Quality improvement mechanisms to improve lymph node staging for lung cancer: Trends from a statewide database

OBJECTIVE

Our statewide thoracic quality collaborative has implemented multiple quality improvement initiatives to improve lung cancer nodal staging. We subsequently implemented a value-based reimbursement initiative to further incentivize quality improvement. We compare the impact of these programs to steer future quality improvement initiatives.

METHODS

Since 2016, our collaborative focused on improving lymph node staging for lung cancer by leveraging unblinded, hospital-level metrics and collaborative feedback. In 2021, a value-based reimbursement initiative was implemented with statewide yearly benchmark rates for (1) preoperative mediastinal staging for ≥T2N0 lung cancer, and (2) sampling ≥5 lymph node stations. Participating surgeons would receive additional reimbursement if either benchmark was met. We reviewed patients from January 2015 to March 2023 at the 21 participating hospitals to determine the differential effects on quality improvement.

RESULTS

We analyzed 6228 patients. In 2015, 212 (39%) patients had ≥5 nodal stations sampled, and 99 (51%) patients had appropriate preoperative mediastinal staging. During 2016 to 2020, this increased to 2253 (62%) patients and 739 (56%) patients, respectively. After 2020, 1602 (77%) patients had ≥5 nodal stations sampled, and 403 (73%) patients had appropriate preoperative mediastinal staging. Interrupted time-series analysis demonstrated significant increases in adequate nodal sampling and mediastinal staging before value-based reimbursement. Afterward, preoperative mediastinal staging rates briefly dropped but significantly increased while nodal sampling did not change.

CONCLUSIONS

Collaborative quality improvement made significant progress before value-based reimbursement, which reinforces the effectiveness of leveraging unblinded data to a collaborative group of thoracic surgeons. Value-based reimbursement may still play a role within a quality collaborative to maintain infrastructure and incentivize participation.

Racial and ethnic disparities in emergency department transfers to public hospitals

OBJECTIVE

To examine racial/ethnic differences in emergency department (ED) transfers to public hospitals and factors explaining these differences.

DATA SOURCES AND STUDY SETTING

ED and inpatient data from the Healthcare Cost and Utilization Project for Florida (2010-2019); American Hospital Association Annual Survey (2009-2018).

STUDY DESIGN

Logistic regression examined race/ethnicity and payer on the likelihood of transfer to a public hospital among transferred ED patients. The base model was controlled for patient and hospital characteristics and year fixed effects. Models II and III added urbanicity and hospital referral region (HRR), respectively. Model IV used hospital fixed effects, which compares patients within the same hospital. Models V and VI stratified Model IV by payer and condition, respectively. Conditions were classified as emergency care sensitive conditions (ECSCs), where transfer is protocolized, and non-ECSCs. We reported marginal effects at the means.

DATA COLLECTION/EXTRACTION METHODS

We examined 1,265,588 adult ED patients transferred from 187 hospitals.

PRINCIPAL FINDINGS

Black patients were more likely to be transferred to public hospitals compared with White patients in all models except ECSC patients within the same initial hospital (except trauma). Black patients were 0.5-1.3 percentage points (pp) more likely to be transferred to public hospitals than White patients in the same hospital with the same payer. In the base model, Hispanic patients were more likely to be transferred to public hospitals compared with White patients, but this difference reversed after controlling for HRR. Hispanic patients were - 0.6 pp to -1.2 pp less likely to be transferred to public hospitals than White patients in the same hospital with the same payer.

CONCLUSIONS

Large population-level differences in whether ED patients of different races/ethnicities were transferred to public hospitals were largely explained by hospital market and the initial hospital, suggesting that they may play a larger role in explaining differences in transfer to public hospitals, compared with other external factors.

Hospital Facility Prices Declined As A Result Of Oregon's Hospital Payment Cap

Hospital prices for commercially insured people are high and vary widely, prompting states to seek ways to control hospital price growth. In October 2019, the Oregon state employee health insurance plan instituted a cap on hospital payments. Using 2014-21 data from the Oregon All Payer All Claims Reporting Program database, we performed a difference-in-differences analysis to test the impact of the cap on hospital facility prices for Oregon's state employee plan enrollees. We found that the cap was not associated with a significant reduction in inpatient facility prices across the post period (-$901.9 per admission) but was associated with a significant reduction in the second year after implementation (-$2,774.20). The cap was associated with a significant reduction in outpatient facility prices over the course of the first twenty-seven months of the policy (-$130.50 per procedure). We estimated $107.5 million (or 4 percent of total plan spending) in savings to the state employee plan during the first two years. The hospital payment cap successfully reduced hospital prices for enrollees in that plan.

Racial and ethnic disparities in medication for opioid use disorder access, use, and treatment outcomes in Medicare

INTRODUCTION

Overdose deaths are increasing disproportionately for minoritized populations in the United States. Disparities in substance use disorder treatment access and use have been a key contributor to this phenomenon. However, little is known about the magnitude of these disparities and the role of social determinants of health (SDOH) and provider characteristics in driving them. Our study measures the association between race and ethnicity and visits with Medication for Opioid Use Disorder (MOUD) providers, MOUD treatment conditional on a provider visit, and opioid overdose following MOUD treatment in Medicare. We also evaluate the role of social determinants of health and provider characteristics in modifying disparities.

METHODS

Using a population of 230,198 US Medicare fee-for-service beneficiaries diagnosed with opioid use disorder (OUD), we estimate logistic regression models to quantify the association between belonging to a racial or ethnic group and the probability of visiting a buprenorphine or naltrexone provider, receiving a prescription or medication administration during or after a visit, and experiencing an opioid overdose after treatment with MOUD. Data included Medicare claims data and the Agency for Health Research and Quality Social Determinants of Health Database files between 2013 and 2017.

RESULTS

Compared to Non-Hispanic White Medicare beneficiaries, Asian/Pacific Islander, American Indian/Alaska Native, Black, Hispanic, and Other/Unknown Race beneficiaries were between 3.0 and 9.3 percentage points less likely to have a visit with a buprenorphine or naltrexone provider. Conditional on having a buprenorphine or naltrexone provider visit, Asian/Pacific Islander, American Indian/Alaska Native, Black, Hispanic, and Other/Unknown Race were between 2.6 and 8.1 percentage points less likely to receive buprenorphine or naltrexone than white beneficiaries. Controlling for provider characteristics and SDOH increased disparities in visits and MOUD treatment for all groups besides American Indians/Alaska Natives. Conditional on treatment, only Black Medicare beneficiaries were at greater associated risk of overdose than non-Hispanic white beneficiaries, although differences became statistically insignificant after controlling for SDOH and including provider fixed effects.

CONCLUSION

Ongoing equity programming and measurement efforts by CMS should include explicit consideration for disparities in access and use of MOUD. This may help ensure greater MOUD utilization by minoritized Medicare beneficiaries and reduce rising disparities in overdose deaths.

Hospital-physician integration and clinical volume in traditional Medicare

OBJECTIVE

To test the effect of hospital-physician integration on primary care physicians' (PCP) clinical volume in traditional Medicare.

DATA SOURCES AND STUDY SETTING

Nationwide retrospective longitudinal study using Medicare claims and other data sources from 2010 to 2016.

STUDY DESIGN

We identified 70,000 PCPs, some of whom remained non-integrated and some who became hospital-integrated during this study period. We used an event study design to identify the effect of integration on key measures of physicians' clinical volume, including the number of claims, work-relative value units (RVUs), professional revenue generated, number of patients treated, and facility fee revenue generated.

PRINCIPAL FINDINGS

Per-physician clinical volume declined by statistically and economically significant margins. Relative to the comparison group who remained non-integrated, work RVUs fell by 7% (95% confidence interval [CI]: -8.6% to -5.5%); the number of patients treated fell by 4% (95% CI: -5.8% to -2.6%); and claims volume among PCPs who became hospital-integrated fell by over 15% (95% CI: -16.8% to -13.5%). Though professional revenue declined by $29,165 (95% CI: -$32,286 to -$26,044), this loss was almost entirely offset by increased facility fee revenue of $28,556 (95% CI: 26,909 to 30,203).

CONCLUSIONS

Hospital-physician integration may affect the quantity of clinical services delivered by PCPs to traditional Medicare beneficiaries. Reductions in clinical volume associated with integration may have long-term consequences for the supply of physician services and patient access to primary care. Future research on physician time use and patient access following hospital integration would further add to the evidence base.

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.

Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy

Importance

Robotic-assisted cholecystectomy is rapidly being adopted into practice, partly based on the belief that it offers specific technical and safety advantages over traditional laparoscopic surgery. Whether robotic-assisted cholecystectomy is safer than laparoscopic cholecystectomy remains unclear.

Objective

To determine the uptake of robotic-assisted cholecystectomy and to analyze its comparative safety vs laparoscopic cholecystectomy.

Design, Setting, and Participants

This retrospective cohort study used Medicare administrative claims data for nonfederal acute care hospitals from January 1, 2010, to December 31, 2019. Participants included 1 026 088 fee-for-service Medicare beneficiaries 66 to 99 years of age who underwent cholecystectomy with continuous Medicare coverage for 3 months before and 12 months after surgery. Data were analyzed August 17, 2022, to June 1, 2023.

Exposure

Surgical technique used to perform cholecystectomy: robotic-assisted vs laparoscopic approaches.

