Changes in Use of Postacute Care Associated With Accountable Care Organizations in Hip Fracture, Stroke, and Pneumonia Hospitalized Cohorts

Trends in the Characteristics and Outcomes of Older Medicare Patients With Traumatic Brain Injury Treated in Inpatient Rehabilitation Facilities: 2013 to 2018

OBJECTIVE

To describe the characteristics and outcomes of older (65+) Medicare beneficiaries with traumatic brain injury (TBI) treated in inpatient rehabilitation facilities between 2013 and 2018.

DESIGN

Descriptive study using IRF Patient Assessment Instrument (IRF-PAI) data reporting trends of the sociodemographic and clinical characteristics and outcomes of inpatient rehabilitation facilities Medicare patients with TBI.

SETTING

Inpatient rehabilitation facilities in the United States.

PARTICIPANTS

99,804 older Medicare fee-for-service and Medicare Advantage patients with TBI (N=99,804).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Length of stay, self-care, and mobility functional outcomes, discharge destination.

RESULTS

The number of older Medicare beneficiaries with TBI treated in inpatient rehabilitation facilities increased from 14,657 in 2013 to 18,791 in 2018, an increase of 28.2%. In addition to this overall increase in patients, we also found the percentage of men increased slightly (52.9% to 54.8%), there was a higher percentage of patients with tier 3 comorbidities, there was a decrease in the variability of length of stay, there was slightly more self-care and mobility improvement and a slightly higher percentage of patients discharged to the community (67.8% in 2013 and 71.6% in 2018). Newer standardized data showed that prior to the injury, more than one-third used a walker and more than three-quarters had a history of recent falls.

CONCLUSIONS

Between 2013 and 2018, the number of Medicare beneficiaries with TBI treated in IRFs increased by approximately 28%. The characteristics of IRF older patients with TBI changed between 2013 and 2018 toward a slightly higher proportion of men, more comorbidities, and a higher percentage being discharged home after inpatient rehabilitation.

Accountable Care Organization Leader Perspectives on the Medicare Shared Savings Program: A Qualitative Study

Importance

The Medicare Shared Savings Program (MSSP) includes more than 400 accountable care organizations (ACOs) and is among the largest and longest running value-based payment efforts in the US. However, given recent program reforms and other changes in the health care system, the experiences and perspectives of ACO leaders remain incompletely characterized.

Objective

To understand the priorities, strategies, and challenges of ACO leaders in MSSP.

Design, Setting, and Participants

In this qualitative study, interviews were conducted with leaders of 49 ACOs of differing sizes, leadership structures, and geographies from MSSP between September 29 and December 29, 2022. Participants were asked about their clinical and care management efforts; how they engaged frontline clinicians; the process by which they distributed shared savings and added or removed practices; and other factors that they believed influenced their success or failure in the program.

Main Outcomes and Measures

Leader perspectives on major themes related to ACO initiatives, performance improvement, and the recruitment, engagement, and retention of clinicians.

Results

Of the 49 ACOs interviewed, 34 were hospital-associated ACOs (69%), 35 were medium or large (>10 000 attributed beneficiaries) (71%), and 17 were rural (35%). The ACOs had a mean (SD) tenure of 8.1 (2.1) years in MSSP. Five major themes emerged: (1) ACO leaders reported a focus on annual wellness visits, coding practices, and care transitions; (2) leaders used both relationship-based and metrics-based strategies to promote clinician engagement; (3) ACOs generally distributed half or more of shared savings to participating practices; (4) ACO recruitment and retention efforts were increasingly influenced by market competition; and (5) some hospital-associated ACOs faced misaligned incentives.

Conclusions and Relevance

In this study, the ACO leaders reported varied approaches to promoting clinician alignment with ACO goals, an emphasis on increasing annual wellness visits, and new pressures related to growth of other care models. Policymakers hoping to modify or expand the program may wish to incorporate these perspectives into future reforms.

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.

Postacute Expenditures Among Patients Discharged Home After Stroke or Transient Ischemic Attack: The COMprehensive Post-Acute Stroke Services (COMPASS) Trial

OBJECTIVES

The COMPASS (COMprehensive Post-Acute Stroke Services) pragmatic trial cluster-randomized 40 hospitals in North Carolina to the COMPASS transitional care (TC) postacute care intervention or usual care. We estimated the difference in healthcare expenditures postdischarge for patients enrolled in the COMPASS-TC model of care compared with usual care.

