Postacute Care for Medicare Advantage Enrollees Who Switched to Traditional Medicare Compared With Those Who Remained in Medicare Advantage

Importance

Medicare Advantage (MA) plans receive capitated per enrollee payments that create financial incentives to provide care more efficiently than traditional Medicare (TM); however, incentives could be associated with MA plans reducing use of beneficial services. Postacute care can improve functional status, but it is costly, and thus may be provided differently to Medicare beneficiaries by MA plans compared with TM.

Objective

To estimate the association of MA compared with TM enrollment with postacute care use and postdischarge outcomes.

Design, Setting, and Participants

This was a cohort study using Medicare data on 4613 hospitalizations among retired Ohio state employees and 2 comparison groups in 2015 and 2016. The study investigated the association of a policy change with use of postacute care and outcomes. The policy changed state retiree health benefits in Ohio from a mandatory MA plan to subsidies for either supplemental TM coverage or an MA plan. After policy implementation, approximately 75% of retired Ohio state employees switched to TM. Hospitalizations for 3 high-volume conditions that usually require postacute rehabilitation were assessed. Data from the Medicare Provider Analysis and Review files were used to identify all hospitalizations in short-term acute care hospitals. Difference-in-difference regressions were used to estimate changes for retired Ohio state employees compared with other 2015 MA enrollees in Ohio and with Kentucky public retirees who were continuously offered a mandatory MA plan. Data analyses were performed from September 1, 2019, to November 30, 2023.

Exposures

Enrollment in Ohio state retiree health benefits in 2015, after which most members shifted to TM.

Main Outcomes and Measures

Received care in an inpatient rehabilitation facility, skilled nursing facility, or home health, or any postacute care; the occurrence of any hospital readmission; the number of days in the community during the 30 days after hospital discharge; and mortality.

Results

The study sample included 2373 hospitalizations for Ohio public retirees, 1651 hospitalizations for other Humana MA enrollees in Ohio, and 589 hospitalizations for public retirees in Kentucky. After the 2016 policy implementation, the percentage of hospitalizations covered by MA decreased by 70.1 (95% CI, -74.2 to -65.9) percentage points (pp), inpatient rehabilitation facility admissions increased by 9.7 (95% CI, 4.7 to 14.7) pp, use of only home health or skilled nursing facility care fell by 8.6 (95% CI, -14.6 to -2.6) pp, and days in the community fell by 1.6 (95% CI, -2.9 to -0.3) days for Ohio public retirees compared with other Humana MA enrollees in Ohio. There was no change in 30-day mortality or hospital readmissions; similar results were found by comparisons using Kentucky public retirees as a control group.

Conclusions and Relevance

The findings of this cohort study indicate that after a change in retiree health benefits, most Ohio public retirees shifted from MA to TM and received more intensive postacute care with no significant change in measured short-term postdischarge outcomes. Future work should consider additional measures of postacute functional status over a longer follow-up period.

The segregation of physician networks providing care to black and white patients with heart disease: Concepts, measures, and empirical evaluation

Black-White disparities in cardiac care may be related to physician referral network segregation. We developed and tested new geographic physician network segregation measures. We used Medicare claims to identify Black and White Medicare heart disease patients and map physician networks for 169 hospital referral regions (HRRs) with over 1000 Black patients. We constructed two network segregation indexes ranging from 0 (integration) to 100 (total segregation): Dissimilarity (the unevenness of Black and White patient distribution across physicians [Dn]) and Absolute Clustering (the propensity of Black patients' physicians to have closer ties with each other than with other physicians [ACLn]). We employed conditional logit models to estimate the probability of using the best (lowest mortality) geographically available hospital for Black and White patients undergoing coronary artery bypass grafting (CABG) surgery in 126 markets with sufficient sample size at increasing levels of network segregation and for low vs. high HRR Black patient population. Physician network segregation was lower than residential segregation (Dissimilarity 21.9 vs. 48.7, and Absolute Clustering 4.8 vs. 32.4) and positively correlated with residential segregation (p < .001). Network segregation effects differed by race and HRR Black patient population. For White patients, higher network segregation was associated with a higher probability of using the best available hospitals in HRRs with few black patients but unchanged (ACLn) or lower (Dn) probability of best hospital use in HRRs with many Black patients. For Black patients, higher network segregation was not associated with a substantial change in the probability of best hospital use regardless of the HRR Black patient population size. Measuring physician network segregation is feasible and associated with nuanced effects on Black-White differences in high-quality hospital use for heart disease. Further work is needed to understand underlying mechanisms and potential uses in health equity policy.

Young Children's Mental Health Improves Following Medicaid Expansion to Low-Income Adults

OBJECTIVE

We investigate whether the Affordable Care Act's Medicaid expansion, implemented in 2014, improved the mental health of young children whose parents are in the policy's target population. We study children ages 2 to 3 in families with incomes less than 138% of the federal poverty level.

METHODS

We use restricted National Health Interview Survey data covering the United States from 2010 to 2018 to conduct an event study-a flexible version of difference-in-differences-of the Medicaid expansion's effects on Mental Health Indicator values for young children. We estimate effects using ordered logit regression.

RESULTS

Children's mental health was statistically significantly better in Medicaid expansion states, compared with non-expansion states, in 3 of 4 post-expansion years. There were no differences between expansion and non-expansion states in the pre-expansion period, lending support to the causal interpretation that the expansion improved children's mental health.

CONCLUSIONS

While Medicaid expansion targets low-income adults, our evidence indicates it improves low-income children's mental health. The expansion is a two-generation investment in prevention. It helps lay a foundation for strong mental health in children's early years and beyond.

Is Bigger Better?: A Closer Look at Small Health Systems in the United States

BACKGROUND

Research on US health systems has focused on large systems with at least 50 physicians. Little is known about small systems.

OBJECTIVES

Compare the characteristics, quality, and costs of care between small and large health systems.

RESEARCH DESIGN

Retrospective, repeated cross-sectional analysis.

SUBJECTS

Between 468 and 479 large health systems, and between 608 and 641 small systems serving fee-for-service Medicare beneficiaries, yearly between 2013 and 2017.

MEASURES

We compared organizational, provider and beneficiary characteristics of large and small systems, and their geographic distribution, using multiple Medicare and Internal Revenue Service administrative data sources. We used mixed-effects regression models to estimate differences between small and large systems in claims-based Healthcare Effectiveness Data and Information Set (HEDIS) quality measures and HealthPartners' Total Cost of Care measure using a 100% sample of Medicare fee-for-service claims. We fit linear spline models to examine the relationship between the number of a system's affiliated physicians and its quality and costs.

RESULTS

The number of both small and large systems increased from 2013 to 2017. Small systems had a larger share of practice sites (43.1% vs. 11.7% for large systems in 2017) and beneficiaries (51.4% vs. 15.5% for large systems in 2017) in rural areas or small towns. Quality performance was lower among small systems than large systems (-0.52 SDs of a composite quality measure) and increased with system size up to ∼75 physicians. There was no difference in total costs of care.

CONCLUSIONS

Small systems are a growing source of care for rural Medicare populations, but their quality performance lags behind large systems. Future studies should examine the mechanisms responsible for quality differences.