Main Outcomes and Measures

The primary outcome was rate of bile duct injury requiring definitive surgical reconstruction within 1 year after cholecystectomy. Secondary outcomes were composite outcome of bile duct injury requiring less-invasive postoperative surgical or endoscopic biliary interventions, and overall incidence of 30-day complications. Multivariable logistic analysis was performed adjusting for patient factors and clustered within hospital referral regions. An instrumental variable analysis was performed, leveraging regional variation in the adoption of robotic-assisted cholecystectomy within hospital referral regions over time, to account for potential confounding from unmeasured differences between treatment groups.

Results

A total of 1 026 088 patients (mean [SD] age, 72 [12.0] years; 53.3% women) were included in the study. The use of robotic-assisted cholecystectomy increased 37-fold from 211 of 147 341 patients (0.1%) in 2010 to 6507 of 125 211 patients (5.2%) in 2019. Compared with laparoscopic cholecystectomy, robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury necessitating a definitive operative repair within 1 year (0.7% vs 0.2%; relative risk [RR], 3.16 [95% CI, 2.57-3.75]). Robotic-assisted cholecystectomy was also associated with a higher rate of postoperative biliary interventions, such as endoscopic stenting (7.4% vs 6.0%; RR, 1.25 [95% CI, 1.16-1.33]). There was no significant difference in overall 30-day complication rates between the 2 procedures. The instrumental variable analysis, which was designed to account for potential unmeasured differences in treatment groups, also showed that robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury (0.4% vs 0.2%; RR, 1.88 [95% CI, 1.14-2.63]).

Conclusions and Relevance

This cohort study's finding of significantly higher rates of bile duct injury with robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy suggests that the utility of robotic-assisted cholecystectomy should be reconsidered, given the existence of an already minimally invasive, predictably safe laparoscopic approach.

Changes in Care Use and Financial Status Associated With Dementia in Older Adults

Importance

Estimating the effects of dementia on care use and financial outcomes is timely, as the population with dementia will more than double in the next few decades.

Objective

To determine the incremental changes associated with dementia in regard to older adults' care use and assess financial consequences for individuals, families, and society.

Design, Setting, and Participants

This population-based cohort study included propensity score matching on national, longitudinal data using extensive baseline variables of sociodemographic characteristics, economic status, family availability, health conditions, disability status, and outpatient care use among 2 groups of US adults aged 55 years or older who did not have dementia. In total, 2387 adults experienced the onset of dementia during the 2-year follow-up (dementia group) and 2387 adults did not (control group). Participants were followed up for 8 years from the baseline. Data were analyzed from February 2021 to August 2023.

Exposure

Dementia determined based on Langa-Weir classification.

Main Outcomes and Measures

Outcomes of care use included monthly care hours from family and unpaid helpers, in-home medical services, hospital stay, and nursing facility stay. Financial outcomes included out-of-pocket medical costs, wealth, and the status of having Medicaid.

Results

Among the full sample, the mean (SD) age was 75.4 [10.4] years, and 59.7% of participants were female. Care use was similar at baseline between the matched groups but was substantially greater for the dementia group vs control group in subsequent years, especially during the 2-year follow-up: 45 vs 13 monthly care hours from family and unpaid helpers, 548 of 2370 participants (23.1%) vs 342 of 2383 (14.4%) using in-home medical care, 1104 of 2369 (46.6%) vs 821 of 2377 (34.5%) with hospital stay, and 489 of 2375 (20.6%) vs 104 of 2384 (4.4%) using a nursing facility. The increase in use of a nursing facility was especially high if baseline family care availability was low. Over the 8-year follow-up in the dementia group, the 2-year out-of-pocket medical costs increased from $4005 to $10 006, median wealth was reduced from $79 339 to $30 490, and those enrolling in Medicaid increased from 379 of 2358 participants (16.1%) to 201 of 676 participants (29.7%). No statistically significant changes in financial outcomes were found in the control group.

Conclusion and Relevance

This cohort study demonstrated that the incremental changes associated with dementia in regard to older adults' long-term care and financial burden are substantial. Family care availability should be accounted for in a comprehensive assessment of predicting the effects of dementia.

The relationship between physical activity, cognitive function and health care use: A mediation analysis

Physical activity is known to provide substantial health benefits and subsequently reduce health care use among older people, but little is known about how much of this effect is due to improved cognitive function as opposed to physical improvements in health. We study the direct and indirect effect of physical activity on health care use using the word recall task as a measure of cognitive function in a mediation framework. We use data from eight waves of the US Health and Retirement Study (HRS) (2004 - 2018) of people aged 65 and older and exploit genetic variations between individuals as an instrumental variable (IV) for cognitive function, a local health care supply measure as IV for health care use, and neighbourhood physical activity as IV for individual physical activity in our simultaneous three-equation model. We find small but negative direct and indirect effects of physical activity through improved cognitive function on the probability to see a GP and being admitted to a hospital, as well as the number of GP visits and the hospital length of stay. Improved cognitive function explains between 5% to 17% of the total effect of physical activity on the reduction in health care use.

Hospital performance in a statewide commercial insurer episode-based incentive program

OBJECTIVES

To evaluate hospital performance and behaviors in the first 2 years of a statewide commercial insurance episode-based incentive pay-for-performance (P4P) program.

STUDY DESIGN

Retrospective cohort study of price- and risk-standardized episode-of-care spending from the Michigan Value Collaborative claims data registry.

METHODS

Changes in hospital-level episode spending between baseline and performance years were estimated during the program years (PYs) 2018 and 2019. The distribution and hospital characteristics associated with P4P points earned were described for both PYs. A difference-in-differences (DID) analysis compared changes in patient-level episode spending associated with program implementation.

RESULTS

Hospital-level episode spending for all conditions declined significantly from the baseline year to the performance year in PY 2018 (-$671; 95% CI, -$1113 to -$230) but was not significantly different for PY 2019 ($177; 95% CI, -$412 to $767). Hospitals earned a mean (SD) total of 6.3 (3.1) of 10 points in PY 2018 and 4.5 (2.9) of 10 points in PY 2019, with few significant differences in P4P points across hospital characteristics. The highest-scoring hospitals were more likely to have changes in case mix index and decreases in spending across the entire episode of care compared with the lowest-scoring hospitals. DID analysis revealed no significant changes in patient-level episode spending associated with program implementation.

CONCLUSIONS

There was little evidence for overall reductions in spending associated with the program, but the performance of the hospitals that achieved greatest savings and incentives provides insights into the ongoing design of hospital P4P metrics.

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.

Genetic nurture in educational attainment

Health is strongly and positively correlated with education, which is one of many reasons to better understand the determinants of education. In this paper, we test for a specific type of family influence on education: genetic nurture. Specifically, we test whether a person's educational attainment is correlated with their sibling's polygenic score (PGS) for education, controlling for their own PGS. Models estimated using data from the National Longitudinal Survey of Adolescent to Adult Health (Add Health) yield strong evidence of genetic nurture; a two-standard deviation increase in a sibling's genetic predisposition to higher education is associated with a 13.6% point increase in the probability that the respondent has a college degree. Evidence of genetic nurture is robust to alternative measures of educational attainment and different measures of the polygenic score. An exploration of mechanisms suggests that omission of parental PGS explains no more than half of the estimated effect, and that the magnitude of the genetic nurture varies with the characteristics of the sibling.

Life satisfaction and body mass index: estimating the monetary value of achieving optimal body weight

According to the World Health Organization, obesity is one of the greatest public-health challenges of the 21st century. Body weight is also known to affect individuals' self-esteem and interpersonal relationships, including romantic ones. We estimate the "utility-maximizing" Body Mass Index (BMI) and calculate the implied monetary value of changes in both individual and spousal BMI, using the compensating income variation method and data from the Swiss Household Panel. We employ the Oster's method (Oster, 2019) to estimate the degree of omitted variable bias in the effect of BMI on life satisfaction. Results suggest that the optimal own BMI is 27.1 and 20.1 for men and women, respectively. The annual value of reaching optimal weight ranges from $7069 for women with underweight to $88,709 for women with obesity and between $95,165 for men with underweight to $32,644 for men with obesity. On average, women value reduction in their own BMI about four times higher than reduction in their spouse's BMI. Men, on the other hand, value a reduction in their spouse's BMI almost twice as much compared to a reduction in their own BMI. This highlights important gender differences and relative effects based on spousal BMI.

Association Between Buprenorphine Treatment Gaps, Opioid Overdose, and Health Care Spending in US Medicare Beneficiaries With Opioid Use Disorder

Importance

Nonadherence to buprenorphine may increase patient risk of opioid overdose and increase health care spending. Quantifying the impacts of nonadherence can help inform clinician practice and policy.

Objective

To estimate the association between buprenorphine treatment gaps, opioid overdose, and health care spending.

Design, Setting, and Participants

This longitudinal case-control study compared patient opioid overdose and health care spending in buprenorphine-treated months with treatment gap months. Individuals who were US Medicare fee-for-service beneficiaries diagnosed with opioid use disorder who received at least 1 two-week period of continuous buprenorphine treatment between 2010 and 2017 were included. Analysis took place between January 2010 and December 2017.

Interventions

A gap in buprenorphine treatment in a month lasting more than 15 consecutive days.

Main Outcomes and Measures

Opioid overdose and total, medical, and drug spending (combined patient out-of-pocket and Medicare spending).

