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Harris A, Philbin S, Post B, Jordan N, Beestrum M, Epstein R, McHugh M. Cost, Quality, and Utilization After Hospital-Physician and Hospital-Post Acute Care Vertical Integration: A Systematic Review. Med Care Res Rev 2024:10775587241247682. [PMID: 38708895 DOI: 10.1177/10775587241247682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Vertical integration of health systems-the common ownership of different aspects of the health care system-continues to occur at increasing rates in the United States. This systematic review synthesizes recent evidence examining the association between two types of vertical integration-hospital-physician (n = 43 studies) and hospital-post-acute care (PAC; n = 10 studies)-and cost, quality, and health services utilization. Hospital-physician integration is associated with higher health care costs, but the effect on quality and health services utilization remains unclear. The effect of hospital-PAC integration on these three outcomes is ambiguous, particularly when focusing on hospital-SNF integration. These findings should raise some concern among policymakers about the trajectory of affordable, high-quality health care in the presence of increasing hospital-physician vertical integration but perhaps not hospital-PAC integration.
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Affiliation(s)
- Alexandra Harris
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sarah Philbin
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brady Post
- Northeastern University, Boston, MA, USA
| | - Neil Jordan
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Molly Beestrum
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard Epstein
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Megan McHugh
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Kakani P, Cutler DM, Rosenthal MB, Keating NL. Trends in Integration Between Physician Organizations and Pharmacies for Self-Administered Drugs. JAMA Netw Open 2024; 7:e2356592. [PMID: 38373001 PMCID: PMC10877451 DOI: 10.1001/jamanetworkopen.2023.56592] [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] [Received: 10/10/2023] [Accepted: 12/27/2023] [Indexed: 02/20/2024] Open
Abstract
Importance Increasing integration across medical services may have important implications for health care quality and spending. One major but poorly understood dimension of integration is between physician organizations and pharmacies for self-administered drugs or in-house pharmacies. Objective To describe trends in the use of in-house pharmacies, associated physician organization characteristics, and associated drug prices. Design, Setting, and Participants A cross-sectional study was conducted from calendar years 2011 to 2019. Participants included 20% of beneficiaries enrolled in fee-for-service Medicare Parts A, B, and D. Data analysis was performed from September 15, 2020, to December 20, 2023. Exposures Prescriptions filled by in-house pharmacies. Main Outcomes and Measures The share of Medicare Part D spending filled by in-house pharmacies by drug class, costliness, and specialty was evaluated. Growth in the number of physician organizations and physicians in organizations with in-house pharmacies was measured in 5 specialties: medical oncology, urology, infectious disease, gastroenterology, and rheumatology. Characteristics of physician organizations with in-house pharmacies and drug prices at in-house vs other pharmacies are described. Results Among 8 020 652 patients (median age, 72 [IQR, 66-81] years; 4 570 114 [57.0%] women), there was substantial growth in the share of Medicare Part D spending on high-cost drugs filled at in-house pharmacies from 2011 to 2019, including oral anticancer treatments (from 10% to 34%), antivirals (from 12% to 20%), and immunosuppressants (from 2% to 9%). By 2019, 63% of medical oncologists, 20% of urologists, 29% of infectious disease specialists, 21% of gastroenterologists, and 22% of rheumatologists were in organizations with specialty-relevant in-house pharmacies. Larger organizations had a greater likelihood of having an in-house pharmacy (0.75 percentage point increase [95% CI, 0.56-0.94] per each additional physician), as did organizations owning hospitals enrolled in the 340B Drug Discount Program (10.91 percentage point increased likelihood [95% CI, 6.33-15.48]). Point-of-sale prices for high-cost drugs were 1.76% [95% CI, 1.66%-1.87%] lower at in-house vs other pharmacies. Conclusions and Relevance In this cross-sectional study of physician organization-operated pharmacies, in-house pharmacies were increasingly used from 2011 to 2019, especially for high-cost drugs, potentially associated with organizations' financial incentives. In-house pharmacies offered high-cost drugs at lower prices, in contrast to findings of integration in other contexts, but their growth highlights a need to understand implications for patient care.
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Affiliation(s)
- Pragya Kakani
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - David M. Cutler
- Department of Economics, Harvard University, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Meredith B. Rosenthal
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Davila H, Mills WL, Clark V, Hartmann CW, Sullivan JL, Mohr DC, Baughman AW, Berlowitz DR, Pimentel CB. Quality Improvement Efforts in VA Community Living Centers Following Public Reporting of Performance. J Aging Soc Policy 2024; 36:118-140. [PMID: 37014929 DOI: 10.1080/08959420.2023.2196913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 01/12/2023] [Indexed: 04/06/2023]
Abstract
For two decades, the U.S. government has publicly reported performance measures for most nursing homes, spurring some improvements in quality. Public reporting is new, however, to Department of Veterans Affairs nursing homes (Community Living Centers [CLCs]). As part of a large, public integrated healthcare system, CLCs operate with unique financial and market incentives. Thus, their responses to public reporting may differ from private sector nursing homes. In three CLCs with varied public ratings, we used an exploratory, qualitative case study approach involving semi-structured interviews to compare how CLC leaders (n = 12) perceived public reporting and its influence on quality improvement. Across CLCs, respondents said public reporting was helpful for transparency and to provide an "outside perspective" on CLC performance. Respondents described employing similar strategies to improve their public ratings: using data, engaging staff, and clearly defining staff roles vis-à-vis quality improvement, although more effort was required to implement change in lower performing CLCs. Our findings augment those from prior studies and offer new insights into the potential for public reporting to spur quality improvement in public nursing homes and those that are part of integrated healthcare systems.
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Affiliation(s)
- Heather Davila
- Center for Access and Delivery Research & Evaluation, Iowa City Department of Veterans Affairs (VA) Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Whitney L Mills
- Center for Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, RI, USA
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Valerie Clark
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Christine W Hartmann
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Jennifer L Sullivan
- Center for Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, RI, USA
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, MA, USA
| | - Amy W Baughman
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School,Boston, MA, USA
| | - Dan R Berlowitz
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Camilla B Pimentel
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
- New England Geriatric Research Education and Clinical Center, VA Bedford Healthcare System, Bedford, MA, USA
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Templeton ZS, Apathy NC, Konetzka RT, Skira MM, Werner RM. The health effects of nursing home specialization in post-acute care. JOURNAL OF HEALTH ECONOMICS 2023; 92:102823. [PMID: 37839286 PMCID: PMC10841893 DOI: 10.1016/j.jhealeco.2023.102823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 09/19/2023] [Accepted: 09/24/2023] [Indexed: 10/17/2023]
Abstract
Nursing homes serve both long-term care and post-acute care (PAC) patients, two groups with distinct financing mechanisms and requirements for care. We examine empirically the effect of nursing home specialization in PAC using 2011-2018 data for Medicare patients admitted to nursing homes following a hospital stay. To address patient selection into specialized nursing homes, we use an instrumental variables approach that exploits variation over time in the distance from the patient's residential ZIP code to the closest nursing home with different levels of PAC specialization. We find that patients admitted to nursing homes more specialized in PAC have lower hospital readmissions and mortality, longer nursing home stays, and higher Medicare spending for the episode of care, suggesting that specialization improves patient outcomes but at higher costs.
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Beauvais B, Mileski M, Ramamonjiarivelo Z, Lee KA, Kruse CS, Betancourt J, Pradhan R, Shanmugam R. The Association Between Facility Affiliations and Revenue Generation in Skilled Nursing Facilities - An Exploratory Study. J Multidiscip Healthc 2023; 16:3099-3114. [PMID: 37901598 PMCID: PMC10612498 DOI: 10.2147/jmdh.s433771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/11/2023] [Indexed: 10/31/2023] Open
Abstract
Background Although hospitals have been the traditional setting for interventional and rehabilitative care, skilled nursing facilities (SNFs) can offer a high-quality and less costly alternative than hospitals. Unfortunately, the financial health of SNFs is often a matter of concern. To partially address these issues, SNF leaders have increased engagement in a number of affiliations to assist in improving quality and reducing operational costs, including Accountable Care Organizations (ACOs), Health Information Exchanges (HIEs), and participation in Bundled Payment for Care Improvement (BPCI) programs. What is not well understood is what impact these affiliations have on the financial viability of the host organizations. Given these factors, this study aims to identify what association, if any, exists between SNF affiliations and revenue generation. Methods Data from calendar year 2022 for n=13,447 SNFs in the US were assessed using multivariate regression analysis. We evaluated two separate dependent measures of revenue generation capacity: net patient revenue per bed and net patient revenue per discharge and considered three unique facility affiliations including (1) ACOs, (2) HIEs, and (3) BPCI participants. Results Six multivariable linear regressions revealed that ACO affiliation is negatively associated with revenue generation on both dependent measures, while HIE affiliation and BPCI participation reflected mixed results. Conclusion A better understanding of the financial impact of SNFs' affiliations may prove insightful. By carefully considering the value of each affiliation, and how each is applicable to any given market, policymakers, funding agencies, and facility leaders may be able to better position SNFs for more sustainable financial performance in a challenging economic environment.
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Affiliation(s)
- Bradley Beauvais
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Michael Mileski
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Zo Ramamonjiarivelo
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Kimberly Ann Lee
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Clemens Scott Kruse
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Jose Betancourt
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Rohit Pradhan
- School of Health Administration, Texas State University, San Marcos, TX, USA
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Klein S, Eaton KP, Bodnar BE, Keller SC, Helgerson P, Parsons AS. Transforming Health Care from Volume to Value: Leveraging Care Coordination Across the Continuum. Am J Med 2023; 136:985-990. [PMID: 37481020 DOI: 10.1016/j.amjmed.2023.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 06/26/2023] [Accepted: 06/26/2023] [Indexed: 07/24/2023]
Affiliation(s)
- Sharon Klein
- Department of Medicine, New York University Langone Health, New York
| | - Kevin P Eaton
- Department of Medicine, New York University Langone Health, Brooklyn
| | - Benjamin E Bodnar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Sara C Keller
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Paul Helgerson
- Department of Medicine, University of Virginia School of Medicine, Charlottesville
| | - Andrew S Parsons
- Department of Medicine, University of Virginia School of Medicine, Charlottesville.
