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Anderson TS, Yeh RW, Herzig SJ, Marcantonio ER, Hatfield LA, Souza J, Landon BE. Trends and Disparities in Ambulatory Follow-Up After Cardiovascular Hospitalizations : A Retrospective Cohort Study. Ann Intern Med 2024; 177:1190-1198. [PMID: 39102715 DOI: 10.7326/m23-3475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Timely follow-up after cardiovascular hospitalization is recommended to monitor recovery, titrate medications, and coordinate care. OBJECTIVE To describe trends and disparities in follow-up after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations. DESIGN Retrospective cohort study. SETTING Medicare. PARTICIPANTS Medicare fee-for-service beneficiaries hospitalized between 2010 and 2019. MEASUREMENTS Receipt of a cardiology visit within 30 days of discharge. Multivariable logistic regression models were used to estimate changes over time overall and across 5 sociodemographic characteristics on the basis of known disparities in cardiovascular outcomes. RESULTS The cohort included 1 678 088 AMI and 4 245 665 HF hospitalizations. Between 2010 and 2019, the rate of cardiology follow-up increased from 48.3% to 61.4% for AMI hospitalizations and from 35.2% to 48.3% for HF hospitalizations. For both conditions, follow-up rates increased for all subgroups, yet disparities worsened for Hispanic patients with AMI and patients with HF who were Asian, Black, Hispanic, Medicaid dual eligible, and residents of counties with higher levels of social deprivation. By 2019, the largest disparities were between Black and White patients (AMI, 51.9% vs. 59.8%, difference, 7.9 percentage points [pp] [95% CI, 6.8 to 9.0 pp]; HF, 39.8% vs. 48.7%, difference, 8.9 pp [CI, 8.2 to 9.7 pp]) and Medicaid dual-eligible and non-dual-eligible patients (AMI, 52.8% vs. 60.4%, difference, 7.6 pp [CI, 6.9 to 8.4 pp]; HF, 39.7% vs. 49.4%, difference, 9.6 pp [CI, 9.2 to 10.1 pp]). Differences between hospitals explained 7.3 pp [CI, 6.7 to 7.9 pp] of the variation in follow-up for AMI and 7.7 pp [CI, 7.2 to 8.1 pp]) for HF. LIMITATION Generalizability to other payers. CONCLUSION Equity-informed policy and health system strategies are needed to further reduce gaps in follow-up care for patients with AMI and patients with HF. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Timothy S Anderson
- Division of General Internal Medicine, University of Pittsburgh, and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (T.S.A.)
| | - Robert W Yeh
- Division of Cardiology and Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts (R.W.Y.)
| | - Shoshana J Herzig
- Harvard Medical School and Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (S.J.H., E.R.M.)
| | - Edward R Marcantonio
- Harvard Medical School and Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (S.J.H., E.R.M.)
| | - Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (L.A.H., J.S.)
| | - Jeffrey Souza
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (L.A.H., J.S.)
| | - Bruce E Landon
- Division of General Medicine, Beth Israel Deaconess Medical Center, and Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (B.E.L.)
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Anderson TS, Herzig SJ, Marcantonio ER, Yeh RW, Souza J, Landon BE. Medicare Transitional Care Management Program and Changes in Timely Postdischarge Follow-Up. JAMA HEALTH FORUM 2024; 5:e240417. [PMID: 38607641 PMCID: PMC11065163 DOI: 10.1001/jamahealthforum.2024.0417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/13/2024] [Indexed: 04/13/2024] Open
Abstract
Importance In 2013, Medicare implemented payments for transitional care management (TCM) services, which provide increased reimbursement to clinicians providing ambulatory care to patients after discharge from medical facilities to the community. Objective To determine whether the introduction of TCM payments was associated with an increase in timely postdischarge follow-up. Design, Setting, and Participants This cross-sectional interrupted time-series study assessed quarterly postdischarge visit rates before (2010-2012) and after (2013-2019) TCM implementation 100% sample of Medicare fee-for-service beneficiaries discharged to the community after a hospital or skilled nursing facility stay. Data analyses were performed February 1 to December 15, 2023. Exposure Implementation of payments for TCM. Main Outcomes and Measures Timely postdischarge primary care follow-up, defined as receipt of a primary care ambulatory visit within 14 days of discharge. Secondary outcomes included receipt of a TCM visit and specialty care follow-up. Results The study sample comprised 79 125 965 eligible discharges. Of these, 55.4% were female; 1.5% were Asian, 12.1% Black, 5.6% Hispanic, and 79.0% were White individuals; and 79.6% were beneficiaries aged 65 years and older. Timely primary care follow-up increased from 31.5% in 2010 to 38.8% in 2019 (absolute increase 7.3%), whereas specialist follow-up increased from 27.6% to 30.8% (absolute increase 3.2%). By 2019, 11.3% of eligible patients received TCM services. Interrupted time-series analyses demonstrated an increased slope of timely primary care follow-up after the introduction of TCM services (pre-TCM slope, 0.12% per quarter vs post-TCM slope, 0.29% per quarter; difference, 0.13%; 95% CI, 0.02% to 0.22%). Receipt of timely follow-up increased for all demographic groups; however, Black, Hispanic, and Medicaid dual-eligible patients and patients residing in urban areas and counties with high-level social deprivation were less likely to receive follow-up during the study period. These disparities widened for Black patients (difference-in-differences in pre-TCM vs post-TCM slope, -0.14%; 95% CI, -0.25% to -0.2%) and patients who were Medicaid dual-eligible (difference-in-differences pre-TCM vs post-TCM slope, -0.21%; 95% CI, -0.35% to -0.07%). Conclusions These findings indicate that Medicare's introduction of payments for TCM services was associated with a persistent increase in the rate of timely postdischarge primary care but did not narrow demographic or socioeconomic disparities. Most beneficiaries did not receive timely primary care follow-up.
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Affiliation(s)
- Timothy S. Anderson
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shoshana J. Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Edward R. Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Robert W. Yeh
- Harvard Medical School, Boston, Massachusetts
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jeffrey Souza
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Bruce E. Landon
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Yordanov D, Oxholm AS, Prætorius T, Kristensen SR. Financial incentives for integrated care: A scoping review and lessons for evidence-based design. Health Policy 2024; 141:104995. [PMID: 38290390 DOI: 10.1016/j.healthpol.2024.104995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 01/11/2024] [Accepted: 01/14/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND In response to the increasing prevalence of people with chronic conditions, healthcare systems restructure to integrate care across providers. However, many systems fail to achieve the desired outcomes. One likely explanation is lack of financial incentives for integrating care. OBJECTIVES We aim to identify financial incentives used to promote integrated care across different types of providers for patients with common chronic conditions and assess the evidence on (cost-)effectiveness and the facilitators/barriers to their implementation. METHODS This scoping review identifies studies published before December 2021, and includes 33 studies from the United States and the Netherlands. RESULTS We identify four types of financial incentives: shared savings, bundled payments, pay for performance, and pay for coordination. Substantial heterogeneity in the (cost-)effectiveness of these incentives exists. Key implementation barriers are a lack of infrastructure (e.g., electronic medical records, communication channels, and clinical guidelines). To facilitate integration, financial incentives should be easy to communicate and implement, and require additional financial support, IT support, training, and guidelines. CONCLUSIONS All four types of financial incentives may promote integrated care but not in all contexts. Shared savings appears to be the most promising incentive type for promoting (cost-)effective care integration with the largest number of favourable studies allowing causal interpretations. The limited evidence pool makes it hard to draw firm conclusions that are transferable across contexts.
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Affiliation(s)
- Dimitar Yordanov
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
| | - Anne Sophie Oxholm
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
| | - Thim Prætorius
- Research Unit for Integrated Care and Prevention, Steno Diabetes Centre Aarhus, Aarhus University Hospital, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark.
| | - Søren Rud Kristensen
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
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Carter AW, Jayawardana S, Costa-Font J, Nasir K, Krumholz HM, Mossialos E. How to Use Quasi-Experimental Methods in Cardiovascular Research: A Review of Current Practice. Circ Cardiovasc Qual Outcomes 2024; 17:e010078. [PMID: 38362765 DOI: 10.1161/circoutcomes.123.010078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND Quasi-experimental methods (QEMs) are a family of techniques used to estimate causal relationships when randomized controlled trials are unfeasible or unethical. They offer a powerful alternative to observational studies by introducing random assignment of individuals or groups into their design, thereby offering stronger means of establishing causation. The use of QEMs in cardiovascular research has not been systematically examined to determine steps toward improving and expanding their use. METHODS We identified 4 main techniques using a systematic search strategy from 2016 to 2021: instrumental variable analysis, interrupted time series analysis, difference-in-differences analysis, and regression discontinuity designs. QEMs are examined as alternatives to randomized controlled trials and traditional observational studies; as more observational data becomes available to researchers, there are more opportunities to apply these techniques. Eligible articles were selected based on publication in high-ranked journals. The quality of eligible articles was appraised using the Joanna Briggs Institute checklist for quasi-experimental studies. RESULTS Data from 380 studies were extracted based on our inclusion criteria. Forty-two of these studies were published in the top 10 medical or top 20 cardiovascular disease journals, and 25 studies were included after quality appraisal. The review identifies the main features and limitations associated with each technique, providing readers with practical guidance on how to apply these to their research. A graphical decision aid was developed to facilitate the routine use of QEMs. CONCLUSIONS The use of QEMs in cardiovascular research published in contemporary, high-impact articles was examined. Findings are biased toward this segment of literature, which represents the latest developments in this growing area of cardiovascular research. The decision aid is a novel schematic that researchers can adopt into practice.
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Affiliation(s)
- Alexander W Carter
- Department of Health Policy, The London School of Economics and Political Science, United Kingdom (A.W.C., S.J., J.C.-F., E.M.)
| | - Sahan Jayawardana
- Department of Health Policy, The London School of Economics and Political Science, United Kingdom (A.W.C., S.J., J.C.-F., E.M.)
| | - Joan Costa-Font
- Department of Health Policy, The London School of Economics and Political Science, United Kingdom (A.W.C., S.J., J.C.-F., E.M.)
| | - Khurram Nasir
- Division of Cardiology, Houston Methodist Hospital, TX (K.N.)
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (H.M.K.)
| | - Elias Mossialos
- Department of Health Policy, The London School of Economics and Political Science, United Kingdom (A.W.C., S.J., J.C.-F., E.M.)
- Centre for Health Policy, The Institute of Global Health Innovation, Imperial College London, United Kingdom (E.M.)
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Li Z, Merrell MA, Eberth JM, Wu D, Hung P. Successes and Barriers of Health Information Exchange Participation Across Hospitals in South Carolina From 2014 to 2020: Longitudinal Observational Study. JMIR Med Inform 2023; 11:e40959. [PMID: 37768730 PMCID: PMC10570901 DOI: 10.2196/40959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 02/15/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The 2009 Health Information Technology for Economic and Clinical Health Act sets three stages of Meaningful Use requirements for the electronic health records incentive program. Health information exchange (HIE) technologies are critical in the meaningful use of electronic health records to support patient care coordination. However, HIE use trends and barriers remain unclear across hospitals in South Carolina (SC), a state with the earliest HIE implementation. OBJECTIVE This study aims to explore changes in the proportion of HIE participation and factors associated with HIE participation, and barriers to exchange and interoperability across SC hospitals. METHODS This study derived data from a longitudinal data set of the 2014-2020 American Hospital Association Information Technology Supplement for 69 SC hospitals. The primary outcome was whether a hospital participated in HIE in a year. A cross-sectional multivariable logistic regression model, clustered at the hospital level and weighted by bed size, was used to identify factors associated with HIE participation. The second outcome was barriers to sending, receiving, or finding patient health information to or from other organizations or hospital systems. The frequency of hospitals reporting each barrier related to exchange and interoperability were then calculated. RESULTS Hospitals in SC have been increasingly participating in HIE, improving from 43% (24/56) in 2014 to 82% (54/66) in 2020. After controlling for other hospital factors, teaching hospitals (adjusted odds ratio [AOR] 3.7, 95% CI 1.0-13.3), system-affiliated hospitals (AOR 6.6, 95% CI 3.2-13.7), and rural referral hospitals (AOR 8.0, 95% CI 1.2-53.4) had higher odds to participate in HIE than their counterparts, whereas critical access hospitals (AOR 0.1, 95% CI 0.02-0.6) were less likely to participate in HIE than their counterparts reimbursed by the prospective payment system. Hospitals with greater ratios of Medicare or Medicaid inpatient days to total inpatient days also reported higher odds of HIE participation. Despite the majority of hospitals reporting HIE participation in 2020, barriers to exchange and interoperability remained, including lack of provider contacts (27/40, 68%), difficulty in finding patient health information (27/40, 68%), adapting different vendor platforms (26/40, 65%), difficulty matching or identifying same patients between systems (23/40, 58%), and providers that do not typically exchange patient data (23/40, 58%). CONCLUSIONS HIE participation has been widely adopted in SC hospitals. Our findings highlight the need to incentivize optimization of HIE and seamless information exchange by facilitating and implementing standardization of health information across various HIE systems and by addressing other technical issues, including providing providers' addresses and training HIE stakeholders to find relevant information. Policies and efforts should include more collaboration with vendors to reduce platform compatibility issues and more user engagement and technical training and support to facilitate effective, accurate, and efficient exchange of provider contacts and patient health information.
