Association of Racial and Socioeconomic Disparities With Outcomes Among Patients Hospitalized With Acute Myocardial Infarction, Heart Failure, and Pneumonia: An Analysis of Within- and Between-Hospital Variation

Importance

Although studies have described differences in hospital outcomes by patient race and socioeconomic status, it is not clear whether such disparities are driven by hospitals themselves or by broader systemic effects.

Objective

To determine patterns of racial and socioeconomic disparities in outcomes within and between hospitals for patients with acute myocardial infarction, heart failure, and pneumonia.

Design, Setting, and Participants

Retrospective cohort study initiated before February 2013, with additional analyses conducted during the peer-review process. Hospitals in the United States treating at least 25 Medicare fee-for-service beneficiaries aged 65 years or older in each race (ie, black and white) and neighborhood income level (ie, higher income and lower income) for acute myocardial infarction, heart failure, and pneumonia between 2009 and 2011 were included.

Main Outcomes and Measures

For within-hospital analyses, risk-standardized mortality rates and risk-standardized readmission rates for race and neighborhood income subgroups were calculated at each hospital. The corresponding ratios using intraclass correlation coefficients were then compared. For between-hospital analyses, risk-standardized rates were assessed according to hospitals' proportion of patients in each subgroup. These analyses were performed for each of the 12 analysis cohorts reflecting the unique combinations of outcomes (mortality and readmission), demographics (race and neighborhood income), and conditions (acute myocardial infarction, heart failure, and pneumonia).

Results

Between 74% (3545 of 4810) and 91% (4136 of 4554) of US hospitals lacked sufficient racial and socioeconomic diversity to be included in this analysis, with the number of hospitals eligible for analysis varying among cohorts. The 12 analysis cohorts ranged in size from 418 to 1265 hospitals and from 144 417 to 703 324 patients. Within included hospitals, risk-standardized mortality rates tended to be lower among black patients (mean [SD] difference between risk-standardized mortality rates in black patients compared with white patients for acute myocardial infarction, -0.57 [1.1] [P = .47]; for heart failure, -4.7 [1.3] [P < .001]; and for pneumonia, -1.0 [2.0] [P = .05]). However, risk-standardized readmission rates among black patients were higher (mean [SD] difference between risk-standardized readmission rates in black patients compared with white patients for acute myocardial infarction, 4.3 [1.4] [P < .001]; for heart failure, 2.8 [1.8] [P < .001], and for pneumonia, 3.7 [1.3] [P < .001]). Intraclass correlation coefficients ranged from 0.68 to 0.79, indicating that hospitals generally delivered consistent quality to patients of differing races. While the coefficients in the neighborhood income analysis were slightly lower (0.46-0.60), indicating some heterogeneity in within-hospital performance, differences in mortality rates and readmission rates between the 2 neighborhood income groups were small. There were no strong, consistent associations between risk-standardized outcomes for white or higher-income neighborhood patients and hospitals' proportion of black or lower-income neighborhood patients.

Conclusions and Relevance

Hospital performance according to race and socioeconomic status was generally consistent within and between hospitals, even as there were overall differences in outcomes by race and neighborhood income. This finding indicates that disparities are likely to be systemic, rather than localized to particular hospitals.

Effects of episode-based payment on health care spending and utilization: Evidence from perinatal care in Arkansas

We study how physicians respond to financial incentives imposed by episode-based payment (EBP), which encourages lower spending and improved quality for an entire episode of care. Specifically, we study the impact of the Arkansas Health Care Payment Improvement Initiative, a multi-payer program that requires providers to enter into EBP arrangements for perinatal care, covering the majority of births in the state. Unlike fee-for-service reimbursement, EBP holds physicians responsible for all care within a discrete episode, rewarding physicians for efficient use of their own services and for efficient management of other health care inputs. In a difference-in-differences analysis of commercial claims, we find that perinatal spending in Arkansas decreased by 3.8% overall under EBP, compared to surrounding states. The decrease was driven by reduced spending on non-physician health care inputs, specifically the prices paid for inpatient facility care. We additionally find a limited improvement in quality of care under EBP.

Evaluation of the Present-on-Admission Indicator among Hospitalized Fee-for-Service Medicare Patients with a Pressure Ulcer Diagnosis: Coding Patterns and Impact on Hospital-Acquired Pressure Ulcer Rates

OBJECTIVES

To evaluate national present-on-admission (POA) reporting for hospital-acquired pressure ulcers (HAPUs) and examine the impact of quality measure exclusion criteria on HAPU rates.

DATA SOURCES/STUDY SETTING

Medicare inpatient, outpatient, and nursing facility data as well as independent provider claims (2010-2011).

STUDY DESIGN

Retrospective cross-sectional study.

DATA COLLECTION/EXTRACTION METHODS

We evaluated acute inpatient hospital admissions among Medicare fee-for-service (FFS) beneficiaries in 2011. Admissions were categorized as follows: (1) no pressure ulcer diagnosis, (2) new pressure ulcer diagnosis, and (3) previously documented pressure ulcer diagnosis. HAPU rates were calculated by varying patient exclusion criteria.

