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Carpenter JG, Kinder D, Smith D, Ersek M, Wachterman M, Thorpe J, Sullivan DR, Bailey J, Shreve S, Kutney-Lee A. Nursing Home Star Ratings and End-Of-Life Care Quality: Lessons Learned From the Veterans Health Administration. J Am Med Dir Assoc 2024; 25:105121. [PMID: 38950589 DOI: 10.1016/j.jamda.2024.105121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/17/2024] [Accepted: 05/24/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVES More than 25% of deaths among older adults occur in nursing homes. Thus, assessments of nursing home quality, including the widely used 5-star rating systems, should reflect quality of end-of-life (EOL) care. Our objective was to examine the associations between Veterans Affairs (VA) nursing home star ratings and quality of EOL care as measured by the VA's Bereaved Family Survey (BFS). DESIGN National, retrospective observational study. SETTING AND PARTICIPANTS VA nursing homes, known as Community Living Centers (CLCs). All veterans who died in a CLC from October 2018 to September 2019 whose next of kin completed a BFS. METHODS Using linked VA data sources, we examined the BFS-Performance Measure (BFS-PM) (ie, the % of BFS respondents who provided an "excellent" overall rating) by the Overall Star Rating and domain star ratings (unannounced survey, staffing, and quality) for the 133 CLCs in our sample. Logistic and linear regression was used to examine the associations between CLC Overall Star Rating and individual-level BFS outcomes. Outcomes included the BFS-PM (primary), the 3 BFS factor scores of Respectful Care and Communication, Emotional and Spiritual Support, and Death Benefits, and 2 symptom management items. RESULTS Differences in the BFS-PM by CLC star rating were small to none and not statistically significant across all star rating domains. The relationship between a higher CLC Overall Star Rating and odds of an "excellent" BFS global rating was not statistically significant. Similarly, no significant associations were observed between a higher CLC Overall Star Rating and scores on the BFS factor scores and symptom management items. CONCLUSIONS AND IMPLICATIONS Our findings suggest that the current CLC star rating system is not sufficient to assess the quality of EOL care. BFS scores, or a comparative EOL quality of care measure, should be integrated into CLC quality rating systems.
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Affiliation(s)
- Joan G Carpenter
- Department of Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, MD, USA; Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
| | - Daniel Kinder
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Dawn Smith
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Melissa Wachterman
- Veterans Affairs Boston Health Care System, Section of General Internal Medicine, Boston, MA, USA; Dana Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Boston, MA, USA
| | - Joshua Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Donald R Sullivan
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA; Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Jennifer Bailey
- Office of Geriatrics and Extended Care, Department of Veterans Affairs, Seattle, WA, USA
| | - Scott Shreve
- Palliative and Hospice Care Program, Department of Veterans Affairs, Seattle, WA, USA; Penn State College of Medicine, Hershey, PA, USA
| | - Ann Kutney-Lee
- Veteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Magnuson JA, Hobbs J, Yakkanti R, Gold PA, Courtney PM, Krueger CA. Lower Revenue Surplus in Medicare Advantage Versus Private Commercial Insurance for Total Joint Arthroplasty: An Analysis of a Single Payor Source at One Institution. J Arthroplasty 2024; 39:26-31.e1. [PMID: 37380139 DOI: 10.1016/j.arth.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Since the Affordable Care Act was passed in 2010, reductions in Medicare reimbursement have led to larger discrepancies between the relative cost of Medicare patients and privately insured patients. The purpose of this study was to compare reimbursement between Medicare Advantage and other insurance plans in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS Patients of a single commercial payor source who underwent primary unilateral TKA or THA at 1 institution between the dates of January 4 and June 30, 2021, were included (n = 833). Variables included insurance type, medical comorbidities, total costs, and surplus amounts. The primary outcome measure was revenue surplus between Medicare Advantage and Private Commercial plans. t-tests, Analyses of Variance, and Chi-Squared tests were used for analysis. A THA represented 47% of cases and a TKA 53%. Of these patients, 31.5% had Medicare Advantage and 68.5% had Private Commercial insurance. Medicare Advantage patients were older and had higher medical comorbidity risk for both TKA and THA. RESULTS Significant differences were observed in medical costs between Medicare Advantage and Private Commercial insurance for THA ($17,148 versus $31,260, P < .001) and TKA ($16,723 versus $33,593, P < .001). Additionally, differences were seen in surplus amounts between Medicare Advantage and Private Commercial insurance for THA ($3,504 versus $7,128, P < .001) and TKA ($5,581 versus $10,477, P < .001). Deficits were higher in Private Commercial patients undergoing TKA (15.2 versus 6%, P = .001). CONCLUSION The lower average surplus associated with Medicare Advantage plans may lead to financial strain on provider groups who care for these patients and face additional overhead costs.
