ACO Affiliated Hospitals Increase Implementation of Care Coordination Strategies

The impact of Medicare shared savings program participation on hospital financial performance: An event-study analysis

OBJECTIVE

To evaluate the impact of hospitals' participation in the Medicare Shared Savings Program (MSSP) on their financial performance.

DATA SOURCES

Centers for Medicare & Medicaid Services Hospital Cost Reports and MSSP Accountable Care Organizations (ACO) Provider-Level Research Identifiable File from 2011 to 2018.

STUDY DESIGN

We used an event-study design to estimate the temporal effects of MSSP participation on hospital financial outcomes and compared within-hospital changes over time between MSSP and non-MSSP hospitals while controlling for hospital and year fixed effects and organizational and service-area characteristics. The following financial outcomes were evaluated: outpatient revenue, inpatient revenue, net patient revenue, Medicare revenue, operating margin, inpatient revenue share, Medicare revenue share, and allowance and discount rate.

DATA COLLECTION/EXTRACTION METHODS

Secondary data linked at the hospital level.

PRINCIPAL FINDINGS

Controlling for trends in non-MSSP hospitals, MSSP participation was associated with differential increases in net patient revenue by $3.28 million (p < 0.001), $3.20 million (p < 0.01), and $4.20 million (p < 0.01) in the second, third, and fourth year and beyond after joining MSSP, respectively. Medicare revenue differentially increased by $1.50 million (p < 0.05), $2.24 million (p < 0.05), and $4.47 million (p < 0.05) in the first, second, and fourth year and beyond. Inpatient revenue share differentially increased by 0.29% (p < 0.05) in the second year and 0.44% (p < 0.05) in the fourth year and beyond. Medicare revenue share differentially increased by 0.17% (p < 0.01), 0.25% (p < 0.01), 0.32% (p < 0.01), and 0.41% (p < 0.01) in consecutive years following MSSP participation. MSSP participation was associated with 0.33% (p < 0.05) and 0.39% (p < 0.05) differential reduction in allowance and discount rate in the second and third years.

CONCLUSIONS

MSSP participation was associated with differential increases in net patient revenue, Medicare revenue, inpatient revenue share, and Medicare revenue share, and a differential reduction in allowance and discount rate.

Nephrologist Performance in the Merit-Based Incentive Payment System

RATIONALE & OBJECTIVE

The Merit-Based Incentive Payment System (MIPS) is the largest quality payment program administered by the Centers for Medicare & Medicaid Services. Little is known about predictors of nephrologist performance in MIPS.

STUDY DESIGN

Cross-sectional analysis.

SETTING & PARTICIPANTS

Nephrologists participating in MIPS in performance year 2018.

PREDICTORS

Nephrologist characteristics: (1) participation type (individual, group, or MIPS alternative payment model [APM]), (2) practice size, (3) practice setting (rural, Health Professional Shortage Area [HPSA], or hospital based), and (4) geography (Census Division).

OUTCOMES

MIPS Final, Quality, Promoting Interoperability, Improvement Activities, and Cost scores. Using published consensus ratings, we also examined the validity of MIPS Quality measures selected by nephrologists.

ANALYTICAL APPROACH

Unadjusted and multivariable-adjusted linear regression models assessing the associations between nephrologist characteristics and MIPS Final scores.

RESULTS

Among 6,117 nephrologists participating in MIPS in 2018, the median MIPS Final score was 100 (interquartile range, 94-100). In multivariable-adjusted analyses, MIPS APM participation was associated with a 12.5-point (95% CI, 10.6-14.4) higher score compared with individual participation. Nephrologists in large (355-4,294 members) and medium (15-354 members) practices scored higher than those in small practices (1-14 members). In analyses adjusted for practice size, practice setting, and geography, among individual and group participants, HPSA nephrologists scored 1.9 (95% CI, -3.6 to -0.1) points lower than non-HPSA nephrologists, and hospital-based nephrologists scored 6.0 (95% CI, -8.3 to -3.7) points lower than non-hospital-based nephrologists. The most frequently reported quality measures by individual and group participants had medium to high validity and were relevant to nephrology care, whereas MIPS APM measures had little relevance to nephrology.