PRINCIPAL FINDINGS

Among admissions with a pressure ulcer diagnosis, we observed a large discrepancy in the proportion of admissions with a HAPU based on hospital-reported POA data (5.2 percent) and the proportion with a new pressure ulcer diagnosis based on patient history in billing claims (49.7 percent). Applying quality measure exclusion criteria resulted in removal of 91.2 percent of admissions with a pressure injury diagnosis from HAPU rate calculations.

CONCLUSIONS

As payers and health care organizations expand the use of quality measures, it is important to consider how the measures are implemented, coding revisions to improve measure validity, and the impact of patient exclusion criteria on provider performance evaluation.

Forgotten patients: ACO attribution omits those with low service use and the dying

OBJECTIVES

Alternative payment models, such as accountable care organizations, hold provider groups accountable for an assigned patient population, but little is known about unassigned patients. We compared clinical and utilization profiles of patients attributable to a provider group with those of patients not attributable to any provider group.

STUDY DESIGN

Cross-sectional study of 2012 Medicare fee-for-service beneficiaries 21 years and older.

METHODS

We applied the Medicare Shared Savings Program attribution approach to assign beneficiaries to 2 mutually exclusive categories: attributable or unattributable. We compared attributable and unattributable beneficiaries according to demographics, dual eligibility for Medicaid, nursing home residency, clinical comorbidities, annual service utilization, annual spending, and 1- and 2-year mortality. We estimated multivariate regression models describing correlates of attribution status.

RESULTS

Most beneficiaries (88%) were attributable to a provider group. The remaining 12% were unattributable. Beneficiaries unattributable to any provider group were more likely to be younger, male, and from a minority group; to have disability as the basis for enrollment; and to live in high-poverty areas. Unattributable beneficiaries included 3 distinct subgroups: nonusers of care, decedents, and those with healthcare service use but no qualifying evaluation and management visits. Many unattributable Medicare beneficiaries had minimal use of healthcare services, with the exception of a small subgroup of beneficiaries who died within the attribution year.

CONCLUSIONS

Attribution approaches that more fully capture unattributable patients with low service use and patients near the end of life should be considered to reward population health efforts and improve end-of-life care.

Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: A secondary analysis of administrative data

BACKGROUND

Medicare Advantage (MA) and Medicare fee-for-service (FFS) plans have different financial incentives. Medicare pays predetermined rates per beneficiary to MA plans for providing care throughout the year, while providers serving FFS patients are reimbursed per utilization event. It is unknown how these incentives affect post-acute care in skilled nursing facilities (SNFs). The objective of this study was to examine differences in rehabilitation service use, length of stay, and outcomes for patients following hip fracture between FFS and MA enrollees.

METHODS AND FINDINGS

This was a retrospective cohort study to examine differences in health service utilization and outcomes between FFS and MA patients in SNFs following hip fracture hospitalization during the period January 1, 2011, to June 30, 2015, and followed up until December 31, 2015. We linked the Master Beneficiary Summary File, Medicare Provider and Analysis Review data, Healthcare Effectiveness Data and Information Set data, the Minimum Data Set, and the American Community Survey. The 6 primary outcomes of interest in this study included 2 process measures and 4 patient-centered outcomes. Process measures included length of stay in the SNF and average rehabilitation therapy minutes (physical and occupational therapy) received per day. Patient-centered outcomes included 30-day hospital readmission, changes in functional status as measured by the 28-point late loss MDS-ADL scale, likelihood of becoming a long-term resident, and successful discharge to the community. Successful discharge from a SNF was defined as being discharged to the community within 100 days of SNF admission and remaining alive in the community without being institutionalized in any acute or post-acute setting for at least 30 days. We analyzed 211,296 FFS and 75,554 MA patients with hip fracture admitted directly to a SNF following an index hospitalization who had not been in a nursing facility or hospital in the preceding year. We used inverse probability of treatment weighting (IPTW) and nursing facility fixed effects regression models to compare treatments and outcomes between MA and FFS patients. MA patients were younger and less cognitively impaired upon SNF admission than FFS patients. After applying IPTW, demographic and clinical characteristics of MA patients were comparable with those of FFS patients. After adjusting for risk factors using IPTW-weighted fixed effects regression models, MA patients spent 5.1 (95% CI -5.4 to -4.8) fewer days in the SNF and received 463 (95% CI to -483.2 to -442.4) fewer minutes of total rehabilitation therapy during the first 40 days following SNF admission, i.e., 12.1 (95% CI -12.7 to -11.4) fewer minutes of rehabilitation therapy per day compared to FFS patients. In addition, MA patients had a 1.2 percentage point (95% CI -1.5 to -1.1) lower 30-day readmission rate, 0.6 percentage point (95% CI -0.8 to -0.3) lower rate of becoming a long-stay resident, and a 3.2 percentage point (95% CI 2.7 to 3.7) higher rate of successful discharge to the community compared to FFS patients. The major limitation of this study was that we only adjusted for observed differences to address selection bias between FFS and MA patients with hip fracture. Therefore, results may not be generalizable to other conditions requiring extensive rehabilitation.

CONCLUSIONS

Compared to FFS patients, MA patients had a shorter course of rehabilitation but were more likely to be discharged to the community successfully and were less likely to experience a 30-day hospital readmission. Longer lengths of stay may not translate into better outcomes in the case of hip fracture patients in SNFs.