Results

Of 34 505 Medicare beneficiaries (17 927 [520%] male; 16 578 [48.1%] female; mean [SD] age, 49.5 [12.7] years; 168 [0.5%] Asian; 2949 [8.5%] Black; 2089 [6.0%] Hispanic; 266 [0.8%] Native American; 28 525 [82.7%] White; 508 [1.5%] other race), 11 524 beneficiaries (33.4%) experienced 1 or more buprenorphine treatment gaps. Treatment gap beneficiaries, compared with nontreatment gap beneficiaries, were more likely to be younger, be male, have a disability, and be Medicaid dual-eligible while less likely to be White, close to a buprenorphine prescriber, and treated with buprenorphine monotherapy (ie, buprenorphine hydrochloride). Beneficiaries were 2.89 (95% CI, 2.20-3.79) times more likely to experience an opioid overdose during buprenorphine treatment gap months compared with treated months. During treatment gap months, spending was $196.41 (95% CI, $110.53-$282.30) more than in treated months. Patients who continued to take buprenorphine dosages of greater than 8 mg/d and 16 mg/d were 2.61 and 2.84 times more likely to overdose in a treatment gap month, respectively, while patients taking buprenorphine dosages of 8 mg/d or less were 3.62 times more likely to overdose in a treatment gap month (maintenance of >16 mg/d: hazard ratio (HR), 2.64 [95% CI, 1.80-3.87]; maintenance of >8 mg/d: HR, 2.84 [95% CI, 2.13-3.78]; maintenance of ≤8 mg/d: HR, 3.62 [95% CI, 1.54-8.50]). Buprenorphine monotherapy was associated with greater risk of overdose and higher spending during treatment gaps months than buprenorphine/naloxone.

Conclusions and Relevance

Medicare patients treated with buprenorphine between 2010 and 2017 had a lower associated opioid overdose risk and spending during treatment months than treatment gap months.

Impact of Spousal Death on Healthcare Costs and Use Among Medicare Beneficiaries: NHATS 2011-2017

BACKGROUND

Spousal death is associated with elevated mortality in the surviving partner; less is known about how healthcare costs and use change following spousal death.

OBJECTIVES

To examine the causal impact of spousal death on Medicare costs and use over time.

DESIGN

Longitudinal cohort study with an event study design.

SETTING

National Health and Aging Trends Study (NHATS) with linked Medicare claims.

PARTICIPANTS

Respondents from 2011-2017 who reported spousal death the prior year, limited to those with traditional Medicare (n=491 with 9,766 respondent-quarters).

MAIN MEASURES

Total Medicare costs; binary indicators for acute hospitalization; emergency department; sub-acute care (including skilled nursing, rehabilitation, and long-term care); and number of outpatient management visits on a quarterly basis 3 years before and after spousal death.

KEY RESULTS

During the first year post-death, quarterly Medicare costs for the surviving spouse were $1,092 higher than pre-death; probability of hospitalization, emergency department, and sub-acute care were 3.3%, 2.8%, and 2.2% higher, respectively; and there were 0.3 more outpatient visits (p<.01 for all). Several outcomes continued to be elevated during the second year, including costs ($1,174 higher per quarter), hospitalization (3.2% higher), and sub-acute care (2.9% higher; p<.01 for all). By the third year, costs returned to pre-death level but hospitalization and sub-acute care (2.9% and 3.1% higher per quarter; p<.05 for both) remained elevated. Cost increases in the first and second years post-death were larger if the deceased spouse was a caregiver ($1,588 and $1,853 per quarter) or female (i.e., among bereaved males; $1,457 and $1,632 per quarter; p<.05 for all).

CONCLUSIONS

Spousal death increased total Medicare costs and use of all healthcare categories among the surviving partner; elevations in hospitalization and sub-acute care persisted through the third year. Clinicians and payors may want to target surviving partners as a high-risk population.

Association of Insurance Coverage With Adoption of Sleeve Gastrectomy vs Gastric Bypass for Patients Undergoing Bariatric Surgery

IMPORTANCE

Instrumental variables can control for selection bias in observational research. However, valid instruments are challenging to identify.

OBJECTIVE

To evaluate regional variation in sleeve gastrectomy following insurance coverage implementation as an instrumental variable in comparative effectiveness research.

DESIGN, SETTING, AND PARTICIPANTS

This serial cross-sectional study included adult patients in a national Medicare claims database who underwent sleeve gastrectomy or Roux-en-Y gastric bypass from 2012 to 2017. Data analysis was performed from January to June 2021.

EXPOSURES

Laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.

MAIN OUTCOMES AND MEASURES

The association of the instrumental variable with treatment (ie, undergoing sleeve gastrectomy), as well as mortality, complications, emergency department visits, hospitalization, reinterventions, and surgical revision.

RESULTS

A total of 76 077 patients underwent bariatric surgery, of whom 44 367 underwent sleeve gastrectomy (mean [SD] age, 56.9 [11.9] years; 32 559 [73.5%] women) and 31 710 underwent gastric bypass (mean (SD) age, 55.9 (11.8) years; 23 750 [74.9%] women). After insurance coverage initiation, there was substantial regional and temporal variation in adoption of sleeve gastrectomy. Prior-year state-level utilization of sleeve gastrectomy was highly associated with undergoing sleeve gastrectomy (Kleibergen-Paap Wald F statistic, 910.3). All but 2 patient characteristics (race and diagnosis of depression) were well-balanced between the top and bottom quartiles of the instrumental variable. Regarding 1-year outcomes, compared with patients undergoing gastric bypass, patients undergoing sleeve gastrectomy had a lower 1-year risk of mortality (0.9%; 95% CI, 0.8%-1.1% vs 1.7%; 95% CI, 1.3%-2.0%), complications (11.6%; 95% CI, 10.9%-12.3% vs 14.1%; 95% CI, 13.0%-15.3%), emergency department visits (48.3%; 95% CI, 46.9%-49.8% vs 53.6%; 95% CI, 52.3%-55.0%), hospitalization (23.4%; 95% CI, 22.4%-24.4% vs 26.5%; 95% CI, 25.1%-28.0%), and reinterventions (8.7%; 95% CI, 8.0%-9.4% vs 12.2%; 95% CI, 11.2%-13.3%). The risk of revision was not different between groups (0.6%; 95% CI, 0.3%-0.8% vs 0.4%; 95% CI, 0.3%-0.6%).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of patients undergoing bariatric surgery, there was significant geographic variation in the use of sleeve gastrectomy following initiation of insurance coverage, which served as a strong instrument to compare 2 bariatric surgical procedures. This approach could be applied to other areas of health services research to serve as a complement to clinical trials.

Hospital-physician integration and risk-coding intensity

Hospital-physician integration has surged in recent years. Integration may allow hospitals to share resources and management practices with their integrated physicians that increase the reported diagnostic severity of their patients. Greater diagnostic severity will increase practices' payment under risk-based arrangements. We offer the first analysis of whether hospital-physician integration affects providers' coding of patient severity. Using a two-way fixed effects model, an event study, and a stacked difference-in-differences analysis of 5 million patient-year observations from 2010 to 2015, we find that the integration of a patient's primary care doctor is associated with a robust 2%-4% increase in coded severity, the risk-score equivalent of aging a physician's patients by 4-8 months. This effect was not driven by physicians treating different patients nor by physicians seeing patients more often. Our evidence is consistent with the hypothesis that hospitals share organizational resources with acquired physician practices to increase the measured clinical severity of patients. Increases in the intensity of coding will improve vertically-integrated practices' performance in alternative payment models and pay-for-performance programs while raising overall health care spending.

Cost Consequences of Age and Comorbidity in Accelerated Postoperative Discharge After Colectomy

BACKGROUND

Prospective payment models have incentivized reductions in length of stay after surgery. The benefits of abbreviated postoperative hospitalization could be undermined by increased readmissions or postacute care use, particularly for older adults or those with comorbid conditions.

OBJECTIVE

The purpose of this study was to determine whether hospitals with accelerated postsurgical discharge accrue total episode savings or incur greater postdischarge payments among patients stratified by age and comorbidity.

DESIGN

This was a retrospective cross-sectional study.

SETTING

National data from the 100% Medicare Provider Analysis and Review files for July 2012 to June 2015 were used.

PATIENTS

We included Medicare beneficiaries undergoing elective colectomy and stratified the cohort by age (65-69, 70-79, ≥80 y) and Elixhauser comorbidity score (low: ≤0; medium: 1-5; and high: >5). Patients were categorized by the hospital's mode length of stay, reflecting "usual" care.

MAIN OUTCOMES MEASURES

In a multilevel model, we compared mean total episode payments and components thereof among age and comorbidity categories, stratified by hospital mode length of stay.

RESULTS

Among 88,860 patients, mean total episode payments were lower in shortest versus longest length of stay hospitals across all age and comorbidity strata and were similar between age groups (65-69 y: $28,951 vs $30,566, p = 0.014; 70-79 y: $31,157 vs $32,044, p = 0.073; ≥80 y: $33,779 vs $35,771, p = 0.005) but greater among higher comorbidity (low: $23,107 vs $24,894, p = 0.001; medium: $30,809 vs $32,282, p = 0.038; high: $44,097 vs $46641, p < 0.001). Postdischarge payments were similar among length-of-stay hospitals by age (65-69 y: ∆$529; 70-79 y: ∆$291; ≥80 y: ∆$872, p = 0.25) but greater among high comorbidity (low: ∆$477; medium: ∆$480; high: ∆$1059; p = 0.02).

LIMITATIONS

Administrative data do not capture patient-level factors that influence postacute care use (preference, caregiver availability).

CONCLUSIONS

Hospitals achieving shortest length of stay after surgery accrue lower total episode payments without a compensatory increase in postacute care spending, even among patients at oldest age and with greatest comorbidity. See Video Abstract at http://links.lww.com/DCR/B624.