The Affordable Care Act Medicaid expansion: A difference-in-differences study of spillover participation in SNAP

The Affordable Care Act’s Medicaid expansion to individuals with adults under 138 percent of the federal poverty level led to insurance coverage for millions of Americans in participating states. This study investigates Medicaid expansion’s potential spillover participation in the Supplemental Nutrition Assistance Program (SNAP; formerly the Food Stamp Program). In addition to providing public insurance, the policy connects individuals to SNAP, affecting social determinants of health such as hunger. We use difference-in-differences regression to estimate the effect of the Medicaid expansion on SNAP participation among approximately 414,000 individuals from across the United States. The Current Population Survey is used to answer the main research question, and the SNAP Quality Control Database allows for supplemental analyses. Medicaid expansion produces a 2.9 percentage point increase (p = 0.002) in SNAP participation among individuals under 138 percent of federal poverty. Subgroup analyses find a larger 5.0 percentage point increase (p = 0.002) in households under 75 percent of federal poverty without children. Able-Bodied Adults Without Dependents (ABAWDs) are a category of individuals with limited access to SNAP. Although they are a subset of adults without children, we found no spillover effect for ABAWDs. We find an increase in SNAP households with $0 income, supporting the finding that spillover was strongest for very-low-income individuals. Joint processing of Medicaid and SNAP applications helps facilitate the connection between Medicaid expansion and SNAP. Our findings contribute to a growing body of evidence that Medicaid expansion does more than improve access to health care by connecting eligible individuals to supports like SNAP. SNAP recipients have increased access to food, an important social determinant of health. Our study supports reducing administrative burdens to help connect individuals to safety net programs. Finally, we note that ABAWDs are a vulnerable group that need targeted program outreach.

The Affordable Care Act Medicaid Expansion, Social Disadvantage, and the Practice Location Choices of New General Internists

BACKGROUND

A recent study found that states that expanded Medicaid under the Affordable Care Act (ACA) gained new general internists who were establishing their first practices, whereas nonexpansion states lost them.

OBJECTIVE

The objective of this study was to examine the level of social disadvantage of the areas of expansion states that gained new physicians and the areas of nonexpansion states that lost them.

RESEARCH DESIGN

We used American Community Survey data to classify commuting zones as high, medium, or low social disadvantage. Using 2009-2019 data from the AMA Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following the expansion to where they located during the 5 years preceding the expansion.

SUBJECTS

A total of 32,102 new general internists.

RESULTS

Compared with preexpansion patterns, new general internists were more likely to locate in expansion states after the expansion, a finding that held for high, medium, and low disadvantage areas. We estimated that, between 2014 and 2019, nonexpansion states lost 371 new general internists (95% confidence interval, 203-540) to expansion states. However, 62.5% of the physicians lost by nonexpansion states were lost from high disadvantage areas even though these areas only accounted for 17.9% of the population of nonexpansion states.

CONCLUSIONS

States that opted not to expand Medicaid lost new general internists to expansion states. A highly disproportionate share of the physicians lost by nonexpansion states were lost from high disadvantage areas, potentially compromising access for all residents irrespective of insurance coverage.

The effects of vertically integrated care on health care use and outcomes in inpatient rehabilitation facilities

OBJECTIVE

To understand the effects of receiving vertically integrated care in inpatient rehabilitation facilities (IRFs) on health care use and outcomes.

DATA SOURCES

Medicare enrollment, claims, and IRF patient assessment data from 2012 to 2014.

STUDY DESIGN

We estimated within-IRF differences in health care use and outcomes between IRF patients admitted from hospitals vertically integrated with the IRF (parent hospital) vs patients admitted from other hospitals. For hospital-based IRFs, the parent hospital was defined as the hospital that owned the IRF and co-located with the IRF. For freestanding IRFs, the parent hospital(s) was defined as the hospital(s) that was in the same health system. We estimated models for freestanding and hospital-based IRFs and for fee-for-service (FFS) and Medicare Advantage (MA) patients. Dependent variables included hospital and IRF length of stay, functional status, discharged to home, and hospital readmissions.

DATA EXTRACTION METHODS

We identified Medicare beneficiaries discharged from a hospital to IRF.

PRINCIPAL FINDINGS

In adjusted models with hospital fixed effects, our results indicate that FFS patients in hospital-based IRFs discharged from the parent hospital had shorter hospital (-0.7 days, 95% CI: -0.9 to -0.6) and IRF (-0.7 days, 95% CI: -0.9 to -0.6) length of stay were less likely to be readmitted (-1.6%, 95% CI: -2.7% to -0.5%) and more likely to be discharged to home care (1.4%, 95% CI: 0.7% to 2.0%), without worse patient clinical outcomes, compared to patients discharged from other hospitals and treated in the same IRFs. We found similar results for MA patients. However, for patients in freestanding IRFs, we found little differences in health care use or patient outcomes between patients discharged from a parent hospital compared to patients from other hospitals.

CONCLUSIONS

Our results indicate that receiving vertically integrated care in hospital-based IRFs shortens institutional length of stay while maintaining or improving health outcomes.

Intergenerational Associations between Parents' and Children's Adverse Childhood Experience Scores

BACKGROUND

Adverse childhood experiences (ACEs) are stressful childhood events associated with behavioral, mental, and physical illness. Parent experiences of adversity may indicate a child's adversity risk, but little evidence exists on intergenerational links between parents' and children's ACEs. This study examines these intergenerational ACE associations, as well as parent factors that mediate them.

METHODS

The Panel Study of Income Dynamics (PSID) 2013 Main Interview and the linked PSID Childhood Retrospective Circumstances Study collected parent and child ACE information. Parent scores on the Aggravation in Parenting Scale, Parent Disagreement Scale, and the Kessler-6 Scale of Emotional Distress were linked through the PSID 1997, 2002, and 2014 PSID Childhood Development Supplements. Multivariate linear and multinomial logistic regression models estimated adjusted associations between parent and child ACE scores.

RESULTS

Among 2205 parent-child dyads, children of parents with four or more ACEs had 3.25-fold (23.1% [95% CI 15.9-30.4] versus 7.1% [4.4-9.8], p-value 0.001) higher risk of experiencing four or more ACEs themselves, compared to children of parents without ACEs. Parent aggravation, disagreement, and emotional distress were partial mediators.

CONCLUSIONS

Parents with higher ACE scores are far more likely to have children with higher ACEs. Addressing parenting stress, aggravation, and discord may interrupt intergenerational adversity cycles.

Effects of the Affordable Care Act Medicaid Expansion on the Distribution of New General Internists Across States

BACKGROUND

Some states expanded Medicaid under the Affordable Care Act, boosting their low-income residents' demand for health care, while other states opted not to expand.

OBJECTIVE

The objective of this study was to determine whether the Medicaid expansion influenced the states selected by physicians just completing graduate medical education for establishing their first practices.

RESEARCH DESIGN

Using 2009-2019 data from the American Medical Association Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following implementation of the expansion to where they located during the 5 years preceding implementation.

SUBJECTS

The sample consisted of 160,842 physicians in 8 specialty groups.

RESULTS

Thirty-three states and the District of Columbia expanded Medicaid by the end of the study period. Compared with preexpansion patterns, we found that physicians in one specialty group-general internal medicine-were increasingly likely to locate in expansion states with time after the expansion. The Medicaid expansion influenced the practice location choices of men and international medical graduates in general internal medicine; women and United States medical graduates did not alter their preexpansion location patterns. Simulations estimated that, between 2014 and 2019, nonexpansion states lost 310 general internists (95% confidence interval, 156-464) to expansion states.

CONCLUSIONS

The Medicaid expansion influenced the practice location choices of new general internists. States that opted not to expand Medicaid under the Affordable Care Act lost general internists to expansion states, potentially affecting access to care for all their residents irrespective of insurance coverage.