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Kalata S, Howard R, Diaz A, Nuliyahu U, Ibrahim AM, Nathan H. Association of Skilled Nursing Facility Ownership by Health Care Networks With Utilization and Spending. JAMA Netw Open 2023; 6:e230140. [PMID: 36808240 PMCID: PMC9941887 DOI: 10.1001/jamanetworkopen.2023.0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
IMPORTANCE Health care mergers and acquisitions have increased vertical integration of skilled nursing facilities (SNFs) in health care networks. While vertical integration may result in improved care coordination and quality, it may also lead to excess utilization, as SNFs are paid a per diem rate. OBJECTIVE To determine the association of vertical integration of SNFs within hospital networks with SNF utilization, readmissions, and spending for Medicare beneficiaries undergoing elective hip replacement. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study evaluated 100% Medicare administrative claims for nonfederal acute care hospitals performing at least 10 elective hip replacements during the study period. Fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent elective hip replacement between January 1, 2016, and December 31, 2017, with continuous Medicare coverage for 3 months before and 6 months after surgery were included. Data were analyzed from February 2 to August 8, 2022. EXPOSURES Treatment at a hospital within a network that also owns at least 1 SNF based on the 2017 American Hospital Association survey. MAIN OUTCOMES AND MEASURES Rates of SNF utilization, 30-day readmissions, and price-standardized 30-day episode payments. Hierarchical multivariable logistic and linear regression clustered at hospitals was performed with adjusting for patient, hospital, and network characteristics. RESULTS A total of 150 788 patients (61.4% women; mean [SD] age, 74.3 [6.4] years) underwent hip replacement. After risk adjustment, vertical SNF integration was associated with a higher rate of SNF utilization (21.7% [95% CI, 20.4%-23.0%] vs 19.7% [95% CI, 18.7%-20.7%]; adjusted odds ratio [aOR], 1.15 [95% CI, 1.03-1.29]; P = .01) and lower 30-day readmission rate (5.6% [95% CI, 5.4%-5.8%] vs 5.9% [95% CI, 5.7%-6.1%]; aOR, 0.94 [95% CI, 0.89-0.99]; P = .03). Despite higher SNF utilization, the total adjusted 30-day episode payments were slightly lower ($20 230 [95% CI, $20 035-$20 425] vs $20 487 [95% CI, $20 314-$20 660]; difference, -$275 [95% CI, -$15 to -$498]; P = .04) driven by lower postacute payments and shorter SNF length of stays. Adjusted readmission rates were particularly low for patients not sent to an SNF (3.6% [95% CI, 3.4%-3.7%]; P < .001) but were significantly higher for patients with an SNF length of stay less than 5 days (41.3% [95% CI, 39.2%-43.3%]; P < .001). CONCLUSIONS AND RELEVANCE In this cross-sectional study of Medicare beneficiaries undergoing elective hip replacements, vertical integration of SNFs in a hospital network was associated with higher rates of SNF utilization and lower rates of readmissions without evidence of higher overall episode payments. These findings support the purported value of integrating SNFs into hospital networks but also suggest that there is room for improving the postoperative care of patients in SNFs early in their stay.
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Affiliation(s)
- Stanley Kalata
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Ryan Howard
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Adrian Diaz
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, The Ohio State University, Columbus
| | - Usha Nuliyahu
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Andrew M. Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
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Belay E, Kelly P, Anastasio A, Cochrane N, Wu M, Seyler T. Predicting Need for Skilled Nursing or Rehabilitation Facility after Outpatient Total Hip Arthroplasty. Hip Pelvis 2022; 34:227-235. [PMID: 36601616 PMCID: PMC9763827 DOI: 10.5371/hp.2022.34.4.227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/02/2022] [Accepted: 08/24/2022] [Indexed: 12/14/2022] Open
Abstract
Purpose Outpatient classified total hip arthroplasty (THA) is a safe option for a select group of patients. An analysis of a national database was conducted to understand the risk factors for unplanned discharge to a skilled nursing facility (SNF) or acute rehabilitation (rehab) after outpatient classified THA. Materials and Methods A query of the National Surgical Quality Improvement Program (NSQIP) database for THA (Current Procedural Terminology [CPT] 27130) performed from 2015 to 2018 was conducted. Patient demographics, American Society of Anesthesiologists (ASA) classification, functional status, NSQIP morbidity probability, operative time, length of stay (LOS), 30-day reoperation rate, readmission rate, and associated complications were collected. Results A total of 2,896 patients underwent outpatient classified THA. The mean age of patients was 61.2 years. The mean body mass index (BMI) was 29.6 kg/m2 with median ASA 2. The results of univariate comparison of SNF/rehab versus home discharge showed that a significantly higher percentage of females (58.7% vs. 46.8%), age >70 years (49.3% vs. 20.9%), ASA ≥3 (58.0% vs. 25.8%), BMI >35 kg/m2 (23.3% vs. 16.2%), and hypoalbuminemia (8.0% vs. 1.5%) (P<0.0001) were discharged to SNF/rehab. The results of multivariable logistic regression showed that female sex (odds ratio [OR] 1.47; P=0.03), age >70 years (OR 3.08; P=0.001), ASA ≥3 (OR 2.56; P=0.001), and preoperative hypoalbuminemia (<3.5 g/dL) (OR 3.76; P=0.001) were independent risk factors for SNF/rehab discharge. Conclusion Risk factors associated with discharge to a SNF/rehab after outpatient classified THA were identified. Surgeons will be able to perform better risk stratification for patients who may require additional postoperative intervention.
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Affiliation(s)
- Elshaday Belay
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Patrick Kelly
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Albert Anastasio
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Niall Cochrane
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mark Wu
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Thorsten Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Rapp T, Sicsic J, Tavassoli N, Rolland Y. Do not PIMP my nursing home ride! The impact of Potentially Inappropriate Medications Prescribing on residents' emergency care use. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022:10.1007/s10198-022-01534-x. [PMID: 36271304 DOI: 10.1007/s10198-022-01534-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Abstract
Nursing home residents often are poly-medicated, which increases their risks of receiving potentially inappropriate medications. This problem has become a major public health issue in many countries, and in particular in France. Indeed, high uses of potentially inappropriate medication prescriptions can lead to adverse effects that are likely to increase emergency room (ER) visits. However, there is a lack of empirical evidence on the causal relationship between the amount of use of potentially inappropriate medications and ER visit risks among nursing homes residents. Indeed, this question is subject to endogeneity issues due to omitted variables that simultaneously affect inappropriate medications prescriptions and ER use. We take advantage of the IDEM Randomized Clinical Trial (Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers) to overcome that issue. Indeed, randomization in the IDEM intervention group created exogenous variations in potentially inappropriate prescriptions, and was thus used as an instrument. Using an instrumental variable model, we show that over a 12-month period, a 1% increase in the share of potentially inappropriate medications spending in total medication spending leads to a 5.7 percentage point increase in residents' ER use risks (p < 0.001). This effect is robust to various model specifications. Moreover, the intensity of this correlation persists over an 18-month period. While tackling wasteful spending has become a priority in most countries, our results have important policy implications. Indeed, reducing potentially inappropriate medication spending in nursing homes should be a key component of value-based aging policies, which objectives are to reduce inefficient care, and provide health care services centered in people's interest.
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Affiliation(s)
- Thomas Rapp
- Université Paris Cité, Chaire AgingUP! and LIRAES, 75006, Paris, France.
- LIEPP Sciences Po, Paris, France.
| | - Jonathan Sicsic
- Université Paris Cité, Chaire AgingUP! and LIRAES, 75006, Paris, France
| | - Neda Tavassoli
- Gérontopôle de Toulouse, Département de Médecine Interne et Gérontologie Clinique, Centre Hospitalo-Universitaire de Toulouse, Toulouse, France
| | - Yves Rolland
- Gérontopôle de Toulouse, Département de Médecine Interne et Gérontologie Clinique, Centre Hospitalo-Universitaire de Toulouse, Toulouse, France
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Amado GC, Ferreira DC, Nunes AM. Vertical integration in healthcare: What does literature say about improvements on quality, access, efficiency, and costs containment? Int J Health Plann Manage 2022; 37:1252-1298. [PMID: 34981855 DOI: 10.1002/hpm.3407] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 06/27/2021] [Accepted: 12/09/2021] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Vertical integration models involve integrating services from different levels of care (e.g., primary care, acute care, post-acute care). Therefore, one of their main objectives is to increase continuity of care, potentially improving outcomes like efficiency, quality, and access or even enabling cost containment. OBJECTIVES This study conducts a literature review and aims at contributing to the contentious discussion regarding the effects of vertical integration reforms in terms of efficiency, costs containment, quality, and access. METHODS We performed a systematic search of the literature published until February 2020. The articles respecting the conceptual framework were included in an exhaustive analysis to study the impact of vertical integration on costs, prices of care, efficiency, quality, and access. RESULTS A sample of 64 papers resulted from the screening process. The impact of vertical integration on costs and prices of care appears to be negative. Decreases in technical efficiency upon vertical integration are practically out of the question. Nevertheless, there is no substantial inclination to visualise a positive influence. The same happens with the quality of care. Regarding access, the lack of available articles on this outcome limits conjectures. CONCLUSIONS In summary, it is not clear yet whether vertically integrated healthcare providers positively impact the overall delivery care system. Nevertheless, the recent growing trend in the number of studies suggests a promising future on the analysis of this topic.
