An Examination Of Medicaid Delivery System Reform Incentive Payment Initiatives Under Way In Six States

The Impact of Payment Reforms on the Safety Net: Examining Effects of the New Jersey Delivery System Reform Incentive Payment Program on Quality of Care Among Medicaid Beneficiaries

The Medicaid Delivery System Reform Incentive Payment (DSRIP) program has been among the most widely adopted value-based payment strategies to drive improved population health management among safety net populations. Using comprehensive claims data from New Jersey and difference-in-differences modeling, the authors examine the impact of DSRIP pay-for-performance disease management programs on outcomes related to targeted chronic conditions. The authors find DSRIP reduced asthma hospitalizations and emergency department visits, pneumonia readmissions, and improved alcohol and drug treatment. Positive program-specific findings are encouraging for future DSRIP-like initiatives and demonstrate provider ability to successfully adapt to payment reforms.

The association between housing and food insecurity among medically underserved cancer patients

PURPOSE

To assess the prevalence of socioeconomic needs and associations between housing characteristics and food insecurity among low-income cancer patients, among whom housing and food insecurity are particularly prevalent.

METHODS

Low-income cancer patients in active treatment (N = 1618) were enrolled in a comprehensive patient navigation program. Food insecurity was assessed using the 18-item US Department of Agriculture US Household Food Security Survey Module. Participants self-reported their need for assistance with housing issues/type of assistance needed, perception of overcrowding, satisfaction with living situation, and household density via a cross-sectional survey. Descriptive analyses, cross-tabulations and tests of proportions, and binary logistic regression were used in data analyses.

RESULTS

Seventy percent of patients were food insecure. Housing characteristics associated with food insecurity were homelessness or living in sheltered/supportive housing (83.3% food insecure), renting (71.9%), and homeownership (58.1%; p < .001); living situation satisfaction (not satisfied, 79.4%; somewhat satisfied, 25.6%; very satisfied, 66%; p < .001); need of housing assistance (79.2%; p < .001), and feeling crowded in their living unit (77.6%; p < .05). Associations of living unit type with food insecurity were significant in the binary logistic regression model (renters 1.68 OR, homeless/sheltered housing 2.80 OR vs homeowners).

CONCLUSION

The vulnerability to food insecurity of patients in this low-income sample was underlined by the high rates found, and clear associations with housing characteristics of homelessness, housing assistance needs, and feeling overcrowded were identified. These results could help shape priorities around screening patients for nutrition and housing needs and developing interventions to address them.

Achieving Triple Aim Outcomes: An Evaluation of the Texas Medicaid Waiver

The Texas Medicaid Waiver, via the Delivery System Reform Incentive Payment (DSRIP) program, has provided a path for Texas to achieve the Triple Aim through its focus on a defined population at the project and system levels, and financial payment policy based on outcomes. Both iterations of the DSRIP program (Waiver 1.0 and 2.0) have helped define populations, created regional collaboration that sets the stage for a true integrator, and provided financial incentives for improving population health, enhancing patient experience, and controlling costs. The flexible design of project menus and measure bundles in DSRIP encouraged a variety of projects, numerous measures of success and (often) overlapping populations of individual served to achieve the ultimate goal of the Triple Aim. This research outlines the major features of Texas DSRIP and demonstrates the Medicaid Waiver effectively contributed to measurable improvements in health, suggesting Texas safety net providers are moving closer to Triple Aim achievement.

Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care

Background

An academic safety-net hospital leveraged the federally funded state Delivery System Reform Incentive Payment programme to implement a hospital-wide initiative to reduce healthcare-associated infections (HAIs) and improve sepsis care.