The association of vertically integrated care with health care use and outcomes

OBJECTIVE

To determine whether vertically integrated hospital and skilled nursing facility (SNF) care is associated with more efficient use of postdischarge care and better outcomes.

DATA SOURCES

Medicare provider, beneficiary, and claims data from 2012 to 2014.

STUDY DESIGN

We compared facility characteristics, quality of care, and health care use for hospital-based SNFs and "virtually integrated" SNFs (defined as freestanding SNFs with close referral relationships with a single hospital) relative to nonintegrated freestanding SNFs. Among patients admitted to integrated SNFs, we estimated differences in health care use and outcomes for patients originating from the parent hospital (ie, receiving vertically integrated care) versus other hospitals using linear regressions that included SNF fixed effects. We estimated bounds for our main estimates that incorporated potential omitted variables bias.

DATA EXTRACTION METHODS

We identified hospital-based SNFs based on provider data. We defined virtually integrated SNFs based on patient flows between hospitals and SNFs. We identified SNF episodes, preceding hospital stays, patient characteristics, health care use, and patient outcomes using Medicare data.

PRINCIPAL FINDINGS

Consistent with prior research, integrated SNFs performed better on quality measures and health care use relative to nonintegrated SNFs (eg, hospital-based SNFs had 11-day shorter stays compared with nonintegrated SNFs adjusting for patient characteristics, P < .001). Stroke patients admitted to hospital-based SNFs from the parent hospital had shorter preceding hospital stays (adjusted difference: -1.2 days, P = .001) and shorter initial SNF stays (adjusted difference: -2.7 days, P = .049); estimates were attenuated but still robust accounting for potential omitted variables bias. For stroke patients, associations between vertically integrated care and other outcomes were either statistically insignificant or not robust to accounting for potential omitted variables bias.

CONCLUSIONS

Vertically integrated hospital and SNF care was associated with shorter hospital and SNF stays. However, there were few beneficial associations with other outcomes, suggesting limited coordination benefits from vertical integration.

Health system affiliation of physician organizations and quality of care for Medicare beneficiaries who have high needs

OBJECTIVE

To test the hypothesis that health systems provide better care to patients with high needs by comparing differences in quality between system-affiliated and nonaffiliated physician organizations (POs) and to examine variability in quality across health systems.

DATA SOURCES

2015 Medicare Data on Provider Practice and Specialty linked physicians to POs. Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and IRS Form 990 data identified health system affiliations. Fee-for-service Medicare enrollment and claims data were used to examine quality.

STUDY DESIGN

This cross-sectional analysis of beneficiaries with high needs, defined as having more than twice the expected spending of an average beneficiary, examined six quality measures: continuity of care, follow-up visits after hospitalizations and emergency department (ED) visits, ED visits, all-cause readmissions, and ambulatory care-sensitive hospitalizations. Using a matched-pair design, we estimated beneficiary-level regression models with PO random effects to compare quality of care in system-affiliated and nonaffiliated POs. We then limited the sample to system-affiliated POs and estimated models with system random effects to examine variability in quality across systems.

PRINCIPAL FINDINGS

Among 2 323 301 beneficiaries with high needs, 52.3% received care from system-affiliated POs. Rates of ED visits were statistically significantly different in system-affiliated POs (117.5 per 100) and nonaffiliated POs (106.8 per 100, P < .0001). Small differences in the other five quality measures were observed across a range of sensitivity analyses. Among systems, substantial variation was observed for rates of continuity of care (90% of systems had rates between 70.8% and 89.4%) and follow-up after ED visits (90% of systems had rates between 56.9% and 73.5%).

CONCLUSIONS

Small differences in quality of care were observed among beneficiaries with high needs receiving care from system POs and nonsystem POs. Health systems may not confer hypothesized quality advantages to patients with high needs.

Racial and ethnic disparities in care for health system-affiliated physician organizations and non-affiliated physician organizations

OBJECTIVE

To assess racial and ethnic disparities in care for Medicare fee-for-service (FFS) beneficiaries and whether disparities differ between health system-affiliated physician organizations (POs) and nonaffiliated POs.

DATA SOURCES

We used Medicare Data on Provider Practice and Specialty (MD-PPAS), Medicare Provider Enrollment, Chain, and Ownership System (PECOS), IRS Form 990, 100% Medicare FFS claims, and race/ethnicity estimated using the Medicare Bayesian Improved Surname Geocoding 2.0 algorithm.

STUDY DESIGN

Using a sample of 16 007 POs providing primary care in 2015, we assessed racial/ethnic disparities on 12 measures derived from claims (2 cancer screenings; diabetic eye examinations; continuity of care; two medication adherence measures; three measures of follow-up visits after acute care; all-cause emergency department (ED) visits, all-cause readmissions, and ambulatory care-sensitive admissions). We decomposed these "total" disparities into within-PO and between-PO components using models with PO random effects. We then pair-matched 1853 of these POs that were affiliated with health systems to similar nonaffiliated POs. We examined differences in within-PO disparities by affiliation status by interacting each nonwhite race/ethnicity with an affiliation indicator.

DATA COLLECTION/EXTRACTION METHODS

Medicare Data on Provider Practice and Specialty identified POs billing Medicare; PECOS and IRS Form 990 identified health system affiliations. Beneficiaries age 18 and older were attributed to POs using a plurality visit rule.

PRINCIPAL FINDINGS

We observed total disparities in 12 of 36 comparisons between white and nonwhite beneficiaries; nonwhites received worse care in 10. Within-PO disparities exceeded between-PO disparities and were substantively important (>=5 percentage points or>=0.2 standardized differences) in nine of the 12 comparisons. Among these 12, nonaffiliated POs had smaller disparities than affiliated POs in two comparisons (P < .05): 1.6 percentage points smaller black-white disparities in follow-up after ED visits and 0.6 percentage points smaller Hispanic-white disparities in breast cancer screening.

CONCLUSIONS

We find no evidence that system-affiliated POs have smaller racial and ethnic disparities than nonaffiliated POs. Where differences existed, disparities were slightly larger in affiliated POs.

Contributions of Geography and Nongeographic Factors to the White-Black Gap in Hospital Quality for Coronary Heart Disease: A Decomposition Analysis

Background

Differences in hospital proximity and nongeographic factors affect disparities in hospital quality for heart disease, but their relative contributions are unknown. The current study quantifies the influences of these factors on the white‐black gap in high‐ and low‐quality hospital use for acute myocardial infarction (AMI) and coronary artery bypass grafting (CABG) surgery.

Methods and Results

We used Medicare claims to identify fee‐for‐service Medicare beneficiaries aged 65 and older hospitalized during 2009–2011 with AMI (n=384 443) and CABG (n=71 411). Hospital quality was measured using publicly available AMI mortality rates. In national and regional analyses, we used conditional multinomial logit models to estimate the white‐black gap in high‐ and low‐quality hospital use and decompose the gap into geographic and nongeographic contributions. Overall, more whites used high‐quality hospitals for both conditions (34.8% versus 32.4% for AMI; 39.0% versus 29.9% for CABG; P<0.001), but after accounting for distance to hospitals, the white‐black gap was significant only for CABG (9.1%; P<0.001). The nongeographic component was significant for both conditions (3.4% for AMI and 7.7% for CABG; P<0.001) and accounted for nearly the entire gap for CABG. In contrast, hospital geographic proximity was not significant. In regional analyses, white beneficiaries had higher rates of high‐quality hospital use in the Northeast (CABG) and South (AMI and CABG), whereas black had higher rates of high‐quality hospital use in the Midwest (AMI).