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Affiliation(s)
- Guilherme C Amado
- Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Diogo C Ferreira
- CERIS, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Alexandre M Nunes
- Instituto Superior de Ciências Sociais e Políticas, Universidade de Lisboa, Lisbon, Portugal
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Werner RM, Templeton Z, Apathy N, Skira MM, Konetzka RT. Trends in Post-Acute Care in US Nursing Homes: 2001-2017. J Am Med Dir Assoc 2021; 22:2491-2495.e2. [PMID: 34823855 PMCID: PMC8654135 DOI: 10.1016/j.jamda.2021.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe recent trends in post-acute care provision within nursing homes, focusing specifically on nursing homes' degree of specialization in post-acute care. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS All US nursing homes between 2001 and 2017 and all fee-for-service Medicare admissions to nursing homes for post-acute care during that time. METHODS We measured post-acute care specialization as annual Medicare admissions per bed for each nursing home and examined changes in the distribution of specialization across nursing homes over the study period. We described the characteristics of nursing homes and the patients they serve based on degree of specialization. RESULTS The average number of Medicare admissions per bed increased from 1.2 in 2001 to 1.6 in 2017, a relative increase of 41%. This upward trend in the number of Medicare admissions per bed was largest among new nursing homes (those established after 2001), increasing 68% from 2001 to 2017. In contrast, nursing homes that eventually closed during the study period experienced no meaningful growth in the number of admissions per bed. Over time, the number of Medicare admissions per bed increased among highly specialized nursing homes. The number of Medicare admissions per bed grew by 66% at the 95th percentile and by 25% at the 99th percentile. Nursing homes delivering the most post-acute care were more likely to be for-profit or part of a chain, had higher staffing levels, and were less likely to admit patients who were Black, Hispanic, or dually enrolled in Medicare and Medicaid. CONCLUSIONS AND IMPLICATIONS Over the last 2 decades, post-acute care has become increasingly concentrated in a subset of nursing homes, which tend to be for-profit, part of a chain, and less likely to serve racial and ethnic minorities and persons on Medicaid. Although these nursing homes may benefit financially from higher Medicare payment, it may come at the expense of equitable access and patient care.
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Affiliation(s)
- Rachel M Werner
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
| | - Zachary Templeton
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nate Apathy
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Meghan M Skira
- Department of Economics, Terry College of Business, University of Georgia, Athens, GA, USA
| | - R Tamara Konetzka
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
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Braun RT, Jung HY, Casalino LP, Myslinski Z, Unruh MA. Association of Private Equity Investment in US Nursing Homes With the Quality and Cost of Care for Long-Stay Residents. JAMA HEALTH FORUM 2021; 2:e213817. [PMID: 35977267 PMCID: PMC8796926 DOI: 10.1001/jamahealthforum.2021.3817] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/04/2021] [Indexed: 11/16/2022] Open
Abstract
Question Is private equity acquisition of nursing homes associated with the quality or cost of care for long-stay nursing home residents? Findings In this cohort study with difference-in-differences analysis of 9864 US nursing homes, including 9632 residents in 302 nursing homes acquired by private equity firms and 249 771 residents in 9562 other for-profit nursing homes without private equity ownership, private equity acquisition of nursing homes was associated with higher costs and increases in emergency department visits and hospitalizations for ambulatory sensitive conditions. Meaning This study suggests that more stringent oversight and reporting on private equity ownership of nursing homes may be warranted. Importance Private equity firms have been acquiring US nursing homes; an estimated 5% of US nursing homes are owned by private equity firms. Objective To examine the association of private equity acquisition of nursing homes with the quality and cost of care for long-stay residents. Design, Setting, and Participants In this cohort study of 302 private equity nursing homes with 9632 residents and 9562 other for-profit homes with 249 771 residents, a novel national database of private equity nursing home acquisitions was merged with Medicare claims and Minimum Data Set assessments for the period from 2012 to 2018. Changes in outcomes for residents in private equity–acquired nursing homes were compared with changes for residents in other for-profit nursing homes. Analyses were performed from March 25 to June 23, 2021. Exposure Private equity acquisitions of 302 nursing homes between 2013 and 2017. Main Outcomes and Measures This study used difference-in-differences analysis to examine the association of private equity acquisition of nursing homes with outcomes. Primary outcomes were quarterly measures of emergency department visits and hospitalizations for ambulatory care–sensitive (ACS) conditions and total quarterly Medicare costs. Antipsychotic use, pressure ulcers, and severe pain were examined in secondary analyses. Results Of the 259 403 residents in the study (170 687 women [65.8%]; 211 154 White residents [81.4%]; 204 928 residents [79.0%] dually eligible for Medicare and Medicaid; mean [SD] age, 79.3 [5.6] years), 9632 residents were in 302 private equity–acquired nursing homes and 249 771 residents were in 9562 other for-profit homes. The mean quarterly rate of ACS emergency department visits was 14.1% (336 072 of 2 383 491), and the mean quarterly rate of ACS hospitalizations was 17.3% (412 344 of 2 383 491); mean (SD) total quarterly costs were $8050.00 ($9.90). Residents of private equity nursing homes experienced relative increases in ACS emergency department visits of 11.1% (1.7 of 15.3; 1.7 percentage points; 95% CI, 0.3-3.0 percentage points; P = .02) and in ACS hospitalizations of 8.7% (1.0 of 11.5; 1.0 percentage point; 95% CI, 0.2-1.1 percentage points; P = .003) compared with residents in other for-profit homes; quarterly costs increased 3.9% (270.37 of 6972.04; $270.37; 95% CI, $41.53-$499.20; P = .02) or $1081 annually per resident. Private equity acquisition was not significantly associated with antipsychotic use (−0.2 percentage points; 95% CI, −1.7 to 1.4 percentage points; P = .83), severe pain (0.2 percentage points; 95% CI, −1.1 to 1.4 percentage points; P = .79), or pressure ulcers (0.5 percentage points; 95% CI, −0.4 to 1.3 percentage points; P = .30). Conclusions and Relevance This cohort study with difference-in-differences analysis found that private equity acquisition of nursing homes was associated with increases in ACS emergency department visits and hospitalizations and higher Medicare costs.
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Affiliation(s)
- Robert Tyler Braun
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Hye-Young Jung
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Lawrence P. Casalino
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Zachary Myslinski
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Mark Aaron Unruh
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
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Sood N, Shier V, Huckfeldt PJ, Weissblum L, Escarce JJ. The effects of vertically integrated care on health care use and outcomes in inpatient rehabilitation facilities. Health Serv Res 2021; 56:828-838. [PMID: 33969480 PMCID: PMC8522568 DOI: 10.1111/1475-6773.13667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To understand the effects of receiving vertically integrated care in inpatient rehabilitation facilities (IRFs) on health care use and outcomes. DATA SOURCES Medicare enrollment, claims, and IRF patient assessment data from 2012 to 2014. STUDY DESIGN We estimated within-IRF differences in health care use and outcomes between IRF patients admitted from hospitals vertically integrated with the IRF (parent hospital) vs patients admitted from other hospitals. For hospital-based IRFs, the parent hospital was defined as the hospital that owned the IRF and co-located with the IRF. For freestanding IRFs, the parent hospital(s) was defined as the hospital(s) that was in the same health system. We estimated models for freestanding and hospital-based IRFs and for fee-for-service (FFS) and Medicare Advantage (MA) patients. Dependent variables included hospital and IRF length of stay, functional status, discharged to home, and hospital readmissions. DATA EXTRACTION METHODS We identified Medicare beneficiaries discharged from a hospital to IRF. PRINCIPAL FINDINGS In adjusted models with hospital fixed effects, our results indicate that FFS patients in hospital-based IRFs discharged from the parent hospital had shorter hospital (-0.7 days, 95% CI: -0.9 to -0.6) and IRF (-0.7 days, 95% CI: -0.9 to -0.6) length of stay were less likely to be readmitted (-1.6%, 95% CI: -2.7% to -0.5%) and more likely to be discharged to home care (1.4%, 95% CI: 0.7% to 2.0%), without worse patient clinical outcomes, compared to patients discharged from other hospitals and treated in the same IRFs. We found similar results for MA patients. However, for patients in freestanding IRFs, we found little differences in health care use or patient outcomes between patients discharged from a parent hospital compared to patients from other hospitals. CONCLUSIONS Our results indicate that receiving vertically integrated care in hospital-based IRFs shortens institutional length of stay while maintaining or improving health outcomes.
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Affiliation(s)
- Neeraj Sood
- Leonard D. Schaeffer Center for Health Policy and Economics, Sol Price School of Public PolicyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Victoria Shier
- Leonard D. Schaeffer Center for Health Policy and Economics, Sol Price School of Public PolicyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Peter J. Huckfeldt
- Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
| | | | - José J. Escarce
- David Geffen School of Medicine at UCLACaliforniaLos AngelesUSA
- UCLA Fielding School of Public Health, Los AngelesCaliforniaUSA
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Abstract
BACKGROUND Hospitals are facing incentives to manage the total cost of care for episodes of illness, including the costs of inpatient care as well as the cost of care provided by physicians and postacute care (PAC) providers. PAC is an especially important component of the overall cost of care. One strategy hospitals employ in managing this cost is to own PAC providers. Prior work on the relationship between PAC ownership and cost has reached mixed conclusions. PURPOSE The aim of this study was to examine the associations between the episodic costs of care and hospital ownership of PAC providers, including skilled nursing facilities (SNFs), home health agencies (HHAs), and inpatient rehabilitation facilities (IRF). METHODOLOGY We examine panel data on hospital ownership of PAC providers from the American Hospital Association for 2013-2015 and cost of care data from Centers for Medicare & Medicaid Services' Value-Based Purchasing Program. Using ordinary least squares, we quantify the association between a hospital's PAC ownership choice (both ownership of any PAC provider and ownership of particular types of providers) and the episodic cost of care. RESULTS In 2015, 80% of hospitals owned some type of PAC provider. We find that ownership of SNFs and HHAs is associated with a lower episodic cost of care, whereas ownership of inpatient rehabilitation facilities is associated with higher episodic costs of care. The effects of ownership do not differ for hospitals that participate in a voluntary shared saving program (Bundled Payment for Care Improvement). CONCLUSION The effects of PAC ownership vary by the type of PAC provider owned. Our results suggest that ownership of SNFs and HHAs may be a viable strategy for success in reimbursement programs that reward hospitals for managing the total costs for episodes of care.