LIMITATIONS

Lack of adjustment for patient characteristics.

CONCLUSIONS

MIPS APM participation, larger practice size, non-HPSA setting, and non-hospital-based setting were associated with higher MIPS scores among nephrologists. Our results inform strategies to improve MIPS program design and generate meaningful distinctions between practices that will drive improvements in care.

Evolving Radiologist Participation in Medicare Shared Savings Program Accountable Care Organizations

PURPOSE

The aim of this study was to temporally characterize radiologist participation in Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs).

METHODS

Using CMS Physician and Other Supplier Public Use Files, ACO provider-level Research Identifiable Files, and Shared Savings Program ACO Public-Use Files for 2013 through 2018, characteristics of radiologist ACO participation were assessed over time.

RESULTS

Between 2013 and 2018, the percentage of Medicare-participating radiologists affiliated with MSSP ACOs increased from 10.4% to 34.9%. During that time, the share of large ACOs (>20,000 beneficiaries) with participating radiologists averaged 87.0%, and the shares of medium ACOs (10,000-20,000) and small ACOs (<10,000) with participating radiologists rose from 62.5% to 66.0% and from 26.3% to 51.6%, respectively. The number of physicians in MSSP ACOs with radiologists was substantially larger than those without radiologists (mean range across years, 573-945 versus 107-179). Primary care physicians constituted a larger percentage of the physician population for ACOs without radiologists (average across years, 66.3% versus 38.5%), and ACOs with radiologists had a higher rate of specialist representation (56.0% versus 33.7%). Beneficiary age, race, and sex demographics were similar among radiologist-participating versus nonparticipating ACOs.

CONCLUSIONS

In recent years, radiologist participation in MSSP ACOs has increased substantially. ACOs with radiologist participation are large and more diverse in their physician specialty composition. Nonparticipating radiologists should prepare accordingly.

Disparities in Preventable Hospitalization Among Patients With Alzheimer Diseases

INTRODUCTION

System-level care coordination strategies can be the most effective to promote continuity of care among people with Alzheimer's disease; however, the evidence is lacking. The objective of this study is to determine whether accountable care organizations are associated with lower rates of potentially preventable hospitalizations for people with Alzheimer's disease and whether hospital accountable care organization affiliation is associated with reduced racial and ethnic disparities in preventable hospitalizations among patients with Alzheimer's disease.

METHODS

This study employed a cross-sectional study design and used 2015 Healthcare Cost and Utilization Project inpatient claims data from 11 states and the 2015 American Hospital Association Annual Survey. Logistic regression and the Blinder-Oaxaca decomposition method were used.

RESULTS

African American patients with Alzheimer's disease were less likely to be hospitalized at accountable care organization‒affiliated hospitals than White patients. Among patients with Alzheimer's disease who were hospitalized, hospital accountable care organization affiliation was associated with lower odds of potentially preventable hospitalizations (OR=0.86, p=0.02; OR=0.66, p<0.001 with propensity score matching) after controlling for patient characteristics, hospital characteristics, and state indicators. Hospital accountable care organization affiliation explained 3.01% (p<0.01) of the disparity in potentially preventable hospitalizations between White and African American patients but could not explain disparities between White and Latinx patients.

CONCLUSIONS

Evidence suggests that accountable care organizations may be able to improve care coordination for people with Alzheimer's disease and to reduce disparities between Whites and African Americans. Further research is needed to determine whether this benefit can be attributed to accountable care organization formation or whether providers that participate in accountable care organizations tend to provide higher-quality care.

Privacy protections to encourage use of health-relevant digital data in a learning health system

The National Academy of Medicine has long advocated for a "learning healthcare system" that produces constantly updated reference data during the care process. Moving toward a rapid learning system to solve intractable problems in health demands a balance between protecting patients and making data available to improve health and health care. Public concerns in the U.S. about privacy and the potential for unethical or harmful uses of this data, if not proactively addressed, could upset this balance. New federal laws prioritize sharing health data, including with patient digital tools. U.S. health privacy laws do not cover data collected by many consumer digital technologies and have not been updated to address concerns about the entry of large technology companies into health care. Further, there is increasing recognition that many classes of data not traditionally considered to be healthcare-related, for example consumer credit histories, are indeed predictive of health status and outcomes. We propose a multi-pronged approach to protecting health-relevant data while promoting and supporting beneficial uses and disclosures to improve health and health care for individuals and populations. Such protections should apply to entities collecting health-relevant data regardless of whether they are covered by federal health privacy laws. We focus largely on privacy but also address protections against harms as a critical component of a comprehensive approach to governing health-relevant data. U.S. policymakers and regulators should consider these recommendations in crafting privacy bills and rules. However, our recommendations also can inform best practices even in the absence of new federal requirements.