Conclusions

White‐black differences in high‐quality hospital use were significant for CABG and related to nongeographic factors. Interventions should consider health system and contextual reasons for these disparities.

Adverse Childhood Experiences and Household Out-of-Pocket Healthcare Costs

INTRODUCTION

Adverse childhood experiences are associated with higher risk of common chronic mental and physical illnesses in adulthood, but little evidence exists on whether this influences medical costs or expenses. This study estimated increases in household medical expenses associated with adults' reported adverse childhood experience scores.

METHODS

Household out-of-pocket medical cost and adverse childhood experience information was collected in the 2011 and 2013 waves of the Panel Study of Income Dynamics and its linked 2014-2015 Panel Study of Income Dynamics Childhood Retrospective Circumstances Study supplement and analyzed in 2017. Generalized linear regression models estimated adjusted annual household out-of-pocket medical cost differences by retrospective adverse childhood experience count and compared costs by family type and size. Logistic models estimated odds of out-of-pocket costs that were >10% of household income or >100% of savings, as well as odds of household debt.

RESULTS

Adverse childhood experience scores were associated with higher out-of-pocket costs. Annual household total out-of-pocket medical costs were $184 (95% CI=$90, $278) or 1.18-fold higher when respondents reported one to two adverse childhood experiences and $311 (95% CI=$196, $426) or 1.30-fold higher when three or more adverse childhood experiences were reported by an adult in the household. Odds of household medical costs >10% of income, >100% of savings, and the presence of household medical debt were 2.48-fold (95% CI=1.40, 4.38), 2.25-fold (95% CI=1.69, 2.99), and 2.29-fold (95% CI=1.56, 3.34) higher when an adult in the household reported three or more adverse childhood experiences compared with none.

CONCLUSIONS

Greater exposure to adverse childhood experiences is associated with higher household out-of-pocket medical costs and financial burden in adulthood.

Sample selection in the face of design constraints: Use of clustering to define sample strata for qualitative research

OBJECTIVE

To sample 40 physician organizations stratified on the basis of longitudinal cost of care measures for qualitative interviews in order to describe the range of care delivery structures and processes that are being deployed to influence the total costs of caring for patients.

DATA SOURCES

Three years of physician organization-level total cost of care data (n = 156 in California) from the Integrated Healthcare Association's value-based pay-for-performance program.

STUDY DESIGN

We fit total cost of care data using mixture and K-means clustering algorithms to segment the population of physician organizations into sampling strata based on 3-year cost trajectories (ie, cost curves).

PRINCIPAL FINDINGS

A mixture of multivariate normal distributions can classify physician organization cost curves into clusters defined by total cost level, shape, and within-cluster variation. K-means clustering does not accommodate differing levels of within-cluster variation and resulted in more clusters being allocated to unstable cost curves. A mixture of regressions approach focuses overly on anomalous trajectories and is sensitive to model coding.

CONCLUSIONS

Statistical clustering can be used to form sampling strata when longitudinal measures are of primary interest. Many clustering algorithms are available; the choice of the clustering algorithm can strongly impact the resulting strata because various algorithms focus on different aspects of the observed data.

Do Skilled Nursing Facilities Selected to Participate in Preferred Provider Networks Have Higher Quality and Lower Costs?

OBJECTIVE

To determine whether skilled nursing facilities (SNFs) chosen by health systems to participate in preferred provider networks exhibited differences in quality, costs, and patient outcomes relative to other SNFs after accounting for differences in case mix.

DATA SOURCES

Medicare provider and claims data, 2012 and 2013.

STUDY DESIGN

We compared SNFs included in preferred networks relative to other SNFs in the same market, prior to the establishment of preferred provider networks.

DATA EXTRACTION METHODS

We linked the SNFs in our sample to facility characteristics and quality data. We identified SNF admissions and hospitalizations in claims data and limited the analysis to patients discharged from the hospitals in our sample. We obtained patient characteristics from Medicare summary files and the preceding hospital stay.

PRINCIPAL FINDINGS

Preferred SNFs exhibited better performance across publicly reported quality measures. Patients admitted to preferred SNFs exhibited shorter stays, lower Medicare payments, and lower probability of SNF readmission relative to nonpreferred SNFs.

CONCLUSIONS

Our results imply that health systems selected SNFs with lower resource use and better performance on quality measures. Thus, the trend toward preferred provider networks could have implications for Medicare spending and patient health.

The Impact of the Hospital Readmissions Reduction Program across Insurance Types in California

OBJECTIVE

Examine 30-day readmission rates for indicator conditions before and after adoption of the Hospital Readmissions Reduction Program (HRRP).

DATA

California hospital discharge data, 2005 to 2014.

STUDY DESIGN

Estimated difference between pre-HRRP trends and post-HRRP rates of hospital readmissions after hospitalization for indicator conditions targeted by the HRRP (heart attack, heart failure, and pneumonia) by payer among insured adults.

PRINCIPAL FINDINGS

Post-HRRP, reductions occurred for the three conditions among Fee-for-Service (FFS) Medicare. Readmissions decreased for heart attack and heart failure in Medicare Managed Care (MC). No reductions were observed in the younger commercially insured.

CONCLUSIONS

Post-HRRP, greater than expected reductions occurred in rehospitalizations for patients with Medicare FFS and Medicare MC. HRRP incentives may be influencing system-wide changes influencing care outside of traditional Medicare.

Less Intense Postacute Care, Better Outcomes For Enrollees In Medicare Advantage Than Those In Fee-For-Service

Traditional fee-for-service (FFS) Medicare's prospective payment systems for postacute care provide little incentive to coordinate care or control costs. In contrast, Medicare Advantage plans pay for postacute care out of monthly capitated payments and thus have stronger incentives to use it efficiently. We compared the use of postacute care in skilled nursing and inpatient rehabilitation facilities by enrollees in Medicare Advantage and FFS Medicare after hospital discharge for three high-volume conditions: lower extremity joint replacement, stroke, and heart failure. After accounting for differences in patient characteristics at discharge, we found lower intensity of postacute care for Medicare Advantage patients compared to FFS Medicare patients discharged from the same hospital, across all three conditions. Medicare Advantage patients also exhibited better outcomes than their FFS Medicare counterparts, including lower rates of hospital readmission and higher rates of return to the community. These findings suggest that payment reforms such as bundling in FFS Medicare may reduce the intensity of postacute care without adversely affecting patient health.

Primary Care-Mental Health Integration in the VA: Shifting Mental Health Services for Common Mental Illnesses to Primary Care

OBJECTIVE

Primary care-mental health integration (PC-MHI) aims to increase access to general mental health specialty (MHS) care for primary care patients thereby decreasing referrals to non-primary care-based MHS services. It remains unclear whether new patterns of usage of MHS services reflect good mental health care. This study examined the relationship between primary care clinic engagement in PC-MHI and use of different MHS services.

METHODS

This was a retrospective longitudinal cohort study of 66,638 primary care patients with mental illnesses in 29 Southern California Veterans Affairs clinics (2008-2013). Regression models used clinic PC-MHI engagement (proportion of all primary care clinic patients who received PC-MHI services) to predict relative rates of general MHS visits and more specialized MHS visits (for example, visits for serious mental illness services), after adjustment for year and clinic fixed effects, other clinic interventions, and patient characteristics.