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15
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Rahman M, White EM, Mills C, Thomas KS, Jutkowitz E. Rural-urban differences in diagnostic incidence and prevalence of Alzheimer's disease and related dementias. Alzheimers Dement 2021; 17:1213-1230. [PMID: 33663019 PMCID: PMC8277695 DOI: 10.1002/alz.12285] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 11/02/2020] [Accepted: 12/04/2020] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Understanding rural-urban variation in the diagnostic incidence and prevalence of Alzheimer's disease and related dementias (ADRD) will inform policies to improve timely diagnosis and access to supportive services for older adults in rural communities. METHODS Using 2008 to 2015 national claims data for fee-for-service Medicare beneficiaries (roughly 170 million person-years), we computed unadjusted and adjusted diagnostic incidence and prevalence estimates for ADRD in metropolitan, micropolitan, and rural counties, and examined differences in survival rates. RESULTS Risk-adjusted ADRD diagnostic incidence was higher in rural versus metropolitan counties despite lower prevalence. Among beneficiaries diagnosed with ADRD in 2008, metropolitan county residents experienced longer survival compared to residents in rural and micropolitan counties. DISCUSSION These data suggest that older adults in rural communities may be underdiagnosed with ADRD, and/or diagnosed at later stages of dementia. Further work is needed to develop strategies to reduce this disparity.
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Affiliation(s)
- Momotazur Rahman
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Elizabeth M White
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Caroline Mills
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Kali S Thomas
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Eric Jutkowitz
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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Huckfeldt PJ, Gu J, Escarce JJ, Karaca-Mandic P, Sood N. The association of vertically integrated care with health care use and outcomes. Health Serv Res 2021; 56:817-827. [PMID: 33728678 DOI: 10.1111/1475-6773.13642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine whether vertically integrated hospital and skilled nursing facility (SNF) care is associated with more efficient use of postdischarge care and better outcomes. DATA SOURCES Medicare provider, beneficiary, and claims data from 2012 to 2014. STUDY DESIGN We compared facility characteristics, quality of care, and health care use for hospital-based SNFs and "virtually integrated" SNFs (defined as freestanding SNFs with close referral relationships with a single hospital) relative to nonintegrated freestanding SNFs. Among patients admitted to integrated SNFs, we estimated differences in health care use and outcomes for patients originating from the parent hospital (ie, receiving vertically integrated care) versus other hospitals using linear regressions that included SNF fixed effects. We estimated bounds for our main estimates that incorporated potential omitted variables bias. DATA EXTRACTION METHODS We identified hospital-based SNFs based on provider data. We defined virtually integrated SNFs based on patient flows between hospitals and SNFs. We identified SNF episodes, preceding hospital stays, patient characteristics, health care use, and patient outcomes using Medicare data. PRINCIPAL FINDINGS Consistent with prior research, integrated SNFs performed better on quality measures and health care use relative to nonintegrated SNFs (eg, hospital-based SNFs had 11-day shorter stays compared with nonintegrated SNFs adjusting for patient characteristics, P < .001). Stroke patients admitted to hospital-based SNFs from the parent hospital had shorter preceding hospital stays (adjusted difference: -1.2 days, P = .001) and shorter initial SNF stays (adjusted difference: -2.7 days, P = .049); estimates were attenuated but still robust accounting for potential omitted variables bias. For stroke patients, associations between vertically integrated care and other outcomes were either statistically insignificant or not robust to accounting for potential omitted variables bias. CONCLUSIONS Vertically integrated hospital and SNF care was associated with shorter hospital and SNF stays. However, there were few beneficial associations with other outcomes, suggesting limited coordination benefits from vertical integration.
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Affiliation(s)
- Peter J Huckfeldt
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jing Gu
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - José J Escarce
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Pinar Karaca-Mandic
- Carlson School of Management, University of Minnesota, Minneapolis, Minnesota, USA
| | - Neeraj Sood
- Schaeffer Center for Health Policy and Economics, Sol Price School of Public Policy, University of Southern California, Los Angeles, California, USA
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Xu H, Bowblis JR, Caprio TV, Li Y, Intrator O. Rural-Urban Differences in Nursing Home Risk-adjusted Rates of Emergency Department Visits: A Decomposition Analysis. Med Care 2021; 59:38-45. [PMID: 33165147 DOI: 10.1097/mlr.0000000000001451] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Higher risk-adjusted rate of emergency department (ED) visits might reflect poor quality of nursing home (NH) care; however, existing evidence is limited regarding rural-urban differences in ED rates of NHs, especially for long-stay residents. OBJECTIVES To determine and quantify sources of rural-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) of long-stay residents. RESEARCH DESIGN We calculated quarterly NH risk-adjusted rates using 2011-2013 national Medicare claims and Minimum Data Set 3.0, and then implemented Generalized Estimating Equation models to examine rural-urban differences in ED rates and Blinder-Oaxaca decomposition to quantify the contributions of NH and market factors. SUBJECTS Privately owned, free-standing NHs in the United States (N=13,260). RESULTS Over the study period, risk-adjusted rates averaged 9.8% for any ED, 3.3% for outpatient ED, and 3.2% for PAED. Compared with urban NHs, rural NHs were associated with significantly lower rates of any ED, outpatient ED, and PAED (β=-1.67%, -0.44%, and -0.28%; all P<0.01). Observable differences in market factors (nursing home bed concentration, hospital beds, and the existence of a critical access hospital) explained about half of the rural-urban differences in rates of any ED and PAED, but not outpatient ED. CONCLUSIONS Decomposition analyses suggested that lower ED rates in rural NHs appear to be related to market availability of hospital resources. Policymakers may focus on not only reducing unnecessary ED visits but also ensuring equitable hospital access in rural areas.
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Affiliation(s)
- Huiwen Xu
- Departments of Surgery, Cancer Control
- Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - John R Bowblis
- Department of Economics, Farmer School of Business
- Scripps Gerontology Center, Miami University, Oxford, OH
| | - Thomas V Caprio
- Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Department of Medicine, Division of Geriatrics, University of Rochester School of Medicine and Dentistry, Rochester
- Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, NY
| | - Yue Li
- Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Orna Intrator
- Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, NY
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18
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Colla C, Yang W, Mainor AJ, Meara E, Ouayogode MH, Lewis VA, Shortell S, Fisher E. Organizational integration, practice capabilities, and outcomes in clinically complex medicare beneficiaries. Health Serv Res 2020; 55 Suppl 3:1085-1097. [PMID: 33104254 PMCID: PMC7720705 DOI: 10.1111/1475-6773.13580] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes. DATA SOURCES Multiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data. STUDY DESIGN Cross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse. DATA COLLECTION/EXTRACTION METHODS 1 604 580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414 209 beneficiaries were considered clinically complex (frailty or 2 + chronic conditions). PRINCIPAL FINDINGS Financial integration and clinical integration were weakly correlated (correlation coefficient = 0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76]). CONCLUSIONS Higher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients.
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Affiliation(s)
- Carrie Colla
- The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of MedicineLebanonNew HampshireUSA
| | - Wendy Yang
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew HampshireUSA
| | - Alexander J. Mainor
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew HampshireUSA
| | - Ellen Meara
- Department of Health Policy and ManagementHarvard University T H Chan School of Public HealthBostonMassachusettsUSA
| | - Marietou H. Ouayogode
- Department of Population Health SciencesUniversity of Wisconsin MadisonMadisonWisconsinUSA
| | - Valerie A. Lewis
- Department of Health Policy and ManagementGillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Elliott Fisher
- Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonNew HampshireUSA
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Xu H, Bowblis JR, Li Y, Caprio TV, Intrator O. Medicaid Nursing Home Policies and Risk-Adjusted Rates of Emergency Department Visits: Does Rural Location Matter? J Am Med Dir Assoc 2020; 21:1497-1503. [DOI: 10.1016/j.jamda.2020.04.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 03/30/2020] [Accepted: 04/26/2020] [Indexed: 11/16/2022]
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Rahman M, White EM, Thomas KS, Jutkowitz E. Assessment of Rural-Urban Differences in Health Care Use and Survival Among Medicare Beneficiaries With Alzheimer Disease and Related Dementia. JAMA Netw Open 2020; 3:e2022111. [PMID: 33090226 PMCID: PMC7582125 DOI: 10.1001/jamanetworkopen.2020.22111] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE There is poor understanding as to how survival and health care use varies among older adults living with Alzheimer disease and related dementia (ADRD) in rural vs urban areas of the United States. OBJECTIVE To describe survival and trajectories of hospital, hospice, nursing home, and home health care use among rural and urban Medicare beneficiaries with ADRD in the 6 years after diagnosis. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study linked Medicare claims data from January 1, 2009, to December 31, 2016, with nursing home and home health assessment data from all US counties. A total of 555 333 Medicare fee-for-service beneficiaries newly diagnosed with ADRD in 2010 were included. A total of 424 561 individuals (76.5%) resided in metropolitan counties, 75 001 (13.5%) in micropolitan counties, and 55 771 (10.0%) in rural counties. EXPOSURES Rurality of beneficiary's county of residence. MAIN OUTCOMES AND MEASURES Number of days survived after initial ADRD diagnosis; percent of survived days per month spent in the hospital, hospice nursing home, community with home health care services, and community without home health care services. RESULTS A total of 555 333 Medicare beneficiaries (mean [SD] age, 82.0 [7.5] years; 345 294 women [62.2%]; 480 286 White [86.5%]) were evaluated. Compared with metropolitan county residents, rural beneficiaries were younger (mean [SD] age, 81.6 [7.6] vs 82.1 [7.5] years), were less likely to be women (34 100 [61.1%] vs 264 688 [62.3%]), were more likely to be White (50 886 [91.2%] vs 361 205 [85.1%]) and Medicaid-eligible (14 264 [25.6%] vs 71 656 [16.9%]), and had fewer preexisting chronic conditions (mean [SD], 6.9 [2.8] vs 7.4 [2.9]). Medicare beneficiaries residing in metropolitan counties survived a mean (SD) of 1183.5 (826.0) days after diagnosis. Adjusting for individual demographic and clinical characteristics, rural and micropolitan county residents survived approximately 1.5 months less than metropolitan residents. The adjusted share of survived days spent in nursing homes was 5.7 (95% CI, 4.0-7.5) percentage points higher for rural vs metropolitan residents. The adjusted share of days in hospitals was 0.7 (95% CI, -0.9 to -0.4) percentage points lower, and the share of days in community without home health care was 4.6 (95% CI, -6.1 to -3.1) percentage points lower for rural vs metropolitan county residents. There were no statistically significant differences in home health or hospice use. Similar patterns were found for micropolitan vs metropolitan residents as for rural vs metropolitan residents, although the magnitude of the differences were smaller. Differences in time spent in community and nursing homes between rural vs metropolitan beneficiaries became more pronounced with further time from diagnosis. CONCLUSIONS AND RELEVANCE Study results suggest that, after diagnosis, rural Medicare beneficiaries with ADRD spend more time in nursing homes and less time in the community, receive less home health care, and have shorter survival than their urban counterparts.