Methods

The study period was from 2013 to 2017. The setting is a 770-bed urban hospital with six intensive care units and a large emergency department. Key interventions implemented were (1) awareness campaign and clinician engagement, (2) implementation of HAI and sepsis bundles, (3) education of clinical personnel using standardised curriculum on bundles, (4) training of key managers, leaders and personnel in quality improvement methods, and (5) electronic medical record-based clinical decision support. Throughout the 5-year period, staff received frequent, clear, visible and consistent messages from leadership regarding the importance of their participation in this initiative, performing hand hygiene and preventing potential regulatory failures. Several process measures including bundle compliance, hand hygiene and culture of safety were monitored. The primary outcomes were rates of central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI) and sepsis mortality.

Results

From 2013 to 2017, the hospital-wide rates of HAI reduced: CLABSI from 1.6 to 0.8 per 1000 catheter-days (Poisson regression estimate: −0.19; 95% CI −0.29 to −0.09; p=0.0002), CAUTI from 4.7 to 1.3 per 1000 catheter-days (−0.34; −0.43 to −0.26; p<0.0001) and SSI after 18 types of procedures from 3.4% to 1.3% (−0.29; −0.34 to −0.24; p<0.0001). Mortality of patients presenting to emergency department with sepsis reduced from 9.4% to 2.9% (−0.42; −0.49 to −0.36; p<0.0001). Adherence to bundles of care and hand hygiene and the hospital culture of patient safety improved. Results were sustained through 2019.

Conclusion

A hospital-wide initiative incentivised by the Delivery System Reform Incentive Payment programme succeeded in reducing HAI and sepsis mortality over 5 years in a sustainable manner.

Association of Implementing an Incentive Metric in the Oregon Medicaid Program With Effective Contraceptive Use

IMPORTANCE

Reducing unintended pregnancy is a national public health priority. Incentive metrics are increasingly used by health systems to improve health outcomes and reduce costs, but limited data exist on the association of incentive metrics with contraceptive use.

OBJECTIVE

To evaluate whether an association exists between implementing an incentive metric and effective contraceptive use within the Oregon Medicaid program.

DESIGN, SETTING, AND PARTICIPANTS

In this state-level, claims-based cohort study, a comparative interrupted time series design was used to evaluate whether the implementation of an effective contraceptive use incentive metric on January 1, 2015, was associated with changes in contraceptive use among Oregon Medicaid adult enrollees when compared with commercially insured women. The participants were adult women at risk of pregnancy (18-50 years of age) living in Oregon from January 1, 2012, through December 31, 2017, and enrolled in Medicaid (532 337 person-years) or in commercial health insurance (1 131 738 person-years).

EXPOSURE

Implementation of an effective contraceptive use incentive metric as defined using the 2019 Oregon Health Authority specifications.

MAIN OUTCOMES AND MEASURES

International Classification of Diseases, Ninth Revision codes; International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes; and Current Procedural Terminology codes were used to identify contraceptive use. Annual rates of effective contraceptive use were measured through health insurance claims.

RESULTS

The final analyses included 532 337 Medicaid person-years and 1 131 738 privately insured person-years. Women enrolled in Medicaid were younger than those with private insurance (47.5% vs 33.2% of women in 2013 younger than 30 years), and approximately 40% of Medicaid enrollees (vs fewer than 10% of women with private insurance) resided in rural locations. Demographic characteristics within each group remained similar before and after the incentive metric was implemented. In the comparative interrupted time series model, relative to the commercially insured comparison group, effective contraceptive use among Medicaid enrollees for all ages combined increased 3.6% (95% CI, 3.1%-4.1%) 1 year after the start of the incentive metric, 7.5% (95% CI, 6.8%-8.2%) at the end of 2 years, and 11.5% (95% CI, 10.5%-12.4%) at the end of 3 years. Prior to the introduction of the incentive, contraceptive use rates among the youngest cohort of Medicaid enrollees (18-24 years of age) were decreasing; following the introduction of the incentive, contraceptive use increased steadily among all enrollees. Among women aged 18 to 24 years, the effective contraceptive use rate increased 16.5 percentage points (95% CI, 14.4-18.6 percentage points) after 3 years. The largest initial increase in contraceptive use was among women enrolled in Medicaid who were 30 to 34 years of age (4.9%; 95% CI, 3.4%-6.3%).