Outpatient Visits Before Ambulatory Care-Sensitive Hospitalization of Children Receiving Medicaid

OBJECTIVES

Hospitalizations for ambulatory care-sensitive conditions (ACSC) are measured to indicate health care system quality, with the premise that fewer hospitalizations would occur with better preceding outpatient care. Our objectives were to identify outpatient care received in the 7 days preceding acute pediatric hospitalizations and to compare receipt of outpatient care by hospitalization type (ACSC vs non-ACSC).

METHODS

This retrospective observational study used a 10-state database of Medicaid claims to identify outpatient visits within 7 days before acute unplanned hospitalization for children aged 0 to 17 years. We used logistic regression to assess the relationship between hospitalization type and occurrence of a preceding outpatient clinic visit, controlling for patient age, race/ethnicity, type of Medicaid, and complex chronic conditions.

RESULTS

Of 254,902 hospitalizations, 28.6% had a preceding outpatient visit. Thirty-five percent of hospitalizations were for ACSC. A greater percentage of ACSC versus non-ACSC hospitalizations had a preceding outpatient visit (31.1% vs 27.3%, P < .001). In multivariable analysis, characteristics associated with a preceding outpatient visit were age <1 versus 13 to 17 years (adjusted odds ratio [aOR] 2.4; 95% confidence interval [CI] 2.3-2.5), ≥2 vs 0 complex chronic conditions (aOR 1.9; 95% CI 1.8-2.0), Medicaid managed care versus fee for service (aOR 1.2; 95% CI 1.2-1.3), and ACSC versus non-ACSC hospitalization (aOR 1.2; 95% CI 1.1-1.2).

CONCLUSIONS

Although receipt of outpatient care was modestly higher in children hospitalized with an ACSC, most hospitalized children did not receive preceding outpatient care. Further investigation is needed to assess why such a large proportion of children do not receive outpatient care before acute unplanned hospitalization, especially for ACSC.

Optimal compensation rule under provider adverse selection and moral hazard

Although healthcare provider payments have been studied extensively in the literature, little is known about the optimal compensation rule when, in addition to unobservable provider effort (moral hazard), the provider's ability type is also private information (adverse selection). We find that when only provider effort is unobservable, to induce the first-best outcome the optimal compensation rule requires zero fee-for-service. When both provider moral hazard and adverse selection exist, the first-best outcome will be infeasible. The second-best compensation rule entails combined use of capitation, fee-for-service, and pay-for-performance.

Changes in Health Care Use Associated With the Introduction of Hospital Global Budgets in Maryland

Importance

In 2014, the State of Maryland placed the majority of its hospitals under all-payer global budgets for inpatient, hospital outpatient, and emergency department care. Goals of the program included reducing unnecessary hospital utilization and encouraging greater use of primary care.

Objective

To compare changes in hospital and primary care use through the first 2 years of Maryland's hospital global budget program among fee-for-service Medicare beneficiaries in Maryland vs matched control areas.

Design, Setting, and Participants

We matched 8 Maryland counties (94 967 beneficiaries) with hospitals in the program to 27 non-Maryland control counties (206 389 beneficiaries). Using difference-in-differences analysis, we compared changes in hospital and primary care use in Maryland vs the control counties from before (2009-2013) to after (2014-2015) the payment change, using 2 different assumptions. First, we assumed that preintervention differences between Maryland and the control counties would have remained constant past 2014 had Maryland not implemented global budgets (parallel trend assumption). Second, we assumed that differences in preintervention trends would have continued without the payment change (differential trend assumption).

Main Outcomes and Measures

Hospital stays (defined as admissions and observation stays); return hospital stays within 30 days of a prior hospital stay; emergency department visits that did not result in admission; price-standardized hospital outpatient department (HOPD) utilization; and visits with primary care physicians (overall and within 7 days of a hospital stay).

Results

We matched 8 Maryland counties with hospitals in the program (94 967 beneficiaries; 41.8% male; mean [SD] age, 72.3 [12.2] years) to 27 non-Maryland control counties (206 389 beneficiaries; 42.8% male; mean [SD] age, 71.7 [12.5] years). Assuming parallel trends, we estimated a differential change in Maryland of -0.47 annual hospital stays per 100 beneficiaries (95% CI, -1.65 to 0.72; P = .43) from the preintervention period (2009-2013) to 2015, but assuming differential trends, we estimated a differential change in Maryland of -1.24 stays per 100 beneficiaries (95% CI, -2.46 to -0.02; P = .047). Assuming parallel trends, we found a significant increase in primary care visits (+10.6 annual visits/100 beneficiaries; 95% CI, 4.6 to 16.6 annual visits/100 beneficiaries; P = .001), but assuming differential trends, we found no change (-0.8 visits/100 beneficiaries; 95% CI, -10.6 to 9.0 visits/100 beneficiaries; P = .87). Comparing estimates with both trend assumptions, we found no consistent changes in emergency department visits, return hospital stays, HOPD use, or posthospitalization primary care visits associated with Maryland's program.

Conclusions and Relevance

We did not find consistent evidence that Maryland's hospital global budget program was associated with reductions in hospital use or increases in primary care visits among fee-for-service Medicare beneficiaries after 2 years. Evaluations over longer periods should be pursued.