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Affiliation(s)
- Momotazur Rahman
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Elizabeth M. White
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Kali S. Thomas
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Eric Jutkowitz
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
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Xu H, Bowblis JR, Caprio TV, Li Y, Intrator O. Nursing Home and Market Factors and Risk-Adjusted Hospitalization Rates Among Urban, Micropolitan, and Rural Nursing Homes. J Am Med Dir Assoc 2020; 22:1101-1106. [PMID: 33008755 DOI: 10.1016/j.jamda.2020.08.029] [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: 05/19/2020] [Revised: 08/17/2020] [Accepted: 08/21/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Hospitalizations are common among long-stay nursing home (NH) residents, but the role of rurality in hospitalization is understudied. This study examines the relationships between rurality, NH, and market characteristics and NH quarterly risk-adjusted hospitalization rates of long-stay residents over 10 quarters (2011 Q2-2013 Q3). DESIGN The longitudinal associations of NH and market factors and hospitalization rates were modeled separately on urban, micropolitan, and rural NHs using generalized estimating equation models and a fully interacted model of all NH and market characteristics with micropolitan and rural indicators to test significance of differences compared with urban NHs. SETTING AND PARTICIPANTS In total, 14,600 unique NHs. MEASURES Risk-adjusted hospitalization rates were calculated from 2011 to 2013 national Medicare claims and NH Minimum Data Set 3.0. Rurality was defined based on the 2010 Rural Urban Commuting Area codes. NH and market characteristics were extracted from Certification and Survey Provider Enhanced Reporting and Area Health Resources File. RESULTS Over the study period, risk-adjusted hospitalization rates averaged 9.8% (standard deviation = 8.2%). No difference was found in the overall hospitalization rates of long-stay NH residents among urban, micropolitan, and rural NHs. Generalized estimating equation models show that urban NHs with higher percentages of Medicare and Medicaid residents and any nurse practitioner/physician assistant were associated with lower rates, but these associations were insignificant in rural settings. Higher registered nurse to total nurses ratio was only associated with lower hospitalization rates in urban settings. Higher median household income was associated with lower hospitalization rates in micropolitan and rural NHs. CONCLUSIONS/IMPLICATIONS Rurality is not associated with hospitalization rates of long-stay residents, but NH and market factors (eg, payer distribution, staffing, and population income) may affect hospitalization differently in micropolitan/rural NHs than urban NHs. Future intervention on hospitalization should target factors unique to micropolitan/rural NHs which adopt strategies appropriate to their setting.
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Affiliation(s)
- Huiwen Xu
- Department of Surgery, Cancer Control, University of Rochester School of Medicine and Dentistry, Rochester, NY; Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - John R Bowblis
- Department of Economics, Farmer School of Business, Miami University, Oxford, OH; Scripps Gerontology Center, Miami University, Oxford, OH
| | - Thomas V Caprio
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY; Division of Geriatrics, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY; Geriatrics and Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, NY
| | - Yue Li
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY; Geriatrics and Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, NY
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The Hospital Readmissions Reduction Program's Impact on Readmissions From Skilled Nursing Facilities. J Healthc Manag 2020; 64:186-196. [PMID: 31999269 DOI: 10.1097/jhm-d-18-00035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
EXECUTIVE SUMMARY Hospital readmissions have long served as an indicator of patient recovery and the effectiveness of care. The present study examines the Hospital Readmissions Reduction Program's (HRRP's) impact on hospital readmissions from skilled nursing facilities (SNFs) and the characteristics of SNFs that were predictive of lower readmission rates. Adjusted 30-day readmission rates among 14,666 SNFs in the United States from 2011 through 2015 were examined using linear regression with generalized estimating equations to determine the relationship of the HRRP mandate to readmission rates from SNFs. Findings indicate a significant downward trend in adjusted 30-day readmission rates over time, decreasing 1.4% from 2011 to 2015. Furthermore, lower readmission rates were associated with SNF characteristics including location in a hospital facility, rural designation, higher registered nurse-to-nurse ratios, and not-for-profit status. We found a substantial decrease in SNF-related readmissions associated with HRRP, which may limit the impact of the Protecting Access to Medicare Act. Policy-makers may consider these systemic and structural differences before drafting future legislation targeting hospital readmission from SNFs. In addition, acute care facility operators who do not have an SNF may consider adding one to their facility and/or consider partnering with SNFs to ensure that high-quality programs in these SNFs are in place to reduce 30-day readmissions to the acute care facilities.
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Ryskina KL, Andy AU, Manges KA, Foley KA, Werner RM, Merchant RM. Association of Online Consumer Reviews of Skilled Nursing Facilities With Patient Rehospitalization Rates. JAMA Netw Open 2020; 3:e204682. [PMID: 32407501 PMCID: PMC7225899 DOI: 10.1001/jamanetworkopen.2020.4682] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 03/01/2020] [Indexed: 11/17/2022] Open
Abstract
Importance There are areas of skilled nursing facility (SNF) experience of importance to the public that are not currently included in public reporting initiatives on SNF quality. Whether patients, hospitals, and payers can leverage the information available from unsolicited online reviews to reduce avoidable rehospitalizations from SNFs is unknown. Objectives To assess the association between rehospitalization rates and online ratings of SNFs; to compare the association of rehospitalization with ratings from a review website vs Medicare Nursing Home Compare (NHC) ratings; and to identify specific topics consistently reported in reviews of SNFs with the highest vs lowest rehospitalization rates using natural language processing. Design, Setting, and Participants A retrospective cross-sectional study of 1536 SNFs with online reviews on Yelp (a website that allows consumers to rate and review businesses and services, scored on a 1- to 5-star rating scale, with 1 star indicating the lowest rating and 5 stars indicating the highest rating) posted between January 1, 2014, and December 31, 2018. The combined data set included 1536 SNFs with 8548 online reviews, NHC ratings, and readmission rates. Main Outcomes and Measures A mean rating from the review website was calculated through the end of each year. Risk-standardized rehospitalization rates were obtained from NHC. Linear regression was used to measure the association between the rehospitalization rate of a SNF and the online ratings. Natural language processing was used to identify topics associated with reviews of SNFs in the top and bottom quintiles of rehospitalization rates. Results The 1536 SNFs in the sample had a median of 6 reviews (interquartile range, 3-13 reviews), with a mean (SD) review website rating of 2.7 (1.1). The SNFs with the highest rating on both the review website and NHC had 2.0% lower rehospitalization rates compared with the SNFs with the lowest rating on both websites (21.3%; 95% CI, 20.7%-21.8%; vs 23.3%; 95% CI, 22.7%-24.0%; P = .04). Compared with the NHC ratings alone, review website ratings were associated with an additional 0.4% of the variation in rehospitalization rates across SNFs (adjusted R2 = 0.009 vs adjusted R2 = 0.013; P = .003). Thematic analysis of qualitative comments on the review website for SNFs with high vs low rehospitalization rates identified several areas of importance to the reviewers, such as the quality of physical infrastructure and equipment, staff attitudes and communication with caregivers. Conclusions and Relevance Skilled nursing facilities with the best rating on both a review website and NHC had slightly lower rehospitalization rates than SNFs with the best rating on NHC alone. However, there was marked variation in the volume of reviews, and many SNF characteristics were underrepresented. Further refinement of the review process is warranted.
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Affiliation(s)
- Kira L. Ryskina
- Perelman School of Medicine, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Anietie U. Andy
- Center for Digital Health, University of Pennsylvania Health System, Philadelphia
| | - Kirstin A. Manges
- Perelman School of Medicine, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
- University of Pennsylvania, Philadelphia
| | | | - Rachel M. Werner
- Perelman School of Medicine, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Raina M. Merchant
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Digital Health, University of Pennsylvania Health System, Philadelphia
- Perelman School of Medicine, Department of Emergency Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
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Livingstone I, Hefele J, Leland N. Characteristics of Nursing Home Providers With Distinct Patterns of Physical and Occupational Therapy Staffing. J Appl Gerontol 2020; 40:443-451. [PMID: 32028819 DOI: 10.1177/0733464820903902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Previous work found a substantial growth in therapy staffing among nursing home providers following the introduction of Medicare's Prospective Payment System (PPS). Since the PPS, however, several new Medicare policies have been implemented that may impact the provision of rehabilitative care in nursing homes. In view of the rising focus on patient outcomes and provider performance, it is worthwhile to explore more recent therapy staffing patterns following the introduction of these Medicare programs. While our results show stable staffing levels through prior policy changes, upcoming Medicare payment changes will likely have a stronger impact that may result in reduced therapy staffing. In addition, given that our findings show that staffing patterns vary across provider type, we may see greater variation as a result of the upcoming changes. Thus, therapy staffing should continue to be monitored and deeper explorations into the impact of staffing changes on patient outcomes should be undertaken.
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Affiliation(s)
- Ian Livingstone
- University of Massachusetts Boston, USA.,RTI International, Waltham, MA, 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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Abstract
Following the Affordable Care Act (ACA), more hospitals vertically integrated into skilled nursing facilities (SNFs). Hospitals are now being penalized for avoidable readmissions, creating a greater demand for better coordination of care between hospitals and SNF. We created a longitudinal panel data set by merging data from the American Hospital Association's Annual Survey, CMS' Hospital Compare, and the Rural Urban Commuting Area data. Hospital and year fixed-effects models were used to examine the relationship between hospital vertical integration into SNF and 30-day pneumonia and heart failure (HF) readmission rates between 2008 and 2011. Our primary analyses modeled the impact of hospital vertical integration into SNF on 30-day readmissions for both pneumonia and HF using hospital and year fixed effects. Our secondary analyses examined whether hospital vertical integration into SNF was associated with a change in readmissions rates among different types of hospitals. Our results indicate that hospitals that vertically integrated into SNF were associated with a reduction in hospital 30-day pneumonia readmission rates (β = -0.233, p = .039). Vertical integration into SNF was not significantly associated with 30-day HF readmissions. Our secondary analyses found variation in the impact of vertical integration on readmission rates among different hospital organizational types.