CONCLUSIONS AND RELEVANCE

Implementation of the effective contraceptive use incentive metric was associated with a significant increase in contraceptive use among Medicaid enrollees relative to a commercially insured comparison group. This finding is relevant given national efforts aimed at adopting a similar metric for widespread use.

Impact of integrating psychiatric assessment officers via telepsychiatry on rural hospitals' emergency revisit rates

OBJECTIVE

To assess the impact of integrating Psychiatric Assessment Officers (PAO) and telepsychiatry in rural hospitals on their all-cause emergency department (ED) revisit rates. As a pilot project, a full-time PAO was embedded in each of three rural hospitals in New York State and was augmented by telepsychiatry.

METHOD

A retrospective data analysis using ED census data obtained from the hospitals. The intervention group, defined as those patients treated by PAOs, was compared via a difference-in-difference method against a contemporaneous comparison group defined as those who visited the same EDs and had PAO-qualifying behavioral health diagnoses but were not seen by PAOs.

RESULTS

The intervention group was associated with an approximately 36% lower all-cause ED revisit rate during the first 90-day period (i.e. 1-90 days) following the initial PAO treatment (p = .003). A reduction of the similar magnitude (44%) persisted into the subsequent 90-day period (i.e., 91-180 days since the initial PAO treatment; p < .001).

CONCLUSION

The PAO telepsychiatry pilot program suggests a potential way to provide relief for overburdened EDs in rural communities that lack resources to treat patients with severe behavioral health symptoms.

Medicaid DSRIP in New Jersey: Trade-offs between Broad Hospital Participation and Safety Net Viability

The Delivery System Reform Incentive Payment (DSRIP) program, an increasingly utilized payment strategy to foster population health management by hospitals and outpatient providers, may sometimes generate financial and operational hardships for safety net hospitals (SNHs). The authors utilized a hospital survey and stakeholder interviews to examine impacts of the New Jersey DSRIP program, particularly focusing on its participatory structure that extended eligibility to all hospitals, and specific effects on SNHs. They found that the New Jersey DSRIP fulfilled its primary objective of conditioning receipt of Medicaid supplementary payments on quality and reporting of care by hospitals. It also provided an impetus to ongoing hospital-directed initiatives and introduced new areas of focus, including behavioral health and obesity. However, stakeholders reported that program implementation was not sensitive to specific constraints, priorities, and resource needs of SNHs. Some of the policies relating to outpatient partnerships, reporting of quality metrics, and monitoring low-income populations were perceived to have placed disproportionate burdens on SNHs. Despite appearing to meet its primary goals, the New Jersey DSRIP experience reveals a critical need to be responsive to problems faced by SNHs so as to limit their short-term transition costs and maintain financial viability for serving their patient populations.

Trends in Mental Health Care Use in Medicare from 2009 to 2014 by Gender Minority and Disability Status

Purpose: This study examines trends in Medicare beneficiaries' mental health care use from 2009 to 2014 by gender minority and disability status. Methods: Using 2009 to 2014 Medicare claims, we modeled mental health care use (outpatient mental health care, inpatient mental health care, and psychotropic drugs) over time, adjusting for age and behavioral health diagnoses. We compared trends for gender minority beneficiaries (identified using diagnosis codes) to trends for a 5% random sample of other beneficiaries, stratified by original entitlement reason (age vs. disability). Results: Adjusted outpatient and inpatient mental health care use decreased and differences generally narrowed between gender minority and other beneficiaries over the study period. Among beneficiaries qualifying through disability, the gap in the number of outpatient and inpatient visits (among those with at least one visit in a given year) widened. Psychotropic drug use rose for all beneficiaries, but the proportion of gender minority beneficiaries in the aged cohort who had a psychotropic medication prescription rose faster than for other aged beneficiaries. Conclusions: Mental health care needs for Medicare beneficiaries may be met increasingly by using psychotropic medications rather than outpatient visits, and this pattern is more pronounced for identified gender minority (especially aged) beneficiaries. These trends may indicate a growing need for research and provider training in safe and effective psychotropic medication prescribing alongside gender-affirming treatments such as hormone therapy, especially for aged gender minority individuals who likely already experience polypharmacy.