Accountable Care Hospitals and Preventable Emergency Department Visits for Rural Dementia Patients

BACKGROUND/OBJECTIVES

This study examined urban/rural differences in the frequency of preventable emergency department (ED) visits among patients with Alzheimer's disease and related dementias (ADRD), with a focus on the variation of accountable care organization (ACO) participation status for hospitals in urban and rural areas.

DESIGN

We performed a cross-sectional study using the 2015 State Emergency Department Databases, the American Hospital Association Annual Survey of Hospitals, and the Area Health Resource File. Individual-, county-, and hospital-level characteristics and state fixed effects were used for model specification.

SETTING

Patients with ADRD from seven states who visited the ED and had routine discharges.

PARTICIPANTS

Our sample consisted of 117,196 patients with ADRD.

MEASUREMENTS

The outcome was preventable ED visits classified using the New York University Emergency Department visit algorithm. We performed a multivariable logistic regression to estimate the variation of preventable ED visits by urban and rural areas.

RESULTS

Rural patients with ADRD had 1.13 higher adjusted odds (P = .007) of going to the ED for a preventable visit compared with their urban counterparts. In addition, ACO-affiliated hospitals had .91 lower adjusted odds (P = .005) of preventable ED visits for ADRD patients compared with hospitals not affiliated with an ACO. Whole-county Mental Health Care Health Professional Shortage Area (HPSA) (odds ratio = 1.14; P = .002) designation was also an indicator of higher preventable ED rates.

CONCLUSION

ACO delivery systems have the potential to decrease rural preventable ED visits among ADRD patients.

Disparities in Medical Debt Among U.S. Adults with Serious Psychological Distress

Purpose: To examine indebtedness for medical care among racial and ethnic minorities and people with serious psychological distress (SPD) using a nationally representative sample in the United States.

Methods: Using the 2014–2017 Medical Expenditure Panel Survey, we examine medical debt among individuals with SPD. We develop a logistic regression model to estimate the odds of medical debt by SPD status. We stratify the odds of medical debt for those with SPD by insurance type.

Results: The results indicate that after controlling for predisposing, enabling, and physical needs factors, those experiencing SPD have double the odds of having medical debt compared with those without SPD. Non-Hispanic blacks had higher odds of medical debt compared with non-Hispanic whites. We find that individuals with SPD covered under private health insurance have double the odds of having medical debts; and those who are uninsured have triple the odds of having medical debt compared with their counterparts without SPD.

Conclusion: The findings suggest that odds of medical debt are higher among people with SPD, even when insured. Additional health policy initiatives to address medical debt among those with SPD may be warranted.

Accountable Care Organizations and Preventable Hospitalizations Among Patients With Depression

INTRODUCTION

Accountable care organizations have been successful in improving quality of care, but little is known about who is benefiting from accountable care organizations and through what mechanism. This study examined variation of potentially preventable hospitalizations for chronic conditions with coexisting depression in adults by hospital accountable care organization affiliation and care coordination strategies by race/ethnicity.

METHODS

Data files of 11 states from 2015 State Inpatient Databases were used to identify potentially preventable hospitalizations for chronic conditions with coexisting depression by race/ethnicity; the 2015 American Hospital Association's Annual Survey was used to identify hospital accountable care organization affiliation; and American Hospital Association's Survey of Care Systems and Payment (collected from January to August 2016) was used to identify hospital Accountable care organizations affiliation and hospital-based care coordination strategies, such as telephonic outreach, and chronic care management. In 2019, multiple logistic regressions was used to test the probability of potentially preventable hospitalization by accountable care organization affiliation and race/ethnicity. The test was repeated on a subsample analysis of accountable care organization-affiliated hospitals by care coordination strategy.

