CI, 7.2%-11.6%; P <.001), bundled payment participants (yes: 21.4%; 95% CI, 17.1%-25.8% vs no: 10.7%; 95% CI, 7.9%-13.4%; P <.001), primary care improvement models (yes: 19.6%; 95% CI, 16.5%-22.6% vs no: 9.6%; 95% CI, 6.0%-13.1%; P <.001), and Medicaid accountable care organizations (yes: 21.8%; 95% CI, 17.4%-26.2% vs no: 11.2%; 95% CI, 8.6%-13.7%; P <.001) had higher rates of screening for all needs. Practices in Medicaid expansion states (yes: 17.7%; 95% CI, 14.8%-20.7% vs no: 11.4%; 95% CI, 8.1%-14.6%; P =.007) and those with more Medicaid revenue (highest tertile: 17.1%; 95% CI, 11.4%-22.7% vs lowest tertile: 9.0%; 95% CI, 6.1%-11.8%; P =.02) were more likely to screen. Academic medical centers were more likely than other hospitals to screen (49.5%; 95% CI, 34.6%-64.4% vs 23.0%; 95% CI, 18.5%-27.5%; P <.001). Conclusions and Relevance: This study's findings suggest that few US physician practices and hospitals screen patients for all 5 key social needs associated with health outcomes. Practices that serve disadvantaged patients report higher screening rates. The role of physicians and hospitals in meeting patients' social needs is likely to increase as more take on accountability for cost under payment reform. Physicians and hospitals may need additional resources to screen for or address patients' social needs.Trust, Money, and Power: Life Cycle Dynamics in Alliances Between Management Partners and Accountable Care Organizations
AbstractMurray, G. F., D’aunno, T., & Lewis, V. A. (n.d.).Publication year
2018Journal title
Milbank QuarterlyVolume
96Issue
4Page(s)
755-781AbstractPolicy Points Accountable care organizations (ACOs) form alliances with management partners to access financial, technical, and managerial support. Alliances between ACOs and management partners are subject to destabilizing tension around decision-making authority, distribution of shared savings, and conflicting goals and values. Management partners may serve either as trainers, ultimately breaking off from the ACO, or as central drivers of the ACO. Management partner participation in ACOs is currently unregulated, and management partners may receive a significant portion (in some cases, majority) of shared savings. Context: Accountable care organizations (ACOs) are a prominent payment and delivery model. Though ACOs are often described as groups of health care providers, nearly 4 in 10 ACOs partner with a management company for services such as financial investment, contracting, data analytics, and care management, according to recent research. However, we know little about how and why these partnerships form. This article aims to understand the reasons providers seek partners, the nature of these relationships, and factors critical to the success or failure of these alliances. Methods: We used qualitative data collected longitudinally from 2012 to 2017 at 2 ACOs to understand relationships between management partners and ACO providers. The data include 115 semistructured interviews and observational data from 7 site visits. Two coders applied 48 codes to the data. We reviewed coded data for emergent themes in the context of alliance life cycle theory. Findings: Qualitative data revealed that management partners brought specific skills and services and also gave providers confidence in pursuing an ACO. Over time, tension between providers and management partners arose around decision-making authority, distribution of shared savings, and conflicting goals and values. We observed 2 outcomes of partnerships: cemented partnerships and dissolution. Key factors distinguishing alliance outcome in these 2 cases include degree of trust between organizations in the alliance; approach to conflict resolution; distribution of power in the alliance; skills and confidence acquired by the ACO over the life of the alliance; continuity of management partner delivery on promised resources; and proportion of savings going to the management partner. Conclusions: The diverging paths for ACOs with management partners suggest 2 different roles that management partners may play in ACO development. In some cases, management partners may serve as trainers, with the partnership dissolving once the ACO gains skills and confidence to work alone. In other cases, the management partner is a central driver of the ACO and unlikely to break off.Mask use, hand hygiene, and seasonal influenza-like illness among young adults: A randomized intervention trial
AbstractAiello, A. E., Murray, G. F., Perez, V., Coulborn, R. M., Davis, B. M., Uddin, M., Shay, D. K., Waterman, S. H., & Monto, A. S. (n.d.).Publication year
2010Journal title
Journal of Infectious DiseasesVolume
201Issue
4Page(s)
