Greater Reductions in Readmission Rates Achieved by Urban Hospitals Participating in the Medicare Shared Savings Program

Financial incentives for integrated care: A scoping review and lessons for evidence-based design

BACKGROUND

In response to the increasing prevalence of people with chronic conditions, healthcare systems restructure to integrate care across providers. However, many systems fail to achieve the desired outcomes. One likely explanation is lack of financial incentives for integrating care.

OBJECTIVES

We aim to identify financial incentives used to promote integrated care across different types of providers for patients with common chronic conditions and assess the evidence on (cost-)effectiveness and the facilitators/barriers to their implementation.

METHODS

This scoping review identifies studies published before December 2021, and includes 33 studies from the United States and the Netherlands.

RESULTS

We identify four types of financial incentives: shared savings, bundled payments, pay for performance, and pay for coordination. Substantial heterogeneity in the (cost-)effectiveness of these incentives exists. Key implementation barriers are a lack of infrastructure (e.g., electronic medical records, communication channels, and clinical guidelines). To facilitate integration, financial incentives should be easy to communicate and implement, and require additional financial support, IT support, training, and guidelines.

CONCLUSIONS

All four types of financial incentives may promote integrated care but not in all contexts. Shared savings appears to be the most promising incentive type for promoting (cost-)effective care integration with the largest number of favourable studies allowing causal interpretations. The limited evidence pool makes it hard to draw firm conclusions that are transferable across contexts.

Accountable Care Organization Attribution and Post-Acute Skilled Nursing Facility Outcomes for People Living With Dementia

OBJECTIVES

Under the Accountable Care Organization (ACO) model, reductions in healthcare spending have been achieved by targeting post-acute care, particularly in skilled nursing facilities (SNFs). People with Alzheimer disease and related dementias (ADRD) are frequently discharged to SNF for post-acute care and may be at particular risk for unintended consequences of SNF cost reduction efforts. We examined SNF length of stay (LOS) and outcomes among ACO-attributed and non-ACO-attributed ADRD patients.

DESIGN

Observational serial cross-sectional study.

SETTING AND PARTICIPANTS

Twenty percent national random sample of fee-for-service Medicare beneficiaries (2013-2017) to identify beneficiaries with a diagnosis of ADRD and with a hospitalization followed by SNF admission (n = 263,676).

METHODS

Our primary covariate of interest was ACO (n = 66,842) and non-ACO (n = 196,834) attribution. Hospital readmission and death were measured for 3 time periods (<30, 31-90, and 91-180 days) following hospital discharge. We used 2-stage least squares regression to predict LOS as a function of ACO attribution, and patient and facility characteristics.

RESULTS

ACO-attributed ADRD patients have shorter SNF LOS than their non-ACO counterparts (31.7 vs 32.8 days; P < .001). Hospital readmission rates for ACO vs non-ACO differed at ≤30 days (13.9% vs 14.6%; P < .001) but were similar at 31-90 days and 91-180 days. No significant difference was observed in mortality post-hospital discharge for ACO vs non-ACO at ≤30 days; however, slightly higher mortality was observed at 31-90 days (8.4% vs 8.8%; P = .002) and 91-180 days (7.6% vs 7.9%; P = .011). No significant association was found between LOS and readmission, with small effects on mortality favoring ACOs in fully adjusted models.

CONCLUSIONS AND IMPLICATIONS

Being an ACO-attributed patient is associated with shorter SNF LOS but is not associated with changes in readmission or mortality after controlling for other factors. Policies that shorten LOS may not have adverse effects on outcomes for people living with dementia.

Primary care physicians' participation in the Medicare shared savings program and preventive services delivery: Evidence from the first 7 years

OBJECTIVE

To evaluate whether primary care physicians' participation in the Medicare Shared Savings Program (MSSP) is associated with changes in their preventive services delivery.

DATA SOURCES

Medicare Provider Utilization and Payment Physician and Other Supplier Public Use File and MSSP Accountable Care Organizations (ACO) Provider-Level Research Identifiable File from 2012 to 2018.

