The Early Impact of the Centers for Medicare & Medicaid Services State Innovation Models Initiative on 30-Day Hospital Readmissions Among Adults With Diabetes

Effect of State-Led Delivery System and Payment Reforms on Population-Level Detection and Management of Diabetes

OBJECTIVE

The Centers for Medicare and Medicaid Services State Innovation Models (SIM) initiative has invested more than $1 billion to test state-led delivery system and payment reforms that can affect diabetes care management. We examined whether SIM implementation between 2013 and 2017 was associated with diagnosed diabetes prevalence or with hospitalization or 30-day readmission rate among diagnosed adults.

RESEARCH DESIGN AND METHODS

The quasiexperimental design compared study outcomes before and after the SIM initiative in 12 SIM states versus five comparison states using difference-in-differences (DiD) regression models of 21,055,714 hospitalizations for adults age ≥18 years diagnosed with diabetes in 889 counties from 2010 to 2017 across the 17 states. For readmission analyses, comparative interrupted time series (CITS) models included 11,812,993 hospitalizations from a subset of nine states.

RESULTS

Diagnosed diabetes prevalence changes were not significantly different between SIM states and comparison states. Hospitalization rates were inconsistent across models, with DiD estimates ranging from -5.34 to -0.37 and from -13.16 to 0.92, respectively. CITS results indicate that SIM states had greater increases in odds of 30-day readmission during SIM implementation compared with comparison states (round 1: adjusted odds ratio [AOR] 1.07; 95% CI 1.04, 1.11; P < 0.001; round 2: AOR 1.06; 95% CI 1.03, 1.10; P = 0.001).

CONCLUSIONS

The SIM initiative was not sufficiently focused to have a population-level effect on diabetes detection or management. SIM states had greater increases in 30-day readmission for adults with diabetes than comparison states, highlighting potential unintended effects of engaging in the multipayer alignment efforts required of state-led delivery system and payment reforms.

The impact of Timothy's Law on hospitalization among patients with mental health conditions in New York State

Background

Timothy's law to reduce mental health care disparities was enacted in January 2007 in New York state (NY). According to Timothy's law, "if a patient is suffering from a Biologically Based Mental Illness, or is a Child with Serious Emotional Disturbances, the Inpatient mental health benefit will be the same as for any other illness". An assessment of its impact on inpatient mental health care is lacking. We provide a rigorous study of this policy intervention’s effect over the first year of its implementation.

Methods

We used a quasi-experimental design to combine the difference-in-difference method and propensity score weighting. Data are from inpatient records in NY and California (CA) (as a control) between January 2006 to December 2006 (the pre-enactment year in NY) and January to December 2007 (the enactment year) for non-Medicare/Medicaid patients hospitalized in both years with specific illnesses covered by Timothy's Law. Change in length of stay from 2006 to 2007 was measured for each patient, and the differences observed in NY and California were compared to each other (Difference-in-Difference), with differences in the characteristics of patients in NY and California addressed through Propensity Score Weighting (PSW).

Results

Before Timothy's Law was enacted (2006), length of stay (LOS) in NY was 16.3 days on average, and length of stay per hospitalization (LOSPH) was 11.72 days on average for the 1237 patients under study in 2006. In 2007, LOS increased by 4.91 days in NY (95% CI (2.89, 7.01)) compared with similar patients in California, and LOSPH by 3.25 days (95% CI (1.96, 4.57)). Among patients with serious mental illness diagnoses, LOS in NY increased by 7.07 days (95% CI (4.15, 10.17)), and LOSPH by 4.04 days (95% CI (1.93, 6.03)) compared to California.

Conclusions

Our study strongly suggests that, within the time frame of just a single year, Timothy's Law significantly increased inpatient mental healthcare utilization in NY. Our study raises the possibility that similar laws in other locations could have similar effects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00535-w.

The impact of the State Innovation Models Initiative on population health

In this paper, we examine the effects of the State Innovation Models Initiative (SIM) on population-level health status. SIM provided $250 million to six states in 2013 for broad delivery system reforms. We use data from the Behavioral Risk Factor Surveillance System for the years 2010-2016. Our sample is restricted to individuals ages 45 and older residing in 6 SIM and 15 control states. Treatment effects in a difference-in-difference design are estimated using a latent factor model for multiple indicators of health status. In addition to estimates for the primary sample, we obtain estimates for six subsamples based on strata of age, education, income, race and urban/rural status. We find that individuals in states that implemented SIM show significant improvements in health status. The effects of SIM are greater among older, Medicare eligible individuals, including those living in rural areas. The State Innovation Models Initiative, which provided financial incentives for states to implement health care delivery system reforms, led to population-level improvements in health status.

Timing of Home Health Care Initiation and 30-Day Rehospitalizations among Medicare Beneficiaries with Diabetes by Race and Ethnicity

Older adults with diabetes are at elevated risk of complications following hospitalization. Home health care services mitigate the risk of adverse events and facilitate a safe transition home. In the United States, when home health care services are prescribed, federal guidelines require they begin within two days of hospital discharge. This study examined the association between timing of home health care initiation and 30-day rehospitalization outcomes in a cohort of 786,734 Medicare beneficiaries following a diabetes-related index hospitalization admission during 2015. Of these patients, 26.6% were discharged to home health care. To evaluate the association between timing of home health care initiation and 30-day rehospitalizations, multivariate logistic regression models including patient demographics, clinical and geographic variables, and neighborhood socioeconomic variables were used. Inverse probability-weighted propensity scores were incorporated into the analysis to account for potential confounding between the timing of home health care initiation and the outcome in the cohort. Compared to the patients who received home health care within the recommended first two days, the patients who received delayed services (3-7 days after discharge) had higher odds of rehospitalization (OR, 1.28; 95% CI, 1.25-1.32). Among the patients who received late services (8-14 days after discharge), the odds of rehospitalization were four times greater than among the patients receiving services within two days (OR, 4.12; 95% CI, 3.97-4.28). Timely initiation of home health care following diabetes-related hospitalizations is one strategy to improve outcomes.