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Affiliation(s)
- Justin A Magnuson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - John Hobbs
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ramakanth Yakkanti
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Peter A Gold
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Chad A Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Tamara Konetzka R, Yan K, Werner RM. Two Decades of Nursing Home Compare: What Have We Learned? Med Care Res Rev 2020; 78:295-310. [PMID: 32538264 DOI: 10.1177/1077558720931652] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Approximately two decades ago, federally mandated public reporting began for U.S. nursing homes through a system now known as Nursing Home Compare. The goals were to provide information to enable consumers to choose higher quality nursing homes and to incent providers to improve the quality of care delivered. We conduct a systematic review of the literature on responses to Nursing Home Compare and its effectiveness in meeting these goals. We find evidence of modest but meaningful response by both consumers and providers. However, we also find evidence that some improvement in scores does not reflect true quality improvement, that disparities by race and income have increased, that risk-adjustment of the measures is likely inadequate, and that several key domains of quality are not represented. Our results support moderate success of Nursing Home Compare in achieving intended goals but also reveal the need for continued refinement.
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Affiliation(s)
| | - Kevin Yan
- The University of Chicago, Chicago, IL, USA
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Ahn A, Ferrer C, Park C, Snyder DJ, Maron SZ, Mikhail C, Keswani A, Molloy IB, Bronson MJ, Moschetti WE, Jevsevar DS, Poeran J, Galatz LM, Moucha CS. Defining and Optimizing Value in Total Joint Arthroplasty From the Patient, Payer, and Provider Perspectives. J Arthroplasty 2019; 34:2290-2296.e1. [PMID: 31204223 DOI: 10.1016/j.arth.2019.05.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/29/2019] [Accepted: 05/14/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study is to define value in bundled total joint arthroplasty (TJA) from the differing perspectives of the patient, payer/employer, and hospital/provider. METHODS Demographic, psychosocial, clinical, financial, and patient-reported outcomes (PROs) data from 2017 to 2018 elective TJA cases at a multihospital academic health system were queried. Value was defined as improvement in PROs (preoperatively to 1 year postoperatively) for patients, improvement in PROs per $1000 of bundle cost for payers, and the normalized sum of improvement in PROs and hospital bundle margin for providers. Bivariate analysis was used to compare high value vs low value (>50th percentile vs <50th percentile). Multivariate analysis was performed to identify predictors. RESULTS A total of 280 patients had PRO data, of which 71 had Medicare claims data. Diabetes (odds ratio [OR], 0.45; P = .02) predicted low value for patients; female gender (OR, 0.25), hypertension (OR, 0.17), pulmonary disease (OR, 0.12), and skilled nursing facility discharge (OR, 0.17) for payers (P ≤ .03 for all); and pulmonary disease (OR, 0.16) and skilled nursing facility discharge (OR, 0.19) for providers (P ≤ .04 for all). CONCLUSION This is the first article to define value in TJA under a bundle payment model from multiple perspectives, providing a foundation for future studies analyzing value-based TJA.
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Affiliation(s)
- Amy Ahn
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Chris Ferrer
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Chris Park
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | | | - Ilda B Molloy
- Department of Orthopaedics, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Michael J Bronson
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
| | - Wayne E Moschetti
- Department of Orthopaedics, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - David S Jevsevar
- Department of Orthopaedics, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Jashvant Poeran
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
| | - Leesa M Galatz
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
| | - Calin S Moucha
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY
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