METHODS

We linked data for patients with stroke or transient ischemic attack enrolled in the COMPASS trial with administrative claims from Medicare fee-for-service (n = 2262), Medicaid (n = 341), and a large private insurer (n = 234). The primary outcome was 90-day total expenditures, analyzed separately by payer. Secondary outcomes were total expenditures 30- and 365-days postdischarge and, among Medicare beneficiaries, expenditures by point of service. In addition to intent-to-treat analysis, we conducted a per-protocol analysis to compare Medicare patients who received the intervention with those who did not, using randomization status as an instrumental variable.

RESULTS

We found no statistically significant difference in total 90-day postacute expenditures between intervention and usual care; the results were consistent across payers. Medicare beneficiaries enrolled in the COMPASS intervention arm had higher 90-day hospital readmission expenditures ($682, 95% CI $60-$1305), 30-day emergency department expenditures ($132, 95% CI $13-$252), and 30-day ambulatory care expenditures ($67, 95% CI $38-$96) compared with usual care. The per-protocol analysis did not yield a significant difference in 90-day postacute care expenditures for Medicare COMPASS patients.

CONCLUSIONS

The COMPASS-TC model did not significantly change patients' total healthcare expenditures for up to 1 year postdischarge.

Risk selection reduces efficiency of value-based healthcare

Value-based healthcare aims to improve efficiency and value for patients. Value-based payment models are a form of provider reimbursement to achieve this. Studies on these models have found positive results, but may be biased by unintended consequences, such as risk selection. Risk selection is a multi-dimensional phenomenon that occurs at the patient, hospital, and system level, and is a source of inefficiency and inequality in healthcare. Risk selection may occur because of selection bias in the outcomes that are evaluated and rewarded, or due to the selection of lower cost patients. Risk selection may also stem from professional reputation. The motivation to engage in risk selection may also arise from differences in the meaning of value. To mitigate these unintended consequences, several strategies can be adopted. These include making value-based payment models attractive, but not mandatory, as well as incentivising transparent reporting of best practices, using adequate risk adjustment, expanding performance metrics, and including patient-reported experience measures. Other mitigation strategies could include adopting a mixture of performance measures, using mixed methods of paying physicians, and implementing monitoring and evaluation mechanisms. However, such approaches are not flawless, and the problem may never be fully solved. This perspective serves as a warning for the constant presence of risk selection, as well as informing policy makers, politicians, and organisations implementing VBP models on ways to minimise the possibility of risk selection.

The Impact of Nurse Practitioner Care and Accountable Care Organization Assignment on Skilled Nursing Services and Hospital Readmissions

BACKGROUND

Accountable care organizations (ACOs) and the employment of nurse practitioners (NP) in place of physicians are strategies that aim to reduce the cost and improve the quality of routine care delivered in skilled nursing facilities (SNF). The recent expansion of ACOs and nurse practitioners into SNF settings in the United States may be associated with improved health outcomes for patients.

OBJECTIVES

To determine the relationship between ACO attribution and NP care delivery during SNF visits and the relationship between NP care delivery during SNF visits and unplanned hospital readmissions.

METHODS

We obtained a sample of 527,329 fee-for-service Medicare beneficiaries with 1 or more SNF stays between 2012 and 2017. We used logistic regression to measure the association between patient ACO attribution and evaluation and management care delivered by NPs in addition to the relationship between evaluation and management services delivered by NPs and hospital readmissions.

RESULTS

ACO beneficiaries were 1.26% points more likely to receive 1 or more E&M services delivered by an NP during their SNF visits [Marginal Effect (ME): 0.0126; 95% CI: (0.009, 0.0160)]. ACO-attributed beneficiaries receiving most of their E&M services from NPs during their SNF visits were at a lower risk of readmission than ACO-attributed beneficiaries receiving no NP E&M care (5.9% vs. 7.1%; P <0.001).

CONCLUSIONS

Greater participation by the NPs in care delivery in SNFs was associated with a reduced risk of patient readmission to hospitals. ACOs attributed beneficiaries were more likely to obtain the benefits of greater nurse practitioner involvement in their care.