RESULTS

Patients were commonly diagnosed as having depression (35%), anxiety (36%), and posttraumatic stress disorder (22%). For every 1 percentage point increase in a clinic's PC-MHI engagement rate, patients at the clinic had 1.2% fewer general MHS visits per year (p<.001) but no difference in more specialized MHS visits. The reduction in MHS visits occurred among patients with depression (-1.1%, p=.01) but not among patients with psychosis; however, the difference between the subsets was not statistically significant.

CONCLUSIONS

Primary care clinics with greater engagement in PC-MHI showed reduced general MHS use rates, particularly for patients with depression, without accompanying reductions in use of more specialized MHS services.

Racial residential segregation, socioeconomic disparities, and the White-Black survival gap

OBJECTIVE

To evaluate the association between racial residential segregation, a prominent manifestation of systemic racism, and the White-Black survival gap in a contemporary cohort of adults, and to assess the extent to which socioeconomic inequality explains this association.

DESIGN

This was a cross sectional study of White and Black men and women aged 35-75 living in 102 large US Core Based Statistical Areas. The main outcome was the White-Black survival gap. We used 2009-2013 CDC mortality data for Black and White men and women to calculate age-, sex- and race adjusted White and Black mortality rates. We measured segregation using the Dissimilarity index, obtained from the Manhattan Institute. We used the 2009-2013 American Community Survey to define indicators of socioeconomic inequality. We estimated the CBSA-level White-Black gap in probability of survival using sequential linear regression models accounting for the CBSA dissimilarity index and race-specific socioeconomic indicators.

RESULTS

Black men and women had a 14% and 9% lower probability of survival from age 35 to 75 than their white counterparts. Residential segregation was strongly associated with the survival gap, and this relationship was partly, but not fully, explained by socioeconomic inequality. At the lowest observed level of segregation, and with the Black socioeconomic status (SES) assumed to be at the White SES level scenario, the survival gap is essentially eliminated.

CONCLUSION

White-Black differences in survival remain wide notwithstanding public health efforts to improve life expectancy and initiatives to reduce health disparities. Eliminating racial residential segregation and bringing Black socioeconomic status (SES) to White SES levels would eliminate the White-Black survival gap.

The Hispanic Paradox: Race/Ethnicity and Nativity, Immigrant Enclave Residence and Cognitive Impairment Among Older US Adults

Hispanics, and particularly foreign-born Mexican Americans, have been shown to fare better across a range of health outcomes than might be expected given the generally higher levels of socioeconomic disadvantage in this population, a phenomena termed the "Hispanic Paradox". Previous research on social disparities in cognitive aging, however, has been unable to address both race/ethnicity and nativity (REN) in a nationally-representative sample of US adults leaving unanswered questions about potentially "paradoxical" advantages of Mexican ethnic-origins and the role of nativity, socioeconomic status (SES), and enclave residence. We employ biennial assessments of cognitive functioning to study prevalent and incident cognitive impairment (CI) within the three largest US REN groups: US-born non-Hispanic whites (US-NHW), US-born non-Hispanic blacks (US-NHB), US-born Mexican Americans (US-MA), and foreign-born Mexican Americans (FB-MA). Data come from a nationally-representative sample of community-dwelling older adults in the Health and Retirement Study linked with the 2000 Census and followed over 10 years (N = 8,433). Large disadvantages in prevalent and incident CI were observed for all REN minorities respective to US-born non-Hispanic whites. Individual and neighborhood SES accounted substantially for these disadvantages and revealed an immigrant advantage: FB-MA odds of prevalent CI were about half those of US-NHW and hazards of incident CI were about half those of US-MA. Residence in an immigrant enclave was protective of prevalent CI among FB-MA. The findings illuminate important directions for research into the sources of cognitive risk and resilience and provide guidance about CI screening within the increasingly diverse aging US population.

Consumer-directed health plans: do doctors and nurses buy in?

OBJECTIVES

Aiming to increase healthcare value, consumer-directed health plans (CDHPs)-high-deductible health insurance plus a personal spending account-equip enrollees with decision-support tools and expose them to the financial implications of their medical decisions. This study examines whether medically knowledgeable consumers are more or less likely to select a CDHP than individuals without medical knowledge.

STUDY DESIGN

Using University of California Los Angeles (UCLA) human resources data, our observational cross-sectional study analyzed the health plan enrollment choices of 3552 faculty and 8429 staff employees.

METHODS

We compared CDHP selection in 2 cohorts: 1) physicians and nonphysician faculty and 2) nurses and nonmedical staff. We used probit regression models to predict CDHP selection, adjusted for job title, demographics (ie, age, gender, race/ethnicity, education, employee income), and coverage type (eg, single).

RESULTS

Approximately 5% of UCLA employees chose the CDHP. After adjusting for sociodemographic characteristics and coverage type, physicians were less likely to choose these plans than nonmedical faculty, when all other covariates were fixed at their means (predicted probability change [ΔP], -1.6%; standard error [SE], 0.8%; P = .05). Nurses also appeared less inclined to choose these plans than nonmedical staff, which approached statistical significance (ΔP, -1.9%; SE, 1.0%; P = .07).

CONCLUSIONS

Overall low rates of CDHP selection were observed in consumers with and without medical knowledge. Although physicians and nurses seem to be better positioned as CDHP consumers, they appeared less likely to select these health plans compared with nonmedical faculty and staff in our study.

Effects of payment reform in more versus less competitive markets

Policymakers are increasingly interested in reducing healthcare costs and inefficiencies through innovative payment strategies. These strategies may have heterogeneous impacts across geographic areas, potentially reducing or exacerbating geographic variation in healthcare spending. In this paper, we exploit a major payment reform for home health care to examine whether reductions in reimbursement lead to differential changes in treatment intensity and provider costs depending on the level of competition in a market. Using Medicare claims, we find that while providers in more competitive markets had higher average costs in the pre-reform period, these markets experienced larger proportional reductions in treatment intensity and costs after the reform relative to less competitive markets. This led to a convergence in spending across geographic areas. We find that much of the reduction in provider costs is driven by greater exit of "high-cost" providers in more competitive markets.

Hospital Competition, Managed Care, and Mortality after Hospitalization for Medical Conditions: Evidence from Three States

This study assessed the effect of hospital competition and HMO penetration on mortality after hospitalization for six medical conditions in California, New York, and Wisconsin. We used linked hospital-discharge and vital-statistics data to study adults hospitalized for myocardial infarction, hip fracture, stroke, gastrointestinal hemorrhage, congestive heart failure, or diabetes. We estimated logistic regression models with death within 30 days of admission as the dependent variable and hospital competition, HMO penetration, and hospital and patient characteristics as explanatory variables. Higher hospital competition was associated with lower mortality in California and New York but not Wisconsin. Higher HMO penetration was associated with lower mortality in California but higher mortality in New York. These findings suggest that hospitals in highly competitive markets compete on quality even in the absence of mature managed-care markets. The findings also underscore the need to consider geographic effects in studies of market structure and hospital quality.

Is the Individual Market More Than a Bridge Market? An Analysis of Disenrollment Decisions

The individual insurance market is perceived by many to provide primarily transition coverage, but there is limited research about how long people stay in this market and what affects their disenrollment decisions. We examine these issues using administrative records and survey data for those enrolled in the individual market in California. We conclude that there is less turnover in this market than is commonly believed. We find that economic factors and coverage characteristics are important in the decision to disenroll, but that perceptions about insurance and the health care system also affect this decision.