Low-Value Service Use in Provider Organizations

OBJECTIVE

To assess whether provider organizations exhibit distinct profiles of low-value service provision.

DATA SOURCES

2007-2011 Medicare fee-for-service claims and enrollment data.

STUDY DESIGN

Use of 31 services that provide minimal clinical benefit was measured for 4,039,733 beneficiaries served by 3,137 provider organizations. Variation across organizations, persistence within organizations over time, and correlations in use of different types of low-value services within organizations were estimated via multilevel modeling, with adjustment for beneficiary sociodemographic and clinical characteristics.

PRINCIPAL FINDINGS

Organizations provided 45.6 low-value services per 100 beneficiaries on average, with considerable variation across organizations (90th/10th percentile ratio, 1.78; 95 percent CI, 1.72-1.84), including substantial between-organization variation within hospital referral regions (90th/10th percentile ratio, 1.66; 95 percent CI, 1.60-1.71). Low-value service use within organizations was highly correlated over time (r, 0.98; 95 percent CI, 0.97-0.99) and positively correlated between 13 of 15 pairs of service categories (average r, 0.26; 95 percent CI, 0.24-0.28), with the greatest correlation between low-value imaging and low-value cardiovascular testing and procedures (r, 0.54).

CONCLUSIONS

Use of low-value services in provider organizations exhibited substantial variation, high persistence, and modest consistency across service types. These findings are consistent with organizations shaping the practice patterns of affiliated physicians.

Diffusion of Bevacizumab Across Oncology Practices: An Observational Study

BACKGROUND

Technological advances can improve care and outcomes but are a primary driver of health care spending growth. Understanding diffusion and use of new oncology therapies is important, given substantial increases in prices and spending on such treatments.

OBJECTIVES

Examine diffusion of bevacizumab, a novel (in 2004) and high-priced biologic cancer therapy, among US oncology practices during 2005-2012 and assess variation in use across practices.

RESEARCH DESIGN

Population-based observational study.

SETTING

A total of 2329 US practices providing cancer chemotherapy.

PARTICIPANTS

Random 20% sample of 236,304 Medicare fee-for-service beneficiaries aged above 65 years in 2004-2012 undergoing infused chemotherapy for cancer.

MEASURES

Diffusion of bevacizumab (cumulative time to first use and 10% use) in practices, variation in use across practices overall and by higher versus lower-value use. We used hierarchical models with practice random effects to estimate the between-practice variation in the probability of receiving bevacizumab and to identify factors associated with use.

RESULTS

We observed relatively rapid diffusion of bevacizumab, particularly in independent practices and larger versus smaller practices. We observed substantial variation in use; the adjusted odds ratio (95% confidence interval) of bevacizumab use was 2.90 higher (2.73-3.08) for practices 1 SD above versus one standard deviation below the mean. Variation was less for higher-value [odds ratio=2.72 (2.56-2.89)] than lower-value uses [odds ratio=3.61 (3.21-4.06)].

CONCLUSIONS

Use of bevacizumab varied widely across oncology practices, particularly for lower-value indications. These findings suggest that interventions targeted to practices have potential for decreasing low-value use of high-cost cancer therapies.

How Do the Hospital Prices Paid by Medicare Advantage Plans and Commercial Plans Compare With Medicare Fee-for-Service Prices?

The prices that private insurers pay hospitals have received considerable attention in recent years, but most of that literature has focused on the commercially insured population. Although nearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, little is known about the prices paid to hospitals by the private insurers that administer such plans. More information on the hospital prices paid by MA plans would provide additional insights into whether MA prices are more closely tied to Medicare fee-for-service (FFS) prices or commercial prices. Moreover, information on whether the hospital prices paid by MA plans vary with market characteristics or other factors would be useful for evaluating the performance of the MA program and analyzing proposals to modify it. In this study, we compared the hospital prices paid by MA plans and commercial plans with Medicare FFS prices using 2013 claims from the Health Care Cost Institute (HCCI) database. The HCCI claims were used to calculate hospital prices for private insurers, and Medicare's payment rules were used to estimate Medicare FFS prices. We focused on stays at acute care hospitals in metropolitan statistical areas (MSAs). We found MA prices to be roughly equal to Medicare FFS prices, on average, but commercial prices were 89% higher than FFS prices. In addition, commercial prices varied greatly across and within MSAs, but MA prices varied much less.

Provider Experiences with Chronic Care Management (CCM) Services and Fees: A Qualitative Research Study

BACKGROUND

Support for ongoing care management and coordination between office visits for patients with multiple chronic conditions has been inadequate. In January 2015, Medicare introduced the Chronic Care Management (CCM) payment policy, which reimburses providers for CCM activities for Medicare beneficiaries occurring outside of office visits.

OBJECTIVE

To explore the experiences, facilitators, and challenges of practices providing CCM services, and their implications going forward.

DESIGN

Semi-structured telephone interviews from January to April 2016 with 71 respondents.

PARTICIPANTS

Sixty billing and non-billing providers and practice staff knowledgeable about their practices' CCM services, and 11 professional society representatives.