Characteristics and Outcomes of Medicare Patients Treated in Inpatient Rehabilitation Facilities: 2013-2018

PURPOSE

The aim of this study was to describe the characteristics and outcomes of Medicare patients treated in inpatient rehabilitation facilities (IRFs) in 2013 through 2018.

DESIGN

A descriptive study was conducted.

METHODS

A total of 2,907,046 IRF Medicare fee-for-service and Medicare Advantage patient stays that ended in 2013 through 2018 were analyzed.

RESULTS

The number of Medicare patients treated in IRFs increased by about 9%, from 466,092 in 2013 to 509,475 in 2018. Although IRF patients' age and racial/ethnic composition remained similar across the years, there was a shift in patients' primary rehabilitation diagnosis, with more patients with stroke, neurological conditions, traumatic and nontraumatic brain injury, fewer patients with orthopedic conditions, and fewer coded as having medically complex conditions. Across the years, the percentage of patients discharged to the community was between 73.0% and 74.4%.

CLINICAL RELEVANCE TO THE PRACTICE OF REHABILITATION NURSING

Rehabilitation nurses should have training and expertise in the management of patients with stroke and neurological conditions to provide high-quality IRF care.

CONCLUSIONS

Between 2013 and 2018, the number of Medicare patients treated in IRFs increased overall. There were more patients with stroke and neurological conditions and fewer patients with orthopedic conditions. Changes to IRF and other post-acute care policies, Medicaid expansion, and alternative payment programs may partially be driving these changes.

Postacute Care Utilization and Episode of Care Payments Following Common Elective Operations

OBJECTIVE

To describe PAC utilization and associated payments for patients undergoing common elective procedures.

SUMMARY OF BACKGROUND DATA

Utilization and costs of PAC are well described for benchmarked conditions and operations but remain understudied for common elective procedures.

METHODS

Cross-sectional study of adult patients in a statewide administrative claims database undergoing elective cholecystectomy, ventral or incisional hernia repair (VIHR), and groin hernia repair from 2012 to 2019. We used multivariable logistic regression to estimate the odds of PAC utilization, and multivariable linear regression to determine the association of 90-day episode of care payments and PAC utilization.

RESULTS

Among 34,717 patients undergoing elective cholecystectomy, 0.7% utilized PAC resulting in significantly higher payments ($19,047 vs $7830, P < 0.001). Among 29,826 patients undergoing VIHR, 1.7% utilized PAC resulting in significantly higher payments ($19,766 vs $9439, P < 0.001). Among 37,006 patients undergoing groin hernia repair, 0.3% utilized PAC services resulting in significantly higher payments ($14,886 vs $8062, P < 0.001). We found both modifiable and non-modifiable risk factors associated with PAC utilization. Morbid obesity was associated with PAC utilization following VIHR [odds ratio (OR) 1.61, 95% confidence interval (CI) 1.29-2.02, P < 0.001]. Male sex was associated with lower odds of PAC utilization for VIHR (OR 0.43, 95% CI 0.35-0.51, P < 0.001) and groin hernia repair (OR 0.62, 95% CI 0.39-0.98, P = 0.039).

CONCLUSIONS

We found both modifiable (eg, obesity) and nonmodifiable (eg, female sex) patient factors that were associated with PAC. Optimizing patients to reduce PAC utilization requires an understanding of patient risk factors and systems and processes to address these factors.

Post-Acute Care Use Associated with Medicare Shared Savings Program and Disparities

OBJECTIVES

Medicare Shared Savings Program (MSSP) was implemented in 2012, but the impact of the MSSP on institutional post-acute care (PAC) use, and by race/ethnicity and payer status is less studied. We studied the impact of hospital participation in the MSSP on institutional PAC use and variations by race/ethnicity and payer status among 3 Medicare patient groups: ischemic stroke, hip fracture, and elective total joint arthroplasty (TJA).

DESIGN

A retrospective analysis of 2010-2016 Medicare Provider Analysis and Review files.

SETTING AND PARTICIPANTS

Medicare fee-for-service patients originally admitted for ischemic stroke, hip fracture, or elective TJA in MSSP-participating hospitals or nonparticipating hospitals.

METHODS

Patient-level linear probability models with difference-in-differences approach were used to compare the changes in institutional PAC use in MSSP-participating hospitals with nonparticipating hospitals as well as to compare the changes in differences by race/ethnicity and payer status in institutional PAC use over time.