Medicaid Coverage of Sexually Transmitted Disease Service Visits

INTRODUCTION

Chlamydia and gonorrhea are the most commonly reported notifiable infections in the U.S., with direct medical costs for the treatment of these infections exceeding $700 million annually. Medicaid currently covers approximately 80 million low-income Americans, including a high percentage of racial and ethnic minorities. Studies have shown that racial and ethnic minority populations, particularly those with low SES, are at an increased risk of acquiring a sexually transmitted disease. Therefore, as Medicaid expands, there will likely be a greater demand for sexually transmitted disease services in community-based physician offices. To determine demand for these services among Medicaid enrollees, this study examined how often Medicaid was used to pay for sexually transmitted disease services received in this setting.

METHODS

This study combined 2014 and 2015 data from the National Ambulatory Medical Care Survey and tested for differences in the proportion of visits with an expected payment source of Medicaid when sexually transmitted disease services were and were not provided. All analyses were conducted in October 2018.

RESULTS

During 2014-2015, an estimated 25 million visits received a sexually transmitted disease service. Medicaid paid for a greater percentage of sexually transmitted disease visits (35.5%, 95% CI=22.5%, 51.1%) compared with non-sexually transmitted disease visits (12.1%, 95% CI=10.8%, 13.6%). Logistic regression modeling, controlling for age, sex, and race of the patient, showed that visits covered by Medicaid had increased odds of paying for a sexually transmitted disease service visit (OR=1.97, 95% CI=1.12, 3.46), compared with other expected payment sources.

CONCLUSIONS

Focusing sexually transmitted disease prevention in Medicaid populations could reduce sexually transmitted disease incidence and resulting morbidity and costs.

Supporting Transformation through Delivery System Reform Incentive Payment Programs: Lessons from New York State

The New York Delivery System Reform Incentive Payment (DSRIP) waiver was viewed as a prototype for Medicaid and safety net redesign waivers in the Affordable Care Act (ACA) era. After the insurance expansions of the ACA were implemented, it was apparent that accountability, value, and quality improvement would be priorities in future waivers in many states. Despite New York's distinct provider relationships, previous coverage expansions, and local and state politics, it is important to understand the key characteristics of the waiver so that other states can learn how to better incorporate value-based arrangements into future waivers or attempts to limit spending under proposed Medicaid per-capita caps or block grants. In this article, we examine the New York DSRIP waiver by drawing on its design, early experiences, and evolution to inform recommendations for the future renewal, implementation, and expansion of redesigned or transformational Medicaid waivers.

Innovating patient care delivery: DSRIP's interrupted time series analysis paradigm

INTRODUCTION

Adoption of Medicaid Section 1115 waiver is one of the many ways of innovating healthcare delivery system. The Delivery System Reform Incentive Payment (DSRIP) pool, one of the two funding pools of the waiver has four categories viz. infrastructure development, program innovation and redesign, quality improvement reporting and lastly, bringing about population health improvement.

BACKGROUND

A metric of the fourth category, preventable hospitalization (PH) rate was analyzed in the context of eight conditions for two time periods, pre-reporting years (2010-2012) and post-reporting years (2013-2015) for two hospital cohorts, DSRIP participating and non-participating hospitals. The study explains how DSRIP impacted Preventable Hospitalization (PH) rates of eight conditions for both hospital cohorts within two time periods.

METHODS

Eight PH rates were regressed as the dependent variable with time, intervention and post-DSRIP Intervention as independent variables. PH rates of eight conditions were then consolidated into one rate for regressing with the above independent variables to evaluate overall impact of DSRIP. An interrupted time series regression was performed after accounting for auto-correlation, stationarity and seasonality in the dataset.