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Affiliation(s)
- Zhong Li
- Department of Public Administration, School of Health Policy and Management, Nanjing Medical University, Nanjing, China
| | - Melinda A Merrell
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
- Rural and Minority Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Jan M Eberth
- Rural and Minority Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
- Department of Health Management and Policy, Drexel University, Philadelphia, PA, United States
| | - Dezhi Wu
- Department of Integrated Information Technology, College of Engineering and Computing, University of South Carolina, Columbia, SC, United States
| | - Peiyin Hung
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
- Rural and Minority Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
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Hamilton WG, Sershon RA, Gupta A, Goldstein L, Kabiri M, Holy CE, Diaz R. Readmission rate and healthcare utilization outcomes of computer-assisted fluoroscopy-based hip navigation versus manual total hip arthroplasty. Expert Rev Med Devices 2023; 20:779-789. [PMID: 37466357 DOI: 10.1080/17434440.2023.2238609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/17/2023] [Accepted: 06/23/2023] [Indexed: 07/20/2023]
Abstract
INTRODUCTION The study evaluates the technology of fluoroscopy-based hip navigation that has shown to improve implant positioning in total hip arthroplasty (THA). METHODS Premier Healthcare data for patients undergoing manual THA or fluoroscopy-based hip navigation THA between 1 January 2016-30 September 2021, were analyzed 90- and 365-day post-THA. The primary outcome was inpatient readmission. Secondary outcomes were operating room (OR) time, length of stay, discharge status, and hospital costs. Baseline covariate differences were balanced using fine stratification and analyzed using generalized linear models. RESULTS Among 4,080 fluoroscopy-based hip navigation THA and 429,533 manual THA balanced patients, hip-related readmission rates were statistically significantly lower for the fluoroscopy-based hip navigation THA cohort vs. manual THA for both 90-day (odd ratio [95% CI]: 0.69 [0.52 to 0.91] and 365-day (0.63 [0.49 to 0.81] follow-up. OR time was higher with fluoroscopy-based hip navigation THA vs. manual THA (134.65 vs. 132.04 minutes); however, fluoroscopy-based hip navigation THA patients were more likely to be discharged to home (93.73% vs. 90.11%) vs. manual THA. Hospital costs were not different between cohorts at 90- and 365-day post-operative. CONCLUSIONS Fluoroscopy-based hip navigation THA resulted in fewer readmissions, greater discharge to home, and similar hospital costs compared to manual THA.
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Affiliation(s)
| | | | - Anshu Gupta
- Epidemiology & Real-World Data Sciences, Johnson & Johnson MedTech, New Brunswick, NJ, USA
| | - Laura Goldstein
- DePuy Synthes Digital, Robotics & Emerging Channels, Raynham, MA, USA
| | - Mina Kabiri
- DePuy Synthes Digital, Robotics & Emerging Channels, Raynham, MA, USA
| | - Chantal E Holy
- Epidemiology & Real-World Data Sciences, Johnson & Johnson MedTech, New Brunswick, NJ, USA
| | - Rodrigo Diaz
- DePuy Synthes, Medical Affairs, Palm Beach Gardens, FL, USA
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Khera R, Kondamudi N, Liu M, Ayers C, Spatz ES, Rao S, Essien UR, Powell-Wiley TM, Nasir K, Das SR, Capers Q, Pandey A. Lifetime healthcare expenses across demographic and cardiovascular risk groups: The application of a novel modeling strategy in a large multiethnic cohort study. Am J Prev Cardiol 2023; 14:100493. [PMID: 37397263 PMCID: PMC10314135 DOI: 10.1016/j.ajpc.2023.100493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/16/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023] Open
Abstract
Objective To understand the burden of healthcare expenses over the lifetime of individuals and evaluate differences among those with cardiovascular risk factors and among disadvantaged groups based on race/ethnicity and sex. Methods We linked data from the longitudinal multiethnic Dallas Heart Study, which recruited participants between 2000 and 2002, with inpatient and outpatient claims from all hospitals in the Dallas-Fort Worth metroplex through December 2018, capturing encounter expenses. Race/ethnicity and sex, as well as five risk factors, hypertension, diabetes, hyperlipidemia, smoking, and overweight/obesity, were defined at cohort enrollment. For each individual, expenses were indexed to age and cumulated between 40 and 80 years of age. Lifetime expenses across exposures were evaluated as interactions in generalized additive models. Results A total of 2184 individuals (mean age, 45±10 years; 61% women, 53% Black) were followed between 2000 and 2018. The mean modeled lifetime cumulative healthcare expenses were $442,629 (IQR, $423,850 to $461,408). In models that included 5 risk factors, Black individuals had $21,306 higher lifetime healthcare spending compared with non-Black individuals (P < .001), and men had modestly higher expenses than women ($5987, P < .001). Across demographic groups, the presence of risk factors was associated with progressively higher lifetime expenses, with significant independent association of diabetes ($28,075, P < .001), overweight/obesity ($8816, P < .001), smoking ($3980, P = .009), and hypertension ($528, P = .02) with excess spending. Conclusion Our study suggests Black individuals have higher lifetime healthcare expenses, exaggerated by the substantially higher prevalence of risk factors, with differences emerging in older age.
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Affiliation(s)
- Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, United States
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, 60 College St, New Haven, CT, United States
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, United States
| | - Nitin Kondamudi
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Mengni Liu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, United States
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, United States
| | - Colby Ayers
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Erica S Spatz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, United States
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, United States
| | - Shreya Rao
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, United States
| | - Utibe R Essien
- Department of Medicine, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA, United States
| | - Tiffany M Powell-Wiley
- Social Determinants of Obesity and Cardiovascular Risk Laboratory, Cardiovascular Branch, National Heart, Lung, and Blood Institute, NIH, 3131 Center Drive, Bethesda, MD, United States
- Intramural Research Program, National Institute on Minority Health and Health Disparities, NIH, 6707 Democracy Boulevard, Suite 800, Bethesda, MD, United States
| | - Khurram Nasir
- Department of Cardiology, Houston Methodist, 6565 Fannin St, Houston, TX, United States
| | - Sandeep R Das
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Quinn Capers
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
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He W, Li M, Cao L, Liu R, You J, Jing F, Zhang J, Zhang W, Feng M. Introducing value-based healthcare perspectives into hospital performance assessment: A scoping review. J Evid Based Med 2023. [PMID: 37228246 DOI: 10.1111/jebm.12534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/18/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Value-based healthcare (VBHC) puts patient outcomes at the center of the healthcare process while optimizing the use of hospital resources across multiple stakeholders. This scoping review was conducted to summarize how VBHC had been represented in theory and in practice, how it had been applied to assess hospital performance, and how well it had been ultimately implemented. METHODS For this review, we followed the PRISMA-ScR protocol and searched five major online databases for articles published between January 2006 and July 2022. We included original articles that used the concept of VBHC to conduct performance assessments of healthcare organizations. We extracted and analyzed key concepts and information on the dimensions of VBHC, specific strategies and methods for using VBHC in performance assessment, and the effectiveness of the assessment. RESULTS We identified 48 eligible studies from 7866 articles. Nineteen nonempirical studies focused on the development of a VBHC performance assessment indicator system, and 29 empirical studies reported on the ways and points of introducing VBHC into performance assessment and its effectiveness. Ultimately, we summarized the key dimensions, processes, and effects of performance assessment after introducing VBHC. CONCLUSION Current healthcare performance assessment has begun to focus on implementing VBHC as an integrated strategy, and future work should further clarify the reliability of metrics and their association with evaluation outcomes and consider the effective integration of clinical outcomes and patient-reported outcomes.
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Affiliation(s)
- Wenbo He
- Institute of Hospital Management, West China Hospital of Sichuan University, Chengdu, China
- Saw Swee Hock School of Public Health and Institute of Data Science, National University of Singapore, Singapore
| | - Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Liujiao Cao
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Rui Liu
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jiuhong You
- School of Rehabilitation Sciences, West China Hospital of Sichuan University, Chengdu, China
| | - Fangyuan Jing
- Basic Discipline of Chinese and Western Integrative, West China Hospital, Sichuan University, Chengdu, China
| | - Jiawen Zhang
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Wei Zhang
- West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu, China
| | - Mengling Feng
- Saw Swee Hock School of Public Health and Institute of Data Science, National University of Singapore, Singapore
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Ying M, Temkin-Greener H, Thirukumaran CP, Joynt Maddox KE, Holloway RG, Li Y. Skilled Nursing Facility Participation in Bundled Payments Was Related to Small Increases in Nurse Staffing Levels. J Appl Gerontol 2023; 42:456-463. [PMID: 36321398 DOI: 10.1177/07334648221137060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
Medicare implemented Bundled Payments for Care Improvement (BPCI) Model 3 in 2013, in which participating skilled nursing facilities (SNFs) were accountable for episode costs. We performed comparative interrupted time series analyses to evaluate associations between SNF BPCI participation and nurse staffing levels, using Medicare claims, resident assessments, and facility-level and market-level files of 2010-2017. For persistent-participating SNFs, BPCI was associated with improved certified nursing assistant (CNA) staffing levels (differential change = .03 hours, p = .025). However, BPCI was not related to changes in registered nurse (RN) and all licensed nurse hours, and nurse skill mix. Among drop-out SNFs, BPCI was associated with increased RN staffing levels (differential change = .02 hours, p = .009), leading to a higher nurse skill ratio (0.51 percentage points, p = .016) than control SNFs. Bundled payments for care improvement had no impact on CNA and all licensed nurse staffing levels. In conclusion, BPCI was associated with statistically significant but small increases in nurse staffing levels.
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Affiliation(s)
- Meiling Ying
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, 6923University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Department of Urology, Dow Division of Health Services Research, 12266University of Michigan Medical School, Ann Arbor, MI, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, 6923University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Caroline P Thirukumaran
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, 6923University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Department of Orthopaedics, 6923University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, 12275Washington University School of Medicine, St Louis, MI, USA
- Center for Health Economics and Policy, 12275Institute for Public Health at Washington University in St Louis, St. Louis, Missouri, USA
| | - Robert G Holloway
- Department of Neurology, 6923University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, 6923University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Enumah SJ, Sundt TM, Chang DC. Association of Measured Quality and Future Financial Performance Among Hospitals Performing Cardiac Surgery. J Healthc Manag 2022; 67:367-379. [PMID: 36074700 DOI: 10.1097/jhm-d-21-00262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
GOAL For decades, hospitals performing cardiac surgery have carried the cost of implementing quality improvement activities and reporting quality outcomes. However, the financial return of such investments is unclear, which weakens the incentive for hospitals to invest in quality improvement activities. This study explored the relationship between a hospital's measured quality and its financial performance. METHODS Using data from the American Hospital Association and Hospital Compare from 2014 to 2018, we performed an observational study of hospitals performing cardiac surgery. We used mixed-effects regression models with fixed-year effects and random intercepts to explore associations between measured quality and hospital financial performance. Our dependent variables were margins (profit divided by revenue) and financial distress; our independent variables included Patient Safety Indicator 90 (PSI-90) and hospital characteristics. PRINCIPAL FINDINGS Our sample included 4,927 hospital-years from 1,209 unique hospitals. Hospitals in the worst-performing PSI-90 score quartile experienced a lower operating margin (-1.26%, 95% CI [-2.10 to -0.41], p = .004), a lower total margin (-0.92%, 95% CI [-1.66 to -0.17], p = .016), and an increased odds of financial distress in the next year (OR: 2.12, 95% CI [1.36-3.30], p = .001) when compared with the best-performing hospitals. PRACTICAL APPLICATIONS Our exploration into financial distress provides managers with a better understanding of the relationship between a hospital's measured quality and its financial position. In reflecting on our findings, hospital leaders may consider viewing patient safety as a modifiable factor that can improve their organization's overall financial health. Our findings suggest that excellent safety performance may be both financially and clinically beneficial to hospitals.