RESULTS

Hospital participation in MSSP was significantly associated with increased institutional PAC use for the ischemic stroke cohort by 1.5 percentage points [95% confidence interval (CI) 0.00-0.3, P < .05] compared with non-MSSP participating hospitals. Regarding variations by race/ethnicity and payer status, for the elective TJA patients, racial minority patients in MSSP-participating hospitals had 3.8 percentage points greater (95% CI 0.01-0.06, P < .01) in institutional PAC use than white patients. Also, for ischemic stroke cohort, dual-eligible patients in MSSP-participating hospitals had 2.0 percentage points greater (95% CI 0.00-0.04, P < .10) in institutional PAC use than Medicare-only patients.

CONCLUSIONS AND IMPLICATIONS

This study found that hospital participation in the MSSP was associated with slightly increased institutional PAC use for ischemic stroke Medicare patients. Also, compared to non-MSSP participating hospitals, MSSP-participating hospitals were more likely to discharge racial minority patients for elective TJA and dual-eligible patients for ischemic stroke to institutional PAC.

Medicare accountable care organizations: post-acute care use and post-surgical outcomes in urologic cancer surgery

OBJECTIVES

To evaluate association between Medicare accountable care organizations (ACOs) participation of hospitals on post-acute care (PAC) use and spending, and post-surgical outcomes in Medicare beneficiaries undergoing urologic cancer surgeries. Despite increasing prevalence of urologic cancer and surgical care contributing to a large proportion of total health care costs, and recent Medicare payment reforms such as accountable care organizations, the role of ACOs in urologic cancer care has been unexplored.

METHODS

We conducted a longitudinal analysis of 2011-2017 Medicare claims data to compare post-surgical outcomes between Medicare ACO and non-ACO patients before and after implementation of Medicare shared savings program (MSSP). Our outcomes of interest were Post-acute care (PAC) use (overall, institutional, and home health), Skilled Nursing Facility (SNF) length of stay and Medicare spending for SNF patients, 30-day and 90-day unplanned readmissions and complications after index procedure.

RESULTS

Study sample included a total of 334,514 Medicare patients undergoing bladder, prostate, kidney cancer surgeries at 524 Medicare ACO and 2066 non-ACO hospitals. For bladder cancer surgery, Medicare ACO participation was associated with significantly reduced overall post-acute care use, but not with changes in readmission or complication rate. For prostate cancer and kidney cancer surgery, we found no significant association between hospital participation in Medicare ACOs and PAC use or post-surgical outcomes.

CONCLUSIONS

Hospital participation in MSSP ACOs leads to lower post-acute care use without compromising patient outcomes for Medicare beneficiaries undergoing bladder cancer surgery. Future research is needed to understand longer-term impact of ACO participation on urologic cancer surgery outcomes.

Association of Physical Therapy Treatment Frequency in the Acute Care Hospital With Improving Functional Status and Discharging Home

BACKGROUND

Physical therapists (PTs) are consulted to address functional deficits during hospitalization, but the effect of PT visit frequency on patients' outcomes is not clear.

OBJECTIVE

The objective of this study was to examine whether PT visit frequency is independently associated with functional improvement, discharge home, and both outcomes combined.

RESEARCH DESIGN

This was a retrospective cohort study.

SUBJECTS

Patients discharged from hospitals in 1 health system between 2017 and 2020, stratified by diagnostic subgroup: cardiothoracic and vascular, general medical/surgical, neurological, oncology, and orthopedic.

MEASURES

PT visit frequency was categorized as ≤2, >2-4, >4-7, >7 visits/week. Functional improvement was defined as ≥5-point improvement in Activity Measure for Post-Acute Care mobility score. Other outcomes were discharge home and both outcomes combined.

RESULTS

There were 243,779 patients included. Proportions within frequency categories ranged from 11.0% (>7 visits/wk) to 40.5% (≤2 visits/wk) and varied by subgroup. In the full sample, 36% of patients improved function, 64% were discharged home, and 27% achieved both outcomes. In adjusted analyses, relative to ≤2 visits/week, the adjusted relative risk (aRR) for functional improvement increased incrementally with higher frequency (aRR=1.20, 95% confidence interval: 1.14-1.26 for >2-4 visits to aRR=1.78, 95% confidence interval: 1.55-2.03 for >7 visits). For all patients and within subgroups, the higher frequency was also associated with a greater likelihood of discharging home and achieving both outcomes.

