Technology, data, people, and partnerships in addressing unmet social needs within Medicaid Managed Care

BACKGROUND

Individuals with unmet social needs experience adverse health outcomes and are subject to greater inequities in health and social outcomes. Given the high prevalence of unmet needs among Medicaid enrollees, many Medicaid managed care organizations (MCOs) are now screening enrollees for unmet social needs and connecting them to community-based organizations (CBOs) with knowledge and resources to address identified needs. The use of screening and referral technology and data sharing are often considered key components in programs integrating health and social services. Despite this emphasis on technology and data collection, research suggests substantial barriers exist in operationalizing effective systems.

METHODS

We used qualitative methods to examine cross-sector perspectives on the use of data and technology to facilitate MCO and CBO partnerships in Kentucky, a state with high Medicaid enrollment, to address enrollee social needs. We recruited participants through targeted sampling, and conducted 46 in-depth interviews with 26 representatives from all six Kentucky MCOs and 20 CBO leaders. Qualitative descriptive analysis, an inductive approach, was used to identify salient themes.

RESULTS

We found that MCOs and CBOs have differing levels of need for data, varying incentives for collecting and sharing data, and differing valuations of what data can or should do. Four themes emerged from interviewees' descriptions of how they use data, including 1) to screen for patient needs, 2) to case manage, 3) to evaluate the effectiveness of programs, and 4) to partner with each other. Underlying these data use themes were areas of alignment between MCOs/CBOs, areas of incongruence, and areas of tension (both practical and ideological). The inability to interface with community partners for data privacy and ownership concerns contributes to division. Our findings suggest a disconnect between MCOs and CBOs regarding terms of their technology interfacing despite their shared mission of meeting the unmet social needs of enrollees.

CONCLUSIONS

While data and technology can be used to identify enrollee needs and determine the most critical need, it is not sufficient in resolving challenges. People and relationships across sectors are vital in connecting enrollees with the community resources to resolve unmet needs.

Hub and spoke framework for study of surgical centralization within United States health systems

BACKGROUND

Hospital consolidation into health systems has mixed effects on surgical quality, potentially related to degree of surgical centralization at high-volume (hub) sites. We developed a novel measure of centralization and evaluated a hub and spoke framework.

METHODS

Surgical centralization within health systems was measured using hospital surgical volumes (American Hospital Association) and health system data (Agency for Healthcare Research and Quality). Hub and spoke hospitals were compared using mixed effects logistic regression and system characteristics associated with surgical centralization were identified using a linear model.

RESULTS

Within 382 health systems containing 3022 hospitals, system hubs perform 63% of cases (IQR 40-84%). Hubs are larger, in metropolitan and urban areas, and more often academically affiliated. Degree of surgical centralization varies ten-fold. Larger, multistate, and investor-owned systems are less centralized. Adjusting for these factors, there is less centralization among teaching systems (p ​< ​0.001).

CONCLUSIONS

A hub-spoke framework applies to most health systems but centralization varies significantly. Future studies of health system surgical care should assess the contributions of surgical centralization and teaching status on differential quality.

Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach

BACKGROUND

Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients.

METHODS

We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project.

RESULTS

Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations.

DISCUSSION

Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease.

CONCLUSIONS

Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).

Show Me the Money! Trends in Funding for Health Services Research

This paper presents longitudinal data representing federal funding for health services research and discusses the observed trends in the larger context of overall funding for research and development in the United States. By putting into context public and private funding trends, the authors examine how these trends effect the supply and demand of the health services research workforce.

Building a Workforce for Future Health Systems: Reflections from Health Policy and Systems Research

INTRODUCTION

The era of the Sustainable Development Goals calls for multidisciplinary research and intersectoral approaches to addressing health challenges. This presents a unique opportunity for multidisciplinary fields concerned with complex systems. Those working in system-oriented fields such as health policy and systems research (HPSR) and health services research must be forward-thinking in optimizing their collective ability to address these global challenges.

OBJECTIVES

The objective of this commentary was to share reflections on challenges and strategies in managing the HPSR workforce in order to stimulate dialogue and cross-learning across similar fields.

STRATEGIES/FINDINGS

The following strategies are discussed here: definitional clarity of expected competencies and coordination across HPS researchers, national investment in HPSR, institutional capacity for coproduction of knowledge across different types of actors, and participatory leadership.

CONCLUSIONS

Creative approaches in training, financing, developing, and leading the diverse workforce required to strengthen health systems can pave the way for its full-time and part-time members to work together.

Defining Episodes of Care in Children's Mental Health Using Administrative Data

Criteria to define an episode of care in children's mental health services are needed. Various criteria were applied to 5 years of visit data from children 4-11 years (N = 5,206) at their first visit to 1 of 3 children's mental health agencies. A minimum of 3 visits with 180 days between episodes optimized agreement with other dates (e.g., telephone intake assessment) marking the start and end of an episode, and clinician-rated number of episodes. Grouping visits into episodes provides a clearer representation of how services are distributed over extended periods of time, facilitating research and enhancing accuracy in service planning.