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Affiliation(s)
- Samuel J Enumah
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Thoralf M Sundt
- Harvard Medical School Division of Cardiac Surgery and Corrigan Minehan Heart Center at Massachusetts General Hospital, Boston, Massachusetts
| | - David C Chang
- Massachusetts General Hospital and Harvard Medical School, Codman Center for Clinical Effectiveness in Surgery, Boston, Massachusetts
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Waters TM, Burns N, Kaplan CM, Graetz I, Benitez J, Cardarelli R, Daniels MJ. Combined impact of Medicare's hospital pay for performance programs on quality and safety outcomes is mixed. BMC Health Serv Res 2022; 22:958. [PMID: 35902910 PMCID: PMC9330620 DOI: 10.1186/s12913-022-08348-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/19/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Three major hospital pay for performance (P4P) programs were introduced by the Affordable Care Act and intended to improve the quality, safety and efficiency of care provided to Medicare beneficiaries. The financial risk to hospitals associated with Medicare's P4P programs is substantial. Evidence on the positive impact of these programs, however, has been mixed, and no study has assessed their combined impact. In this study, we examined the combined impact of Medicare's P4P programs on clinical areas and populations targeted by the programs, as well as those outside their focus. METHODS We used 2007-2016 Healthcare Cost and Utilization Project State Inpatient Databases for 14 states to identify hospital-level inpatient quality indicators (IQIs) and patient safety indicators (PSIs), by quarter and payer (Medicare vs. non-Medicare). IQIs and PSIs are standardized, evidence-based measures that can be used to track hospital quality of care and patient safety over time using hospital administrative data. The study period of 2007-2016 was selected to capture multiple years before and after introduction of program metrics. Interrupted time series was used to analyze the impact of the P4P programs on study outcomes targeted and not targeted by the programs. In sensitivity analyses, we examined the impact of these programs on care for non-Medicare patients. RESULTS Medicare P4P programs were not associated with consistent improvements in targeted or non-targeted quality and safety measures. Moreover, mortality rates across targeted and untargeted conditions were generally getting worse after the introduction of Medicare's P4P programs. Trends in PSIs were extremely mixed, with five outcomes trending in an expected (improving) direction, five trending in an unexpected (deteriorating) direction, and three with insignificant changes over time. Sensitivity analyses did not substantially alter these results. CONCLUSIONS Consistent with previous studies for individual programs, we detect minimal, if any, effect of Medicare's hospital P4P programs on quality and safety. Given the growing evidence of limited impact, the administrative cost of monitoring and enforcing penalties, and potential increase in mortality, CMS should consider redesigning their P4P programs before continuing to expand them.
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Affiliation(s)
- Teresa M. Waters
- grid.266539.d0000 0004 1936 8438Department of Health Management and Policy, University of Kentucky College of Public Health, 111 Washington, Avenue, KY 40536 Lexington, USA
| | - Natalie Burns
- grid.15276.370000 0004 1936 8091Department of Statistics, University of Florida, 102 Griffin-Floyd Hall, PO Box 118545, 32611 Gainesville, FL USA
| | - Cameron M. Kaplan
- grid.42505.360000 0001 2156 6853Department of Medicine, University of Southern California Keck School of Medicine, 2020 Zonal Ave. IRD 306, 90089 Los Angeles, CA USA
| | - Ilana Graetz
- grid.189967.80000 0001 0941 6502Department of Health Policy and Management, Emory University School of Public Health, 1518 Clifton Road NE, 30322 Atlanta, GA USA
| | - Joseph Benitez
- grid.266539.d0000 0004 1936 8438Department of Health Management and Policy, University of Kentucky College of Public Health, 111 Washington, Avenue, KY 40536 Lexington, USA
| | - Roberto Cardarelli
- grid.266539.d0000 0004 1936 8438Department of Family Medicine, University of Kentucky College of Medicine, 2195 Harrodsburg Road, Suite 125, 40504 Lexington, KY USA
| | - Michael J. Daniels
- grid.15276.370000 0004 1936 8091Department of Statistics, University of Florida, 102 Griffin-Floyd Hall, PO Box 118545, 32611 Gainesville, FL USA
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Probst MA, Janke AT, Haimovich AD, Venkatesh AK, Lin MP, Kocher KE, Nemnom MJ, Thiruganasambandamoorthy V. Development of a Novel Emergency Department Quality Measure to Reduce Very Low-Risk Syncope Hospitalizations. Ann Emerg Med 2022; 79:509-517. [PMID: 35487840 PMCID: PMC9117517 DOI: 10.1016/j.annemergmed.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE Emergency department (ED) evaluations for syncope are common, representing 1.3 million annual US visits and $2 billion in related hospitalizations. Despite evidence supporting risk stratification and outpatient management, variation in syncope hospitalization rates persist. We sought to develop a new quality measure for very low-risk adult ED patients with syncope that could be applied to administrative data. METHODS We developed this quality measure in 2 phases. First, we used an existing prospective, observational ED patient data set to identify a very low-risk cohort with unexplained syncope using 2 variables: age less than 50 years and no history of heart disease. We then applied this to the 2019 Nationwide Emergency Department Sample (NEDS) to assess its potential effect, assessing for hospital-level factors associated with hospitalization variation. RESULTS Of the 8,647 adult patients in the prospective cohort, 3,292 (38%) patients fulfilled these 2 criteria: age less than 50 years and no history of heart disease. Of these, 15 (0.46%) suffered serious adverse events within 30 days. In the NEDS, there were an estimated 566,031 patients meeting these 2 criteria, of whom 15,507 (2.7%; 95% confidence interval [CI] 2.48% to 3.00%) were hospitalized. We found substantial variation in the hospitalization rates for this very low-risk cohort, with a median rate of 1.7% (range 0% to 100%; interquartile range 0% to 3.9%). Factors associated with increased hospitalization rates included a yearly ED volume of more than 80,000 (odds ratio [OR] 3.14; 95% CI 2.02 to 4.89) and metropolitan teaching status (OR 1.5; 95% CI 1.24 to 1.81). CONCLUSION In summary, our novel syncope quality measure can assess variation in low-value hospitalizations for unexplained syncope. The application of this measure could improve the value of syncope care.
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Affiliation(s)
- Marc A Probst
- Department of Emergency Medicine, Columbia University Medical Center, New York, NY.
| | - Alexander T Janke
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Adrian D Haimovich
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Michelle P Lin
- Department of Emergency Medicine and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Keith E Kocher
- Department of Emergency Medicine and Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Abstract
PURPOSE OF REVIEW The past decade has brought increased efforts to better understand causes for ACS readmissions and strategies to minimize them. This review seeks to provide a critical appraisal of this rapidly growing body of literature. RECENT FINDINGS Prior to 2010, readmission rates for patients suffering from ACS remained relatively constant. More recently, several strategies have been implemented to mitigate this including improved risk assessment models, transition care bundles, and development of targeted programs by federal organizations and professional societies. These strategies have been associated with a significant reduction in ACS readmission rates in more recent years. With this, improvements in 30-day post-discharge mortality rates are also being appreciated. As we continue to expand our knowledge on independent risk factors for ACS readmissions, further strategies targeting at-risk populations may further decrease the rate of readmissions. Efforts to understand and reduce 30-day ACS readmission rates have resulted in overall improved quality of care for patients.
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Enumah SJ, Resnick AS, Chang DC. Association of measured quality with financial health among U.S. hospitals. PLoS One 2022; 17:e0266696. [PMID: 35443004 PMCID: PMC9020707 DOI: 10.1371/journal.pone.0266696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 03/24/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND High-quality care is a clear objective for hospital leaders, but hospitals must balance investing in quality with financial stability. Poor hospital financial health can precipitate closure, limiting patients' access to care. Whether hospital quality is associated with financial health remains poorly understood. The objective of this study was to compare financial performance at high-quality and low-quality hospitals. METHODS We performed a retrospective observational cohort study of U.S. hospitals using the American Hospital Association and Hospital Compare datasets for years 2013 to 2018. We used multilevel mixed-effects linear and logistic regression models with fixed year effects and random intercepts for hospitals to identify associations between hospitals' measured quality outcomes-30-day hospital-wide readmission rate and the patient safety indicator-90 (PSI-90)-and their financial margins and risk of financial distress in the same year and the subsequent year. Our sample included 20,919 observations from 4,331 unique hospitals. RESULTS In 2018, the median 30-day readmission rate was 15.2 (interquartile range [IQR] 14.8-15.6), the median PSI-90 score was 0.96 (IQR 0.89-1.07), the median operating margin was -1.8 (IQR -9.7-5.9), and 750 (22.7%) hospitals experienced financial distress. Hospitals in the best quintile of readmission rates experienced higher operating margins (+0.95%, 95% CI [0.51-1.39], p < .001) and lower odds of distress (odds ratio [OR] 0.56, 95% CI [0.45-0.70], p < .001) in the same year as compared to hospitals in the worst quintile. Hospitals in the best quintile of PSI-90 had higher operating margins (+0.62%, 95% CI [0.17-1.08], p = .007) and lower odds of financial distress (OR 0.70, 95% CI [0.55-0.89], p = .003) as compared to hospitals in the worst quintile. The results were qualitatively similar for the same-year and lag-year analyses. CONCLUSION Hospitals that deliver high-quality outcomes may experience superior financial performance compared to hospitals with poor-quality outcomes.
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Affiliation(s)
- Samuel J. Enumah
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Andrew S. Resnick
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Quality and Safety, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - David C. Chang
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Codman Center for Clinical Effectiveness in Surgery, Boston, Massachusetts, United States of America
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Peckham A, Rudoler D, Bhatia D, Allin S, Abdelhalim R, Marchildon GP. What Can Canada Learn From Accountable Care Organizations: A Comparative Policy Analysis. Int J Integr Care 2022; 22:1. [PMID: 35480852 PMCID: PMC8992768 DOI: 10.5334/ijic.5677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/15/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Accountable Care Organizations (ACOs), implemented in the United States (US), aim to reduce costs and integrate care by aligning incentives among providers and payers. Canadian governments are interested adopting such models to integrate care, though comparative studies assessing the applicability and transferability of ACOs in Canada are lacking. In this comparative study, we performed a narrative literature review to examine how Canadian health systems could support ACO models. Methods We reviewed empirical studies (published 2011-2020) that evaluated ACO impacts in the US. Thematic analysis and critical appraisal were performed to identify factors associated with positive ACO impacts. These factors were compared with the Canadian context to assess the applicability and transferability of ACO models within Canada. Findings Physician-led models, global budgets and financial incentives, and focus on collaborative care may optimize ACO impacts. While reforms towards alternative payments and team-based care are not unprecedented in Canada, significant further reforms to physician remuneration, intersectoral collaboration, and accountability for performance are required to support ACO-like models. Conclusion This comparative study uncovered several insights on the applicability and transferability of ACOs to the Canadian context. Further comparative research outside the US is needed to infer the essential components of successful ACO models.