CONCLUSIONS

More frequent PT visits during hospitalization may facilitate functional improvement and discharge home. Most patients, however, receive infrequent visits. Further research is needed to determine the optimal delivery of PT services to meet individual patient needs.

What Can Canada Learn From Accountable Care Organizations: A Comparative Policy Analysis

Introduction:

Accountable Care Organizations (ACOs), implemented in the United States (US), aim to reduce costs and integrate care by aligning incentives among providers and payers. Canadian governments are interested adopting such models to integrate care, though comparative studies assessing the applicability and transferability of ACOs in Canada are lacking. In this comparative study, we performed a narrative literature review to examine how Canadian health systems could support ACO models.

Methods:

We reviewed empirical studies (published 2011–2020) that evaluated ACO impacts in the US. Thematic analysis and critical appraisal were performed to identify factors associated with positive ACO impacts. These factors were compared with the Canadian context to assess the applicability and transferability of ACO models within Canada.

Findings:

Physician-led models, global budgets and financial incentives, and focus on collaborative care may optimize ACO impacts. While reforms towards alternative payments and team-based care are not unprecedented in Canada, significant further reforms to physician remuneration, intersectoral collaboration, and accountability for performance are required to support ACO-like models.

Conclusion:

This comparative study uncovered several insights on the applicability and transferability of ACOs to the Canadian context. Further comparative research outside the US is needed to infer the essential components of successful ACO models.

[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.

Alternative Payment Models and Associations With Stroke Outcomes, Spending, and Service Utilization: A Systematic Review

Stroke contributes an estimated $28 billion to US health care costs annually, and alternative payment models aim to improve outcomes and lower spending over fee-for-service by aligning economic incentives with high value care. This systematic review evaluates historical and current evidence regarding the impacts of alternative payment models on stroke outcomes, spending, and utilization. Included studies evaluated alternative payment models in 4 categories: pay-for-performance (n=3), prospective payments (n=14), shared savings (n=5), and capitated payments (n=14). Pay-for-performance models were not consistently associated with improvements in clinical quality indicators of stroke prevention. Studies of prospective payments suggested that poststroke spending was shifted between care settings without consistent reductions in total spending. Shared savings programs, such as US Medicare accountable care organizations and bundled payments, were generally associated with null or decreased spending and service utilization and with no differences in clinical outcomes following stroke hospitalizations. Capitated payment models were associated with inconsistent effects on poststroke spending and utilization and some worsened clinical outcomes. Shared savings models that incentivize coordination of care across care settings show potential for lowering spending with no evidence for worsened clinical outcomes; however, few studies evaluated clinical or patient-reported outcomes, and the evidence, largely US-based, may not generalize to other settings.

Rationale for a Clinical Trial That Compares Acute Stroke Rehabilitation at Inpatient Rehabilitation Facilities to Skilled Nursing Facilities: Challenges and Opportunities

In the United States, approximately 400,000 patients with acute stroke are discharged annually to inpatient rehabilitation facilities (IRFs) or skilled nursing facilities (SNFs). Typically, IRFs provide time-intensive therapy for an average of 2-3 weeks, whereas SNFs provide more moderately intensive therapy for 4-5 weeks. The factors that influence discharge to an IRF or SNF are multifactorial and poorly understood. The complexity of these factors in combination with subjective clinical indications contributes to large variations in the use of IRFs and SNFs. This has significant financial implications for health care expenditure, given that stroke rehabilitation at IRFs costs approximately double that at SNFs. To control health care spending without compromising outcomes, the Institute of Medicine has stated that policy reforms that promote more efficient use of IRFs and SNFs are critically needed. A major barrier to the formulation of such policies is the highly variable and low-quality evidence for the comparative effectiveness of IRF- vs SNF-based stroke rehabilitation. The current evidence is limited by the inability of observational data to control for residual confounding, which contributes to substantial uncertainty around any magnitude of benefit for IRF- vs SNF-based care. Furthermore, it is unclear which specific patients would receive the most benefit from each setting. A randomized controlled trial addresses these issues, because random treatment allocation facilitates an equitable distribution of measured and unmeasured confounders. We discuss several measurement, practical, and ethical issues of a trial and provide our rationale for design suggestions that overcome some of these issues.