CONSECUENCIAS DE LA EDAD Y LAS COMORBILIDADES ASOCIADAS, EN EL COSTO DE LA ATENCIN EN PACIENTES SOMETIDOS A COLECTOMA EN PROGRAMAS DE ALTA POSOPERATORIA ACELERADA

ANTECEDENTES:Los modelos de pago prospectivo, han sido un incentivo para reducir la estancia hospitalaria después de la cirugía. Los beneficios de una hospitalización posoperatoria "abreviada" podrían verse afectados por un aumento en los reingresos o en la necesidad de cuidados postoperatorios tempranos luego del periodo agudo, particularmente en los adultos mayores o en aquellos con comorbilidades.OBJETIVO:Determinar si los hospitales que han establecido protocolos de alta posoperatoria "acelerada" generan un ahorro en cada episodio de atención o incurren en mayores gastos después del alta, entre los pacientes estratificados por edad y por comorbilidades.DISEÑO:Estudio transversal retrospectivo.AJUSTE:Revisión a partir de la base de datos nacional del 100% de los archivos del Medicare Provider Analysis and Review desde julio de 2012 hasta junio de 2015.PACIENTES:Se incluye a los beneficiarios de Medicare a quienes se les practicó una colectomía electiva. La cohorte se estratificó por edad (65-69 años, 70-79, ≥80) y por la puntuación de comorbilidad de Elixhauser (baja: ≤0; media: 1-5; y alta: > 5). Los pacientes se categorizaron de acuerdo con la modalidad de la duración de la estancia hospitalaria del hospital, lo que representa lo que se considera es una atención usual para dicho centro.PRINCIPALES MEDIDAS DE RESULTADO:En un modelo multinivel, comparamos la media de los pagos por episodio y los componentes de los mismos, entre las categorías de edad y comorbilidad, estratificados por la modalidad de la duración de la estancia hospitalaria.RESULTADOS:En los 88,860 pacientes, los pagos promedio por episodio fueron menores en los hospitales con una modalidad de estancia más corta frente a los de mayor duración, en todos los estratos de edad y comorbilidad, y fueron similares entre los grupos de edad (65-69: $28,951 vs $30,566, p = 0,014; 70-79: $31,157 vs $32,044, p = 0,073; ≥ 80 $33,779 vs $35,771, p = 0,005), pero mayor entre los pacientes con comorbilidades más altas (baja: $23,107 vs $24,894, p = 0,001; media $30,809 vs $32,282, p = 0,038; alta: $44,097 vs $46,641, p <0,001). Los pagos generados luego del alta hospitalaria fueron similares con relación a la estancia hospitalaria de los diferentes hospitales con respecto a la edad (65-69 años: ∆ $529; 70-79 años: ∆ $291; ≥80 años: ∆ $872, p = 0,25), pero mayores en aquellos con más alta comorbilidad (baja ∆ $477, medio ∆ $480, alto ∆ $1059, p = 0,02).LIMITACIONES:Las bases de datos administrativas no capturan los factores del paciente que influyen en el cuidado luego del estado posoperatorio agudo (preferencia, disponibilidad del proveedor del cuidado).CONCLUSIONES:Los hospitales que logran una estancia hospitalaria más corta después de la cirugía, acumulan pagos más bajos por episodio, sin un incremento compensatorio del gasto en la atención pos-aguda, incluso entre pacientes de mayor edad y con mayor comorbilidad. Consulte Video Resumen en http://links.lww.com/DCR/B624. (Traducción-Dr Eduardo Londoño-Schimmer).

Association Between Organizational Quality and Out-of-Network Primary Care Among Accountable Care Organizations That Care for High vs Low Proportions of Patients of Racial and Ethnic Minority Groups

Question

How is the quality of care delivered by a Medicare accountable care organization (ACO) associated with the level of out-of-network primary care among organizations that care for high vs low proportions of patients of racial and ethnic minority groups?

Findings

In this retrospective cohort study of 3 955 951 beneficiary-years within 528 Medicare ACOs, the ACOs that cared for more patients of racial and ethnic minority groups had significantly higher rates of out-of-network primary care than those that cared for fewer patients of racial and ethnic minority groups. The level of out-of-network primary care was negatively associated with performance among ACOs with many patients of racial and ethnic minority groups across most quality metrics examined.

Meaning

The study findings suggest that organizational efforts to limit out-of-network primary care at ACOs caring for many patients of racial and ethnic minority groups could serve as a tangible, accessible corrective for reducing health care disparities among the populations that they serve.

Importance

Medicare accountable care organizations (ACOs) that disproportionately care for patients of racial and ethnic minority groups deliver lower quality care than those that do not, potentially owing to differences in out-of-network primary care among them.

Objective

To examine how organizational quality is associated with out-of-network primary care among ACOs that care for high vs low proportions of patients of racial and ethnic minority groups.

Design, Setting, and Participants

A retrospective cohort study was conducted between March 2019 and October 2021 using claims data (2013 to 2016) from a national sample of Medicare beneficiaries. Among beneficiaries who were assigned to 1 of 528 Medicare ACOs, a distinction was made between those treated by organizations that cared for high (vs low) proportions of patients of racial and ethnic minority groups. For each ACO, the amount of out-of-network primary care that it delivered annually was determined. Multivariable models were fit to evaluate how the quality of care that beneficiaries received varied by the proportion of care provided to patients of racial and ethnic minority groups by the ACO and its amount of out-of-network primary care.

Exposures

The degree of care provided to patients of racial and ethnic minority groups by the ACO and its amount of out-of-network primary care.

Main Outcomes and Measures

The ACO quality assessed with 5 preventive care services and 4 utilization metrics.

Results

Among 3 955 951 beneficiary-years (2 320 429 [58.7%] women; 71 218 [1.8%] Asian, 267 684 [6.8%] Black, 44 059 [1.1%] Hispanic, 4922 [0.1%] North American Native, and 3 468 987 [87.7%] White individuals and 56 157 [1.4%] of Other race and ethnicity), those assigned to ACOs serving many patients of racial and ethnic minority groups at the mean level of out-of-network primary care were less likely than those assigned to ACOs serving fewer patients of racial and ethnic minority groups to receive diabetic retinal examinations (predicted probability, 49.4% [95%CI, 49.0%-49.7%] vs 51.6% [95% CI, 51.5%-51.8%]), glycated hemoglobin testing (predicted probability, 58.5% [95% CI, 58.2%-58.5%] vs 60.4% [95% CI, 60.3%-60.6%]), or low-density lipoprotein cholesterol testing (predicted probability, 85.2% [95% CI, 85.0%-85.5%] vs 86.0% [95% CI, 85.9%-86.1%]). They were also more likely to experience all-cause 30-day readmissions (predicted probability, 16.4% [95% CI, 16.1%-16.7%] vs 15.7% [95% CI, 15.6%-15.8%]). However, as the level of out-of-network primary care decreased, these gaps closed substantially, such that beneficiaries at ACOs that served many and fewer patients of racial and ethnic minority groups in the lowest percentile of out-of-network primary care received care of comparable quality.

Conclusions and Relevance

This large cohort study found that quality performance among ACOs serving many patients of racial and ethnic minority groups was negatively associated with their level of out-of-network primary care.

Small practice participation and performance in Medicare accountable care organizations

OBJECTIVES

Alternative payment models (APMs) encouraging provider collaboration may help small practices overcome the participation challenges that they face in APMs. We aimed to determine whether small practices in accountable care organizations (ACOs) reduced their beneficiaries' spending more than large practices in ACOs.

STUDY DESIGN

Retrospective cohort study of Medicare patients attributed to ACOs and non-ACOs.

METHODS

We conducted a modified difference-in-differences analysis that allowed us to compare large vs small practices before and after the Medicare Shared Savings Program (MSSP) ACO started, between 2010 and 2016. Our sample included Medicare fee-for-service beneficiaries with 12 months of Medicare Part A and Part B (unless death) who were attributed to small (≤ 15 providers) and large (> 15 providers) practices participating in ACOs and non-ACOs. The outcome was patient annual spending based on CMS' total per capita costs.

RESULTS

Patients attributed to small practices in ACOs had annual Medicare spending decreases of $269 (95% CI, $213-$325; P < .001) more than patients attributed to large practices in ACOs. Small ACO practices reduced spending more than large practices by $165 for physician services (95% CI, $140-$190; P < .001), $113 for hospital/acute care (95% CI, $65-162; P < .001), and $52 for other services (95% CI, $27-$77; P < .001). Small practices in ACOs spent $253 more on average at baseline than small practices in non-ACOs. ACOs with a higher proportion of small practices were more likely to receive shared savings payments.

CONCLUSIONS

Small practices in ACOs controlled costs more so than large practices. Small practice participation may generate higher savings for ACOs.

Long-term effects of job loss on male health: BMI and health behaviors

Employment is one of the most critical determinants of health and health behaviors for adults. This study focuses on Ukraine and measures how an involuntary job loss - defined as job loss due to business closures, reorganizations, bankruptcies, or privatization - affects BMI, being overweight or obese, smoking, alcohol consumption, and physical activity. There are three reasons to study Ukraine in the aftermath of an enormous economic transition that resulted in employment contraction as high as 40 % compared to 1990. First, nearly all published studies on the relationship between job loss and health and health behaviors have been on developed countries, meaning that our study fills the gap in the literature on transition economies. Second, the job losses that we study are plausibly exogenous and affected a significant share of the population. Third, the longitudinal survey follows individuals for up to 10 years starting from 2003, allowing us to capture the long-term effects of past job loss on outcomes at a specific point in time and their trajectories across the life cycle. Applying growth-curve models, we show that past involuntary job loss significantly alters the age trajectories of all considered outcomes at both extensive and intensive margins.