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Affiliation(s)
- Allie Peckham
- Center for Innovation in Healthy and Resilient Aging, Edson College of Nursing and Health Innovation, Arizona State University, 550 North 3rd St, Phoenix, Arizona, 85004, USA
- North American Observatory on Health Systems and Policies, 155 College St, Suite 425, Toronto, Ontario M5T 3M6, Canada
| | - David Rudoler
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, Suite 425, Toronto, Ontario M5T 3M6, Canada
- Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe St N, Unit UA3000, Oshawa, Ontario L1H 7K4, Canada
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell St, Toronto, Ontario M5S 2S1, Canada
| | - Dominika Bhatia
- North American Observatory on Health Systems and Policies, 155 College St, Suite 425, Toronto, Ontario M5T 3M6, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, Suite 425, Toronto, Ontario M5T 3M6, Canada
| | - Sara Allin
- North American Observatory on Health Systems and Policies, 155 College St, Suite 425, Toronto, Ontario M5T 3M6, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, Suite 425, Toronto, Ontario M5T 3M6, Canada
| | - Reham Abdelhalim
- North American Observatory on Health Systems and Policies, 155 College St, Suite 425, Toronto, Ontario M5T 3M6, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, Suite 425, Toronto, Ontario M5T 3M6, Canada
| | - Gregory P. Marchildon
- North American Observatory on Health Systems and Policies, 155 College St, Suite 425, Toronto, Ontario M5T 3M6, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, Suite 425, Toronto, Ontario M5T 3M6, Canada
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Adler-Milstein J, Linden A, Hollingsworth JM, Ryan AM. Association of Primary Care Engagement in Value-Based Reform Programs With Health Services Outcomes: Participation and Synergies. JAMA HEALTH FORUM 2022; 3:e220005. [PMID: 35977280 PMCID: PMC8903108 DOI: 10.1001/jamahealthforum.2022.0005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 01/06/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Policy makers envision synergistic benefits from primary care reform programs that advance infrastructure and processes in the context of a supportive payment environment. However, these programs have been operationalized and implemented separately, raising the question of whether synergies are achieved. Objective To evaluate associations between primary care engagement in voluntary delivery system and/or payment reform programs and health services outcomes. Design Setting and Participants This was an observational longitudinal analysis of US ambulatory primary care organizations (PCOs) with attributed Medicare fee-for-service beneficiaries (1.6-1.9 million unique beneficiaries annually) using data for 2009, 2010, and 2015 to 2017; PCOs included multispecialty practices that delivered primary care. Data analyses were performed from January 2020 to December 2021. Exposures Annual PCO participation in or recognition by (1) the Centers for Medicare & Medicaid's meaningful use (MU) program, (2) the National Committee for Quality Assurance's Patient-Centered Medical Home (PCMH) program, and/or (3) the Medicare Shared Savings Program (MSSP), an Accountable Care Organizations program. Main Outcomes and Measures Independent and joint associations between an additional year of participation by a PCO in each of the 3 reform programs, and 3 types of outcomes: (1) hospital utilization (all-cause admissions, ambulatory care sensitive admissions, all-cause readmissions, all-cause emergency department visits); (2) evidence-based diabetes guideline adherence (≥1 annual glycated hemoglobin test, low-density lipoprotein cholesterol test, nephropathy screening, and eye examination); and (3) Medicare spending (total, acute inpatient, and skilled nursing facility). Results The study sample comprised 47 880 unique PCOs (size ≤10 beneficiaries, 50%; ≤1-2 clinicians, 65%) and approximately 5.61 million unique Medicare beneficiaries (mean [SD] age, 71.4 [12.7] years; 3 207 568 [57.14%] women; 4 474 541 [79.71%] non-Hispanic White individuals) across the study years (2009, 2010, 2015-2017). Of the hospital utilization measures, only ambulatory care sensitive admission was associated with improved performance, showing a statistically significant marginal effect size for joint participation in MU and MSSP (-0.0002; 95% CI, -0.0005 to 0.0000) and MSSP alone (-0.0003; 95% CI, -0.0005 to -0.0001). For diabetes adherence, joint participation in PCMH and MU was associated with 0.06 more measures met (95% CI, 0.03 to 0.10) while participation in all 3 programs was associated with 0.05 more measures met (95% CI, 0.02 to 0.09). Stand-alone PCMH and stand-alone MU participation were also associated with improved performance. Joint participation in MU and MSSP was associated with $33.89 lower spending (95% CI, -$65.79 to -$1.99) as was stand-alone MSSP participation (-$37.04; 95% CI, -$65.73 to -$8.35). Conclusions and Relevance This longitudinal observational study found that participation by PCOs in single or multiple reform programs was associated with better performance for only a subset of health services outcomes. More consistent and larger synergies may be realized with improved alignment of program requirements and goals.
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Affiliation(s)
- Julia Adler-Milstein
- Department of Medicine, University of California, San Francisco
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco
| | - Ariel Linden
- Department of Medicine, University of California, San Francisco
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco
| | | | - Andrew M. Ryan
- Health Management and Policy, Center for Evaluating Health Reform, School of Public Health, University of Michigan, Ann Arbor
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Moret A, Madelaine L, Cottenet J, Sophie Mariet A, Quantin C, Bernard A, Pagès PB. [Readmissions after lung resection in France: The PMSI database]. Rev Mal Respir 2021; 38:673-680. [PMID: 34175166 DOI: 10.1016/j.rmr.2021.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Readmission within 30 days is an indicator of the quality of care, because it often reflects post-discharge care that is not optimal. The objective of this work is to measure over time on the one hand the readmission rate and on the other hand the number of hospitals with a standardized readmission rate beyond the national average. METHOD All patients with major pulmonary resection for lung cancer in France were extracted from the PMSI national database. Readmission within 30 days was defined as any new hospitalization either in the same hospital or in another establishment. RESULTS From January 1, 2005 to December 31, 2018, 110,603 patients were included. The 30-day all-cause readmissions rate was 24.9% (n=27,540). Patients after pneumonectomy had a readmission rate of 37% (n=4918) and 23% after lobectomy (n=2684) (P<0.0001). For the first period, we counted 10 hospitals with a standardized readmissions rate above the 99.8 limit and 10 hospitals above the 95% limit. For the second period, 8 hospitals had a standardized readmission rate above the 99.8% limit and 11 hospitals above the 95% limit. For the third period, 7 hospitals had a standardized readmission rate above the 99.8% limit and 6 hospitals above the 95% limit. CONCLUSION Readmissions to hospital 30 days after major lung resection for cancer in France declined little during these three periods. Measures to prevent readmissions should be introduced.
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Affiliation(s)
- A Moret
- Service de chirurgie thoracique et cardio-vasculaire, CHU Dijon, Dijon, France
| | - L Madelaine
- Service de chirurgie thoracique et cardio-vasculaire, CHU Dijon, Dijon, France; Inserm UMR 1231, université de Bourgogne, Dijon, France
| | - J Cottenet
- Departement de biostatistique, CHU Bocage, Université de Bourgogne, Dijon, France
| | - A Sophie Mariet
- Departement de biostatistique, CHU Bocage, Université de Bourgogne, Dijon, France
| | - C Quantin
- Departement de biostatistique, CHU Bocage, Université de Bourgogne, Dijon, France; Inserm, CIC 1432, Centre d'investigation clinique, hôpital de Dijon, université de Bourgogne, Dijon, France; Inserm, UVSQ, Institut Pasteur, université Paris-Saclay, Paris, France
| | - A Bernard
- Service de chirurgie thoracique et cardio-vasculaire, CHU Dijon, Dijon, France.
| | - P B Pagès
- Service de chirurgie thoracique et cardio-vasculaire, CHU Dijon, Dijon, France; Inserm UMR 1231, université de Bourgogne, Dijon, France
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Elysee G, Yu H, Herrin J, Horwitz LI. Association between 30-day readmission rates and health information technology capabilities in US hospitals. Medicine (Baltimore) 2021; 100:e24755. [PMID: 33663091 PMCID: PMC7909153 DOI: 10.1097/md.0000000000024755] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/17/2020] [Accepted: 01/25/2021] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT Health information technology (IT) is often proposed as a solution to fragmentation of care, and has been hypothesized to reduce readmission risk through better information flow. However, there are numerous distinct health IT capabilities, and it is unclear which, if any, are associated with lower readmission risk.To identify the specific health IT capabilities adopted by hospitals that are associated with hospital-level risk-standardized readmission rates (RSRRs) through path analyses using structural equation modeling.This STROBE-compliant retrospective cross-sectional study included non-federal U.S. acute care hospitals, based on their adoption of specific types of health IT capabilities self-reported in a 2013 American Hospital Association IT survey as independent variables. The outcome measure included the 2014 RSRRs reported on Hospital Compare website.A 54-indicator 7-factor structure of hospital health IT capabilities was identified by exploratory factor analysis, and corroborated by confirmatory factor analysis. Subsequent path analysis using Structural equation modeling revealed that a one-point increase in the hospital adoption of patient engagement capability latent scores (median path coefficient ß = -0.086; 95% Confidence Interval, -0.162 to -0.008), including functionalities like direct access to the electronic health records, would generally lead to a decrease in RSRRs by 0.086%. However, computerized hospital discharge and information exchange capabilities with other inpatient and outpatient providers were not associated with readmission rates.These findings suggest that improving patient access to and use of their electronic health records may be helpful in improving hospital performance on readmission; however, computerized hospital discharge and information exchange among clinicians did not seem as beneficial - perhaps because of the quality or timeliness of information transmitted. Future research should use more recent data to study, not just adoption of health IT capabilities, but also whether their usage is associated with lower readmission risk. Understanding which capabilities impact readmission risk can help policymakers and clinical stakeholders better focus their scarce resources as they invest in health IT to improve care delivery.
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Affiliation(s)
- Gerald Elysee
- Health Information Technology Programs, Benjamin Franklin Institute of Technology, Boston, MA
| | - Huihui Yu
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven
| | - Jeph Herrin
- Section of Cardiology, Department of Internal Medicine, Yale School of Medicine, New Haven, New Haven, CT
| | - Leora I. Horwitz
- Division of Healthcare Delivery Science, Department of Population Health, Center for Healthcare Innovation and Delivery Science, New York University Grossman School of Medicine, New York, NY
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Buhr RG, Jackson NJ, Kominski GF, Dubinett SM, Mangione CM, Ong MK. Readmission Rates for Chronic Obstructive Pulmonary Disease Under the Hospital Readmissions Reduction Program: an Interrupted Time Series Analysis. J Gen Intern Med 2020; 35:3581-3590. [PMID: 32556878 PMCID: PMC7728926 DOI: 10.1007/s11606-020-05958-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/04/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Hospital readmission rates decreased for myocardial infarction (AMI), heart failure (CHF), and pneumonia with implementation of the first phase of the Hospital Readmissions Reduction Program (HRRP). It is not established whether readmissions fell for chronic obstructive pulmonary disease (COPD), an HRRP condition added in 2014. OBJECTIVE We sought to determine whether HRRP penalties influenced COPD readmissions among Medicare, Medicaid, or privately insured patients. DESIGN We analyzed a retrospective cohort, evaluating readmissions across implementation periods for HRRP penalties ("pre-HRRP" January 2010-April 2011, "implementation" May 2011-September 2012, "partial penalty" October 2012-September 2014, and "full penalty" October 2014-December 2016). PATIENTS We assessed discharged patients ≥ 40 years old with COPD versus those with HRRP Phase 1 conditions (AMI, CHF, and pneumonia) or non-HRRP residual diagnoses in the Nationwide Readmissions Database. INTERVENTIONS HRRP was announced and implemented during this period, forming a natural experiment. MEASUREMENTS We calculated differences-in-differences (DID) for 30-day COPD versus HRRP Phase 1 and non-HRRP readmissions. KEY RESULTS COPD discharges for 1.2 million Medicare enrollees were compared with 22 million non-HRRP and 3.4 million HRRP Phase 1 discharges. COPD readmissions decreased from 19 to 17% over the study. This reduction was significantly greater than non-HRRP conditions (DID - 0.41%), but not HRRP Phase 1 (DID + 0.02%). A parallel trend was observed in the privately insured, with significant reduction compared with non-HRRP (DID - 0.83%), but not HRRP Phase 1 conditions (DID - 0.45%). Non-significant reductions occurred in Medicaid (DID - 0.52% vs. non-HRRP and - 0.21% vs. Phase 1 conditions). CONCLUSIONS In Medicare, HRRP implementation was associated with reductions in COPD readmissions compared with non-HRRP controls but not versus other HRRP conditions. Parallel findings were observed in commercial insurance, but not in Medicaid. Condition-specific penalties may not reduce readmissions further than existing HRRP trends.
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Affiliation(s)
- Russell G Buhr
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA.
- Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, USA.