KEY RESULTS

Practice respondents noted that most patients expressed positive views of CCM services. Practice respondents also perceived several patient benefits, including improved adherence to treatment, access to care team members, satisfaction, care continuity, and care coordination. Facilitators of CCM provision included having an in-practice care manager, patient-centered medical home recognition, experience developing care plans, patient trust in their provider, and supplemental insurance to cover CCM copayments. Most billing practices reported few problems obtaining patients' consent for CCM, though providers felt that CMS could better facilitate consent by marketing CCM's goals to beneficiaries. Barriers reported by professional society representatives and by billing and non-billing providers included inadequacy of CCM payments to cover upfront investments for staffing, workflow modification, and time needed to manage complex patients. Other barriers included inadequate infrastructure for health information exchange with other providers and limited electronic health record capabilities for documenting and updating care plans. Practices owned by hospital systems and large medical groups faced greater bureaucracy in implementing CCM than did smaller, independent practices.

CONCLUSIONS

Improving providers' experiences with and uptake of CCM will require addressing several challenges, including the upfront investment for CCM set-up and the time required to provide CCM to more complex patients.

Behavioral Health Integration into Primary Care: a Microsimulation of Financial Implications for Practices

BACKGROUND

New payments from Medicare encourage behavioral health services to be integrated into primary care practice activities.

OBJECTIVE

To evaluate the financial impact for primary care practices of integrating behavioral health services.

DESIGN

Microsimulation model.

PARTICIPANTS

We simulated patients and providers at federally qualified health centers (FQHCs), non-FQHCs in urban and rural high-poverty areas, and practices outside of high-poverty areas surveyed by the National Association of Community Health Centers, National Ambulatory Medical Care Survey, National Health and Nutrition Examination Survey, and National Health Interview Survey.

INTERVENTIONS

A collaborative care model (CoCM), involving telephone-based follow-up from a behaviorist care manager, or a primary care behaviorist model (PCBM), involving an in-clinic behaviorist.

MAIN MEASURES

Net revenue change per full-time physician.

KEY RESULTS

When behavioral health integration services were offered only to Medicare patients, net revenue was higher under CoCM (averaging $25,026 per MD in year 1 and $28,548/year in subsequent years) than PCBM (-$7052 in year 1 and -$3706/year in subsequent years). When behavioral health integration services were offered to all patients and were reimbursed by Medicare and private payers, only practices adopting the CoCM approach consistently gained net revenues. The outcomes of the model were sensitive to rates of patient referral acceptance, presentation, and therapy completion, but the CoCM approach remained consistently financially viable whereas PCBM would not be in the long-run across practice types.

CONCLUSIONS

New Medicare payments may offer financial viability for primary care practices to integrate behavioral health services, but this viability depends on the approach toward care integration.

Long-term Effects of Managed Care

Managed care (MC) plans have been introduced to curb the ever increasing health care costs. Many previous studies on effectiveness lacked a long-term perspective; hence, the sustainability of (possible) savings remains unclear. Moreover, because of their incentives, MC plans are susceptible to under-provision of care. Most of these possibly negative effects can only be observed in the long-term. This paper analyzes the long-term effects of MC plans on cost savings, mortality, and the use of service, using administrative data from a large Swiss health insurer. The identification is based on a propensity-score matching approach, where individuals who enter an MC plan are compared over 10 years to individuals who remain in a standard fee-for-service plan. Cost savings are substantial and sustainable, and the mortality rate is lower in MC plans. Cost savings are driven by fewer consultations and fewer days in hospital care, although the probability of visiting a provider at least once per year is similar or even higher for persons in MC plans. Copyright © 2016 John Wiley & Sons, Ltd.

Socioeconomic Differences in Use of Low-Value Cancer Screenings and Distributional Effects in Medicare

OBJECTIVE

Consuming low-value health care not only highlights inefficient resource use but also brings an important concern regarding the economics of disparities. We identify the relation of socioeconomic characteristics to the use of low-value cancer screenings in Medicare fee-for-service (FFS) settings, and quantify the amount subsidized from nonusers and taxpayers to users of these screenings.

DATA SOURCES

2007-2013 Medicare Current Beneficiary Survey, Medicare FFS claims, and the Area Health Resource Files.

STUDY DESIGN

Our sample included enrollees in FFS Part B for the entire calendar year. We excluded beneficiaries with a claims-documented or self-reported history of targeted cancers, or those enrolled in Medicaid or Medicare Advantage plans. We identified use of low-value Pap smears, mammograms, and prostate-specific antigen tests based on established algorithms, and estimated a logistic model with year dummies separately for each test.

DATA COLLECTION/EXTRACTION METHODS

Secondary data analyses.

PRINCIPAL FINDINGS

We found a statistically significant positive association between privileged socioeconomic characteristics and use of low-value screenings. Having higher income and supplemental private insurance strongly predicted more net subsidies from Medicare.

CONCLUSIONS

FFS enrollees who are better off in terms of sociodemographic characteristics receive greater subsidies from taxpayers for using low-value cancer screenings.

Cost Effectiveness of Genotype-Guided Warfarin Dosing in Patients with Mechanical Heart Valve Replacement Under the Fee-for-Service System

BACKGROUND

Although studies assessing the cost effectiveness of genotype-guided warfarin dosing for the management of atrial fibrillation, deep vein thrombosis, and pulmonary embolism have been reported, no publications have addressed genotype-guided warfarin therapy in mechanical heart valve replacement (MHVR) patients or genotype-guided warfarin therapy under the fee-for-service (FFS) insurance system.