Family Care Availability And Implications For Informal And Formal Care Used By Adults With Dementia In The US

Despite the important role that family members can play in dementia care, little is known about the association between the availability of family members and the type of care, informal (unpaid) or formal (paid), that is actually delivered to older adults with dementia in the US. Using data about older adults with dementia from the Health and Retirement Study, we found significantly lower spousal availability but greater adult child availability among women versus men, non-Hispanic Blacks versus non-Hispanic Whites, and people with lower versus higher socioeconomic status. Adults with dementia and disability who have greater family availability were significantly more likely to receive informal care and less likely to use formal care. In particular, the predicted probability of a community-dwelling adult moving to a nursing home during the subsequent two years was substantially lower for those who had a co-resident adult child (11 percent) compared with those who did not have a co-resident adult child but had at least one adult child living close (20 percent) and with those who have all children living far (23 percent). Health care policies on dementia should consider potential family availability in predicting the type of care that people with dementia will use and the potential disparities in consequences for them and their families.

Competing Causes of Death in Older Adults with Thyroid Cancer

Background: Understanding the impact of comorbidities and competing risks of death when caring for older adults with thyroid cancer is key for personalized management. The objective of this study was to determine whether older adults with thyroid cancer are more likely to die from thyroid cancer or other etiologies, and determine patient factors associated with each. Methods: The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify patients aged ≥66 years diagnosed with thyroid cancer (papillary, follicular, Hürthle cell, medullary, anaplastic, and other) between 2000 and 2015 (median follow-up, 50 months). We analyzed time to event (i.e., death from other causes or death from thyroid cancer) using cumulative incidence functions. Competing risk hazards regression was used to determine the association between patient (e.g., age at diagnosis and specific comorbidities) and tumor characteristics (e.g., SEER stage) with two competing mortality outcomes: death from other causes and death from thyroid cancer. Results: Of 21,509 patients with a median age of 72 years (range 66-106), 4168 (19.4%) died of other causes and 2644 (12.3%) died of thyroid cancer during the study period. For differentiated thyroid cancer patients, likelihood of dying from other causes exceeds likelihood of dying from thyroid cancer, whereas the opposite is true for anaplastic thyroid cancer. For medullary thyroid cancer, after 6.25 years patients are more likely to die from other etiologies than thyroid cancer. Using competing risks hazards regression, male sex (hazards ratio [HR] 1.47; 95% confidence interval [CI 1.37-1.57]), black race (HR 1.30; CI [1.16-1.46]), and comorbidities (e.g., heart disease, HR 1.34; CI [1.25-1.44]; chronic lower respiratory disease, HR 1.25; CI [1.17-1.34]) were associated with death from other causes. Tumor characteristics such as histology, tumor size, and stage correlated with death from thyroid cancer (e.g., distant SEER stage compared with localized, HR 12.65; CI [10.91-14.66]). Conclusions: The clinical context, including patients' specific comorbidities, should be considered when diagnosing and managing thyroid cancer. Our findings can be used to develop decision models that account for competing causes of death, as an aid for clinical decision making.

Clinical and Economic Outcomes of Enhanced Recovery Dissemination in Michigan Hospitals

OBJECTIVE

To evaluate real-world effects of enhanced recovery protocol (ERP) dissemination on clinical and economic outcomes after colectomy.

SUMMARY BACKGROUND DATA

Hospitals aiming to accelerate discharge and reduce spending after surgery are increasingly adopting perioperative ERPs. Despite their efficacy in specialty institutions, most studies have lacked adequate control groups and diverse hospital settings and have considered only in-hospital costs. There remain concerns that accelerated discharge might incur unintended consequences.

METHODS

Retrospective, population-based cohort including patients in 72 hospitals in the Michigan Surgical Quality Collaborative clinical registry (N = 13,611) and/or Michigan Value Collaborative claims registry (N = 14,800) who underwent elective colectomy, 2012 to 2018. Marginal effects of ERP on clinical outcomes and risk-adjusted, price-standardized 90-day episode payments were evaluated using mixed-effects models to account for secular trends and hospital performance unrelated to ERP.

RESULTS

In 24 ERP hospitals, patients Post-ERP had significantly shorter length of stay than those Pre-ERP (5.1 vs 6.5 days, P < 0.001), lower incidence of complications (14.6% vs 16.9%, P < 0.001) and readmissions (10.4% vs 11.3%, P = 0.02), and lower episode payments ($28,550 vs $31,192, P < 0.001) and postacute care ($3,384 vs $3,909, P < 0.001). In mixed-effects adjusted analyses, these effects were significantly attenuated-ERP was associated with a marginal length of stay reduction of 0.4 days (95% confidence interval 0.2-0.6 days, P = 0.001), and no significant difference in complications, readmissions, or overall spending.

CONCLUSIONS

ERPs are associated with small reduction in postoperative length of hospitalization after colectomy, without unwanted increases in readmission or postacute care spending. The real-world effects across a variety of hospitals may be smaller than observed in early-adopting specialty centers.

Perioperative Outcomes and Trends in the Use of Robotic Colectomy for Medicare Beneficiaries From 2010 Through 2016

Importance

The use of robotic surgery for common operations like colectomy is increasing rapidly in the United States, but evidence for its effectiveness is limited and may not reflect real-world practice.

Objective

To evaluate outcomes of and trends in the use of robotic, laparoscopic, and open colectomy across diverse practice settings.

Design, Setting, and Participants

This population-based study of Medicare beneficiaries undergoing elective colectomy was conducted between January 2010 and December 2016. We used an instrumental variable analysis to account for both measured and unmeasured differences in patient characteristics between robotic, open, and laparoscopic colectomy procedures. Data were analyzed from January 21, 2019, to March 1, 2019.

Exposures

Receipt of robotic colectomy.

Main Outcomes and Measures

Incidence of postoperative medical and surgical complications and length of stay.

Results

A total of 191 292 procedures (23 022 robotic procedures [12.0%], 87 639 open procedures [45.8%], and 80 631 laparoscopic colectomy procedures [42.0%]) were included. Robotic colectomy was associated with a lower adjusted rate of overall complications than open colectomy (17.6% [95% CI, 16.9%-18.2%] vs 18.6% [95% CI, 18.4%-18.7%]; relative risk [RR], 0.94 [95% CI, 0.91-0.98]). This difference was driven by lower rates of medical complications (15.5% [95% CI, 14.8%-16.2%] vs 16.9% [95% CI, 16.7%-17.1%]; RR, 0.92 [95% CI, 0.87-0.96]) because surgical complications were higher with the robotic approach (3.0% [95% CI, 2.8%-3.2%] vs 2.4% [95% CI, 2.3%-2.5%]; RR, 1.18 [95% CI, 1.04-1.35]). There were no differences in complications between robotic and laparoscopic colectomy (11.1% [95% CI, 10.5%-11.6%] vs 11.0% [95% CI, 10.8%-11.2%]; RR, 1.00 [95% CI, 0.95-1.05]). There was an overall shift toward greater proportional use of robotic colectomy from 0.7% (457 of 65 332 patients) in 2010 to 10.9% (8274 of 75 909 patients) in 2016. In hospitals with the highest adoption of robotic colectomy between 2010 and 2016, increasing use of robotic colectomy (0.8% [100 of 12 522 patients] to 32.8% [5416 of 16 511 patients]) was associated with a greater replacement of laparoscopic operations (43.8% [5485 of 12 522 patients] to 25.2% [4161 of 16 511 patients]) than open operations (55.4% [6937 of 12 522 patients] to 41.9% [6918 of 16 511 patients]).

Conclusions and Relevance

While robotic colectomy was associated with minimal safety benefit over open colectomy and had comparable outcomes with laparoscopic colectomy, population-based trends suggest that it replaced a greater proportion of laparoscopic rather than open colectomy, especially in hospitals with the highest adoption of robotics.

Evolving Cost-Quality Relationship in Pediatric Heart Surgery

BACKGROUND

For the >40,000 US children undergoing congenital heart surgery annually, the relationship between hospital quality and costs remains unclear. Prior studies report conflicting results and clinical outcomes have continued to improve over time. We examined a large contemporary cohort, aiming to better inform ongoing initiatives seeking to optimize healthcare value in this population.

METHODS

Clinical information (Society of Thoracic Surgeons Congenital Database) was merged with standardized cost data (Pediatric Health Information Systems) for children undergoing heart surgery from 2010-2015. In-hospital cost variability was analyzed using Bayesian hierarchical models adjusted for case-mix. Quality metrics examined included in-hospital mortality, post-operative complications, length of stay (PLOS), and a composite.

RESULTS

Overall 32 hospitals (n=45,315 patients) were included. Median adjusted cost/case varied across hospitals from $67,700 to $51,200 in the high vs. low cost tertile (ratio 1.32, 95% credible interval 1.29-1.35), and all quality metrics also varied across hospitals. Across cost tertiles there were no significant differences in the quality metrics examined, with the exception of PLOS. The PLOS findings were driven by high-risk STAT 4-5 cases [adjusted median LOS 16.8 vs. 14.9 days in high vs. low cost tertile (ratio 1.13, 1.05-1.24)], and ICU PLOS.

CONCLUSIONS

Contemporary congenital heart surgery costs vary across hospitals but were not associated with most quality metrics examined, highlighting that performance in one area does not necessarily convey to others. Cost variability was associated with PLOS, particularly related to ICU PLOS and high-risk cases. Care processes influencing PLOS may provide targets for value-based initiatives in this population.