- Center for the Study of Healthcare Innovation, Implementation, and Policy, Health Services Research & Development, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, USA.
| | - Nicholas J Jackson
- Department of Medicine Statistics Core, University of California, Los Angeles, Los Angeles, CA, USA
| | - Gerald F Kominski
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
- Center for Health Policy Research, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Steven M Dubinett
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, USA
| | - Carol M Mangione
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Michael K Ong
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, USA
- Center for the Study of Healthcare Innovation, Implementation, and Policy, Health Services Research & Development, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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20
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Palmer AM, Rojewski AM, Chen LS, Fucito LM, Galiatsatos P, Kathuria H, Land SR, Morgan GD, Ramsey AT, Richter KP, Wen X, Toll BA. Tobacco Treatment Program Models in US Hospitals and Outpatient Centers on Behalf of the SRNT Treatment Network. Chest 2020; 159:1652-1663. [PMID: 33259805 DOI: 10.1016/j.chest.2020.11.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 01/13/2023] Open
Abstract
Because tobacco use remains one of the leading causes of disease, disability, and mortality, tobacco treatment programs should be integrated into medical systems such as hospitals and outpatient centers. Medical providers have a unique, high-impact opportunity to initiate smoking cessation treatment with patients. However, there are several barriers that may hinder the development and implementation of these programs. The purpose of this review was to address such barriers by illustrating several examples of successful tobacco treatment programs in US health-care systems that were contributed by the authors. This includes describing treatment models, billing procedures, and implementation considerations. Using an illustrative review of vignettes from existing programs, various models are outlined, emphasizing commonalities and unique features, strengths and limitations, resources necessary, and other relevant considerations. In addition, clinical research and dissemination trials from each program are described to provide evidence of feasibility and efficacy from these programs. This overview of example treatment models designed for hospitals and outpatient centers provides guidelines for any emerging tobacco cessation services within these contexts. For existing treatment programs, this review provides additional insight and ideas about improving these programs within their respective medical systems.
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Affiliation(s)
- Amanda M Palmer
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Alana M Rojewski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Li-Shiun Chen
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO
| | - Lisa M Fucito
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Panagis Galiatsatos
- Department of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore MD
| | - Hasmeena Kathuria
- The Pulmonary Center, Boston University Medical Center, Boston University, Boston, MA
| | - Stephanie R Land
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Glen D Morgan
- Department of Family Medicine, University of North Carolina, Chapel Hill, NC
| | - Alex T Ramsey
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO
| | - Kimber P Richter
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS
| | - Xiaozhong Wen
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY
| | - Benjamin A Toll
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC.
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21
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Mahmoudi E, Kamdar N, Furgal A, Sen A, Zazove P, Bynum J. Potentially Preventable Hospitalizations Among Older Adults: 2010-2014. Ann Fam Med 2020; 18:511-519. [PMID: 33168679 PMCID: PMC7708283 DOI: 10.1370/afm.2605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We undertook a study to examine national trends in potentially preventable hospitalizations-those for ambulatory care-sensitive conditions that could have been avoided if patients had timely access to primary care-across 3,200 counties and various subpopulations of older adults in the United States. METHODS We used 2010-2014 Medicare claims data to examine trends in potentially preventable hospitalizations among beneficiaries aged 65 years and older and developed heat maps to examine county-level variation. We used a generalized estimating equation and adjusted the model for demographics, comorbidities, dual eligibility (Medicare and Medicaid), ZIP code-level income, and county-level number of primary care physicians and hospitals. RESULTS Across the 3,200 study counties, potentially preventable hospitalizations decreased in 327 counties, increased in 123 counties, and did not change in the rest. At the population level, the adjusted rate of potentially preventable hospitalizations declined by 3.45 percentage points from 19.42% (95% CI, 18.4%-20.5%) in 2010 to 15.97% (95% CI, 15.3%-16.6%) in 2014; it declined by 2.93, 2.87, and 3.33 percentage points among White, Black, and Hispanic patients to 14.96% (95% CI, 14.67%-15.24%), 17.92% (95% CI, 17.27%-18.58%), and 17.10% (95% CI, 16.25%-18.0%), respectively. Similarly, the rate for dually eligible patients fell by 3.71 percentage points from 21.62% (95% CI, 20.5%-22.8%) in 2010 to 17.91% (95% CI, 17.2%-18.7%) in 2014. (P <.001 for all). CONCLUSIONS During 2010-2014, rates of potentially preventable hospitalization did not change in the majority of counties. At the population level, although the rate declined among all subpopulations, dually eligible patients and Black and Hispanic patients continued to have substantially higher rates compared with non-dually eligible and White patients, respectively.
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Affiliation(s)
- Elham Mahmoudi
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Neil Kamdar
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Allison Furgal
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ananda Sen
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Phillip Zazove
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Julie Bynum
- Institute of Gerontology, University of Michigan, Ann Arbor, Michigan
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22
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Early Performance of Hospital Value-based Purchasing Program in Medicare: A Systematic Review. Med Care 2020; 58:734-743. [PMID: 32692140 DOI: 10.1097/mlr.0000000000001354] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Under the Affordable Care Act, the Centers for Medicare and Medicaid Services has greatly expanded inpatient fee-for-value programs including the Hospital Value-based Purchasing (HVBP) program. Existing evidence from the HVBP program is mixed. There is a need for a systematic review of the HVBP program to inform discussions on how to improve the program's effectiveness. OBJECTIVE To review and summarize studies that evaluated the HVBP program's impact on clinical processes, patient satisfaction, costs and outcomes, or assessed hospital characteristics associated with performance on the program. DESIGN We searched the MEDLINE/PubMed, Scopus, ProQuest database for literature published between January 2013 and July 2019 using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. RESULTS Of 988 studies reviewed, 33 studies that met the selection criteria were included. A small group of studies (n=7) evaluated the impact of the HVBP program, and no impact on processes or patient outcomes was reported. None of the included studies evaluated the effect of HVBP program on health care costs. Other studies (n=28) evaluated the hospital characteristics associated with HVBP performance, suggesting that safety-net hospitals reportedly performed worse on several quality and cost measures. Other hospital characteristics' associations with performance were unclear. CONCLUSIONS Our findings suggest that the current HVBP does not lead to meaningful improvements in quality of care or patient outcomes and may negatively affect safety-net hospitals. More rigorous and comprehensive adjustment is needed for more valid hospital comparisons.
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23
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Navathe AS, Dinh C, Dykstra SE, Werner RM, Liao JM. Overlap between Medicare's Voluntary Bundled Payment and Accountable Care Organization Programs. J Hosp Med 2020; 15:356-359. [PMID: 31433775 PMCID: PMC7412968 DOI: 10.12788/jhm.3288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/09/2019] [Accepted: 07/11/2019] [Indexed: 11/20/2022]
Abstract
Accountable care organizations (ACOs) and bundled payments represent prominent value-based payment models, but the magnitude of overlap between the two models has not yet been described. Using Medicare data, we defined overlap based on attribution to Medicare Shared Savings Program (MSSP) ACOs and hospitalization for Bundled Payments for Care Improvement (BPCI) episodes at BPCI participant hospitals. Between 2013 and 2016, overlap as a share of ACO patients increased from 2.7% to 10% across BPCI episodes, while overlap as a share of all bundled payment patients increased from 19% to 27%. Overlap from the perspectives of both ACO and bundled payments varied by specific episode. In the first description of overlap between ACOs and bundled payments, one in every ten MSSP patients received care under BPCI by the end of our study period, whereas more than one in every four patients receiving care under BPCI were also attributed to MSSP. Policymakers should consider strategies to address the clinical and policy implications of increasing payment model overlap.
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Affiliation(s)
- Amol S Navathe
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Health Incentives and Behavioral Economics, University of Penn-sylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Claire Dinh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah E Dykstra
- The Wharton School of Business, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel M Werner
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- The Wharton School of Business, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Liao
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Value and Systems Science Lab, University of Washington School of Medicine, Seattle, Washington
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24
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Wasfy JH, Hidrue MK, Ngo J, Tanguturi VK, Cafiero-Fonseca ET, Thompson RW, Johnson N, McDermott ST, Singh JP, Del Carmen MG, Ferris TG. Association of an Acute Myocardial Infarction Readmission-Reduction Program With Mortality and Readmission. Circ Cardiovasc Qual Outcomes 2020; 13:e006043. [PMID: 32393130 DOI: 10.1161/circoutcomes.119.006043] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reducing hospital readmission after acute myocardial infarction (AMI) has the potential to both improve quality and reduce costs. As such, readmission after AMI has been a target of financial penalties through Medicare. However, substantial concern exists about potential adverse effects and efficacious readmission-reduction strategies are not well validated. METHODS AND RESULTS We started an AMI readmissions reduction program in November 2017. Between July 2016 and February 2019, hospital billing data were queried to detect all inpatient hospitalizations at the Massachusetts General Hospital for AMI. Thirty-day readmission was identified through hospital billing data, and mortality was extracted from our electronic health record. The data set was merged with claims data for patients in accountable care organizations to detect readmission at other hospitals. We performed segmented linear regression, adjusting for secular trend and case mix, to assess the independent association of our program on both outcome variables. After inclusion and exclusion criteria were applied, the study population included 2020 patients. The overall 30-day readmission rate was higher before the intervention than after the intervention (15.5% versus 10.7%, P=0.002). The overall 30-day mortality rate was similar in both time periods (1.8% versus 1.4%, P=0.457). The program was associated with initial reduction in 30-day readmission (-9.8%, P=0.0002) and 30-day mortality (-2.6%, P=0.041). The program did not change trend in 30-day readmission (+0.19% readmissions/mo, P=0.554) and trend in 30-day mortality (-0.21% deaths/mo, P=0.119). CONCLUSIONS An AMI readmissions reduction program that increases outpatient and emergency department (ED) access to cardiology care is associated with reduced 30-day readmission and 30-day mortality. Similar statistical techniques can be used to conduct a rigorous, mechanistic program evaluation of other quality improvement initiatives.
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Affiliation(s)
- Jason H Wasfy
- Cardiology Division, Department of Medicine (J.H.W., V.K.T., S.T.M., J.P.S.), Massachusetts General Hospital, Harvard Medical School, Boston.,Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.)
| | - Michael K Hidrue
- Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.)
| | - Jacqueline Ngo
- Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.).,Performance Analysis and Improvement Unit, Massachusetts General Hospital, Boston (J.N., E.T.C.-F., N.J.)
| | - Varsha K Tanguturi
- Cardiology Division, Department of Medicine (J.H.W., V.K.T., S.T.M., J.P.S.), Massachusetts General Hospital, Harvard Medical School, Boston
| | | | - Ryan W Thompson
- Department of Medicine (T.G.F., R.W.T.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Natalie Johnson
- Performance Analysis and Improvement Unit, Massachusetts General Hospital, Boston (J.N., E.T.C.-F., N.J.)
| | - Susan T McDermott
- Cardiology Division, Department of Medicine (J.H.W., V.K.T., S.T.M., J.P.S.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jagmeet P Singh
- Cardiology Division, Department of Medicine (J.H.W., V.K.T., S.T.M., J.P.S.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology (M.G.d.C.), Massachusetts General Hospital, Harvard Medical School, Boston.,Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.)
| | - Timothy G Ferris
- Department of Medicine (T.G.F., R.W.T.), Massachusetts General Hospital, Harvard Medical School, Boston.,Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.)
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25
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Abstract
INTRODUCTION Hospital Value-Based Purchasing (HVBP) is an initiative that rewards acute-care hospitals with incentive payments for the quality of care they provide. A hospital's trauma certification has the potential to influence HVBP scores as attaining the certification provides indication of the service quality offered by the hospital. As such, this study focuses on hospitals' level of trauma certification attainment through the American College of Surgeons and whether this certification is associated with greater HVBP. METHODS A retrospective review of the 2015 HVBP database, 2015 Area Health Resources Files (AHRF) database, and the 2015 American Hospital Association (AHA) database is utilized, and propensity score matching was employed to determine the association between level of trauma certification and scores on HVBP dimensions. RESULTS Results reveal trauma certification is associated with lower HVBP domain scores when compared to hospitals without trauma certification. In addition, hospitals with a greater degree of trauma specialization were associated with lower total performance score and efficiency domain scores. CONCLUSIONS Although payers attempt to connect hospital reimbursements with quality and outcomes, unintended consequences may occur. In response to these results, HVBP risk adjustment and scoring methods should receive further scrutiny.