491-498AbstractBackground. During the influenza A(HlNl) pandemic, antiviral prescribing was limited, vaccines were not available early, and the effectiveness of nonpharmaceutical interventions (NPIs) was uncertain. Our study examined whether use of face masks and hand hygiene reduced the incidence of influenza-like illness (ILI). Methods. A randomized intervention trial involving 1437 young adults living in university residence halls during the 2006 2007 influenza season was designed. Residence halls were randomly assigned to 1 of 3 groups face mask use, face masks with hand hygiene, or control for 6 weeks. Generalized models estimated rate ratios for clinically diagnosed or survey-reported ILl weekly and cumulatively. Results. We observed significant reductions in ILl during weeks 4 6 in the mask and hand hygiene group, compared with the control group, ranging from 35% (confidence interval [CI], 9% 53%) to 51% (CI, 13% 73%), after adjusting for vaccination and other covariates. Face mask use alone showed a similar reduction in ILl compared with the control group, but adjusted estimates were not statistically significant. Neither face mask use and hand hygiene nor face mask use alone was associated with a significant reduction in the rate of ILl cumulatively. Conclusions. These findings suggest that face masks and hand hygiene may reduce respiratory illnesses in shared living settings and mitigate the impact of the influenza A(H1N1) pandemic.More than just a communication medium: What older adults say about television and depression
AbstractNguyen, G. T., Wittink, M. N., Murray, G. F., & Barg, F. K. (n.d.).Publication year
2008Journal title
GerontologistVolume
48Issue
3Page(s)
300-310AbstractPurpose: Older adults watch more television than younger people do. Television's role in mental health has been described in the general population, but less is known about how older adults think of television in the context of depression. Design and Methods: Using a semistructured interview created to help clinicians understand how older adults conceptualize depression diagnosis and treatment, we conducted a qualitative study of 102 patients aged 65 years or older. We recruited them from primary care offices and interviewed them in their homes. During our analysis, we found that many respondents offered spontaneous thoughts about the relationship between television and depression. We extracted all television-related content from the interview transcripts and identified themes by using grounded theory. Results: Participants cited television as a way to identify depression in themselves or others (either through overuse or lack of interest) or as a way to cope with depressive symptoms. Some felt that television could be harmful, particularly when content was high in negativity. A substantial number of participants discussed more than one of these themes, and a few mentioned all three. Married people were more likely to discuss television's role in identifying depression. Participants with low education more often mentioned that television could be helpful, whereas those with a history of depression treatment were more likely to discuss television's potential harm. Implications: Researchers should conduct further studies to help them better understand the relationship among depression, television viewing, and individual viewpoints concerning television's role in geriatric depression. An exploration of these issues may yield new approaches to help clinicians address depression in late life.A mixed-methods approach to understanding loneliness and depression in older adults
AbstractBarg, F. K., Huss-Ashmore, R., Wittink, M. N., Murray, G. F., Bogner, H. R., & Gallo, J. J. (n.d.).Publication year
2006Journal title
Journals of Gerontology - Series B Psychological Sciences and Social SciencesVolume
61Issue
6Page(s)
S329-S339AbstractObjectives. Depression in late life may be difficult to identify, and older adults often do not accept depression treatment offered. This article describes the methods by which we combined an investigator-defined definition of depression with a person-derived definition of depression in order to understand how older adults and their primary care providers overlapped and diverged in their ideas about depression. Methods. We recruited a purposive sample of 102 persons aged 65 years and older with and without significant depressive symptoms on a standardized assessment scale (Center for Epidemiologic Studies-Depression scale) from primary care practices and interviewed them in their homes. We applied methods derived from anthropology and epidemiology (consensus analysis, semi-structured interviews, and standardized assessments) in order to understand the experience and expression of late-life depression. Results. Loneliness was highly salient to older adults whom we asked to describe a depressed person or themselves when depressed. Older adults viewed loneliness as a precursor to depression, as self-imposed withdrawal, or as an expectation of aging. In structured interviews, loneliness in the week prior to interview was highly associated with depressive symptoms, anxiety, and hopelessness. Discussion. An improved understanding of how older adults view loneliness in relation to depression, derived from multiple methods, may inform clinical practice.