Medicare's Hospital Value-Based Purchasing Program Values Quality over QALYs

Medicare's Hospital Value-Based Purchasing Program (HVBP) is the first national pay-for-performance program to combine measures of quality of care with a measure of episode spending. We estimated the implicit tradeoffs between mortality reduction and spending reduction. To earn points in HVBP, a hospital can either lower mortality or reduce spending, creating a tradeoff between the 2 measures. We analyzed the quality performance and earned points of 2814 hospitals using publicly available data. We then quantified the tradeoffs between spending and mortality in terms of quality-adjusted life-years (QALYs). If incentives in the program were balanced, then the tradeoff between spending and QALYs should be comparable with those of high-value health interventions, roughly $50,000 to $200,000 per QALY. Instead, the tradeoff in HVBP was about $1.2 million per QALY. HVBP overvalues improvements in quality of care relative to spending reductions. We propose 2 possible policy adjustments that could improve incentives for hospitals to deliver high-value care.

Hospital-physician integration and Medicare's site-based outpatient payments

OBJECTIVE

To determine the relationship between Medicare's site-based outpatient billing policy and hospital-physician integration.

DATA SOURCES

National Medicare claims data from 2010 to 2016.

STUDY DESIGN

For each physician-year, we calculated the disparity between Medicare reimbursement under hospital ownership and under physician ownership. Using logistic regression analysis, we estimated the relationship between these payment differences and hospital-physician integration, adjusting for region, market concentration, and time fixed effects. We measured integration status using claims data and legal tax names.

DATA COLLECTION

The study included integrated and non-integrated physicians who billed Medicare between January 1, 2010, and December 31, 2016 (n = 2 137 245 physician-year observations).

PRINCIPAL FINDINGS

Medicare reimbursement for physician services would have been $114 000 higher per physician per year if a physician were integrated compared to being non-integrated. Primary care physicians faced a 78% increase, medical specialists 74%, and surgeons 224%. These payment differences exhibited a modest positive relationship to hospital-physician vertical integration. An increase in this outpatient payment differential equivalent to moving from the 25th to 75th percentile was associated with a 0.20 percentage point increase in the probability of integrating with a hospital (95% CI: 0.0.10-0.30). This effect was slightly larger among primary care physicians (0.27, 95% CI: 0.18 to 0.35) and medical specialists (0.26, 95% CI: 0.05 to 0.48), while not significantly different from zero among surgeons (-0.02; 95% CI: -0.27 to 0.22).

CONCLUSIONS

The payment differences between outpatient settings were large and grew over time. Even routine annual outpatient payment updates from Medicare may prompt some hospital-physician vertical integration, particularly among primary care physicians and medical specialists.

Long-term healthcare provider availability following large-scale hurricanes: A difference-in-differences study

Background

Hurricanes Katrina and Sandy were two of the most significant disasters of the 21^st century that critically impacted communities and the health of their residents. Despite the assumption that disasters affect access to healthcare, to our knowledge prior studies have not rigorously examined availability of healthcare providers following disasters.

Objective

The objective of this study was to examine availability of healthcare providers following large-scale hurricanes.

Methods

Using historical data on healthcare providers from the National Plan and Provider Enumeration System and county-level population characteristics, we conducted a quasi-experimental study to examine the effect of large-scale hurricanes on healthcare provider availability in the short-term and long-term. We separately examined availability of primary care physicians, medical specialists, surgeons, and nurse practitioners. A difference-in-differences analysis was used to control for time variant factors comparing county-level health care provider availability in affected and unaffected counties the year before Hurricanes Katrina and Sandy, to five years after each storm.

Results

Counties affected by Hurricane Katrina compared to unaffected locales experienced a decrease of 3.59 primary care physicians per 10,000 population (95% CI: -6.5, -0.7), medical specialists (decrease of 5.9 providers per 10,000 (95% CI: -11.3, -0.5)), and surgeons (decrease of 2.1 (95% CI: -3.8, -0.37)). However, availability of nurse practitioners did not change appreciably. Counties affected by Hurricane Sandy exhibited less pronounced changes. Changes in availability of primary care physicians, nurse practitioners, medical specialists, and surgeons were not statistically significant.

Conclusion

Large-scale hurricanes appear to affect availability of healthcare providers for up to several years following impact of the storm. Effects vary depending on the characteristics of the community. Primary care physicians and medical specialists availability was the most impacted, potentially having long-term implications for population health in the context of disaster recovery.

Determinants of Value in Coronary Artery Bypass Grafting

Background Over 180 000 coronary artery bypass grafting (CABG) procedures are performed annually, accounting for $7 to $10 billion in episode expenditures. Assessing tradeoffs between spending and quality contributing to value during 90-day episodes has not been conducted but is essential for success in bundled reimbursement models. We, therefore, identified determinants of variability in hospital 90-day episode value for CABG. Methods Medicare and private payor admissions for isolated CABG from 2014 to 2016 were retrospectively linked to clinical registry data for 33 nonfederal hospitals in Michigan. Hospital composite risk-adjusted complication rates (≥1 National Quality Forum-endorsed, Society of Thoracic Surgeons measure: deep sternal wound infection, renal failure, prolonged ventilation >24 hours, stroke, re-exploration, and operative mortality) and 90-day risk-adjusted, price-standardized episode payments were used to categorize hospitals by value by defining the intersection between complications and spending. Results Among 2573 total patients, those at low- versus high-value hospitals had a higher percentage of prolonged length of stay >14 days (9.3% versus 2.4%, P=0.006), prolonged ventilation (17.6% versus 4.8%, P<0.001), and operative mortality (4.8% versus 0.6%, P=0.001). Mean total episode payments were $51 509 at low-compared with $45 526 at high-value hospitals (P<0.001), driven by higher readmission ($3675 versus $2177, P=0.005), professional ($7462 versus $6090, P<0.001), postacute care ($7315 versus $5947, P=0.031), and index hospitalization payments ($33 474 versus $30 800, P<0.001). Among patients not experiencing a complication or 30-day readmission (1923/2573, 74.7%), low-value hospitals had higher inpatient evaluation and management payments ($1405 versus $752, P<0.001) and higher utilization of inpatient rehabilitation (7% versus 2%, P<0.001), but lower utilization of home health (66% versus 73%, P=0.016) and emergency department services (13% versus 17%, P=0.034). Conclusions To succeed in emerging bundled reimbursement programs for CABG, hospitals and physicians should identify strategies to minimize complications while optimizing inpatient evaluation and management spending and use of inpatient rehabilitation, home health, and emergency department services.

Sources of Hospital Variation in Postacute Care Spending After Cardiac Surgery

BACKGROUND

Postacute care is a major driver of cardiac surgical episode spending, but the sources of variation in spending have not been explored. The objective of this study was to identify sources of variation in postacute care spending within 90-days of discharge following coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) and the relationship between postacute care spending and other postdischarge utilization.

METHODS AND RESULTS

A retrospective analysis was conducted of public and private administrative claims for Michigan residents insured by Medicare fee-for-service and Blue Cross Blue Shield of Michigan/Blue Care Network commercial and Medicare Advantage plans undergoing CABG (n=11 208) or AVR (n=6122) in 33 nonfederal acute care Michigan hospitals between January 1, 2015 and December 31, 2018. Postacute care use was present in 9662 (86.2%) CABG episodes and 4242 (69.3%) AVR episodes, with respective mean (SD) 90-day spending of $4398±$6124 and $3465±$5759. Across hospitals, mean postacute care spending ranged from $3280 to $8186 for CABG and $2246 to $7710 for AVR. Inpatient rehabilitation and skilled nursing facility care accounted for over 80% of the variation spending between low and high postacute care spending hospitals. At the hospital-level, postacute care spending was modestly correlated across procedures and payers. Spending associated with readmissions, emergency department visits, and outpatient facility care was significantly different between low and high postacute care spending hospitals in CABG and AVR episodes.

CONCLUSIONS

There was wide hospital variation in postacute care spending after cardiac surgery, which was primarily driven by differential use and intensity in facility-based postacute care. Optimizing facility-based postacute care after cardiac surgery offers unique opportunities to reduce potentially unwarranted care variation.

Comparative Effectiveness of Neoadjuvant Therapy and Upfront Resection for Patients with Resectable Pancreatic Adenocarcinoma: An Instrumental Variable Analysis

BACKGROUND

Neoadjuvant therapy (NAT) is increasingly being used in the management of patients with resectable pancreatic ductal adenocarcinoma (PDAC); however, there is a lack of evidence regarding the benefit among these patients.

OBJECTIVE

The aim of this study was to evaluate overall survival (OS) in PDAC patients with resectable disease treated with NAT or upfront resection through instrumental variable (IV) analysis.

DESIGN

A national cohort study of resectable PDAC patients in the National Cancer Data Base (2007-2015) treated with either upfront surgery or resection after NAT. Using multivariable modeling and IV methods, OS was compared between those treated with NAT and upfront resection. The IV was hospital-level NAT utilization in the most recent year prior to treatment.

RESULTS

The cohort included 16,666 patients (14,012 upfront resection; 2654 NAT) treated at 779 hospitals. Among those treated with upfront resection, 59.9% received any adjuvant therapy. NAT patients had higher median (27.9 months, 95% confidence interval [CI] 26.2-29.1) and 5-year OS (24.1%, 95% CI 21.9-26.3%) compared with those treated with upfront surgery (median 21.2 months, 95% CI 20.7-21.6; 5-year survival 20.9%, 95% CI 20.1-21.7%). After multivariable modeling, NAT was associated with an approximately 20% decrease in the risk of death (hazard ratio [HR] 0.78, 95% CI 0.73-0.84), and this effect was magnified in the IV analysis (HR 0.61, 95% CI 0.47-0.79).