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26
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Ahn S, Hussein M, Mahmood A, Smith ML. Emergency department and inpatient utilization among U.S. older adults with multiple chronic conditions: a post-reform update. BMC Health Serv Res 2020; 20:77. [PMID: 32013969 PMCID: PMC6998236 DOI: 10.1186/s12913-020-4902-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 01/13/2020] [Indexed: 02/08/2023] Open
Abstract
Background The Affordable Care Act (ACA) was enacted to enhance access to care primarily among nonelderly and low-income populations; however, several provisions addressed key determinants of emergency department (ED) and inpatient visits among Medicare beneficiaries over age 65 years. We take stock of the overall changes in these visits among older Medicare beneficiaries, focusing on those with multiple chronic conditions (MCCs), and provide a nationally representative post-reform update. Methods We analyzed a sample of 32,919 older adults (65+) on Medicare from the 2006–2015 Medical Expenditure Panel Survey (MEPS). Using a survey-weighted two-part model, we examined changes in ED visits, inpatient visits, and length of stay (LOS) by MCC status, before (2006–2010), during (2011–2013), and after the ACA (2014–2015). Results Prior to the ACA, 18.1% of Medicare older adults had ≥1 ED visit, whereas 17.1% had ≥1 inpatient visits, with an average of 5.1 nights/visit. Following ACA reforms, among those with 2+ chronic conditions, the rate of ever having an ED visit increased by 4.3 percentage points [95% confidence intervals [CI]: 2.5, 6.1, p < 0.01], whereas the rate of inpatient visits decreased by 1.4 percentage points [95%CI: − 2.9, 0.2, p < 0.1], after multivariable adjustment. Conclusions We found sizable increases in ED visits and nontrivial decreases in inpatient visits among older Medicare beneficiaries with MCCs, underscoring the continuing need for improving access to and quality of care among older adults with MCCs to decrease reliance on the ED and reduce preventable hospitalizations.
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Affiliation(s)
- SangNam Ahn
- The Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, 133 Robison Hall, Memphis, TN, 38152, USA. .,Center for Population Health and Aging, Texas A&M University, College Station, 212 Adriance Lab Rd, 1266 TAMU, College Station, TX, 77843, USA.
| | - Mustafa Hussein
- Joseph J. Zilber School of Public Health, University of Wisconsin, Milwaukee, WI, 53205, USA.,Institute for Research on Poverty, University of Wisconsin, Madison, WI, 53706, USA
| | - Asos Mahmood
- The Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, 133 Robison Hall, Memphis, TN, 38152, USA
| | - Matthew Lee Smith
- Center for Population Health and Aging, Texas A&M University, College Station, 212 Adriance Lab Rd, 1266 TAMU, College Station, TX, 77843, USA.,College of Public Health, The University of Georgia, 30602, Athens, GA, USA
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Changes in Hospital Referral Patterns to Skilled Nursing Facilities Under the Hospital Readmissions Reduction Program. Med Care 2020; 57:695-701. [PMID: 31335756 DOI: 10.1097/mlr.0000000000001169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals for higher-than-expected readmission rates. Almost 20% of Medicare fee-for-service (FFS) patients receive postacute care in skilled nursing facilities (SNFs) after hospitalization. SNF patients have high readmission rates. OBJECTIVE The objective of this study was to investigate the association between changes in hospital referral patterns to SNFs and HRRP penalty pressure. DESIGN We examined changes in the relationship between penalty pressure and outcomes before versus after HRRP announcement among 2698 hospitals serving 6,936,393 Medicare FFS patients admitted for target conditions: acute myocardial infarction, heart failure, or pneumonia. Hospital-level penalty pressure was the expected penalty rate in the first year of the HRRP multiplied by Medicare discharge share. OUTCOMES Informal integration measured by the percentage of referrals to hospitals' most referred SNF; formal integration measured by SNF acquisition; readmission-based quality index of the SNFs to which a hospital referred discharged patients; referral rate to any SNF. RESULTS Hospitals facing the median level of penalty pressure had modest differential increases of 0.3 percentage points in the proportion of referrals to the most referred SNF and a 0.006 SD increase in the average quality index of SNFs referred to. There were no statistically significant differential increases in formal acquisition of SNFs or referral rate to SNF. CONCLUSIONS HRRP did not prompt substantial changes in hospital referral patterns to SNFs, although readmissions for patients referred to SNF differentially decreased more than for other patients, warranting investigation of other mechanisms underlying readmissions reduction.
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28
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Psotka MA, Fonarow GC, Allen LA, Joynt Maddox KE, Fiuzat M, Heidenreich P, Hernandez AF, Konstam MA, Yancy CW, O'Connor CM. The Hospital Readmissions Reduction Program. JACC-HEART FAILURE 2020; 8:1-11. [DOI: 10.1016/j.jchf.2019.07.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 07/08/2019] [Accepted: 07/29/2019] [Indexed: 12/19/2022]
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Strategies for Delivering Value-Based Care: Do Care Management Practices Improve Hospital Performance? J Healthc Manag 2019; 64:430-444. [PMID: 31725571 DOI: 10.1097/jhm-d-18-00049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
EXECUTIVE SUMMARY Value-based payment has the potential to rein in the volume incentive inherent in fee-for-service payment by holding providers accountable for the quality of patient care they deliver. Success under the new payment structure will depend on how effectively key organizational reforms are embraced by providers in the implementation of quality improvement processes for care delivery. This study examined the relationship between implementation of care management processes (CMPs, the specific tactics that enable the practice of value-based care) and hospital performance under value-based payment. Using the American Hospital Association's Survey of Care Systems and Payment and the Centers for Medicare & Medicaid Services' Hospital Compare, we estimated the relationship between hospital implementation of CMPs and performance as it relates to spending, patient satisfaction, readmission reduction, value-based purchasing, and clinical care outcomes. We found that hospitals increased implementation of CMPs from 2013 to 2014, which has led to modest changes in performance. We concluded that care coordination is associated with greater improvements in hospital performance. However, the long-term effects of resulting changes in care delivery may differ from the short-term effects. Thus, study findings underscore the importance of continued evaluation of care management practice as a strategy for optimizing delivery of high-quality, efficient patient care.
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30
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Yuan N, Dudley RA, Boscardin WJ, Lin GA. Electronic health records systems and hospital clinical performance: a study of nationwide hospital data. J Am Med Inform Assoc 2019; 26:999-1009. [PMID: 31233144 PMCID: PMC7647234 DOI: 10.1093/jamia/ocz092] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 05/11/2019] [Accepted: 05/18/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Electronic health records (EHRs) were expected to yield numerous benefits. However, early studies found mixed evidence of this. We sought to determine whether widespread adoption of modern EHRs in the US has improved clinical care. METHODS We studied hospitals reporting performance measures from 2008-2015 in the Centers for Medicare and Medicaid Services Hospital Compare database that also reported having an EHR in the American Hospital Association 2015 IT supplement. Using interrupted time-series analysis, we examined the association of EHR implementation, EHR vendor, and Meaningful Use status with 11 process measures and 30-day hospital readmission and mortality rates for heart failure, pneumonia, and acute myocardial infarction. RESULTS A total of 1246 hospitals contributed 8222 hospital-years. Compared to hospitals without EHRs, hospitals with EHRs had significant improvements over time on 5 of 11 process measures. There were no substantial differences in readmission or mortality rates. Hospitals with CPSI EHR systems performed worse on several process and outcome measures. Otherwise, we found no substantial improvements in process measures or condition-specific outcomes by duration of EHR use, EHR vendor, or a hospital's Meaningful Use Stage 1 or Stage 2 status. CONCLUSION In this national study of hospitals with modern EHRs, EHR use was associated with better process of care measure performance but did not improve condition-specific readmission or mortality rates regardless of duration of EHR use, vendor choice, or Meaningful Use status. Further research is required to understand why EHRs have yet to improve standard outcome measures and how to better realize the potential benefits of EHR systems.
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Affiliation(s)
- Neal Yuan
- Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - R Adams Dudley
- Center for Healthcare Value, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - W John Boscardin
- Department of Epidemiology and Biostatistics and Division of Geriatrics, University of California at San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Grace A Lin
- Center for Healthcare Value, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
- Division of General Internal Medicine, University of California, San Francisco, California, USA
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31
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Liao JM, Emanuel EJ, Venkataramani AS, Huang Q, Dinh CT, Shan EZ, Wang E, Zhu J, Cousins DS, Navathe AS. Association of Bundled Payments for Joint Replacement Surgery and Patient Outcomes With Simultaneous Hospital Participation in Accountable Care Organizations. JAMA Netw Open 2019; 2:e1912270. [PMID: 31560389 PMCID: PMC6777392 DOI: 10.1001/jamanetworkopen.2019.12270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 08/11/2019] [Indexed: 11/14/2022] Open
Abstract
Importance An increasing number of hospitals have participated in Medicare's bundled payment and accountable care organization (ACO) programs. Although participation in bundled payments has been associated with savings for lower-extremity joint replacement (LEJR) surgery, simultaneous participation in ACOs may be associated with different outcomes given the prevalence of LEJR among patients receiving care at ACO participant organizations and potential overlap in care redesign strategies adopted under the 2 payment models. Objective To examine whether simultaneous participation in a Medicare Shared Savings Program (MSSP) ACO affects the association between hospitals' participation in LEJR episodes under the Bundled Payments for Care Improvement (BPCI) initiative and patient outcomes compared with participation in the BPCI initiative alone. Design, Setting, and Participants This cohort study, conducted from January 1 to May 31, 2019, used 2011 to 2016 Medicare claims data and incorporated an instrumental variable with a difference-in-differences method among 483 008 fee-for-service Medicare beneficiaries undergoing LEJR surgery at 212 bundled payment participant hospitals, 105 coparticipant hospitals, and 1413 nonparticipant hospitals in the United States. Exposures Hospital participation in both the BPCI initiative and the MSSP (coparticipants), BPCI only (bundled payment participants), or neither (nonparticipants). Main Outcomes and Measures Changes in clinical outcomes and mean LEJR episode spending. Results A total of 483 008 patients (mean [SD] age, 73.0 [8.4] years; 308 173 [63.8%] female) were included in the study. No differential changes were found in patient and hospital characteristics across participation groups. In adjusted analysis, coparticipants had 1.5% (95% CI, 0.7%-2.2%; P < .001) more unplanned readmissions than did bundled payment participants. Compared with bundled payment participants, coparticipants also had differentially greater decreases in hospital length of stay (adjusted difference-in-differences value, -5.3%; 95% CI, -7.1% to -3.5%; P < .001) and home health care use (adjusted difference-in-differences value, -3.4%; 95% CI, -4.5% to -2.3%; P < .001) and greater increases in postdischarge outpatient follow-up (adjusted difference-in-differences value, 2.1%; 95% CI, 0.9%-3.3%; P < .001). Coparticipants and bundled payment participants did not have differential changes in episode spending (adjusted difference-in-differences value, 0.4%; 95% CI, -0.7% to 1.6%; P = .46), although both groups had more decreased spending compared with nonparticipants. Conclusions and Relevance Among bundled payment participants, coparticipation in ACOs was not associated with LEJR episode savings but was associated with differential changes in postacute care use patterns and unplanned readmissions. These findings support the longer-term benefits of LEJR bundles and suggest that coparticipants may adopt care redesign strategies that differ from hospitals with bundled payments only.
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Affiliation(s)
- Joshua M. Liao
- Department of Medicine, University of Washington School of Medicine, Seattle
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Ezekiel J. Emanuel
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Atheendar S. Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Qian Huang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Claire T. Dinh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eric Z. Shan
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Deborah S. Cousins
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Amol S. Navathe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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Brice YN, Joynt Maddox KE. Is duration of hospital participation in meaningful use associated with value in Medicare? JAMIA Open 2019; 2:238-245. [PMID: 31984359 PMCID: PMC6951993 DOI: 10.1093/jamiaopen/ooz005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/23/2018] [Accepted: 02/08/2019] [Indexed: 11/13/2022] Open
Abstract
AbstractObjectives“Meaningful Use” (MU) of electronic health records (EHRs) is a measure used by Medicare to determine whether hospitals are comprehensively using electronic tools. Whether hospitals’ engagement in value-based initiatives such as MU is associated with value—defined as high quality and low costs—is unknown. Our objectives were to describe hospital participation in MU, and determine whether duration of participation is associated with value.Materials and MethodsWe linked national Medicare data with MU and other hospital-level and market data. We analyzed bivariate relationships to characterize duration of participation. We estimated inverse probability-weighted multilevel logistic regressions to evaluate whether duration of participation was associated with higher likelihood of value—operationalized as having performance on 30-day readmission and inpatient spending at or below the national average.ResultsOf 2860 short-term hospitals, 59% had 4 or 5 years of MU participation by 2015; 7% had 1 or 2 years. There were differences by duration of participation across location, ownership, and size. Seventeen percent of hospitals were classified as high-value. Controlling for hospital characteristics, and holding constant market location, there was no evidence of a statistical association between duration of participation and value (odds ratio = 1.05, 95% confidence interval: 0.91–1.21; P = .51). Examining the 2 outcomes separately, there was a significant relationship between duration of participation and lower Medicare inpatient spending, but not 30-day readmission.DiscussionSustained participation in MU is associated with lower Medicare spending, but not with lower readmission rates.ConclusionPolicy interventions aimed at increasing value may need a broader focus than EHR implementation and use.