STUDY DESIGN

The design was a two-way fixed effects model estimating within-provider changes in preventive services delivery over time controlling for provider time-invariant characteristics, national time trends, and characteristics of served patients. The following preventive services were evaluated: influenza vaccination, pneumococcal vaccination, clinical depression screening, colorectal cancer screening, breast cancer screening, Body Mass Index (BMI) screening and follow-up, tobacco use assessment, and annual wellness visits. Both the likelihood of providing services and the volume of services delivered were evaluated.

DATA COLLECTION/EXTRACTION METHODS

Secondary data linked at the provider level.

PRINCIPAL FINDINGS

MSSP participation was associated with an increase in the likelihood of providing influenza vaccination (0.7 percentage-points), pneumococcal vaccination (2.0 percentage-points), clinical depression screening (2.1 percentage-points), tobacco use assessment (0.3 percentage-points), and annual wellness visits (4.1 percentage-points). A similar increase was found for the volume of services delivered per 100 patients for several preventive services: influenza vaccination (0.18), pneumococcal vaccination (0.56), clinical depression screening (0.46), and annual wellness visits (1.52). MSSP participation was associated with a decrease in the likelihood (-0.4 percentage-points) and the volume of colorectal cancer screening (-0.03).

CONCLUSIONS

Primary care physicians' participation in MSSP was associated with an increase in the likelihood and the volume of several preventive services.

[10 Years Accountable Care Organizations in the USA: Impulses for Health Care Reform in Germany?]

GOAL OF THE STUDY

An intent of the Patient Protection and Affordable Care Acts (ACA), also know as Obama Care, was to slow the expenditure growth in the public Medicare-System by shifting the accountability for health care outcomes and costs to the provider. For this purpose, provider were allowed to form networks, which would then take accountability for a defined population - Accountable Care Organizations (ACOs). Ten years after the introduction of ACOs, this paper looks at the impact of ACOs both on quality of care and costs of care to assess if ACOs can be a model of care delivery for Germany.

METHODS

In a mixed-method approach, a rapid review was conducted in Health System Evidence and PubMed. This was supported with further papers identified using the snowballing-technique. After screening the abstracts, we included articles containing information on cost- and/or quality impact of US-Medicare-ACOs. The findings of the rapid review were challenged with 16 ACO-experts and stakeholder in the USA.

RESULTS

In total, we included 60 publications which incorporated 6 reports that were either conducted directly by governmental institutions or ordered by them, along with 3 previous reviews. Among these, 31 contained information on costs of care, 18 contained information on quality of care and 11 had information on both aspects. The publications show that ACOs reduced costs of of care. Cost reductions were achieved compared to historic costs, to populations not cared for in ACOs, and counterfactuals. Quality of care stayed the same or improved.

CONCLUSION

ACOs contributed to slowing the cost growth in US Medicare without compromising quality of care. Thus, a transferal of this model of care to Germany should be considered. However, various policies have led to ACOs failing to unleash their full potential. Against this background, and against the background of stark differences between US Medicare and the German health care system, a critical reflection of the necessary policies underlying ACOs-like structures in Germany, needs to be undertaken.

Skilled Nursing Facility Participation in a Voluntary Medicare Bundled Payment Program: Association With Facility Financial Performance

IMPORTANCE

Model 3 of the Bundled Payments for Care Improvement (BPCI) is an alternative payment model in which an entity takes accountability for the episode costs. It is unclear how BPCI affected the overall skilled nursing facility (SNF) financial performance and the differences between facilities with differing racial/ethnic and socioeconomic status (SES) composition of the residents.

OBJECTIVE

The objective of this study was to determine associations between BPCI participation and SNF finances and across-facility differences in SNF financial performance.

DESIGN, SETTING, AND PARTICIPANTS

A longitudinal study spanning 2010-2017, based on difference-in-differences analyses for 575 persistent-participation SNFs, 496 dropout SNFs, and 13,630 eligible nonparticipating SNFs.

MAIN OUTCOME MEASURES

Inflation-adjusted operating expenses, revenues, profit, and profit margin.