CONCLUSIONS

In patients with resectable PDAC, NAT is associated with improved survival relative to upfront resection. Given the benefits of multimodality therapy and the challenges in receiving adjuvant therapy, consideration should be given to treating all PDAC patients with NAT.

Effect of statewide reduction in extended care facility use after joint replacement on hospital readmission

BACKGROUND

Extended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments.

METHODS

We performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012-2013) and after (2016-2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests.

RESULTS

Of the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P < .0001) without increased readmission rates (8.0% vs 7.6%, P = .10) or payments ($1,087 vs $1,026, P = .14). Emergency department use increased (7.8% vs 8.9%, P < .0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to -16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use.

CONCLUSION

Despite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement.

Intersectoral Costs and Benefits of Mental and Behavioural Disorders in the Education Sector: an Exploration of Costing Methods

BACKGROUND

The inclusion of indirect spillover costs and benefits that occur in non-healthcare sectors of society is necessary to make optimal societal decisions when assessing the cost effectiveness of healthcare interventions. Education costs and benefits are relevant in the disease area of mental and behavioral disorders, but their inclusion in economic evaluations is largely neglected due to lack of methodological knowledge.

AIM OF THE STUDY

This study aims to explore, using a scoping review, the identification, measurement, and valuation methods used to assess the impact of mental and behavioural disorders on education costs and benefits.

METHODS

A scoping review was conducted to identify articles that were set in the education sector and assessed education costs and benefits. An adapted 5-step approach was used: (i) initating a scoping review; (ii) identifying component studies; (iii) data extraction; (iv) reporting results; (v) discussion and interpretation of findings. Results were summarized in a narrative synthesis per identification, measurement, and valuation method.

RESULTS

177 component articles were identified in the scoping review that reported 61 mutually exclusive education costs and benefits. The nomenclature used to describe the costs and benefits was poorly defined, heterogeneous in nature and largely context dependent. This was also reflected in the diverse number of measurement and valuation methods found in the component articles.

DISCUSSION

This is the first study, which offers a classification of education costs and benefits and costing methods reported by studies set in the education sector. In conclusion, mental and behavioral disorders have a notable impact on a variety of different education costs and benefits.

IMPLICATIONS FOR HEALTH POLICIES

The classification provided in the current study gives an indication of the wide-spread impact of mental and behavioral disorders on the education sector. Hence, the inclusion of relevant education costs and benefits in economic evaluations for mental and behavioral disorders is necessary to make optimal societal decisions.

IMPLICATIONS FOR FURTHER RESEARCH

By exploring a new area of research from a sector-specific perspective, the current study adds to the existing intersectoral cost and benefit literature base. Future research should focus on standardizing costing methods in pharmacoeconomic guidelines and assessing the relative importance of individual education costs and benefits in economic evaluations for specific interventions and diseases.

Putting Providers At-Risk through Capitation or Shared Savings: How Strong are Incentives for Upcoding and Treatment Changes?

BACKGROUND

Alternative payment models, including Accountable Care Organizations and fully capitated models, change incentives for treatment over fee-for-service models and are widely used in a variety of settings. The level of payment may affect the assignment to a payment category, but to date the upcoding literature has been motivated largely incorporating financial penalties for upcoding rather than by a theoretical model that incorporates the downstream effects of upcoding on service provision requirements.

AIMS OF THE STUDY

In this paper, we contribute to the literature on upcoding by developing a new theoretical model that is applicable to capitated, case-rate and shared savings payment systems. This model incorporates the downstream effects of upcoding on service provision requirements rather than just the avoidance of penalties. This difference is important especially for shared-savings models with quality benchmarks.

METHODS

We test implications of our theoretical model on changes in severity determination and service use associated with changes in case-rate payments in a publicly-funded mental health care system. We model provider-assigned severity categories as a function of risk-adjusted capitated payments using conditional logit regressions and counts of service days per month using negative binomial models.

RESULTS

We find that severity determination is only weakly associated with the payment rate, with relatively small upcoding effects, but that level of use shows a greater degree of association.

DISCUSSION

These results are consistent with our theoretical predictions where the marginal utility of savings or profit is small, as would be expected from public sector agencies. Upcoding did seem to occur, but at very small levels and may have been mitigated after the county and providers had some experience with the new system. The association between the payment levels and the number of service days in a month, however, was significant in the first period, and potentially at a clinically important level. Limitations include data from a single county/multiple provider system and potential unmeasured confounding during the post-implementation period.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

Providers in our data were not at risk for inpatient services but decreases in use of outpatient services associated with rate decreases may lead to further increases in inpatient use and therefore expenditures over time.

IMPLICATIONS FOR HEALTH POLICIES

Health program directors and policy makers need to be acutely aware of the interplay between provider payments and patient care and eventual health and mental health outcomes.

IMPLICATIONS FOR FURTHER RESEARCH

Further research could examine the implications of the theoretical model of upcoding in other payment systems, estimate the power of the tiered-risk systems, and examine their influence on clinical outcomes.

The Relationship Between Imaging and Thyroid Cancer Diagnosis and Survival

BACKGROUND

Controversy exists over whether there has been a true increase in the occurrence of thyroid cancer or overdiagnosis secondary to imaging practices. Because cancer overdiagnosis is associated with detection of indolent disease, overdiagnosis can be associated with perceived improvement in survival.

MATERIALS AND METHODS

Surveillance, Epidemiology, and End Results-Medicare linked database was used to determine the relationship between type of imaging leading to thyroid cancer diagnosis and survival. Disease-specific and overall survival were evaluated in 11,945 patients aged ≥66 years with differentiated thyroid cancer diagnosed between January 1, 2001, and September 30, 2015, who prior to their cancer diagnosis initially underwent thyroid ultrasound versus other imaging capturing the neck. Analyses were performed using the Kaplan-Meier method and Cox proportional hazards model with propensity score.

RESULTS

Patients who underwent thyroid ultrasound as compared with other imaging had improved disease-specific and overall survival (p < .001, p < .001). However, those who underwent thyroid ultrasound were less likely to have comorbidities (p < .001) and more likely to be younger (p < .001), be female (p < .001), have localized cancer (p < .001), and have tumor size ≤1 cm (p < .001). After using propensity score analysis and adjusting for tumor characteristics, type of initial imaging still correlated with better overall survival but no longer correlated with better disease-specific survival.

CONCLUSION

There is improved disease-specific survival in patients diagnosed with thyroid cancer after thyroid ultrasound as compared with after other imaging. However, better disease-specific survival is related to these patients being younger and healthier and having lower-risk cancer, suggesting that thyroid ultrasound screening contributes to cancer overdiagnosis.

IMPLICATIONS FOR PRACTICE

The findings from this study have implications for patients, physicians, and policy makers. Patients who have thyroid ultrasound as their initial imaging are fundamentally different from those who are diagnosed after other imaging. Because patients undergoing ultrasound are younger and healthier and are diagnosed with lower-risk thyroid cancer, they are less likely to die of their thyroid cancer. However, being diagnosed with thyroid cancer can lead to cancer-related worry and create risks for harm from treatments. Thus, efforts are needed to reduce inappropriate use of ultrasound, abide by the U.S. Preventive Services Task Force recommendations, and apply nodule risk stratification tools when appropriate.

Valuing pain using the subjective well-being method

Chronic pain clearly lowers utility, but valuing the reduction in utility is empirically challenging. Here, we use improvements over prior applications of the subjective well-being method to estimate the implied trade-off between pain and income using four waves of the Health and Retirement Study (2008-2014), a nationally representative survey on individuals age 50 and older. We model income with a flexible functional form, allowing the trade-off between pain and income to vary across income groups. We control for individual fixed effects in the life-satisfaction equations and instrument for income in some models. We find values for avoiding pain ranging between 56-145 USD per day. These results are lower than previously reported and suggest that the higher previous estimates may be heavily affected by the highest income level and confounded by endogeneity in the income variable. As expected, we find that the value of pain relief increases with pain severity.

Estimating Resource Utilization in Congenital Heart Surgery

BACKGROUND

Optimal methods to assess resource utilization in congenital heart surgery remain unclear. We compared traditional cost-to-charge ratio methods with newer standardized cost methods that aim to more directly assess resources consumed.

METHODS

Clinical data from The Society of Thoracic Surgeons Database were linked with resource use data from the Pediatric Health Information Systems Database (2010 to 2015). Standardized cost methods specific to the congenital heart surgery population were developed and compared with cost-to-charge ratio methods. Resource use in the overall population and variability across hospitals were described using hierarchical mixed effect models adjusting for case-mix.

RESULTS

Overall, 43 hospitals (65,331 patients) were included. There were minimal population-level differences in the distribution of resource use as estimated by the two methods. At the hospital level, there was less apparent variability in resource use across centers with the standardized cost vs cost-to-charge ratio method, overall (coefficient of variation 20% vs 25%) and across complexity (The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery [STAT]) categories. When hospitals were categorized into tertiles by resource use, 33% changed classification depending on which resource use method was used (26% by one tertile and 7% by two tertiles).

CONCLUSIONS

In this first evaluation of standardized cost methodology in the congenital heart population, we found minimal differences vs traditional methods at the population level. At the hospital level, the magnitude of variation in resource use was less with standardized cost methods, and approximately one third of centers changed resource use categories depending on the methodology used. Because of these differences, care should be taken in future studies and in benchmarking and reporting efforts in selecting optimal methodology.

Low-Value Care and Clinician Engagement in a Large Medicare Shared Savings Program ACO: a Survey of Frontline Clinicians

BACKGROUND

Although the Medicare Shared Savings Program (MSSP) created new incentives for organizations to improve healthcare value, Accountable Care Organizations (ACOs) have achieved only modest reductions in the use of low-value care.

