Meaningful Use and Hospital Performance on Post-Acute Utilization Indicators.

OBJECTIVES: To examine trends in hospital post-acute utilization indicators and to determine whether improvement in these indicators is associated with attesting to meaningful use (MU). DATA SOURCES: Medicare claims-based, repeated measures on 30-day hospital-wide all-cause readmission and emergency department (ED) utilization rates for 160 short-stay hospitals (2009-2012); Medicare EHR Incentive Program Payments files (2011-2012); and other hospital and market data. STUDY DESIGN: Interrupted time series with concurrent comparison group. PRINCIPAL FINDINGS: Propensity score-weighted multilevel models for change demonstrate that 30-day readmission rates (unadjusted) fell from 13.4 percent in 2009 to 12.1 percent in 2012. Similarly, 30-day ED utilization declined from 18.9 percent to 17.3 percent during the same period. However, MU and non-MU hospitals were indistinguishable vis-à-vis performance. Controlling for hospital and market characteristics, MU was unrelated to 30-day readmission. In contrast, 30-day ED utilization deteriorated. CONCLUSIONS: Hospitals with MU Stage 1 designation did not show significantly higher improvement on post-acute utilization compared to their counterparts without. To achieve gains in quality and safety, potentially associated with EHRs, and to advance care coordination and patient engagement, the regulators should strengthen accountability by linking comprehensive, outcomes-based performance measures to specific MU objectives.

Linking Spending and Quality Indicators to Measure Value and Efficiency in Health Care.

Policy makers and stakeholders have reached a consensus that both quality and spending or resource use indicators should be jointly measured and prioritized to meet the objectives of our health system. However, the relative merits of alternative approaches that combine quality and spending indicators are not well understood. We conducted a literature review to identify different approaches that combine indicators of quality and spending measures to profile provider efficiency in the context of specific applications in health care. Our investigation identified seven alternative models that are either in use or have been proposed to evaluate provider efficiency. We then used publicly available data to profile hospitals using these approaches. Profiles of hospital efficiency using alternative models yielded wide variation in performance, underscoring the importance of model selection. By identifying the current efficiency models and evaluating their trade-offs within specific programmatic contexts, our analysis informs stakeholder and policy maker decisions about how to link quality and spending indicators when measuring efficiency in health care.

Racial/Ethnic disparities in patient experience with communication in hospitals: real differences or measurement errors?

BACKGROUND: An important aspect of medical care is clear and effective communication, which can be particularly challenging for individuals based on race/ethnicity. Quality of communication is measured systematically in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, and analyzed frequently such as in the National Healthcare Disparities Report. Caution is needed to discern differences in communication quality from racial/ethnic differences in perceptions about concepts or expectations about their fulfillment. OBJECTIVES: To examine assumptions about the degree of commonality across racial/ethnic groups in their perceptions and expectations, and to investigate the validity of conclusions regarding racial/ethnic differences in communication quality. METHODS: We used 2007 HCAHPS data from the National CAHPS Benchmarking Database to construct racial/ethnic samples that controlled for other patient characteristics (828 per group). Using multiple-groups confirmatory factor analyses, we tested whether the factor structure and model parameters (ie, factor loadings, intercepts) differed across groups. RESULTS: We identified support for basic tests of equivalence across 7 racial/ethnic groups in terms of equivalent factor structure and loadings. Even stronger support was found for Communication with Doctors and Nurses. However, potentially important nonequivalence was found for Communication about Medicines, including instances of statistically significant differences between non-Hispanic whites and non-Hispanic blacks, Asians, and Native Hawaiian/other Pacific Islanders. CONCLUSIONS: Our results provide strongest support for racial/ethnic comparisons on Communication with Nurses and Doctors, and reason to caution against comparisons on Communication about Medicines due to significant differences in model parameters across groups; that is, a lack of invariance in the intercept.

Images of imaging: how to process and display imaging utilization for large populations.

OBJECTIVE: We propose a method of processing and displaying imaging utilization data for large populations. CONCLUSION: The comprehensive and finely grained picture of imaging utilization yielded by our methods is a first step toward population-based imaging utilization management. We believe that our methods for the categorization and display of imaging utilization will prove to be widely useful.

Incidence and cost of pneumonia in medicare beneficiaries.