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Affiliation(s)
| | - Karen E Joynt Maddox
- John T. Milliken Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA
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Physician Participation in Medicare Accountable Care Organizations and Spillovers in Commercial Spending. Med Care 2019; 57:305-311. [PMID: 30789539 DOI: 10.1097/mlr.0000000000001081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
IMPORTANCE The benefits of public payment policy may extend to private populations through "spillover" effects. If cost-saving efforts in Medicare also reduce costs among commercially insured patients, Medicare payment systems could be a versatile policy tool in future reform efforts. OBJECTIVES To determine whether physicians who participated in a Medicare Accountable Care Organization (ACO) reduced spending among their commercial patients. DESIGN This was a retrospective, longitudinal study which was conducted using Blue Cross Blue Shield of Michigan (BCBSM) claims data from 2010 to 2015. We compared patients seen by physicians who participated in a Medicare ACO to patients whose physicians were not part of an ACO. We used a difference-in-differences (DIDs) design to test whether physician participation in an ACO was associated with reduced spending among their commercially insured patients. We also tested for heterogeneous effects: we assessed whether spillovers were larger among patients with clinical conditions (acute myocardial infarction, pneumonia, congestive heart failure) that have previously been targeted by Medicare payment programs. SETTING This was a population-based study of commercially insured patients in Michigan. PARTICIPANTS Patients who experienced a significant clinical episode (eg, labor and delivery, acute myocardial infarction) between 2010 and 2015. EXPOSURE Our patient-level exposure is treatment by a Medicare ACO-affiliated physician. MAIN OUTCOMES AND MEASURES Medical spending of 0-90 days and 91-365 days after a clinical episode. RESULTS Patients in the exposure group (n=54,750) and in the control group (n=137,883) were similar in demographic characteristics of age, sex, and type of clinical episodes. Adjusted mean 90-day spending in the preexposure period was $21,292 among the exposure group and $21,157 among the comparison group; these means declined to $21,250 and $20,995 in the postperiod, yielding a DIDs estimate of $119 [95% confidence interval (CI), -$170 to $408]. Adjusted means for 91-365 days spending in the preperiod were $4258 among the exposure group and $4251 among the comparison group; these means rose to $4338 and $4421 in the postperiod, yielding a DIDs estimate of -$90 (95% CI, -$312 to $132). We also separately examined patients with conditions that have been targeted by other Medicare payment programs. Among these patients, 90-day spending did not differ between exposure and comparison groups (DIDs, -$223; 95% CI, -$2037 to $1591), although 91-365 days spending decreased among the exposure group with marginal statistical significance (DIDs, -$1160; 95% CI, -$2459 to $140). CONCLUSIONS AND RELEVANCE Physicians who participated in Medicare ACOs did not reduce spending among most of their commercially insured patients. Medicare policy is unlikely to confer significant spillover benefits to the commercially insured population.
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Borza T, Oerline MK, Skolarus TA, Norton EC, Dimick JB, Jacobs BL, Herrel LA, Ellimoottil C, Hollingsworth JM, Ryan AM, Miller DC, Shahinian VB, Hollenbeck BK. Association Between Hospital Participation in Medicare Shared Savings Program Accountable Care Organizations and Readmission Following Major Surgery. Ann Surg 2019; 269:873-878. [PMID: 29557880 PMCID: PMC6146076 DOI: 10.1097/sla.0000000000002737] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the effect of Medicare Shared Savings Program accountable care organizations (ACOs) on hospital readmission after common surgical procedures. SUMMARY BACKGROUND DATA Hospital readmissions following surgery lead to worse patient outcomes and wasteful spending. ACOs, and their associated hospitals, have strong incentives to reduce readmissions from 2 distinct Centers for Medicare and Medicaid Services policies. METHODS We performed a retrospective cohort study using a 20% national Medicare sample to identify beneficiaries undergoing 1 of 7 common surgical procedures-abdominal aortic aneurysm repair, colectomy, cystectomy, prostatectomy, lung resection, total knee arthroplasty, and total hip arthroplasty-between 2010 and 2014. The primary outcome was 30-day risk-adjusted readmission rate. We performed difference-in-differences analyses using multilevel logistic regression models to quantify the effect of hospital ACO affiliation on readmissions following these procedures. RESULTS Patients underwent a procedure at one of 2974 hospitals, of which 389 were ACO affiliated. The 30-day risk-adjusted readmission rate decreased from 8.4% (95% CI, 8.1-8.7%) to 7.0% (95% CI, 6.7-7.3%) for ACO affiliated hospitals (P < 0.001) and from 7.9% (95% CI, 7.8-8.0%) to 7.1% (95% CI, 6.9-7.2%) for non-ACO hospitals (P < 0.001). The difference-in-differences of the 2 trends demonstrated an additional 0.52% (95% CI, 0.97-0.078%) absolute reduction in readmissions at ACO hospitals (P = 0.021), which would translate to 4410 hospitalizations avoided. CONCLUSION Readmissions following common procedures decreased significantly from 2010 to 2014. Hospital affiliation with Shared Savings ACOs was associated with significant additional reductions in readmissions. This emphasis on readmission reduction is 1 mechanism through which ACOs improve value in a surgical population.
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Affiliation(s)
- Tudor Borza
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Mary K. Oerline
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Ted A. Skolarus
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Edward C. Norton
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Economics, University of Michigan, Ann Arbor, Michigan
- National Bureau of Economic Research, Cambridge, MA
| | - Justin B. Dimick
- Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Bruce L. Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Lindsey A. Herrel
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Chad Ellimoottil
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - John M. Hollingsworth
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Andrew M. Ryan
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Economics, University of Michigan, Ann Arbor, Michigan
| | - David C. Miller
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Vahakn B. Shahinian
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Brent K. Hollenbeck
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
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Nathan H, Thumma JR, Ryan AM, Dimick JB. Early Impact of Medicare Accountable Care Organizations on Inpatient Surgical Spending. Ann Surg 2019; 269:191-196. [PMID: 29771724 PMCID: PMC7058185 DOI: 10.1097/sla.0000000000002819] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether hospital participation in accountable care organizations (ACOs) is associated with reduced Medicare spending for inpatient surgery. BACKGROUND ACOs have proliferated rapidly and now cover more than 32 million Americans. Medicare Shared Savings Program (MSSP) ACOs have shown modest success in reducing medical spending. Whether they have reduced surgical spending remains unknown. METHODS We used 100% Medicare claims from 2010 to 2014 for patients aged 65 to 99 years undergoing 6 common elective surgical procedures [abdominal aortic aneurysm (AAA) repair, colectomy, coronary artery bypass grafting (CABG), hip or knee replacement, or lung resection]. We compared total Medicare payments for 30-day surgical episodes, payments for individual components of care (index hospitalization, readmissions, physician services, and postacute care), and clinical outcomes for patients treated at MSSP ACO hospitals versus matched controls at non-ACO hospitals. We accounted for preexisting trends independent of ACO participation using a difference-in-differences approach. RESULTS Among 341,675 patients at 427 ACO hospitals and 1,024,090 matched controls at 1531 non-ACO hospitals, patient and hospital characteristics were well-balanced. Average baseline payments were similar at ACO versus non-ACO hospitals. ACO participation was not associated with reductions in total Medicare payments [difference-in-differences estimate=-$72, confidence interval (CI95%): -$228 to +$84] or individual components of payments. ACO participation was also not associated with clinical outcomes. Duration of ACO participation did not affect our estimates. CONCLUSION Although Medicare ACOs have had success reducing spending for medical care, they have not had similar success with surgical spending. Given that surgical care accounts for 30% of total health care costs, ACOs and policymakers must pay greater attention to reducing surgical expenditures.
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Affiliation(s)
- Hari Nathan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Jyothi R. Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Andrew M. Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Justin B. Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
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Navathe AS, Liao JM, Polsky D, Shah Y, Huang Q, Zhu J, Lyon ZM, Wang R, Rolnick J, Martinez JR, Emanuel EJ. Comparison Of Hospitals Participating In Medicare's Voluntary And Mandatory Orthopedic Bundle Programs. Health Aff (Millwood) 2019; 37:854-863. [PMID: 29863929 DOI: 10.1377/hlthaff.2017.1358] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We analyzed data from Medicare and the American Hospital Association Annual Survey to compare characteristics and baseline performance among hospitals in Medicare's voluntary (Bundled Payments for Care Improvement initiative, or BPCI) and mandatory (Comprehensive Care for Joint Replacement Model, or CJR) joint replacement bundled payment programs. BPCI hospitals had higher mean patient volume and were larger and more teaching intensive than were CJR hospitals, but the two groups had similar risk exposure and baseline episode quality and cost. BPCI hospitals also had higher cost attributable to institutional postacute care, largely driven by inpatient rehabilitation facility cost. These findings suggest that while both voluntary and mandatory approaches can play a role in engaging hospitals in bundled payment, mandatory programs can produce more robust, generalizable evidence. Either mandatory or additional targeted voluntary programs may be required to engage more hospitals in bundled payment programs.
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Affiliation(s)
- Amol S Navathe
- Amol S. Navathe ( ) is an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, in Philadelphia
| | - Joshua M Liao
- Joshua M. Liao is an assistant professor in the Department of Medicine at the University of Washington School of Medicine, in Seattle
| | - Daniel Polsky
- Daniel Polsky is the Robert D. Eilers Professor in Health Care Management and Economics and executive director of the Leonard Davis Institute of Health Economics, both at the University of Pennsylvania
| | - Yash Shah
- Yash Shah is a research assistant in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Qian Huang
- Qian Huang is a statistical analyst in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Jingsan Zhu
- Jingsan Zhu is assistant director of data analytics in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Zoe M Lyon
- Zoe M. Lyon is a senior research coordinator, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania
| | - Robin Wang
- Robin Wang is an undergraduate student in the College of Arts and Sciences, Cornell University, in Ithaca, New York
| | - Josh Rolnick
- Josh Rolnick is an associate fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Joseph R Martinez
- Joseph R. Martinez is an MD-PhD student in the Perelman School of Medicine, University of Pennsylvania
| | - Ezekiel J Emanuel
- Ezekiel J. Emanuel is the Diane V. S. Levy and Robert M. Levy University Professor, chair of the Department of Medical Ethics and Health Policy, and vice provost for global initiatives, all at the University of Pennsylvania
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Hintze AJ, Greenleaf EK, Schilling AL, Hollenbeak CS. Thirty-day Readmission Rates for Carotid Endarterectomy Versus Carotid Artery Stenting. J Surg Res 2018; 235:270-279. [PMID: 30691806 DOI: 10.1016/j.jss.2018.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 09/04/2018] [Accepted: 10/02/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Because of the emergence of readmission-related Medicare penalties, efforts are being made to identify and reduce patient readmissions. The purpose of this study was to compare rates and risk factors for 30-d readmission and hospital length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) among patients treated for carotid artery stenosis in Pennsylvania. MATERIALS AND METHODS Data were from the Pennsylvania Health Care Cost Containment Council (PHC4). We identified 15,966 patients who underwent CEA (n = 13,557) or CAS (n = 2409) in Pennsylvania between 2011 and 2014. Logistic regression was used to determine risk factors for 30-d readmission, whereas linear regression was used to model factors influencing LOS. Propensity score analysis was used to control for imbalanced covariates between procedures. RESULTS Thirty-day readmission rates in Pennsylvania after CEA and CAS for carotid artery stenosis were similar (9.8% and 9.6%, respectively; P = 0.794). Not home discharge destination, Charlson comorbidity index ≥2, and LOS >1 d were all significantly associated with readmission risk. Procedure type (CEA or CAS) did not significantly influence risk. A significant difference in LOS was found between CEA and CAS, but the magnitude of the difference was small (2.38 for CAS versus 2.59 for CEA; P = 0.007). Black race, urgent and emergent cases, and not home discharges significantly increased LOS by notable amounts (1, 1.5, 3.9, and 1.9 d, respectively). CONCLUSIONS Carotid artery stenosis patients in Pennsylvania undergoing CEA or CAS had similar 30-d readmission rates. Although LOS was significantly different, the magnitude of the difference was not large.