RESULTS

Preventable hospitalizations were significantly lower among accountable care organization-affiliated hospitals than accountable care organization-unaffiliated hospitals. Lower preventable hospitalization rates were observed among white, African American, Native American, and Hispanic patients. Effective care coordination strategies varied by patients' race. Results also showed variation of the adoption of specific care coordination strategies among accountable care organization-affiliated hospitals. Analysis further indicated effective care coordination strategies varied by patients' race.

CONCLUSIONS

Accountable care organizations and specifically designed care coordination strategies can potentially improve preventable hospitalization rates and racial disparities among patients with depression. Findings support the integration of mental and physical health services and provide insights for Centers for Medicare and Medicaid Services risk adjustment efforts across race/ethnicity and socioeconomic status.

In their own words: a qualitative study of factors promoting resilience and recovery among postpartum women with opioid use disorders

BACKGROUND

Opioid use disorder (OUD) is associated with substantial morbidity and mortality for women, especially during the perinatal period. Opioid overdose has become a significant cause of maternal death in the United States, with rates highest in the immediate postpartum year. While pregnancy is a time of high motivation for healthcare engagement, unique challenges exist for pregnant women with OUD seeking both substance use treatment and maternity care, including managing change after birth. How women successfully navigate these barriers, engage in treatment, and abstain from substance use during pregnancy and postpartum is poorly understood. The aim of this study is to explore the experiences of postpartum women with OUD who successfully engaged in both substance use treatment and maternity care during pregnancy, to understand factors contributing to their ability to access care and social support.

METHODS

We conducted semi-structured, in-depth interviews with postpartum women in sustained recovery (n = 10) engaged in a substance use treatment program in northern New England. Interviews were analyzed using grounded theory methodology.

RESULTS

Despite multiple barriers, women identified pregnancy as a change point from which they were able to develop self-efficacy and exercise agency in seeking care. A shift in internal motivation enabled women to disclose need for OUD treatment to maternity care providers, a profoundly significant moment. Concurrently, women developed a new capacity for self-care, demonstrated through managing relationships with providers and family members, and overcoming logistical challenges which had previously seemed overwhelming. This transformation was also expressed in making decisions based on pregnancy risk, engaging with and caring for others, and providing peer support. Women developed resilience through the interaction of inner motivation and their ability to positively utilize or transform external factors.

CONCLUSIONS

Complex interactions occurred between individual-level changes in treatment motivation due to pregnancy, emerging self-efficacy in accessing resources, and engagement with clinicians and peers. This transformative process was identified by women as a key factor in entering recovery during pregnancy and sustaining it postpartum. Clinicians and policymakers should target the provision of services which promote resilience in pregnant women with OUD.

Integrating local health departments to reduce suicide-related emergency department visits among people with substance use disorders - Evidence from the state of Maryland

Individuals with a substance use disorder (SUD) are six times as likely than those without a SUD to attempt suicide, however just 18% of the SUD population has received treatment. One of the barriers to treatment is appropriate and timely mental health services. This resulted in a substantial increase in emergency department (ED) visits related to SUD and suicide. This study sought to determine if the number of suicide-related ED visits for patients with SUD is associated with the types of mental health activities provided by their local health department (LHD). Specifically, we examined whether patients with a SUD aged 18-64 experienced reductions in suicide-related ED visits when their LHD directly engaged in mental health activities, such as (1) primary prevention for mental illness or (2) mental health services. Using linked datasets for 2012 from the National Profile of Local Health Departments, U.S. Census data, Area Health Resource File, and Maryland's State Emergency Department Databases (SEDD), we employed multivariable logistic regressions and instrumental variable models to examine this association. After adjusting for the endogeneity of LHDs' activity measures and controlling for individual-, hospital-, LHD-, and county-level characteristics, results demonstrated patients with a SUD experienced a 6% and 5% reduction in suicide-related ED visits when their LHD directly provided primary prevention for mental illness and mental health services, respectively. The results are small but significant, with robust standard errors. This study suggests LHDs may be key players in preventing suicide-related ED visits among the SUD population.