Why and How to Demonstrate the Value of Rehabilitation Services

The health care delivery landscape in the United States is changing as payment models consider both costs and health outcomes, which are key components of value in health care. Without evidence about the effectiveness and costs of rehabilitation interventions, it is difficult to judge the value of rehabilitation interventions. Understanding the short- and long-term costs associated with implementing a rehabilitation intervention and the intervention's cost-effectiveness compared with other alternatives is critical to supporting decision-making by policymakers, health care administrators, and other decision makers. This article describes the policy context for considering the costs and outcomes of postacute care and rehabilitation interventions, introduces methods for assessing the value of rehabilitation interventions, and summarizes the challenges and opportunities associated with applying value measurement to rehabilitation services. Assessing the value of rehabilitation interventions is critical as we continue to identify, implement, and sustain evidence-based interventions that promote the health and function of people with disabilities.

Association of ACO Shared Savings Success and Serious Illness Spending

EXECUTIVE SUMMARY

Accountable care organizations (ACOs) need confidence in their return on investment to implement changes in care delivery that prioritize seriously ill and high-cost Medicare beneficiaries. The objective of this study was to characterize spending on seriously ill beneficiaries in ACOs with Medicare Shared Savings Program (MSSP) contracts and the association of spending with ACO shared savings. The population included Medicare fee-for-service beneficiaries identified with serious illness (N = 2,109,573) using the Medicare Master Beneficiary Summary File for 100% of ACO-attributed beneficiaries linked to MSSP beneficiary files (2014-2016). Lower spending for seriously ill Medicare beneficiaries and risk-bearing contracts in ACOs were associated with achieving ACO shared savings in the MSSP. For most ACOs, the seriously ill contribute approximately half of the spending and constitute 8%-13% of the attributed population. Patient and geographic (county) factors explained $2,329 of the observed difference in per beneficiary per year spending on seriously ill beneficiaries between high- and low-spending ACOs. The remaining $12,536 may indicate variation as a result of potentially modifiable factors. Consequently, if 10% of attributed beneficiaries were seriously ill, an ACO that moved from the worst to the best quartile of per capita serious illness spending could realize a reduction of $1,200 per beneficiary per year for the ACO population overall. Though the prevalence and case mix of seriously ill populations vary across ACOs, this association suggests that care provided for seriously ill patients is an important consideration for ACOs to achieve MSSP shared savings.

Frontiers of Upstream Stroke Prevention and Reduced Stroke Inequity Through Predicting, Preventing, and Managing Hypertension and Atrial Fibrillation: A Call to Action From the Value in Healthcare Initiative's Predict & Prevent Learning Collaborative

Stroke is one of the leading causes of morbidity and mortality in the United States. While age-adjusted stroke mortality was falling, it has leveled off in recent years due in part to advances in medical technology, health care options, and population health interventions. In addition to adverse trends in stroke-related morbidity and mortality across the broader population, there are sociodemographic inequities in stroke risk. These challenges can be addressed by focusing on predicting and preventing modifiable upstream risk factors associated with stroke, but there is a need to develop a practical framework that health care organizations can use to accomplish this task across diverse settings. Accordingly, this article describes the efforts and vision of the multi-stakeholder Predict & Prevent Learning Collaborative of the Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. This article presents a framework of a potential upstream stroke prevention program with evidence-based implementation strategies for predicting, preventing, and managing stroke risk factors. It is meant to complement existing primary stroke prevention guidelines by identifying frontier strategies that can address gaps in knowledge or implementation. After considering a variety of upstream medical or behavioral risk factors, the group identified 2 risk factors with substantial direct links to stroke for focusing the framework: hypertension and atrial fibrillation. This article also highlights barriers to implementing program components into clinical practice and presents implementation strategies to overcome those barriers. A particular focus was identifying those strategies that could be implemented across many settings, especially lower-resource practices and community-based enterprises representing broad social, economic, and geographic diversity. The practical framework is designed to provide clinicians and health systems with effective upstream stroke prevention strategies that encourage scalability while allowing customization for their local context.

Trends in Postacute Care Use and Outcomes After Hip and Knee Replacements in Dual-Eligible Medicare and Medicaid Beneficiaries, 2013-2016

IMPORTANCE

Several Medicare alternative payment models were implemented in recent years, but their implications for socioeconomic gaps in postacute care (PAC) are unknown.