OBJECTIVE

The aim of this study was to evaluate the cost effectiveness of genotype-guided warfarin dosing in patients with MHVR under the FFS system from the Korea healthcare sector perspective.

METHODS

A decision-analytic Markov model was developed to evaluate the cost effectiveness of genotype-guided warfarin dosing compared with standard dosing. Estimates of clinical adverse event rates and health state utilities were derived from the published literature. The outcome measure was the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY). One-way and probabilistic sensitivity analyses were performed to explore the range of plausible results.

RESULTS

In a base-case analysis, genotype-guided warfarin dosing was associated with marginally higher QALYs than standard warfarin dosing (6.088 vs. 6.083, respectively), at a slightly higher cost (US$6.8) (year 2016 values). The ICER was US$1356.2 per QALY gained. In probabilistic sensitivity analysis, there was an 82.7% probability that genotype-guided dosing was dominant compared with standard dosing, and a 99.8% probability that it was cost effective at a willingness-to-pay threshold of US$50,000 per QALY gained.

CONCLUSION

Compared with only standard warfarin therapy, genotype-guided warfarin dosing was cost effective in MHVR patients under the FFS insurance system.

Overtreatment in the United States

Background

Overtreatment is a cause of preventable harm and waste in health care. Little is known about clinician perspectives on the problem. In this study, physicians were surveyed on the prevalence, causes, and implications of overtreatment.

Methods

2,106 physicians from an online community composed of doctors from the American Medical Association (AMA) masterfile participated in a survey. The survey inquired about the extent of overutilization, as well as causes, solutions, and implications for health care. Main outcome measures included: percentage of unnecessary medical care, most commonly cited reasons of overtreatment, potential solutions, and responses regarding association of profit and overtreatment.

Findings

The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures. The most common cited reasons for overtreatment were fear of malpractice (84.7%), patient pressure/request (59.0%), and difficulty accessing medical records (38.2%). Potential solutions identified were training residents on appropriateness criteria (55.2%), easy access to outside health records (52.0%), and more practice guidelines (51.5%). Most respondents (70.8%) believed that physicians are more likely to perform unnecessary procedures when they profit from them. Most respondents believed that de-emphasizing fee-for-service physician compensation would reduce health care utilization and costs.

Conclusion

From the physician perspective, overtreatment is common. Efforts to address the problem should consider the causes and solutions offered by physicians.

The Impact of Medication-Based Risk Adjustment on the Association Between Veteran Health Outcomes and Dual Health System Use

BACKGROUND

Veterans commonly receive care from both Veterans Health Administration (VA) and non-VA sources (i.e., dual use). A major challenge in comparing health outcomes between dual users and VA-predominant users is applying an accurate method of risk adjustment.

OBJECTIVE

To determine how different comorbidity indices affect the association between patterns of dual use and health outcomes.

DESIGN

Retrospective cohort.

PARTICIPANTS

A total of 316,775 community-dwelling Veterans (≥65 years) with type 2 diabetes who were enrolled in VA and fee-for-service Medicare from 2008 to 2010.

METHODS

We determined the associations between dual use and death or diabetes-related hospitalization in FY 2010 using multivariable models incorporating claims-based (Elixhauser) or medication-based (RxRisk-V) risk adjustment. Dual use was classified using four previously identified groups of health services users: 1) VA-predominant, 2) VA + Medicare visits and labs, 3) VA + Medicare test strips, and 4) VA + Medicare medications.

KEY RESULTS

Controlling for Elixhauser comorbidities, dual-use groups 2-4 had significantly decreased odds of death or hospitalization compared to VA-predominant users. Controlling for RxRisk-V comorbidities, groups 2-4 had increased odds of death compared to VA-predominant users, but variable odds of hospitalization, with group 2 having increased odds (OR 1.06, CI 1.04-1.09), while groups 3 (OR 0.96, CI 0.94-0.99) and 4 (OR 0.93, CI 0.89-0.97) had decreased odds.

CONCLUSIONS

The method of risk adjustment drastically influences the direction of effect in health outcomes among dual users of VA and Medicare. These findings underscore the need for standardized and reliable risk adjustment methods that are not susceptible to measurement differences across different health systems.

Medicare Advantage Enrollment Update 2017

PURPOSE

The RUPRI Center for Rural Health Policy Analysis reports annually on rural beneficiary enrollment in Medicare Advantage (MA) plans, noting any trends or new developments evident in the data. These reports are based on data through March of each year, capturing results of open enrollment periods.

KEY FINDINGS

(1) Nationally, 1 in 3 Medicare beneficiaries is enrolled in an MA plan. In non-metropolitan areas, nearly 1 in 4 (23.5 percent) beneficiaries is enrolled in an MA plan. (2) Enrollment in MA plans, measured either as an overall count or as a proportion of eligible Medicare beneficiaries, has increased in both metropolitan and non-metropolitan populations since 2004. (3) Between 2015 and 2017, the proportion of non-metropolitan Medicare-eligible beneficiaries enrolled in local preferred provider organization (PPO), regional PPO, and "other" plans (including cost, health care pre-payment [HCPP], medical savings account [MSA] and demonstration plans) remained relatively steady. During the same period, the proportion of Medicare-eligible beneficiaries enrolled in health maintenance organization (HMO) plans increased slightly (from 28.5 percent in 2015 to 29.8 percent in 2017) while the proportion enrolled in private fee-for-service (PFFS) plans decreased slightly (from 5.6 percent in 2015 to 3.8 percent in 2017).