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Affiliation(s)
- Aidan J Hintze
- Division of Outcomes Research and Quality, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Erin K Greenleaf
- Division of Outcomes Research and Quality, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Amber L Schilling
- Division of Outcomes Research and Quality, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Christopher S Hollenbeak
- Division of Outcomes Research and Quality, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania; Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania; Department of Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania.
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Navathe AS, Liao JM, Dykstra SE, Wang E, Lyon ZM, Shah Y, Martinez J, Small DS, Werner RM, Dinh C, Ma X, Emanuel EJ. Association of Hospital Participation in a Medicare Bundled Payment Program With Volume and Case Mix of Lower Extremity Joint Replacement Episodes. JAMA 2018; 320:901-910. [PMID: 30193276 PMCID: PMC6142996 DOI: 10.1001/jama.2018.12345] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 08/06/2018] [Indexed: 12/23/2022]
Abstract
Importance Medicare's Bundled Payments for Care Improvement (BPCI) initiative for lower extremity joint replacement (LEJR) surgery has been associated with a reduction in episode spending and stable-to-improved quality. However, BPCI may create unintended effects by prompting participating hospitals to increase the overall volume of episodes paid for by Medicare, which could potentially eliminate program-related savings or prompt them to shift case mix to lower-risk patients. Objective To evaluate whether hospital BPCI participation for LEJR was associated with changes in overall volume and case mix. Design, Setting, and Participants Observational study using Medicare claims data and a difference-in-differences method to compare 131 markets (hospital referral regions) with at least 1 BPCI participant hospital (n = 322) and 175 markets with no participating hospitals (n = 1340), accounting for 580 043 Medicare beneficiaries treated before (January 2011-September 2013) and 462 161 after (October 2013-December 2015) establishing the BPCI initiative. Hospital-level case-mix changes were assessed by comparing 265 participating hospitals with a 1:1 propensity-matched set of nonparticipating hospitals from non-BPCI markets. Exposures Hospital BPCI participation. Main Outcomes and Measures Changes in market-level LEJR volume in the before vs after BPCI periods and changes in hospital-level case mix based on demographic, socioeconomic, clinical, and utilization factors. Results Among the 1 717 243 Medicare beneficiaries who underwent LEJR (mean age, 75 years; 64% women; and 95% nonblack race/ethnicity), BPCI participation was not significantly associated with a change in overall market-level volume. The mean quarterly market volume in non-BPCI markets increased 3.8% from 3.8 episodes per 1000 beneficiaries before BPCI to 3.9 episodes per 1000 beneficiaries after BPCI was launched. For BPCI markets, the mean quarterly market volume increased 4.4% from 3.6 episodes per 1000 beneficiaries before BPCI to 3.8 episodes per 1000 beneficiaries after BPCI was launched. The adjusted difference-in-differences estimate between the market types was 0.32% (95% CI, -0.06% to 0.69%; P = .10). Among 20 demographic, socioeconomic, clinical, and utilization factors, BPCI participation was associated with differential changes in hospital-level case mix for only 1 factor, prior skilled nursing facility use (adjusted difference-in-differences estimate, -0.53%; 95% CI, -0.96% to -0.10%; P = .01) in BPCI vs non-BPCI markets. Conclusions and Relevance In this observational study of Medicare beneficiaries who underwent LEJR, hospital participation in Bundled Payments for Care Improvement was not associated with changes in market-level lower extremity joint replacement volume and largely was not associated with changes in hospital case mix. These findings may provide reassurance regarding 2 potential unintended effects associated with bundled payments for LEJR.
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MESH Headings
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Diagnosis-Related Groups
- Economics, Hospital
- Episode of Care
- Female
- Hospitals, High-Volume
- Hospitals, Low-Volume
- Humans
- Long-Term Care/statistics & numerical data
- Male
- Medicare/economics
- Rehabilitation Centers/statistics & numerical data
- Reimbursement Mechanisms
- Skilled Nursing Facilities/statistics & numerical data
- United States
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Affiliation(s)
- Amol S. Navathe
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Joshua M. Liao
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Sarah E. Dykstra
- The Wharton School of Business, University of Pennsylvania, Philadelphia
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Zoe M. Lyon
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Yash Shah
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joseph Martinez
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- The Wharton School of Business, University of Pennsylvania, Philadelphia
| | - Dylan S. Small
- The Wharton School of Business, University of Pennsylvania, Philadelphia
| | - Rachel M. Werner
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Claire Dinh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Xinshuo Ma
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ezekiel J. Emanuel
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Ivers NM, Dhalla I, Brown A. Aligning innovations in health funding with innovations in care. CMAJ 2018; 190:E957-E960. [PMID: 30104189 DOI: 10.1503/cmaj.171312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Noah M Ivers
- Women's College Research Institute and Institute for Health System Solutions and Virtual Care (Ivers), Women's College Hospital; Department of Family and Community Medicine (Ivers), University of Toronto; Institute of Health Policy, Management and Evaluation (Ivers, Dhalla), Dalla Lana School of Public Health, University of Toronto; Health Quality Ontario (Dhalla); Department of Medicine (Dhalla), St. Michael's Hospital and University of Toronto; Dalla Lana School of Public Health (Brown), University of Toronto, Toronto, Ont.
| | - Irfan Dhalla
- Women's College Research Institute and Institute for Health System Solutions and Virtual Care (Ivers), Women's College Hospital; Department of Family and Community Medicine (Ivers), University of Toronto; Institute of Health Policy, Management and Evaluation (Ivers, Dhalla), Dalla Lana School of Public Health, University of Toronto; Health Quality Ontario (Dhalla); Department of Medicine (Dhalla), St. Michael's Hospital and University of Toronto; Dalla Lana School of Public Health (Brown), University of Toronto, Toronto, Ont
| | - Adalsteinn Brown
- Women's College Research Institute and Institute for Health System Solutions and Virtual Care (Ivers), Women's College Hospital; Department of Family and Community Medicine (Ivers), University of Toronto; Institute of Health Policy, Management and Evaluation (Ivers, Dhalla), Dalla Lana School of Public Health, University of Toronto; Health Quality Ontario (Dhalla); Department of Medicine (Dhalla), St. Michael's Hospital and University of Toronto; Dalla Lana School of Public Health (Brown), University of Toronto, Toronto, Ont
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Greater Reductions in Readmission Rates Achieved by Urban Hospitals Participating in the Medicare Shared Savings Program. Med Care 2018; 56:686-692. [DOI: 10.1097/mlr.0000000000000945] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Saloner B, Stoller KB, Alexander GC. Moving Addiction Care to the Mainstream - Improving the Quality of Buprenorphine Treatment. N Engl J Med 2018; 379:4-6. [PMID: 29972745 PMCID: PMC6522243 DOI: 10.1056/nejmp1804059] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Brendan Saloner
- From the Departments of Health Policy and Management (B.S.) and Epidemiology (G.C.A.), Johns Hopkins Bloomberg School of Public Health, the Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine (K.B.S.), the Center for Drug Safety and Effectiveness, Johns Hopkins University (G.C.A.), and the Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine (G.C.A.) - all in Baltimore
| | - Kenneth B Stoller
- From the Departments of Health Policy and Management (B.S.) and Epidemiology (G.C.A.), Johns Hopkins Bloomberg School of Public Health, the Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine (K.B.S.), the Center for Drug Safety and Effectiveness, Johns Hopkins University (G.C.A.), and the Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine (G.C.A.) - all in Baltimore
| | - G Caleb Alexander
- From the Departments of Health Policy and Management (B.S.) and Epidemiology (G.C.A.), Johns Hopkins Bloomberg School of Public Health, the Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine (K.B.S.), the Center for Drug Safety and Effectiveness, Johns Hopkins University (G.C.A.), and the Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine (G.C.A.) - all in Baltimore
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Anderlini D. The United States Health Care System is Sick: From Adam Smith to Overspecialization. Cureus 2018; 10:e2720. [PMID: 30079286 PMCID: PMC6067811 DOI: 10.7759/cureus.2720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 05/31/2018] [Indexed: 12/19/2022] Open
Abstract
The United States (US) health care system is sick. High cost affects the nation and the people. The poor outcomes mainly impact the patients. If we do not fix it, the system will implode because of the unsustainable economic burden. The choice to shape the health care system on the "pin factory" model described by Adam Smith is the cause of the failure. The key players in the health care system are accordingly molded. Many factors tightly intertwined need to be addressed. Medical education, the role of family doctor, the overspecialization and, not least, the translation of discoveries into clinical practice are among them. The failure of the US health care system is a complex and multi-factorial issue which requires a global approach.
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We do not know what we do not know: innovative approaches to value measurement. Curr Opin Urol 2018; 28:336-341. [PMID: 29697473 DOI: 10.1097/mou.0000000000000512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Over the past several years, there has been an increasing focus on improving the 'value' of healthcare delivered, defined as the ratio of clinical outcomes to the costs incurred to achieve them. The former U.S. Secretary of Health and Human Services Sylvia Burwell announced in 2015 that the majority of healthcare payments in the Medicare and Medicaid programmes will align with value by 2018. Although this has yet to fully mature, numerous health systems have restructured with a goal of improving the value of care delivered to their populations. Nevertheless, there remain important unanswered questions regarding how we measure value in the current U.S. healthcare system. The purpose of this review is to highlight innovations that are not only making it easier to measure value but also to improve care from the patient, provider and healthcare system perspectives. RECENT FINDINGS Behavioural start-ups and the introduction of relatively inexpensive health coaches are starting to permeate the healthcare landscape. These coaches are the consumers' advocate, acting as the quarterback of an extended care team in order to optimize health. Furthermore, time-driven activity-based costing has allowed us to understand costs on a more granular level, and novel tracking software may further automate these costing algorithms in order to better facilitate their dissemination. SUMMARY We must all work to enable new models of care that improve value by incentivizing individuals, payers and providers to improve health, rather than treat the disease after it manifests. We must also continue to improve the efficiency of healthcare delivery largely through improvements in value measurement.
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Erickson KF, Zheng Y, Ho V, Winkelmayer WC, Bhattacharya J, Chertow GM. Market Competition and Health Outcomes in Hemodialysis. Health Serv Res 2018; 53:3680-3703. [PMID: 29468675 DOI: 10.1111/1475-6773.12835] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine whether market competition is associated with improved health outcomes in hemodialysis. DATA SOURCES Secondary analysis of data from a national dialysis registry between 2001 and 2011. STUDY DESIGN We conducted one- and two-part linear regression models, using each hospital service area (HSA) as its own control, to examine the independent associations among market concentration and health outcomes. DATA COLLECTION We selected cohorts of patients receiving in-center hemodialysis in the United States at the start of each calendar year. We used information about dialysis facility ownership and the location where patients received dialysis to measure an index of market concentration-the Hirschman-Herfindahl Index (HHI)-for HSA and year, which ranges from near zero (perfect competition) to one (monopoly). PRINCIPAL FINDINGS An average reduction in HHI by 0.2 (one standard deviation in 2011) was associated with 2.9 fewer hospitalizations per 100 patient-years (95 percent CI, 0.4 to 5.4). If these findings were generalized to the entire in-center hemodialysis population, this would translate to 8,100 (95 percent CI 1,200 to 15,000) fewer hospitalizations in 2011. There was no association between change in market competition and mortality. CONCLUSIONS Market competition in dialysis may lead to improved health outcomes.
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Affiliation(s)
- Kevin F Erickson
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX.,Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX.,Baker Institute for Public Policy, Rice University, Houston, TX
| | - Yuanchao Zheng
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Vivian Ho
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX.,Baker Institute for Public Policy, Rice University, Houston, TX
| | - Wolfgang C Winkelmayer
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX
| | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
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