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Huang SS, Bowblis JR. Private equity ownership and nursing home quality: an instrumental variables approach. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2019; 19:273-299. [PMID: 30357589 DOI: 10.1007/s10754-018-9254-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/05/2018] [Indexed: 06/08/2023]
Abstract
Since the 2000s, private equity (PE) firms have been actively acquiring nursing homes (NH). This has sparked concerns that with stronger profit motive and aggressive use of debt financing, PE ownership may tradeoff quality for higher profits. To empirically address this policy concern, we construct a panel dataset of all for-profit NHs in Ohio from 2005 to 2010 and link it with detailed resident-level data. We compare the quality of care provided to long-stay residents at PE NHs and other for-profit (non-PE) NHs. To account for unobservable resident selection, we use differential distance to the nearest PE NH relative to the nearest non-PE NH in an instrumental variables approach with and without NH fixed effects. In contrast to concerns of the public regarding quality deterioration associated with PE ownership, we find that PE ownership does not lead to lower quality for long-stay NH residents, at least in the medium term.
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Affiliation(s)
- Sean Shenghsiu Huang
- Georgetown University, 3700 Reservoir Rd., NW, St. Mary's Hall, Washington, DC, 20057, USA.
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Cornell PY, Grabowski DC, Norton EC, Rahman M. Do report cards predict future quality? The case of skilled nursing facilities. JOURNAL OF HEALTH ECONOMICS 2019; 66:208-221. [PMID: 31280055 PMCID: PMC7248645 DOI: 10.1016/j.jhealeco.2019.05.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 04/23/2019] [Accepted: 05/20/2019] [Indexed: 05/20/2023]
Abstract
Report cards on provider performance are intended to improve consumer decision-making and address information gaps in the market for quality. However, inadequate risk adjustment of report-card measures often biases comparisons across providers. We test whether going to a skilled nursing facility (SNF) with a higher star rating leads to better quality outcomes for a patient. We exploit variation over time in the distance from a patient's residential ZIP code to SNFs with different ratings to estimate the causal effect of admission to a higher-rated SNF on health care outcomes, including mortality. We found that patients who go to higher-rated SNFs achieved better outcomes, supporting the validity of the SNF report card ratings.
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Affiliation(s)
- Portia Y Cornell
- Department of Health Services Policy and Practice, Brown University, Box G-S121(6), Providence, RI, 02912, United States; Providence Veterans Administration Medical Center, United States.
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA, 02115, United States.
| | - Edward C Norton
- Department of Health Management and Policy and Department of Economics, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, United States; National Bureau of Economic Research, United States.
| | - Momotazur Rahman
- Department of Health Services Policy and Practice, Brown University, Box G-S121(6), Providence, RI, 02912, United States.
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Huang SS, Banaszak-Holl J, Yuan S, Hirth RA. The Determinants and Variation of Nursing Home Private-Pay Prices: Organizational and Market Structure. Med Care Res Rev 2019; 78:173-180. [PMID: 31218922 DOI: 10.1177/1077558719857335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nursing home (NH) care is arguably the most significant financial risk faced by the elderly without long-term care insurance or Medicaid coverage. Annual out-of-pocket expenditures for NH care can easily exceed $70,000. However, our understanding of private-pay prices is limited by data availability. Utilizing a unique data set on NH prices from 2005 through 2010 across eight states, we find that NH price growth has consistently outpaced growth in consumer and medical care prices. After adjusting for geographical and facility differences, for-profit chains charge the lowest prices, independently operated for-profit and nonprofit NHs have similar prices, and nonprofit chains charge the highest prices. Adjusted prices are also likely to be higher when NHs have higher occupancy rates and markets are more concentrated. The significant differences in price across organizational and market structures suggest private-pay prices can be an important factor when evaluating and comparing the value of NH care.
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Oseran AS, Lage DE, Jernigan MC, Metlay JP, Shah SJ. A “Hospital-Day-1” Model to Predict the Risk of Discharge to a Skilled Nursing Facility. J Am Med Dir Assoc 2019; 20:689-695.e5. [DOI: 10.1016/j.jamda.2019.03.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/22/2019] [Accepted: 03/30/2019] [Indexed: 10/26/2022]
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Werner RM, Coe NB, Qi M, Konetzka RT. Patient Outcomes After Hospital Discharge to Home With Home Health Care vs to a Skilled Nursing Facility. JAMA Intern Med 2019; 179:617-623. [PMID: 30855652 PMCID: PMC6503560 DOI: 10.1001/jamainternmed.2018.7998] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Use of postacute care is common and costly in the United States, but there is significant uncertainty about whether the choice of postacute care setting matters. Understanding these tradeoffs is particularly important as new alternative payment models push patients toward lower-cost settings for care. OBJECTIVE To investigate the association of patient outcomes and Medicare costs of discharge to home with home health care vs discharge to a skilled nursing facility. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study used Medicare claims data from short-term acute-care hospitals in the United States and skilled nursing facility and home health assessment data from January 1, 2010, to December 31, 2016, on Medicare beneficiaries who were discharged from the hospital to home with home health care or to a skilled nursing facility. To address the endogeneity of treatment choice, an instrumental variables approach used the differential distance between the beneficiary's home zip code and the closest home health agency and the closest skilled nursing facility as an instrument. EXPOSURES Receipt of postacute care at home vs in a skilled nursing facility. MAIN OUTCOMES AND MEASURES Readmission within 30 days of hospital discharge, death within 30 days of hospital discharge, improvement in functional status during the postacute care episode, and Medicare payment for postacute care and total payment for the 60-day episode. RESULTS A total of 17 235 854 hospitalizations (62.2% women and 37.8% men; mean [SD] age, 80.5 [7.9] years) were discharged either to home with home health care (38.8%) or to a skilled nursing facility (61.2%) during the study period. Discharge to home was associated with a 5.6-percentage point higher rate of readmission at 30 days compared with discharge to a skilled nursing facility (95% CI, 0.8-10.3; P = .02). There were no significant differences in 30-day mortality rates (-2.0 percentage points; 95% CI, 0.8-10.3; P = .12) or improved functional status (-1.9 percentage points; 95% CI, -12.0 to 8.2; P = .71). Medicare payment for postacute care was significantly lower for those discharged to home compared with those discharged to a skilled nursing facility (-$5384; 95% CI, -$6932 to -$3837; P < .001), as was total Medicare payment within the first 60 days after admission (-$4514; 95% CI, -$6932 to -$3837; P < .001). CONCLUSIONS AND RELEVANCE Among Medicare beneficiaries eligible for postacute care at home or in a skilled nursing facility, discharge to home with home health care was associated with higher rates of readmission, no detectable differences in mortality or functional outcomes, and lower Medicare payments.
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Affiliation(s)
- Rachel M Werner
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Norma B Coe
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
| | - Mingyu Qi
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia
| | - R Tamara Konetzka
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
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Konetzka RT, Yang F, Werner RM. Use of instrumental variables for endogenous treatment at the provider level. HEALTH ECONOMICS 2019; 28:710-716. [PMID: 30672042 PMCID: PMC6462231 DOI: 10.1002/hec.3861] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 12/17/2018] [Accepted: 01/07/2019] [Indexed: 05/22/2023]
Abstract
Health economists are often interested in the effects of provider-level attributes (e.g., nonprofit status or quality rating) on patient outcomes, but estimation is subject to selection bias due to correlation with other omitted provider-level attributes that also affect patient outcomes. Recently, researchers have attempted to use patient-level instrumental variables, such as differential distance, to solve this problem of a provider-level endogenous treatment variable in settings where patients are nested within providers. However, to satisfy validity assumptions, an instrumental variable for a provider attribute must be at the provider level or a larger unit of aggregation, not at the patient level. A patient-level instrument cannot predict variation in a provider attribute separately from other, potentially unmeasured, provider attributes. In this paper, we explain this misapplication, review the extent of this problem in recent literature, and offer alternative approaches to avoid this misapplication of patient-level instrumental variables.
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Affiliation(s)
- R. Tamara Konetzka
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Fan Yang
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado
| | - Rachel M. Werner
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Forder J, Gousia K, Saloniki EC. The impact of long-term care on primary care doctor consultations for people over 75 years. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:375-387. [PMID: 30187252 PMCID: PMC6438947 DOI: 10.1007/s10198-018-0999-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 08/14/2018] [Indexed: 06/08/2023]
Abstract
Many countries are adopting policies to create greater coordination and integration between acute and long-term care services. This policy is predicated on the assumption that these service areas have interdependent outcomes for patients. In this paper, we study the interdependencies between the long-term (home care) services and consultations with a primary care doctor, as used by people over 75 years. Starting with a model of individual's demand for doctor consultations, given supply, we formalize the hypothesis that exogenous increases to home care supply will reduce the number of consultations where these services are technical substitutes. Furthermore, greater coordination of public service planning and use of pooled budgets could lead to better outcomes because planners can account for these externalities. We test our main hypothesis using data from the British Household Panel Study for 1991-2009. To address potential concerns about endogeneity, we use a set of instrumental variables for home care motivated by institutional features of the social care system. We find that there is a statistically significant substitution effect between home care and doctor visits, which is robust across a range of specifications. This result has implications for policies that consider increased coordination between health care and social care systems.
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Affiliation(s)
- Julien Forder
- Personal Social Services Research Unit, University of Kent, Canterbury, Kent, CT2 7NX, UK
| | - Katerina Gousia
- Personal Social Services Research Unit, University of Kent, Canterbury, Kent, CT2 7NX, UK.