Trends in readmission rates for safety net hospitals and non-safety net hospitals in the era of the US Hospital Readmission Reduction Program: a retrospective time series analysis using Medicare administrative claims data from 2008 to 2015

OBJECTIVE

To compare trends in readmission rates among safety net and non-safety net hospitals under the US Hospital Readmission Reduction Program (HRRP).

DESIGN

A retrospective time series analysis using Medicare administrative claims data from January 2008 to June 2015.

SETTING

We examined 3254 US hospitals eligible for penalties under the HRRP, categorised as safety net or non-safety net hospitals based on the hospital's proportion of patients with low socioeconomic status.

PARTICIPANTS

Admissions for Medicare fee-for-service patients, age ≥65 years, discharged alive, who had a valid five-digit zip code and did not have a principal discharge diagnosis of cancer or psychiatric illness were included, for a total of 52 516 213 index admissions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Mean hospital-level, all-condition, 30-day risk-adjusted standardised unplanned readmission rate, measured quarterly, along with quarterly rate of change, and an interrupted time series examining: April-June 2010, after HRRP was passed, and October-December 2012, after HRRP penalties were implemented.

RESULTS

58.0% (SD 15.3) of safety net hospitals and 17.1% (SD 10.4) of non-safety net hospitals' patients were in the lowest quartile of socioeconomic status. The mean safety net hospital standardised readmission rate declined from 17.0% (SD 3.7) to 13.6% (SD 3.6), whereas the mean non-safety net hospital declined from 15.4% (SD 3.0) to 12.7% (SD 2.5). The absolute difference in rates between safety net and non-safety net hospitals declined from 1.6% (95% CI 1.3 to 1.9) to 0.9% (0.7 to 1.2). The quarterly decline in standardised readmission rates was 0.03 percentage points (95% CI 0.03 to 0.02, p<0.001) greater among safety net hospitals over the entire study period, and no differential change among safety net and non-safety net hospitals was found after either HRRP was passed or penalties enacted.

CONCLUSIONS

Since HRRP was passed and penalties implemented, readmission rates for safety net hospitals have decreased more rapidly than those for non-safety net hospitals.

Defining hip fracture with claims data: outpatient and provider claims matter

Medicare claims are commonly used to identify hip fractures, but there is no universally accepted definition. We found that a definition using inpatient claims identified fewer fractures than a definition including outpatient and provider claims. Few additional fractures were identified by including inconsistent diagnostic and procedural codes at contiguous sites.

INTRODUCTION

Medicare claims data is commonly used in research studies to identify hip fractures, but there is no universally accepted definition of fracture. Our purpose was to describe potential misclassification when hip fractures are defined using Medicare Part A (inpatient) claims without considering Part B (outpatient and provider) claims and when inconsistent diagnostic and procedural codes occur at contiguous fracture sites (e.g., femoral shaft or pelvic).

METHODS

Participants included all long-stay nursing home residents enrolled in Medicare Parts A and B fee-for-service between 1/1/2008 and 12/31/2009 with follow-up through 12/31/2011. We compared the number of hip fractures identified using only Part A claims to (1) Part A plus Part B claims and (2) Part A and Part B claims plus discordant codes at contiguous fracture sites.

RESULTS

Among 1,257,279 long-stay residents, 40,932 (3.2%) met the definition of hip fracture using Part A claims, and 41,687 residents (3.3%) met the definition using Part B claims. 4566 hip fractures identified using Part B claims would not have been captured using Part A claims. An additional 227 hip fractures were identified after considering contiguous fracture sites.

CONCLUSIONS

When ascertaining hip fractures, a definition using outpatient and provider claims identified 11% more fractures than a definition with only inpatient claims. Future studies should publish their definition of fracture and specify if diagnostic codes from contiguous fracture sites were used.

Hospital Characteristics Associated With Risk-standardized Readmission Rates

BACKGROUND

Safety-net and teaching hospitals are somewhat more likely to be penalized for excess readmissions, but the association of other hospital characteristics with readmission rates is uncertain and may have relevance for hospital-centered interventions.

OBJECTIVE

To examine the independent association of 8 hospital characteristics with hospital-wide 30-day risk-standardized readmission rate (RSRR).

DESIGN

This is a retrospective cross-sectional multivariable analysis.

SUBJECTS

US hospitals.

MEASURES

Centers for Medicare and Medicaid Services specification of hospital-wide RSRR from July 1, 2013 through June 30, 2014 with race and Medicaid dual-eligibility added.