BACKGROUND: Pneumonia is a frequent and serious illness in elderly people, with a significant impact on mortality and health-care costs. Lingering effects may influence clinical outcomes and medical service use beyond the acute hospitalization. This study describes the incidence and mortality of pneumonia in elderly Medicare beneficiaries based on treatment setting (outpatient, inpatient) and location of origin (health-care associated, community acquired) and estimates short- and long-term direct medical costs and mortality associated with an inpatient episode of pneumonia. METHODS: Administrative claims from a 5% sample of fee-for-service Medicare beneficiaries aged ≥ 65 years from 2005 through 2007 were used. Total direct medical costs for patients during and after hospitalization for pneumonia compared with similar patients without pneumonia (the excess cost of pneumonia) were estimated using propensity score matching. RESULTS: The age-adjusted annual cumulative incidence of any pneumonia was 47.4 per 1,000 beneficiaries (13.3 per 1,000 inpatient primary pneumonia), increasing with age; one-half of pneumonia cases were treated in the hospital. Thirty-day mortality was twice as high among beneficiaries with health-care-associated pneumonia than among those hospitalized with community-acquired pneumonia (13.4% vs 6.4%). Total medical costs for beneficiaries during and 1 year following a pneumonia hospitalization were $15,682 higher than matched control patients without pneumonia. The total annual excess cost of hospital-treated pneumonia as a primary diagnosis in the elderly fee-for-service Medicare population in 2010 is estimated conservatively at > $7 billion. CONCLUSIONS: Pneumonia in elderly people is associated with high acute-care costs and an overall impact on total direct medical costs and mortality during and after an acute episode.

Substance abuse treatment utilization among adults living with HIV/AIDS and alcohol or drug problems.

This is a prospective cohort study to identify factors associated with receipt of substance abuse treatment (SAT) among adults with alcohol problems and HIV/AIDS. Data from the HIV Longitudinal Interrelationships of Viruses and Ethanol study were analyzed. Generalized estimating equation logistic regression models were fit to identify factors associated with any service utilization. An alcohol dependence diagnosis had a negative association with SAT (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [95% CI] = 0.19-0.67), as did identifying sexual orientation other than heterosexual (AOR = 0.46, CI = 0.29-0.72) and having social supports that use alcohol/drugs (AOR = 0.62, CI = 0.45-0.83). Positive associations with SAT include presence of hepatitis C antibody (AOR = 3.37, CI = 2.24-5.06), physical or sexual abuse (AOR = 2.12, CI = 1.22-3.69), social supports that help with sobriety (AOR = 1.92, CI = 1.28-2.87), homelessness (AOR = 2.40, CI = 1.60-3.62), drug dependence diagnosis (AOR = 2.64, CI = 1.88-3.70), and clinically important depressive symptoms (AOR = 1.52, CI = 1.08-2.15). While reassuring that factors indicating need for SAT among people with HIV and alcohol problems (e.g., drug dependence) are associated with receipt, nonneed factors (e.g., sexual orientation, age) that should not decrease likelihood of receipt of treatment were identified.

Factors associated with attendance in 12-step groups (Alcoholics Anonymous/Narcotics Anonymous) among adults with alcohol problems living with HIV/AIDS.

BACKGROUND: Despite the value of 12-step meetings, few studies have examined factors associated with attendance among those living with HIV/AIDS, such as the impact of HIV disease severity and demographics. OBJECTIVE: This study examines predisposing characteristics, enabling resources and need on attendance at Alcoholic Anonymous (AA) and Narcotics Anonymous (NA) meetings among those living with HIV/AIDS and alcohol problems. METHODS: Secondary analysis of prospective data from the HIV-Longitudinal Interrelationships of Viruses and Ethanol study, a cohort of 400 adults living with HIV/AIDS and alcohol problems. Factors associated with AA/NA attendance were identified using the Anderson model for vulnerable populations. Generalized estimating equation logistic regression models were fit to identify factors associated with self-reported AA/NA attendance. RESULTS: At study entry, subjects were 75% male, 12% met diagnostic criteria for alcohol dependence, 43% had drug dependence and 56% reported attending one or more AA/NA meetings (past 6 months). In the adjusted model, female gender negatively associated with attendance, as were social support systems that use alcohol and/or drugs, while presence of HCV antibody, drug dependence diagnosis, and homelessness associated with higher odds of attendance. CONCLUSIONS: Non-substance abuse related barriers to AA/NA group attendance exist for those living with HIV/AIDS, including females and social support systems that use alcohol and/or drugs. Positive associations of homelessness, HCV infection and current drug dependence were identified. These findings provide implications for policy makers and treatment professionals who wish to encourage attendance at 12-step meetings for those living with HIV/AIDS and alcohol or other substance use problems.

Emergency department utilization patterns for Medicare beneficiaries with serious mental disorders.