- Centre for Health Services Studies, University of Kent, Canterbury, Kent, CT2 7NX, UK.
| | - Eirini-Christina Saloniki
- Personal Social Services Research Unit, University of Kent, Canterbury, Kent, CT2 7NX, UK
- Centre for Health Services Studies, University of Kent, Canterbury, Kent, CT2 7NX, UK
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Gupta S, Zengul FD, Davlyatov GK, Weech-Maldonado R. Reduction in Hospitals' Readmission Rates: Role of Hospital-Based Skilled Nursing Facilities. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2019; 56:46958018817994. [PMID: 30894035 PMCID: PMC6429649 DOI: 10.1177/0046958018817994] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hospital readmission within 30 days of discharge is an important quality measure given that it represents a potentially preventable adverse outcome. Approximately, 20% of Medicare beneficiaries are readmitted within 30 days of discharge. Many strategies such as the hospital readmission reduction program have been proposed and implemented to reduce readmission rates. Prior research has shown that coordination of care could play a significant role in lowering readmissions. Although having a hospital-based skilled nursing facility (HBSNF) in a hospital could help in improving care for patients needing short-term skilled nursing or rehabilitation services, little is known about HBSNFs' association with hospitals' readmission rates. This study seeks to examine the association between HBSNFs and hospitals' readmission rates. Data sources included 2007-2012 American Hospital Association Annual Survey, Area Health Resources Files, the Centers for Medicare and Medicaid Services (CMS) Medicare cost reports, and CMS Hospital Compare. The dependent variables were 30-day risk-adjusted readmission rates for acute myocardial infarction (AMI), congestive heart failure, and pneumonia. The independent variable was the presence of HBSNF in a hospital (1 = yes, 0 = no). Control variables included organizational and market factors that could affect hospitals' readmission rates. Data were analyzed using generalized estimating equation (GEE) models with state and year fixed effects and standard errors corrected for clustering of hospitals over time. Propensity score weights were used to control for potential selection bias of hospitals having a skilled nursing facility (SNF). GEE models showed that the presence of HBSNFs was associated with lower readmission rates for AMI and pneumonia. Moreover, higher SNFs to hospitals ratio in the county were associated with lower readmission rates. These findings can inform policy makers and hospital administrators in evaluating HBSNFs as a potential strategy to lower hospitals' readmission rates.
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Affiliation(s)
- Shivani Gupta
- 1 The University of Southern Mississippi, Hattiesburg, USA
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Ramkumar PN, Gwam C, Navarro SM, Haeberle HS, Karnuta JM, Delanois RE, Mont MA. Discharge to the skilled nursing facility: patient risk factors and perioperative outcomes after total knee arthroplasty. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:65. [PMID: 30963060 DOI: 10.21037/atm.2018.12.62] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Patients receiving a total knee arthroplasty (TKA) who fail to meet inpatient criteria for outpatient physical therapy or an acute rehabilitation facility are increasingly being discharged to skilled nursing facilities (SNFs). However, in some facilities, postoperative care and therapy may be suboptimal. In order to recognize the circumstances predisposing patients to a SNF discharge and quantify perioperative risks, we used a nationwide TKA database to compare those who were and were not discharged to SNFs with respect to: (I) patient and hospital characteristics; (II) comorbidities; (III) lengths of stay (LOS); and (IV) inpatient complications. Methods The National Inpatient Sample database was queried for all individuals who received primary TKA (ICD-9-CM 81.54) between January 1st, 2009 and December 31st, 2013, yielding a total of 3,218,419 patients. Discharge disposition was readily identifiable, and the SNF patients numbered 403,575 (12.5%) vs. 2,814,574 discharged to home or a non-SNF setting (87.5%). A multi-level logistic regression analysis was conducted using patient and hospital specific factors as predictor variables in order to see if differences existed between the two cohorts. A two-tailed P value was set as the threshold for statistical significance. Results Patients discharged to SNFs post-TKA were older (mean, 72 vs. 65 years, P<0.001), more often female [odds ratio (OR) 1.74, P<0.001], black (OR 1.246, P<0.001), from the South (OR 1.856, P<0.001), and had various comorbidities including: preexisting psychoses (OR 1.703, P<0.001), history of drug abuse (OR 1.682, P<0.001), neurological disorders (OR 1.359, P<0.001), and depression (OR 1.334, P<0.001). The mean LOS for TKA patients discharged to SNFs was 17% longer (P<0.001). Patients discharged to SNFs were more likely to endure inpatient medical complications (OR 1.3, P<0.001), specifically pulmonary congestion or edema. Conclusions Patients discharged to SNF had specific demographic characteristics and risk factors, increased LOS, more frequent inpatient medical complications, and greater hospital costs. Knowledge of these risk factors may be critical from the perspective of the new value-based reimbursement system for orthopaedic surgeon to intervene early and appropriately select the patients likely and capable of completing the rigorous postoperative TKA rehabilitation.
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Affiliation(s)
- Prem N Ramkumar
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Chukwuweike Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Sergio M Navarro
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Heather S Haeberle
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jaret M Karnuta
- Department of Orthopedic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Michael A Mont
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York City, NY, USA
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Huang SS, Bowblis JR. The principal-agent problem and owner-managers: An instrumental variables application to nursing home quality. HEALTH ECONOMICS 2018; 27:1653-1669. [PMID: 29968263 DOI: 10.1002/hec.3792] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/16/2018] [Accepted: 05/28/2018] [Indexed: 06/08/2023]
Abstract
The literature on provider ownership has primarily focused broadly on for-profits compared with nonprofits and chains versus nonchains. However, the understanding of more nuanced ownership arrangements within individual facilities is limited. Utilizing the principal-agent and managerial control frameworks, we study the role of managerial ownership and its relationship to quality among for-profit nursing homes (NHs). We identify NH administrators with more than 5% ownership (owner-manager) from Ohio Medicaid Cost Reports (2005-2010) and link these data to long-stay resident records in the Minimum Data Set. Using differential distance to the nearest NHs with a salaried manager relative to an owner-manager, we address the differential selection into these two types of NHs. After instrumenting for admissions to owner-managed NHs, quality among long-stay residents at owner-managed NHs is generally better than NHs with salaried managers. We find suggestive evidence that the magnitudes of quality difference are larger when the principal-agent problem is likely more pronounced, such as when NHs that are part of a multifacility chain and located in more concentrated markets.
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Affiliation(s)
- Sean Shenghsiu Huang
- Department of Health Systems Administration, Georgetown University, Washington, DC, United States
| | - John R Bowblis
- Department of Economics in the Farmer School of Business and Scripps Gerontology Center, Miami University, Oxford, Ohio, United States
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Zuckerman RB, Wu S, Chen LM, Joynt Maddox KE, Sheingold SH, Epstein AM. The Five-Star Skilled Nursing Facility Rating System and Care of Disadvantaged Populations. J Am Geriatr Soc 2018; 67:108-114. [DOI: 10.1111/jgs.15629] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/31/2018] [Accepted: 08/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Rachael B. Zuckerman
- Department of Health and Human Services; Office of the Assistant Secretary for Planning and Evaluation; Washington District of Columbia
| | - Shannon Wu
- Department of Health Policy and Management; Bloomberg School of Public Health, Johns Hopkins University; Baltimore Maryland
| | - Lena M. Chen
- Department of Health and Human Services; Office of the Assistant Secretary for Planning and Evaluation; Washington District of Columbia
- Department of Internal Medicine, Institute for Healthcare Policy and Innovation; University of Michigan Health System, Center for Healthcare Outcomes and Policy, University of Michigan; Ann Arbor Michigan
| | - Karen E. Joynt Maddox
- Department of Health and Human Services; Office of the Assistant Secretary for Planning and Evaluation; Washington District of Columbia
- Cardiovascular Division, Department of Medicine; School of Medicine, Washington University; St. Louis Missouri
| | - Steven H. Sheingold
- Department of Health and Human Services; Office of the Assistant Secretary for Planning and Evaluation; Washington District of Columbia
| | - Arnold M. Epstein
- Department of Health Policy and Management, T.H. Chan School of Public Health, Harvard University; Department of Medicine, Brigham and Women's Hospital; Boston Massachusetts
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Yuan Y, Louis C, Cabral H, Schneider JC, Ryan CM, Kazis LE. Socioeconomic and Geographic Disparities in Accessing Nursing Homes With High Star Ratings. J Am Med Dir Assoc 2018; 19:852-859.e2. [DOI: 10.1016/j.jamda.2018.05.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/26/2018] [Accepted: 05/21/2018] [Indexed: 10/28/2022]
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Konetzka RT, Stuart EA, Werner RM. The effect of integration of hospitals and post-acute care providers on Medicare payment and patient outcomes. JOURNAL OF HEALTH ECONOMICS 2018; 61:244-258. [PMID: 29428772 PMCID: PMC6081263 DOI: 10.1016/j.jhealeco.2018.01.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 12/14/2017] [Accepted: 01/19/2018] [Indexed: 05/08/2023]
Abstract
In this paper we examine empirically the effect of integration on Medicare payment and rehospitalization. We use 2005-2013 data on Medicare beneficiaries receiving post-acute care (PAC) in the U.S. to examine integration between hospitals and the two most common post-acute care settings: skilled nursing facilities (SNFs) and home health agencies (HHA), using two measures of integration-formal vertical integration and informal integration representing preferential relationships between providers without formal relationships. Our identification strategy is twofold. First, we use longitudinal models with a fixed effect for each hospital-PAC pair in a market to test how changes in integration impact patient outcomes. Second, we use an instrumental variable approach to account for patient selection into integrated providers. We find that vertical integration between hospitals and SNFs increases Medicare payments and reduces rehospitalization rates. However, vertical integration between hospitals and HHAs has little effect, nor does informal integration between hospitals and either PAC setting.
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Affiliation(s)
- R Tamara Konetzka
- Department of Public Health Sciences, University of Chicago, United States
| | - Elizabeth A Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, United States
| | - Rachel M Werner
- Division of General Internal Medicine, University of Pennsylvania, United States; Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA, United States.