RESULTS

We included 6,789,839 admissions to 4474 hospitals of Medicare fee-for-service beneficiaries aged over 64 years. In multivariable analyses, there was regional variation: hospitals in the mid-Atlantic region had the highest RSRRs [0.98 percentage points higher than hospitals in the Mountain region; 95% confidence interval (CI), 0.84-1.12]. For-profit hospitals had an average RSRR 0.38 percentage points (95% CI, 0.24-0.53) higher than public hospitals. Both urban and rural hospitals had higher RSRRs than those in medium metropolitan areas. Hospitals without advanced cardiac surgery capability had an average RSRR 0.27 percentage points (95% CI, 0.18-0.36) higher than those with. The ratio of registered nurses per hospital bed was not associated with RSRR. Variability in RSRRs among hospitals of similar type was much larger than aggregate differences between types of hospitals.

CONCLUSIONS

Overall, larger, urban, academic facilities had modestly higher RSRRs than smaller, suburban, community hospitals, although there was a wide range of performance. The strong regional effect suggests that local practice patterns are an important influence. Disproportionately high readmission rates at for-profit hospitals may highlight the role of financial incentives favoring utilization.

Changes in Postacute Care in the Medicare Shared Savings Program

Importance

Postacute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit postacute care spending has implications for the importance and design of other payment models that include postacute care.

Objective

To assess changes in postacute care spending and use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred.

Design, Setting, and Participants

With the use of fee-for-service Medicare claims from a random 20% sample of beneficiaries with 25 544 650 patient-years, 8 395 426 hospital admissions, and 1 595 352 stays in skilled nursing facilities (SNFs) from January 1, 2009, to December 31, 2014, difference-in-difference comparisons of beneficiaries served by ACOs with beneficiaries served by local non-ACO health care professionals (control group) were performed before vs after entry into the MSSP. Differential changes were estimated separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014.

Exposures

Patient attribution to an ACO in the MSSP.

Main Outcomes and Measures

Postacute spending, discharge to a facility, length of SNF stays, readmissions, use of highly rated SNFs, and mortality, adjusted for patient characteristics.

Results

For the 2012 cohort of 114 ACOs, participation in the MSSP was associated with an overall reduction in postacute spending (differential change in 2014 for ACOs vs control group, -$106 per beneficiary [95% CI, -$176 to -$35], or -9.0% of the precontract unadjusted mean of $1172; P = .003) that was driven by differential reductions in acute inpatient care, discharges to facilities rather than home (-0.6 percentage points [95% CI, -1.1 to 0.0], or -2.7% of the unadjusted precontract mean of 22.6%; P = .03), and length of SNF stays (-0.60 days per stay [95% CI, -0.99 to -0.22], or -2.2% of the precontract unadjusted mean of 27.07 days; P = .002). Reductions in use of SNFs and length of stay were largely due to within-hospital or within-SNF changes in care specifically for ACO patients. Participation in the MSSP was associated with smaller significant reductions in SNF spending in 2014 for the 2013 ACO cohort (-$27 per beneficiary [95% CI, -$49 to -$6], or -3.3% of the precontract unadjusted mean of $813; P = .01) but not in the 2013 or 2014 cohort's first year of participation (-$13 per beneficiary [95% CI, -$33 to $6]; P = .19; and $4 per beneficiary [95% CI, -$15 to $24]; P = .66). Estimates were similar for ACOs with and without financial ties to hospitals. Participation in the MSSP was not associated with significant changes in 30-day readmissions, use of highly rated SNFs, or mortality.

Conclusions and Relevance

Participation in the MSSP has been associated with significant reductions in postacute spending without ostensible deterioration in quality of care. Spending reductions were more consistent with clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital-wide initiatives by ACOs or use of preferred SNFs.

The Effects of Introducing Mixed Payment Systems for Physicians: Experimental Evidence

Mixed payment systems have become a prominent alternative to paying physicians through fee-for-service and capitation. While theory shows mixed payment systems to be superior, causal effects on physicians' behavior when introducing mixed systems are not well understood empirically. We systematically analyze the influence of fee-for-service, capitation, and mixed payment systems on physicians' service provision. In a controlled laboratory setting, we implement an exogenous variation of the payment method. Medical and non-medical students in the role of physicians in the lab (N = 213) choose quantities of medical services affecting patients' health outside the lab. Behavioral data reveal significant overprovision of medical services under fee-for-service and significant underprovision under capitation, although less than predicted when assuming profit maximization. Introducing mixed payment systems significantly reduces deviations from patient-optimal treatment. Although medical students tend to be more patient regarding, our results hold for both medical and non-medical students. Responses to incentive systems can be explained by a behavioral model capturing individual altruism. In particular, we find support that altruism plays a role in service provision and can partially mitigate agency problems, but altruism is heterogeneous in the population. Copyright © 2015 John Wiley & Sons, Ltd.

Geographic Variations in Incremental Costs of Heart Disease Among Medicare Beneficiaries, by Type of Service, 2012

Using 2012 data on fee-for-service Medicare claims, we documented regional and county variation in incremental standardized costs of heart disease (ie, comparing costs between beneficiaries with heart disease and beneficiaries without heart disease) by type of service (eg, inpatient, outpatient, post-acute care). Absolute incremental total costs varied by region. Although the largest absolute incremental total costs of heart disease were concentrated in southern and Appalachian counties, geographic patterns of costs varied by type of service. These data can be used to inform development of policies and payment models that address the observed geographic disparities.