Does Age Matter? Association Between Usual Source of Care and Hypertension Control in the US Population: Data From NHANES 2007-2012

BACKGROUND

The positive role of having a usual source of care (USOC) on the receipt of preventative services is known. However, associations between USOC and hypertension control and the differential association across age groups is unknown in the US population.

METHODS

We used data from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2012. Multivariable logistic regression was used to evaluate the association between having a USOC and hypertension control. The differential effect of USOC on hypertension control by age was assessed using predicted marginal effects across age groups in the multivariable logistic model.

RESULTS

In adjusted analyses, those with a USOC had higher odds of hypertension control (odds ratio = 3.89, 95% confidence interval (CI): 2.15-6.98). The marginal effect of having a USOC is associated with a 30 percentage point higher probability of controlled blood pressure compared to those without a USOC (marginal probability = 0.30, 95% CI: 0.19-0.41). The marginal effect of USOC on hypertension control varied by age groups, with a statistically significantly lower marginal effect of USOC on hypertension seen among those older than 74 years of age (marginal probability = 0.27, 95% CI: 0.18-0.36) and younger than 35 years of age (marginal probability = 0.23, 95% CI: 0.14-0.33).

CONCLUSION

Having a USOC is significantly associated with improved hypertension control in the US population. The variation in the association across age groups has important implications in targeting age-specific antihypertensive strategies to reduce the burden of hypertension in the US population.

Constructing a Time-Invariant Measure of the Socio-economic Status of U.S. Census Tracts

Contextual research on time and place requires a consistent measurement instrument for neighborhood conditions in order to make unbiased inferences about neighborhood change. We develop such a time-invariant measure of neighborhood socio-economic status (NSES) using exploratory and confirmatory factor analyses fit to census data at the tract level from the 1990 and 2000 U.S. Censuses and the 2008-2012 American Community Survey. A single factor model fit the data well at all three time periods, and factor loadings--but not indicator intercepts--could be constrained to equality over time without decrement to fit. After addressing remaining longitudinal measurement bias, we found that NSES increased from 1990 to 2000, and then--consistent with the timing of the "Great Recession"--declined in 2008-2012 to a level approaching that of 1990. Our approach for evaluating and adjusting for time-invariance is not only instructive for studies of NSES but also more generally for longitudinal studies in which the variable of interest is a latent construct.

Implementing Computerized Provider Order Entry in Acute Care Hospitals in the United States Could Generate Substantial Savings to Society

BACKGROUND

Computerized provider order entry (CPOE) with clinical decision support is a basic criterion for hospitals' meaningful use of electronic health record systems. A study was conducted to evaluate from the societal perspective the cost-utility of implementing CPOE in acute care hospitals in the United States.

METHODS

A decision-analytical model compared CPOE with paper ordering among patients admitted to acute care hospitals with >25 beds. Parameters included start-up and maintenance costs, as well as costs for provider time use, medication and laboratory test ordering, and preventable adverse drug events. Probabilistic analyses produced incremental costs, effectiveness, and cost-effectiveness ratios for hospitals in four bed-size categories (25-72, 72-141, 141-267, 267-2,249).

RESULTS

Relative to paper ordering and using typical estimates of implementation costs, CPOE had, on average, >99% probability of yielding savings to society and improving health. Per hospital in each size category, mean life-time savings -in millions-were $11.6 (standard deviation, $9.30), $34.4 ($21.2), $71.8 ($43.8), and $170 ($119) (2012 dollars), respectively, and quality-adjusted life-years (QALYs) gained were 19.9 (16.9), 53.7 (38.7), 109 (79.6), and 249 (205). Incremental effectiveness and costs were less favorable in certain circumstances, such as high implementation costs. Nationwide, anticipated increases in CPOE implementation from 2009 through 2015 could save $133 billion and 201,000 QALYs.

CONCLUSIONS

In addition to improving health, implementing CPOE with clinical decision support could yield substantial long-term savings to society in the United States, although results for individual hospitals are likely to vary.

Effects of Medicare payment reform: evidence from the home health interim and prospective payment systems

Medicare continues to implement payment reforms that shift reimbursement from fee-for-service toward episode-based payment, affecting average and marginal payment. We contrast the effects of two reforms for home health agencies. The home health interim payment system in 1997 lowered both types of payment; our conceptual model predicts a decline in the likelihood of use and costs, both of which we find. The home health prospective payment system in 2000 raised average but lowered marginal payment with theoretically ambiguous effects; we find a modest increase in use and costs. We find little substantive effect of either policy on readmissions or mortality.

Medicare payment reform and provider entry and exit in the post-acute care market

OBJECTIVE

To understand the impacts of Medicare payment reform on the entry and exit of post-acute providers.

DATA SOURCES

Medicare Provider of Services data, Cost Reports, and Census data from 1991 through 2010.

STUDY DESIGN

We examined market-level changes in entry and exit after payment reforms relative to a preexisting time trend. We also compared changes in high Medicare share markets relative to lower Medicare share markets and for freestanding relative to hospital-based facilities.

DATA EXTRACTION METHODS

We calculated market-level entry, exit, and total stock of home health agencies, skilled nursing facilities, and inpatient rehabilitation facilities from Provider of Services files between 1992 and 2010. We linked these measures with demographic information from the Census and American Community Survey, information on Certificate of Need laws, and Medicare share of facilities in each market drawn from Cost Report data.

PRINCIPAL FINDINGS

Payment reforms reducing average and marginal payments reduced entries and increased exits from the market. Entry effects were larger and more persistent than exit effects. Entry and exit rates fluctuated more for home health agencies than skilled nursing facilities. Effects on number of providers were consistent with entry and exit effects.

CONCLUSIONS

Payment reform affects market entry and exit, which in turn may affect market structure, access to care, quality and cost of care, and patient outcomes. Policy makers should consider potential impacts of payment reforms on post-acute care market structure when implementing these reforms.

The effect of prospective payment on admission and treatment policy: evidence from inpatient rehabilitation facilities

We examine provider responses to the Medicare inpatient rehabilitation facility (IRF) prospective payment system (PPS), which simultaneously reduced marginal reimbursement and increased average reimbursement. IRFs could respond to the PPS by changing the number of patients admitted, admitting different types of patients, or changing the intensity of care. We use Medicare claims data to separately estimate each type of provider response. We also examine changes in patient outcomes and spillover effects on other post-acute care providers. We find that costs of care initially fell following the PPS, which we attribute to changes in treatment decisions rather than the characteristics of patients admitted to IRFs within the diagnostic categories we examine. However, the probability of admission to IRFs increased after the PPS due to the expanded admission policies of providers. We find modest spillover effects in other post-acute settings and negative health impacts for only one of three diagnostic groups studied.

The effects of quality of care on costs: a conceptual framework

CONTEXT

The quality of health care and the financial costs affected by receiving care represent two fundamental dimensions for judging health care performance. No existing conceptual framework appears to have described how quality influences costs.

METHODS

We developed the Quality-Cost Framework, drawing from the work of Donabedian, the RAND/UCLA Appropriateness Method, reports by the Institute of Medicine, and other sources.