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Rahman M, Gadbois EA, Tyler DA, Mor V. Hospital-Skilled Nursing Facility Collaboration: A Mixed-Methods Approach to Understanding the Effect of Linkage Strategies. Health Serv Res 2018; 53:4808-4828. [PMID: 30079445 DOI: 10.1111/1475-6773.13016] [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] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To characterize the nature and degree of hospitals' efforts to collaborate with skilled nursing facilities (SNFs) and associated patient outcomes. DATA SOURCES/STUDY SETTING Qualitative data were collected through 138 interviews with staff in 16 hospitals and 25 SNFs in eight markets across the United States in 2015. Quantitative data include Medicare claims data for the 290,603 patients discharged from those 16 hospitals between 2008 and 2015. STUDY DESIGN/DATA COLLECTION Semi-structured interviews with hospital and SNF staff were coded and used to classify hospitals' collaboration efforts with SNFs into high versus low collaboration hospitals, and risk-adjusted, claims-based hospital readmission rates from SNF were compared. PRINCIPAL FINDINGS Hospital collaboration efforts were defined as establishing SNF partners, transition management initiatives, and hospital staff visits to SNFs. High collaboration hospitals were more likely to send patients to SNFs (as opposed to home, home with home health, or other PAC settings), sent a higher share of patients to high quality SNFs, and had fewer hospital readmissions from SNF sooner than did low collaboration hospitals. CONCLUSIONS Although collaboration with SNF requires significant administrative and clinical time investment, it is associated with positive patient outcomes.
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Affiliation(s)
- Momotazur Rahman
- Center for Gerontology and Healthcare Research, Brown University, Providence, RI
| | - Emily A Gadbois
- Center for Gerontology and Healthcare Research, Brown University, Providence, RI
| | - Denise A Tyler
- Aging, Disability& Long-Term Care, RTI International, Waltham, MA
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University, Providence, RI
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Shubeck SP, Regenbogen SE. Private payer value initiatives: The Michigan Model. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2018.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Liao JM, Konetzka RT, Werner RM. Trends in hospital-SNF relationships in the care of Medicare beneficiaries. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2018; 6:175-179. [PMID: 29748087 DOI: 10.1016/j.hjdsi.2018.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 04/05/2018] [Accepted: 05/02/2018] [Indexed: 11/24/2022]
Abstract
Improving the value of post-acute care at skilled nursing facilities (SNFs) has become a Medicare policy priority. Anecdotally, hospitals have responded by formally acquiring or pursuing tighter informal connections with SNFs. We evaluated the trend in connections between US acute care hospitals and Medicare-certified SNFs between 2000 and 2013 using vertical integration and two novel network-based measures (number of SNF partners, and discharge concentration). Among 4441 hospitals and 17,215 SNFs, hospitals with weaker connections with SNFs were more often non-profit, major teaching hospitals with a larger number of discharges and beds. We found an apparent weakening of hospital-SNF connections over time for all three measures. Over one-third (39%) of hospitals were vertically integrated in 2000 compared to 8.2% in 2013. The number of SNF partners increased between 2000 and 2013, while hospitals' discharge concentration declined steadily. Additional work is needed to understand the implications of these trends.
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Affiliation(s)
- Joshua M Liao
- Department of Medicine, University of Washington, Seattle, WA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.
| | - R Tamara Konetzka
- Department of Public Health Services, University of Chicago, Chicago, IL, United States
| | - Rachel M Werner
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States; Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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43
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Forder J, Vadean F, Rand S, Malley J. The impact of long-term care on quality of life. HEALTH ECONOMICS 2018; 27:e43-e58. [PMID: 29098741 PMCID: PMC5901009 DOI: 10.1002/hec.3612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 08/30/2017] [Accepted: 09/26/2017] [Indexed: 05/15/2023]
Abstract
Long-term care services are provided to help people manage the consequences of impairment, but their impact goes beyond the meeting of basic needs. Accordingly, the main aim was to explore the marginal effectiveness of care when measured in terms of people's overall care-related quality of life (CRQoL) and assess changes in marginal effect for increasing intensity. The associated aim was to refine and apply an observational method to estimate marginal effectiveness. A "production function" approach was used with survey data, including Adult Social Care Outcomes Toolkit-measured CRQoL, whereby we statistically modelled the expected relationship between service utilisation rates and CRQoL. This method seeks to limit endogeneity issues by controlling on observables and using instrumental variable. Using a survey of publicly funded long-term care service users in England, we found that community-based long-term care significantly improved people's CRQoL but with diminishing marginal effects and effects differentiated by baseline impairment levels. There are implications for how the care system should respond to changes in global public budgets. For example, where there is unmet need, a system aimed to maximise (unadjusted) CRQoL would put more emphasis on access (more recipients) than intensity of support compared to a system operating on a needs basis.
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Affiliation(s)
- Julien Forder
- Quality and Outcomes of Person‐centred Care Policy Research Unit (QORU), PSSRUUniversity of KentUK
| | - Florin Vadean
- Quality and Outcomes of Person‐centred Care Policy Research Unit (QORU), PSSRUUniversity of KentUK
| | - Stacey Rand
- Quality and Outcomes of Person‐centred Care Policy Research Unit (QORU), PSSRUUniversity of KentUK
| | - Juliette Malley
- Quality and Outcomes of Person-centred Care Policy Research Unit (QORU), PSSRULondon School of EconomicsUK
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Lage DE, Jernigan MC, Chang Y, Grabowski DC, Hsu J, Metlay JP, Shah SJ. Living Alone and Discharge to Skilled Nursing Facility Care after Hospitalization in Older Adults. J Am Geriatr Soc 2018; 66:100-105. [PMID: 29072783 DOI: 10.1111/jgs.15150] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND/OBJECTIVES Community-based older adults are increasingly living alone. When they become ill, they might need greater support from the healthcare system than would those who live with others. There also has been a growing concern about the high use of postacute care such as skilled nursing facility (SNF) care and the level of variation in this use between hospitals and regions. Our objective was to examine whether living alone contributed to the risk of being discharged to a SNF. DESIGN Retrospective cohort study. SETTING Massachusetts General Hospital. PARTICIPANTS Community-dwelling individuals aged 50 and older admitted to the medical service and discharged alive between July 2014 and August 2015 (N = 7,029). MEASUREMENTS We extracted demographic, clinical, and functional data from the electronic medical record and used multivariable logistic regression to determine whether living alone at the time of hospitalization was associated with subsequent discharge to a SNF. RESULTS Of eligible individuals, 24.8% reported living alone before admission. Those living alone were more likely to be female, older, and more independent before admission than those living with others. Of all participants, 10.9% were discharged to a SNF. After adjustment, participants living alone had more than twice the odds of being discharged to a SNF (odds ratio = 2.23, 95% confidence interval = 1.85-2.69, P < .001). DISCUSSION People living alone are more likely to be discharged to SNFs, even when compared to other individuals with similar levels of clinical complexity and functional status. To the extent that this variation is due to a lack of home support, it could be possible to reduce SNF use through additional home services after hospital discharge.
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Affiliation(s)
- Daniel E Lage
- Massachusetts General Hospital, Department of Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
| | - Michael C Jernigan
- Massachusetts General Hospital, Department of Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
| | - Yuchiao Chang
- Massachusetts General Hospital, Department of Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
| | - David C Grabowski
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
| | - John Hsu
- Massachusetts General Hospital, Department of Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
| | - Joshua P Metlay
- Massachusetts General Hospital, Department of Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
| | - Sachin J Shah
- University of California San Francisco, Department of Medicine, San Francisco, California
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Hansen KE, Hyer K, Holup AA, Smith KM, Small BJ. Analyses of Complaints, Investigations of Allegations, and Deficiency Citations in United States Nursing Homes. Med Care Res Rev 2017; 76:736-757. [DOI: 10.1177/1077558717744863] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Quality of care in nursing homes has been evaluated from varying perspectives, but few studies analyze complaints made to surveyors. This study analyzed complaints, investigations, and citations for nursing homes nationwide. Using the complaint and survey data sets, analyses match nursing home complaints with findings of investigations conducted. Results showed the average complaint rate was 13.3 complaints per 100 residents and that 43.2% of complaint allegations were substantiated, with complaints about care and services provided being the most prevalent. Variability was noted among the Centers for Medicare and Medicaid Services regions and, on average, 47.5% of facilities had five or more complaints in a given year. While additional research could evaluate the effect of complaint investigations on nursing home quality, results indicated that complaints and subsequent investigations provide further information regarding quality for residents. Results also suggest improvements in the training for surveyors and more consistency across Centers for Medicare and Medicaid Services survey regions.
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Konetzka RT, Werner RM. Relationships between Acute and Postacute Care Providers: Measurement and Estimation. Health Serv Res 2017; 52:1621-1628. [PMID: 28580644 PMCID: PMC5583305 DOI: 10.1111/1475-6773.12715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- R. Tamara Konetzka
- Department of Public Health SciencesDepartment of MedicineThe University of Chicago Biological SciencesChicagoIL
| | - Rachel M. Werner
- Division of General Internal MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Philadelphia VAMedical CenterPhiladelphiaPA
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Fowler AC, Grabowski DC, Gambrel RJ, Huskamp HA, Stevenson DG. Corporate Investors Increased Common Ownership In Hospitals And The Postacute Care And Hospice Sectors. Health Aff (Millwood) 2017; 36:1547-1555. [DOI: 10.1377/hlthaff.2017.0591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Annabelle C. Fowler
- Annabelle C. Fowler ( ) is a PhD candidate in health policy at Harvard University, in Cambridge, Massachusetts
| | - David C. Grabowski
- David C. Grabowski is a professor in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - Robert J. Gambrel
- Robert J. Gambrel was a data analyst in the Department of Health Policy, Vanderbilt University School of Medicine, in Nashville, Tennessee, at the time of writing. He is now a data specialist at Intermedix, in Nashville
| | - Haiden A. Huskamp
- Haiden A. Huskamp is the 30th Anniversary Professor of Health Care Policy in the Department of Health Care Policy, Harvard Medical School
| | - David G. Stevenson
- David G. Stevenson is an associate professor in the Department of Health Policy, Vanderbilt University School of Medicine
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