Transfer Frequency as a Measure of Hospital Capability and Regionalization

OBJECTIVE

To provide metrics for quantifying the capability of hospitals and the degree of care regionalization.

DATA SOURCE

Administrative database covering more than 10 million hospital encounters during a 3-year period (2012-2014) in Massachusetts.

PRINCIPAL FINDINGS

We calculated the condition-specific probabilities of transfer for all acute care hospitals in Massachusetts and devised two new metrics, the Hospital Capability Index (HCI) and the Regionalization Index (RI), for analyzing hospital systems. The HCI had face validity, accurately differentiating academic, teaching, and community hospitals of varying size. Individual hospital capabilities were clearly revealed in "fingerprints" of their condition-specific transfer behavior. The RI also performed well, with those of specific conditions successfully quantifying the concentration of care arising from regulatory and public health activity. The median RI of all conditions within the Massachusetts health care system was 0.21 (IQR, 0.13-0.36), with a long tail of conditions that were very highly regionalized. Application of the HCI and RI metrics together across the entire state identified the degree of interdependence among its hospitals.

CONCLUSIONS

Condition-specific transfer activity, as captured in the HCI and RI, provides quantitative measures of hospital capability and regionalization of care.

Appropriateness of Prostate Cancer Imaging among Veterans in a Delivery System without Incentives for Overutilization

OBJECTIVE

To determine the frequency of appropriate and inappropriate prostate cancer imaging in an integrated health care system.

DATA SOURCES/STUDY SETTING

Veterans Health Administration Central Cancer Registry linked to VA electronic medical records and Medicare claims (2004-2008).

STUDY DESIGN

We performed a retrospective cohort study of VA patients diagnosed with prostate cancer (N = 45,084). Imaging (CT, MRI, bone scan, PET) use was assessed among patients with low-risk disease, for whom guidelines recommend against advanced imaging, and among high-risk patients for whom guidelines recommend it.

PRINCIPAL FINDINGS

We found high rates of inappropriate imaging among men with low-risk prostate cancer (41 percent) and suboptimal rates of appropriate imaging among men with high-risk disease (70 percent). Veterans utilizing Medicare-reimbursed care had higher rates of inappropriate imaging [OR: 1.09 (1.03-1.16)] but not higher rates of appropriate imaging. Veterans treated in middle [OR: 0.51 (0.47-0.56)] and higher [OR: 0.50 (0.46-0.55)] volume medical centers were less likely to undergo inappropriate imaging without compromising appropriate imaging.

CONCLUSIONS

Our results highlight the overutilization of imaging, even in an integrated health care system without financial incentives encouraging provision of health care services. Paradoxically, imaging remains underutilized among high-risk patients who could potentially benefit from it most.

EHR Adoption and Hospital Performance: Time-Related Effects

OBJECTIVE

To assess whether, 5 years into the HITECH programs, national data reflect a consistent relationship between EHR adoption and hospital outcomes across three important dimensions of hospital performance.

DATA SOURCES/STUDY SETTING

Secondary data from the American Hospital Association and CMS (Hospital Compare and EHR Incentive Programs) for nonfederal, acute-care hospitals (2009-2012).

STUDY DESIGN

We examined the relationship between EHR adoption and three hospital outcomes (process adherence, patient satisfaction, efficiency) using ordinary least squares models with hospital fixed effects. Time-related effects were assessed through comparing the impact of EHR adoption pre (2008/2009) versus post (2010/2011) meaningful use and by meaningful use attestation cohort (2011, 2012, 2013, Never). We used a continuous measure of hospital EHR adoption based on the proportion of electronic functions implemented.

DATA COLLECTION/EXTRACTION METHODS

We created a panel dataset with hospital-year observations.

PRINCIPAL FINDINGS

Higher levels of EHR adoption were associated with better performance on process adherence (0.147; p < .001) and patient satisfaction (0.118; p < .001), but not efficiency (0.01; p = .78). For all three outcomes, there was a stronger, positive relationship between EHR adoption and performance in 2010/2011 compared to 2008/2009. We found mixed results based on meaningful use attestation cohort.

CONCLUSIONS

Performance gains associated with EHR adoption are apparent in more recent years. The large national investment in EHRs appears to be delivering more consistent benefits than indicated by earlier national studies.

Assessing organizational change in multisector community health alliances

OBJECTIVE

The purpose of this article was to identify some common organizational features of multisector health care alliances (MHCAs) and the analytic challenges presented by those characteristics in assessing organizational change.

DATA SOURCES

Two rounds of an Internet-based survey of participants in 14 MHCAs.

STUDY DESIGN

We highlight three analytic challenges that can arise when quantitatively studying the organizational characteristics of MHCAs-assessing change in MHCA organization, assessment of construct reliability, and aggregation of individual responses to reflect organizational characteristics. We illustrate these issues using a leadership effectiveness scale (12 items) validated in previous research and data from 14 MHCAs participating in the Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) program.

FINDINGS

High levels of instability and turnover in MHCA membership create challenges in using survey data to study changes in key organizational characteristics of MHCAs. We offer several recommendations to diagnose the source and extent of these problems.