RESULTS

In the individual regression model, PH rates showed statistically significant coefficients for seven out of eight conditions in DSRIP participating hospitals. In the combined regression model, the coefficient of the PH rate showed a statistically significant decrease with negative p-values for regression coefficients in DSRIP participating hospitals compared to positive/increased p-values for regression coefficients in DSRIP non-participating hospitals.

CONCLUSION AND IMPLICATIONS

Several macro- and micro-level factors may have likely contributed DSRIP hospitals outperforming DSRIP non-participating hospitals. Healthcare organization/provider collaboration, support from healthcare professionals, DSRIP's design, state reimbursement and coordination in care delivery methods may have led to likely success of DSRIP.

LEVEL OF EVIDENCE

IV, a retrospective cohort study based on longitudinal data.

Preparing Home Health Aides to Serve as Health Coaches for Home Care Patients With Chronic Illness: Findings and Lessons Learned From a Mixed-Method Evaluation of Two Pilot Programs

This article highlights findings from a mixed-method evaluation of two pilot programs that utilized Home Health Aides (HHAs) as health coaches for home care patients with chronic illness, including (1) a dedicated health coaching program for patients with heart failure and (2) an integrated program for HHAs working with chronically ill patients. Interviews were conducted with HHAs and staff to understand their experiences implementing program activities. Data from clinical assessments and surveys were employed to examine the characteristics and outcomes of patients. HHAs viewed health coaching positively and described it as an informative process that is dependent on patient motivation and willingness to change. Patients in both programs reported improvement in self-care maintenance. Patients in the chronic illness program also reported improved quality-of-life.

Factors Perceived as Influencing Local Health Department Involvement in Mental Health

INTRODUCTION

Local health departments (LHDs) are potentially well positioned to implement population-based approaches to mental health promotion, but research indicates that most LHDs are not substantively engaged in activities to address mental health. Little is known about factors that influence if and how LHDs address population mental health. The objectives of this qualitative study were to (1) understand how LHD officials perceive population mental health; (2) identify factors that influence these perceptions and LHD activities to address population mental health; and (3) develop an empirically derived conceptual framework of LHD engagement in population mental health.

METHODS

Twenty-one semi-structured interviews were conducted with a purposive sample of LHD officials and analyzed using thematic content analysis in 2014-2015. Transcripts were double coded, inter-rater reliability statistics were calculated, and categories with κ ≥0.60 were retained.

RESULTS

Respondents perceived mental health as a public health issue and expressed that it has emerged as a priority through community health needs assessment processes, such as those conducted for health department accreditation. However, most LHDs were not substantively engaged in population mental health activities because of limited resources, knowledge, data, and hesitancy to infringe upon the territory of local behavioral health agencies. LHDs and local behavioral health agencies had difficulty communicating and collaborating because of divergent perspectives and financing arrangements.

CONCLUSIONS

LHD officials are eager to embrace population mental health, but resources, training and education, and systems-level changes are needed. Contemporary reforms to the structure and financing of the U.S. health system offer opportunities to address these challenges.

Medicaid At 50: Remarkable Growth Fueled By Unexpected Politics

Medicaid has grown exponentially since the mid-1980s, during both conservative Republican and liberal Democratic administrations. How has this happened? The answer is rooted in three political variables: interest groups, political culture, and American federalism. First, interest-group support (from hospitals, nursing homes, and insurers) is more influential than the fragmented group opposition (from underpaid office-based physicians). Second, Medicaid provides a partial counterweight to conservative charges of a federal health care takeover because of the states' roles in administering the program. Third, Medicaid's intergovernmental fiscal partnership creates financial incentives for state and federal officials to expand enrollment-expansions that these policy makers often favor, given the program's increasingly important role in the nation's health care system. This institutional dynamic is here called catalytic federalism.