OBJECTIVES

To determine the longitudinal trends in PAC use and outcomes after hip and knee replacements and in gaps among 3 groups: Medicare-only patients, dual-eligible patients with full Medicaid benefits, and dual-eligible patients with partial Medicaid benefits.

DESIGN, SETTING, AND PARTICIPANTS

A cohort study was conducted of PAC use and outcomes among Medicare fee-for-service patients undergoing hip or knee replacement surgery from January 1, 2013, to December 31, 2016, in approximately 3000 hospitals, using Medicare claims, assessment, hospital, and skilled nursing facility (SNF) files. Statistical analysis was performed from October 1, 2018, to December 17, 2019.

MAIN OUTCOMES AND MEASURES

Risk-adjusted differences among dual-eligible groups in institutional PAC use (SNF, inpatient rehabilitation, or long-term hospital care), readmission rate, and payment for readmissions; for patients discharged to a SNF, risk-adjusted differences in SNF quality measured by star ratings, proportion successfully discharged to the community, proportion transitioned to long-stay residence, and SNF length of stay and payments.

RESULTS

The sample included 1 302 256 patients (837 256 women [64.3%]; mean [SD] age, 75.4 [7.2] years) who underwent joint replacement. The proportion of patients discharged to institutional PAC and the 30-day and 90-day readmission rates decreased for all 3 groups during the period from 2013 to 2016. In 2013, institutional PAC use was 43.7% (95% CI, 43.5%-43.9%) for Medicare-only patients (n = 1 182 555), 70.1% (95% CI, 69.4%-70.8%; n = 60 461) for dual-eligible patients with full benefits, and 70.3% (95% CI, 69.6%-71.0%; n = 59 240) for dual-eligible patients with partial benefits; in 2016, the rates decreased to 32.5% (95% CI, 32.4%-32.7%) for Medicare-only patients, 62.3% (95% CI, 61.5%-63.0%) for dual-eligible patients with full benefits, and 61.5% (95% CI, 60.7%-62.3%) for dual-eligible patients with partial benefits. Among patients discharged to SNFs, outcomes remained flat over time. For example, the proportion of patients successfully discharged to the community remained at 80.5% (95% CI, 80.4%-80.7%) for Medicare-only patients, 59.8% (95% CI, 59.3%-60.3%) for dual-eligible patients with full benefits, and 50.0% (95% CI, 49.4%-50.5%) for dual-eligible patients with partial benefits. Multivariable analyses with adjustment for patient, hospital (or SNF), and geographical covariates suggested maintained or enlarged gaps in all outcomes.

CONCLUSIONS AND RELEVANCE

This study suggests that, during the period from 2013 to 2016, Medicare patients undergoing hip or knee replacement showed reduced institutional PAC use, reduced readmissions, and, among those discharged to SNFs, roughly unchanged outcomes. However, dual-eligible patients, especially those with partial Medicaid benefits, had persistently worse outcomes than Medicare-only patients.

Health information exchange between hospital and skilled nursing facilities not associated with lower readmissions

OBJECTIVE

To assess whether an electronic health record (EHR) portal to enable health information exchange (HIE) between a hospital and three skilled nursing facilities (SNFs) reduced likelihood of patient readmission.

SETTING/DATA

Secondary data; all discharges from a large academic medical center to SNFs between July 2013 and March 2017, combined with portal usage records from SNFs with HIE access.

DESIGN

We use difference-in-differences to determine whether portal implementation reduced likelihood of readmission over time for patients discharged to HIE-enabled SNFs, relative to those discharged to nonenabled facilities. Additional descriptive analyses of audit log data characterize portal use within enabled facilities.

DATA COLLECTION

Encounter-level clinical EHR data were merged with EHR audit log data that captured portal usage in the timeframe associated with a patient transition from hospital to SNF.

PRINCIPAL FINDINGS

Declines in likelihood of 30-day readmission were not significantly different for patients in HIE-enabled vs control SNFs (diff-in-diff = 0.022; P = .431). We observe similar null effects with shorter readmission windows. The portal was used for 46 percent of discharges, with significant usage pattern variation within/across facilities.

CONCLUSIONS

Implementation of a hospital-SNF EHR portal did not reduce readmissions from enabled SNFs. Emergent HIE use cases need to be better defined and leveraged for design and implementation that generates value in the context of postacute transitions.