FINDINGS

The Quality-Cost Framework describes how health-related quality of care (aspects of quality that influence health status) affects health care and other costs. Structure influences process, which, in turn, affects proximate and ultimate outcomes. Within structure, subdomains include general structural characteristics, circumstance-specific (e.g., disease-specific) structural characteristics, and quality-improvement systems. Process subdomains include appropriateness of care and medical errors. Proximate outcomes consist of disease progression, disease complications, and care complications. Each of the preceding subdomains influences health care costs. For example, quality improvement systems often create costs associated with monitoring and feedback. Providing appropriate care frequently requires additional physician visits and medications. Care complications may result in costly hospitalizations or procedures. Ultimate outcomes include functional status as well as length and quality of life; the economic value of these outcomes can be measured in terms of health utility or health-status-related costs. We illustrate our framework using examples related to glycemic control for type 2 diabetes mellitus or the appropriateness of care for low back pain.

CONCLUSIONS

The Quality-Cost Framework describes the mechanisms by which health-related quality of care affects health care and health status-related costs. Additional work will need to validate the framework by applying it to multiple clinical conditions. Applicability could be assessed by using the framework to classify the measures of quality and cost reported in published studies. Usefulness could be demonstrated by employing the framework to identify design flaws in published cost analyses, such as omitting the costs attributable to a relevant subdomain of quality.

Exploring psychosocial pathways between neighbourhood characteristics and stroke in older adults: the cardiovascular health study

OBJECTIVES

to investigate whether psychosocial pathways mediate the association between neighbourhood socioeconomic disadvantage and stroke.

METHODS

prospective cohort study with a follow-up of 11.5 years.

SETTING

the Cardiovascular Health Study, a longitudinal population-based cohort study of older adults ≥65 years.

MEASUREMENTS

the primary outcome was adjudicated incident ischaemic stroke. Neighbourhood socioeconomic status (NSES) was measured using a composite of six census-tract variables. Psychosocial factors were assessed with standard measures for depression, social support and social networks.

RESULTS

of the 3,834 white participants with no prior stroke, 548 had an incident ischaemic stroke over the 11.5-year follow-up. Among whites, the incident stroke hazard ratio (HR) associated with living in the lowest relative to highest NSES quartile was 1.32 (95% CI = 1.01-1.73), in models adjusted for individual SES. Additional adjustment for psychosocial factors had a minimal effect on hazard of incident stroke (HR = 1.31, CI = 1.00-1.71). Associations between NSES and stroke incidence were not found among African-Americans (n = 785) in either partially or fully adjusted models.

CONCLUSIONS

psychosocial factors played a minimal role in mediating the effect of NSES on stroke incidence among white older adults.

Are our actions aligned with our evidence? The skinny on changing the landscape of obesity

Recent debate about the role of food deserts in the United States (i.e., places that lack access to healthy foods) has prompted discussion on policies being enacted, including efforts that encourage the placement of full-service supermarkets into food deserts. Other initiatives to address obesogenic neighborhood features include land use zoning and parks renovations. Yet, there is little evidence to demonstrate that such policies effect change. While we suspect most researchers and policymakers would agree that effective neighborhood change could be a powerful tool in combating obesity, we desperately need strong and sound evidence to guide decisions about where and how to invest.

Income eligibility thresholds, premium contributions, and children's coverage outcomes: a study of CHIP expansions

OBJECTIVE

To understand the effects of Children's Health Insurance Program (CHIP) income eligibility thresholds and premium contribution requirements on health insurance coverage outcomes among children.

DATA SOURCES

2002-2009 Annual Social and Economic Supplements of the Current Population Survey linked to data from multiple secondary data sources.

STUDY DESIGN

We use a selection correction model to simultaneously estimate program eligibility and coverage outcomes conditional upon eligibility. We simulate the effects of three premium schedules representing a range of generosity levels and the effects of income eligibility thresholds ranging from 200 to 400 percent of the federal poverty line.

PRINCIPAL FINDINGS

Premium contribution requirements decrease enrollment in public coverage and increase enrollment in private coverage, with larger effects for greater contribution levels. Our simulation results suggest minimal changes in coverage outcomes from eligibility expansions to higher income families under premium schedules that require more than a modest contribution (medium or high schedules).

CONCLUSIONS

Our simulation results are useful counterpoints to previous research that has estimated the average effect of program expansions as they were implemented without disentangling the effects of premiums or other program features. The sensitivity to premiums observed suggests that although contribution requirements may be effective in reducing crowd-out, they also have the potential, depending on the level of contribution required, to nullify the effects of CHIP expansions entirely. The persistence of uninsurance among children under the range of simulated scenarios points to the importance of Affordable Care Act provisions designed to make the process of obtaining coverage transparent and navigable.

Neighborhood socioeconomic disadvantage and mortality after stroke

OBJECTIVE

Residence in a socioeconomically disadvantaged community is associated with mortality, but the mechanisms are not well understood. We examined whether socioeconomic features of the residential neighborhood contribute to poststroke mortality and whether neighborhood influences are mediated by traditional behavioral and biologic risk factors.

METHODS

We used data from the Cardiovascular Health Study, a multicenter, population-based, longitudinal study of adults ≥65 years. Residential neighborhood disadvantage was measured using neighborhood socioeconomic status (NSES), a composite of 6 census tract variables representing income, education, employment, and wealth. Multilevel Cox proportional hazard models were constructed to determine the association of NSES to mortality after an incident stroke, adjusted for sociodemographic characteristics, stroke type, and behavioral and biologic risk factors.

RESULTS

Among the 3,834 participants with no prior stroke at baseline, 806 had a stroke over a mean 11.5 years of follow-up, with 168 (20%) deaths 30 days after stroke and 276 (34%) deaths at 1 year. In models adjusted for demographic characteristics, stroke type, and behavioral and biologic risk factors, mortality hazard 1 year after stroke was significantly higher among residents of neighborhoods with the lowest NSES than those in the highest NSES neighborhoods (hazard ratio 1.77, 95% confidence interval 1.17-2.68).

CONCLUSION

Living in a socioeconomically disadvantaged neighborhood is associated with higher mortality hazard at 1 year following an incident stroke. Further work is needed to understand the structural and social characteristics of neighborhoods that may contribute to mortality in the year after a stroke and the pathways through which these characteristics operate.

Critical determinants of the epilepsy treatment gap: a cross-national analysis in resource-limited settings

PURPOSE

Epilepsy is one of the most common serious neurologic disorders worldwide. Our objective was to determine which economic, health care, neurology, and epilepsy-specific resources were associated with untreated epilepsy in resource-constrained settings.

METHODS

A systematic review of the literature identified community-based studies in resource-constrained settings that calculated the epilepsy treatment gap, the proportion with untreated epilepsy, from prevalent active epilepsy cases. Economic, health care, neurology, and epilepsy-specific resources were taken from existing datasets. Poisson regression models with jackknifed standard errors were used to create bivariate and multivariate models comparing the association between treatment status and economic and health resource indicators. Relative risks were reported.

KEY FINDINGS

Forty-seven studies of 8,285 individuals from 24 countries met inclusion criteria. Bivariate analysis demonstrated that individuals residing in rural locations had significantly higher risks of untreated epilepsy (relative risk [RR] 1.63; 95% confidence interval [CI] 1.26-2.11). Significantly lower risks of untreated epilepsy were observed for higher physician density (RR 0.65, 95% CI 0.55-0.78), presence of a lay (RR 0.74, 95% CI 0.60-0.91) or professional association for epilepsy (RR 0.73, 95% CI 0.59-0.91), or postgraduate neurology training program (RR 0.67, 95% CI 0.55-0.82). In multivariate models, higher physician density maintained significant effects (RR 0.67; 95% CI 0.52-0.88).