OBJECTIVE

To assess ACO engagement of clinicians and whether engagement was associated with clinicians' reported difficulty implementing recommendations against low-value care.

DESIGN

Cross-sectional survey of ACO clinicians in 2018.

PARTICIPANTS

1289 clinicians in the Physician Organization of Michigan ACO, including generalist physicians (18%), internal medicine specialists (16%), surgeons (10%), other physician specialists (27%), and advanced practice providers (29%). Response rate was 34%.

MAIN MEASURES

Primary exposures included clinicians' participation in ACO decision-making, awareness of ACO incentives, perceived influence on practice, and perceived quality improvement. Our primary outcome was clinicians' reported difficulty implementing recommendations against low-value care.

RESULTS

Few clinicians participated in the decision to join the ACO (3%). Few clinicians were aware of ACO incentives, including knowing the ACO was accountable for both spending and quality (23%), successfully lowered spending (9%), or faced upside risk only (3%). Few agreed (moderately or strongly) the ACO changed compensation (20%), practice (19%), or feedback (15%) or that it improved care coordination (17%) or inappropriate care (13%). Clinicians reported they had difficulty following recommendations against low-value care 18% of the time; clinicians reported patients had difficulty accepting recommendations 36% of the time. Increased ACO awareness (1 standard deviation [SD]) was associated with decreased difficulty (- 2.3 percentage points) implementing recommendations (95% confidence interval [CI] - 3.8, - 0.7), as was perceived quality improvement (1 SD increase, - 2.1 percentage points, 95% CI, - 3.4, - 0.8). Participation in ACO decision-making and perceived influence on practice were not associated with recommendation implementation.

CONCLUSIONS

Clinicians participating in a large Medicare ACO were broadly unaware of and unengaged with ACO objectives and activities. Whether low clinician engagement limits ACO efforts to reduce low-value care warrants further longitudinal study.

The Affordable Care Act Medicaid Expansion and Smoking Cessation Among Low-Income Smokers

INTRODUCTION

This study sought to empirically evaluate whether the Medicaid expansion under the Affordable Care Act increased smoking cessation among low-income childless adult smokers.

METHODS

The effects of the Medicaid expansion on smoking quit attempts and the probability of 30- and 90-day smoking cessation were evaluated using logistic regression and data from the 2010-2011 and 2014-2015 waves of the Tobacco Use Supplement to the Current Population Survey. Using boosted logistic regression, the Tobacco Use Supplement was restricted to an analytic sample composed of childless adults with high probability of being <138% of the federal poverty level. Propensity score weighting was used to compare changes in smoking cessation among a sample of current and past smokers in states that expanded Medicaid with a control sample of current and past smokers in states that did not expand Medicaid with similar sociodemographic characteristics and smoking histories. This study additionally controlled for state socioeconomic trends, welfare policies, and tobacco control policies. Analysis was conducted between January 2018 and June 2019.

RESULTS

After weighting by propensity score and adjusting for state socioeconomic trends, welfare policies, and tobacco control policies, the Medicaid expansion was not associated with increases in smoking quit attempts or smoking cessation.

CONCLUSIONS

The Medicaid expansion did not appear to improve smoking cessation, despite extending health insurance eligibility to 2.3 million low-income smokers. Greater commitments to reducing barriers to cessation benefits and increasing smoking cessation in state Medicaid programs are needed to reduce smoking in low-income populations.

Spending On Postacute Care After Hospitalization In Commercial Insurance And Medicare Around Age Sixty-Five

Postacute care costs are the primary determinant of episode spending around hospitalization. Yet there is little evidence that greater spending on postacute care improves readmission rates or functional recovery. Recent Medicare payment reform evaluations have suggested that postacute care spending is responsive to episode-based incentives. However, it remains unknown whether Medicare payment policies are responsible for excess postacute care spending, compared with that of commercial payers. In a population-based, statewide collaborative of Michigan hospitals, we used regression discontinuity design among propensity-weighted, age-adjusted cohorts to compare postacute care spending between patients with commercial insurance and those with Medicare around age sixty-five. Spending was 68-230 percent greater among fee-for-service Medicare beneficiaries than among similar commercially insured people across varied medical and surgical conditions. Despite greater spending, there were no differences in readmission rates. These findings suggest that postacute care utilization is highly sensitive to payer influence, and there may be an opportunity for additional savings in Medicare without sacrificing quality.

Performance in the Medicare Shared Savings Program After Accounting for Nonrandom Exit: An Instrumental Variable Analysis

BACKGROUND

Accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) are associated with modest savings. However, prior research may overstate this effect if high-cost clinicians exit ACOs.

OBJECTIVE

To evaluate the effect of the MSSP on spending and quality while accounting for clinicians' nonrandom exit.

DESIGN

Similar to prior MSSP analyses, this study compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics. To further account for selection effects, the share of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as a falsification outcome. The authors also tested for compositional changes among MSSP participants.

SETTING

Fee-for-service Medicare, 2008 through 2014.

PATIENTS

A 20% sample (97 204 192 beneficiary-quarters).

MEASUREMENTS

Total spending, 4 quality indicators, and hospitalization for hip fracture.

RESULTS

In adjusted longitudinal models, the MSSP was associated with spending reductions (change, -$118 [95% CI, -$151 to -$85] per beneficiary-quarter) and improvements in all 4 quality indicators. In instrumental variable models, the MSSP was not associated with spending (change, $5 [CI, -$51 to $62] per beneficiary-quarter) or quality. In falsification tests, the MSSP was associated with hip fracture in the adjusted model (-0.24 hospitalizations for hip fracture [CI, -0.32 to -0.16 hospitalizations] per 1000 beneficiary-quarters) but not in the instrumental variable model (0.05 hospitalizations [CI, -0.10 to 0.20 hospitalizations] per 1000 beneficiary-quarters). Compositional changes were driven by high-cost clinicians exiting ACOs: High-cost clinicians (99th percentile) had a 30.4% chance of exiting the MSSP, compared with a 13.8% chance among median-cost clinicians (50th percentile).

LIMITATION

The study used an observational design and administrative data.

CONCLUSION

After adjustment for clinicians' nonrandom exit, the MSSP was not associated with improvements in spending or quality. Selection effects-including exit of high-cost clinicians-may drive estimates of savings in the MSSP.

PRIMARY FUNDING SOURCE

Horowitz Foundation for Social Policy, Agency for Healthcare Research and Quality, and National Institute on Aging.

Do report cards predict future quality? The case of skilled nursing facilities

Report cards on provider performance are intended to improve consumer decision-making and address information gaps in the market for quality. However, inadequate risk adjustment of report-card measures often biases comparisons across providers. We test whether going to a skilled nursing facility (SNF) with a higher star rating leads to better quality outcomes for a patient. We exploit variation over time in the distance from a patient's residential ZIP code to SNFs with different ratings to estimate the causal effect of admission to a higher-rated SNF on health care outcomes, including mortality. We found that patients who go to higher-rated SNFs achieved better outcomes, supporting the validity of the SNF report card ratings.

Testing for family influences on obesity: The role of genetic nurture

A large literature has documented strong positive correlations among siblings in health, including body mass index (BMI) and obesity. This paper tests whether that is explained by a specific type of peer effect in obesity: genetic nurture. Specifically, we test whether an individual's weight is affected by the genes of their sibling, controlling for the individual's own genes. Using genetic data in Add Health, we find no credible evidence that an individual's BMI is affected by the polygenic risk score for BMI of their full sibling when controlling for the individual's own polygenic risk score for BMI. Thus, we find no evidence that the positive correlations in BMI between siblings are attributable to genetic nurture within families.

Association Between Hospital Participation in Medicare Shared Savings Program Accountable Care Organizations and Readmission Following Major Surgery

OBJECTIVE

To evaluate the effect of Medicare Shared Savings Program accountable care organizations (ACOs) on hospital readmission after common surgical procedures.

SUMMARY BACKGROUND DATA

Hospital readmissions following surgery lead to worse patient outcomes and wasteful spending. ACOs, and their associated hospitals, have strong incentives to reduce readmissions from 2 distinct Centers for Medicare and Medicaid Services policies.

METHODS

We performed a retrospective cohort study using a 20% national Medicare sample to identify beneficiaries undergoing 1 of 7 common surgical procedures-abdominal aortic aneurysm repair, colectomy, cystectomy, prostatectomy, lung resection, total knee arthroplasty, and total hip arthroplasty-between 2010 and 2014. The primary outcome was 30-day risk-adjusted readmission rate. We performed difference-in-differences analyses using multilevel logistic regression models to quantify the effect of hospital ACO affiliation on readmissions following these procedures.

RESULTS

Patients underwent a procedure at one of 2974 hospitals, of which 389 were ACO affiliated. The 30-day risk-adjusted readmission rate decreased from 8.4% (95% CI, 8.1-8.7%) to 7.0% (95% CI, 6.7-7.3%) for ACO affiliated hospitals (P < 0.001) and from 7.9% (95% CI, 7.8-8.0%) to 7.1% (95% CI, 6.9-7.2%) for non-ACO hospitals (P < 0.001). The difference-in-differences of the 2 trends demonstrated an additional 0.52% (95% CI, 0.97-0.078%) absolute reduction in readmissions at ACO hospitals (P = 0.021), which would translate to 4410 hospitalizations avoided.

CONCLUSION

Readmissions following common procedures decreased significantly from 2010 to 2014. Hospital affiliation with Shared Savings ACOs was associated with significant additional reductions in readmissions. This emphasis on readmission reduction is 1 mechanism through which ACOs improve value in a surgical population.