RESULTS

BPCI was associated with reductions of $0.63 million in operating expenses and $0.57 million in operating revenues for the persistent-participation group but had no impact on the dropout group compared with nonparticipating SNFs. Among persistent-participation SNFs, the BPCI-related declines were $0.74 million in operating expenses and $0.52 million in operating revenues for majority-serving SNFs; and $1.33 and $0.82 million in operating expenses and revenues, respectively, for non-Medicaid-dependent SNFs. The between-facility SES gaps in operating expenses were reduced (differential difference-in-differences estimate=$1.09 million). Among dropout SNFs, BPCI showed mixed effects on across-facility SES and racial/ethnic differences in operating expenses and revenues. The BPCI program showed no effect on operating profit measures.

CONCLUSIONS

BPCI led to reduced operating expenses and revenues for SNFs that participated and remained in the program but had no effect on operating profit indicators and mixed effects on SES and racial/ethnic differences across SNFs.

The Effect of Medicare Shared Savings Program on Readmissions and Variations by Race/Ethnicity and Payer Status (December 9, 2020)

OBJECTIVE

Accountable care organizations in the Medicare Shared Savings Program (MSSP) in the United States attempt to reduce cost and improve quality for their patients by improving care coordination across care settings. We examined the impact of hospital participation in the MSSP on 30-day readmissions for several groups of Medicare inpatients, and by race/ethnicity and payer status.

MAIN DATA SOURCE

A 2010-2016 Medicare Provider Analysis and Review files.

RESEARCH DESIGN

With propensity score matched sample of MSSP and non-MSSP-participating hospitals, patient-level linear probability models with difference-in-differences approach were used to compare the changes in readmission rates for Medicare fee-for-service patients initially admitted for ischemic stroke, hip fracture, or total joint arthroplasty in MSSP-participating hospitals with non-MSSP-participating hospitals as well as to compare the changes in disparities in readmission rates over time.

PRINCIPAL FINDINGS

Hospital participation in MSSP was associated with further reduced readmission rate by 1.1 percentage points (95% confidence interval: -0.02 to 0.00, P<0.05) and 1.5 percentage points (95% confidence interval: -0.03 to 0.00, P=0.08) for ischemic stroke and hip fracture cohorts, respectively, compared with non-MSSP-participating hospitals, after the third year of hospital participation in the MSSP. There was no evidence that MSSP had an impact on racial/ethnic disparities, but increased disparity by payer status (dual vs. Medicare-only) was observed. These findings together suggest that MSSP accountable care organizations may take at least 3 years to achieve reduced readmissions and may increase disparities by payer status.

Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients

IMPORTANCE

The Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown.

OBJECTIVE

To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs.

MAIN OUTCOME MEASURES

Risk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident.

RESULTS

The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities.

CONCLUSIONS

The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.

Associations between Medicaid expansion and nurse staffing ratios and hospital readmissions

OBJECTIVE

To examine the associations between Medicaid expansion and nurse staffing ratios and hospital-wide readmission rates.

DATA SOURCES

Secondary data from the 2011-2016 Healthcare Cost Report Information System, the American Hospital Association Annual Survey, and the Hospital Compare data.

STUDY DESIGN

Difference-in-difference models are used to compare outcomes in hospitals located in states that expanded Medicaid with those located in nonexpansion states. The changes in nurse staffing ratios and hospital-wide readmission rates are calculated in each one of the postexpansion years (2014, 2015, and 2016), compared to pre-expansion.

PRINCIPAL FINDINGS

Results indicate that nurse staffing ratios increased, whereas hospital-wide readmission rates declined in expansion states relative to nonexpansion states. Nurse staffing ratios increased by 0.33, 0.42, and 0.46 registered nurses hours per adjusted patient days in 2014, 2015, and 2016 in hospitals located in expansion states, compared with hospitals in nonexpansion states after expansion. This increase was statistically significant (P < .001) in 2015 and 2016, but marginally significant (P = .016) in 2014. Hospital-wide readmission rates statistically significantly decreased by 9, 16, and 18 per 10 000 patients (P < .001) in 2014, 2015, and 2016, respectively, in expansion vs nonexpansion states hospitals after expansion.

CONCLUSIONS

Medicaid expansion was associated with gradually improved hospitals' nurse staffing ratios and hospital-wide readmission rates from 2014 through 2016. The continued monitoring of quality measures of hospitals can help assess the impact of Medicaid expansion over a longer period of time.