SIGNIFICANCE

Even among resource-limited regions, people with epilepsy in countries with fewer economic, health care, neurology, and epilepsy-specific resources are more likely to have untreated epilepsy. Community-based epilepsy care programs have improved access to treatment, but in order to decrease the epilepsy-treatment gap, poverty and inequalities of health care, neurology, and epilepsy resources must be dealt with at the local, national, and global levels.

Take-up of public insurance and crowd-out of private insurance under recent CHIP expansions to higher income children

OBJECTIVE

To analyze the effects of states' expansions of Children's Health Insurance Program (CHIP) eligibility to children in higher income families on health insurance coverage outcomes.

DATA SOURCES

2002-2009 Current Population Survey linked to multiple secondary data sources.

STUDY DESIGN

Instrumental variables estimation of linear probability models. Outcomes are whether the child had any public insurance, any private insurance, or no insurance coverage during the year.

PRINCIPAL FINDINGS

Among children in families with incomes between two and four times the federal poverty line (FPL), four enrolled in CHIP for every 100 who became eligible. Roughly half of the newly eligible children who took up public insurance were previously uninsured. The upper bound "crowd-out" rate was estimated to be 46 percent.

CONCLUSIONS

The CHIP expansions to children in higher income families were associated with limited uptake of public coverage. Our results additionally suggest that there was crowd-out of private insurance coverage.

Medicare postacute care payment reforms have potential to improve efficiency of care, but may need changes to cut costs

The Affordable Care Act mandates changes in payment policies for Medicare postacute care services intended to contain spending in the long run and help ensure the program's financial sustainability. In addition to reducing annual payment increases to providers under the existing prospective payment systems, the act calls for demonstration projects of bundled payment, accountable care organizations, and other strategies to promote care coordination and reduce spending. Experience with the adoption of Medicare prospective payment systems in postacute care settings approximately a decade ago suggests that current reforms could, but need not necessarily, produce such undesirable effects as decreased access for less profitable patients, poorer patient outcomes, and only short-lived curbs on spending. Policy makers will need to be vigilant in monitoring the impact of the Affordable Care Act reforms and be prepared to amend policies as necessary to ensure that the reforms exert persistent controls on spending without compromising the delivery of patient-appropriate postacute services.

Health Care Experiences of Hispanics in New and Traditional U.S. Destinations

Over the past 15 years, striking new settlement patterns have emerged that have brought about unprecedented geographic dispersion in the population of approximately 45 million Hispanics in the United States. In this study, the authors compare the health care experiences of working age U.S.-born Mexican Americans and Mexican immigrants living in new and traditional Hispanic destinations. They use a geocoded version of the Medical Expenditure Panel Survey Household Component linked to contextual data from secondary sources. They characterize destinations as new or traditional using information on the percentage of the population that was Hispanic in 1990 and the growth in percent Hispanic between 1990 and 2000. The authors find that, compared with living in destinations with a well-established Hispanic presence, U.S.-born Mexican Americans living in new destinations have less favorable health care outcomes, including a greater probability of having an unmet need for or delay in receiving medical care and reduced satisfaction with care.

The Women's Health Initiative: The food environment, neighborhood socioeconomic status, BMI, and blood pressure

Using data (n = 60,775 women) from the Women's Health Initiative Clinical Trial (WHI CT)-a national study of postmenopausal women aged 50-79 years-we analyzed cross-sectional associations between the availability of different types of food outlets in the 1.5 miles surrounding a woman's residence, census tract neighborhood socioeconomic status (NSES), BMI, and blood pressure (BP). We simultaneously modeled NSES and food outlets using linear and logistic regression models, adjusting for multiple sociodemographic factors, population density and random effects at the tract and metropolitan statistical area (MSA) level. We found significant associations between NSES, availability of food outlets and individual-level measurements of BMI and BP. As grocery store/supermarket availability increased from the 10th to the 90th percentile of its distribution, controlling for confounders, BMI was lower by 0.30 kg/m(2). Conversely, as fast-food outlet availability increased from the 10th to the 90th percentile, BMI was higher by 0.28 kg/m(2). When NSES increased from the 10th to the 90th percentile of its distribution, BMI was lower by 1.26 kg/m(2). As NSES increased from the 10th to the 90th percentile, systolic and diastolic BP were lower by 1.11 mm Hg and 0.40 mm Hg, respectively. As grocery store/supermarket outlet availability increased from the 10th and 90th percentiles, diastolic BP was lower by 0.31 mm Hg. In this national sample of postmenopausal women, we found important independent associations between the food and socioeconomic environments and BMI and BP. These findings suggest that changes in the neighborhood environment may contribute to efforts to control obesity and hypertension.

Cost implications of ACGME's 2011 changes to resident duty hours and the training environment

BACKGROUND

In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) will implemented stricter duty-hour limits and related changes to the training environment. This may affect preventable adverse event (PAE) rates.

OBJECTIVES

To estimate direct costs under various implementation approaches, and examine net costs to teaching hospitals and cost-effectiveness to society across a range of hypothetical changes in PAEs.

DESIGN

A decision-analytical model represented direct costs and PAE rates, mortality, and costs.

DATA SOURCES

Published literature and publicly available data.

TARGET POPULATION

Patients admitted to hospitals with ACGME-accredited programs.

TIME HORIZON

One year.

PERSPECTIVES

All teaching hospitals, major teaching hospitals, society.

INTERVENTION

ACGME's 2011 Common Program Requirements.

OUTCOME MEASURES

Direct annual costs (all accredited hospitals), net cost (major teaching hospitals), cost per death averted (society). RESULTS OF BASE-ANALYSIS: Nationwide, duty-hour changes would cost $177 million annually if interns maintain current productivity, vs. up to $982 million if they transfer work to a mixture of substitutes; training-environment changes will cost $204 million. If PAEs decline by 7.2-25.8%, net costs to major teaching hospitals will be zero. If PAEs fall by 3%, the cost to society per death averted would be -$523,000 (95%-confidence interval: -$1.82 million to $685,000) to $2.44 million ($271,000 to $6.91 million). If PAEs rise, the policy will be cost-increasing for teaching hospitals and society.

RESULTS OF SENSITIVITY ANALYSIS

The total direct annual cost nationwide would be up to $1.34 billion using nurse practitioners/physician assistants, $1.64 billion using attending physicians, $820 million hiring additional residents, vs. 1.42 billion using mixed substitutes.

LIMITATIONS

The effect on PAEs is unknown. Data were limited for some model parameters.

CONCLUSION

Implementation decisions greatly affect the cost. Unless PAEs decline substantially, teaching hospitals will lose money. If PAEs decline modestly, the requirements might be cost-saving or cost-effective to society.

Medicare's bundled payment pilot for acute and postacute care: analysis and recommendations on where to begin

In the National Pilot Program on Payment Bundling, a subset of Medicare providers will receive a single payment for an episode of acute care in a hospital, followed by postacute care in a skilled nursing or rehabilitation facility, the patient's home, or other appropriate setting. This article examines the promises and pitfalls of bundled payments and addresses two important design decisions for the pilot: which conditions to include, and how long an episode should be. Our analysis of Medicare data found that hip fracture and joint replacement are good conditions to include in the pilot because they exhibit strong potential for cost savings. In addition, these conditions pose less financial risk for providers than other common ones do, so including them would make participation in the program more appealing to providers. We also found that longer episode lengths captured a higher percentage of costs and hospital readmissions while adding little financial risk. We recommend that the Medicare pilot program test alternative design features to help foster payment innovation throughout the health system.