OBJECTIVE: This study examined emergency department use among Medicare beneficiaries with serious mental disorders. METHODS: Drawn from the 2004 national 5% sample of Medicare beneficiaries, the sample in this study (N=129,805) included fee-for-service enrollees with primary diagnoses of schizophrenia, major depression, other major affective disorders, or other psychoses. Emergency department use was compared by psychiatric diagnostic category and presence of a claim related to substance use disorder. RESULTS: Having any emergency department visit was common for beneficiaries aged >or=65 years (58.3%) and beneficiaries <65 years who were Medicare eligible because of a disability (48.5%). Emergency department visits with a primary psychiatric diagnosis occurred for 14.8% of disabled beneficiaries and 6.7% of aged beneficiaries. Use varied by diagnosis and was higher for those with any substance-related claims (p<.01). CONCLUSIONS: Emergency department use was common in the sample. Within each eligibility category, use varied by psychiatric diagnostic category and presence of a substance-related claim.

The relationship between Medicare's process of care quality measures and mortality.

Using Medicare inpatient claims and Hospital Compare process of care quality data from the period 2004-2006, we estimate two model specifications to test for the presence of correlational and causal relationships between hospital process of care performance measures and risk-adjusted (RA) 30-day mortality for heart attack, heart failure, and pneumonia. Our analysis indicates that while Hospital Compare process performance measures are correlated with 30-day mortality for each diagnosis, after we account for unobserved heterogeneity, process of care performance is no longer associated with mortality for any diagnosis. This suggests that the relationship between hospital-level process of care performance and mortality is not causal. Implications for pay-for-performance are discussed.

Measuring outcomes and efficiency in medicare value-based purchasing.

The Medicare program may soon adopt value-based purchasing (VBP), in which hospitals could receive incentives that are conditional on meeting specified performance objectives. The authors advocate for a market-oriented framework and direct measures of system-level value that are focused on better outcomes and lower total cost of care. They present a multidimensional framework for measuring outcomes of care and a method to adjust incentive payments based on efficiency. Incremental reforms based on VBP could provoke transformational changes in total patient care by linking payments to value related to the whole patient experience, recognizing shared accountability among providers.

The impact of publicly funded managed care on adolescent substance abuse treatment outcomes.

This study compares the 12-month changes in substance use following admission to substance abuse treatment in Massachusetts between adolescents enrolled in Medicaid managed care and other publicly funded adolescents. Two hundred and fifty-five adolescents were interviewed as they entered substance abuse treatment and at 6 and 12 month follow-ups. Medicaid enrollment data were used to determine the managed care enrollment status. One hundred forty two (56%) adolescents were in the managed care group and 113 (44%) comprise the comparison group. Substance use outcomes include a count of negative consequences of substance use, days of alcohol use, days of cannabis use, and days of any substance use in the previous 30 days. Repeated measures analysis of covariance (ANCOVA) was used to assess change with time of measurement and managed care status as main effects and the interaction of time and managed care included to measure differences between the groups over time. Although several changes across time were detected for all four outcomes, we found no evidence of an impact of managed care for any of the outcomes. The results of our study do not support the fears that behavioral managed care, by imposing limits on services provided, would substantially reduce the effectiveness of substance abuse treatment for adolescents. At the same time, the results do not support those who believe that the continuity of care and improved resource utilization claimed for managed care would improve outcomes.

The precarious pricing system for hospital services.

Over the past twenty-five years, the average ratio of hospital charges for services (gross revenues) to payments received (net revenues) has grown from 1.1 to 2.6. This reflects a transition from predominantly cost- and charge-based payment systems to regulated and negotiated fixed payments. Hospitals have been able to squeeze additional revenues from remaining charge-based payers and services by sharply increasing charges, negatively affecting the uninsured. Although protection of the uninsured seems warranted, it might be difficult to regulate hospital pricing systems in isolation from other controversial issues, such as the acceptability of cross-subsidies and the role of market forces.

The impact of employment counseling on substance user treatment participation and outcomes.

The nationally representative Alcohol and Drug Services Study (ADSS, 1996--1999) is used to examine employment counseling's impact on treatment participation and on postdischarge abstinence and employment. Employment counseling (EC) is among the more frequently received ancillary services in substance user treatment. The ADSS study sample showed it was received by 13% of all (N=988) nonmethadone outpatient clients, and 42% of the 297 clients with a need for it. Clients who received needed EC (met need) are compared to clients who did not receive needed EC (unmet need). Met-need clients had significantly longer treatment duration and greater likelihood of employment postdischarge than unmet-need clients. Both groups were as likely to complete treatment and be abstinent at follow-up. Implications are discussed. Future needed research and unresolved critical issues are also noted.

Escalating health care spending: is it desirable or inevitable?

This study analyzes changing trends in U.S. health spending and concludes that although the long-term growth trend has been a good predictor of future spending, periodic differences in the growth trend are important. Of particular concern is the rapid acceleration in health spending beginning in 1998. If left unchecked, the current growth rate will result in almost 24 percent of GDP spent on health by 2011. The authors question whether such unconstrained spending levels are either desirable or inevitable, and they offer a guide to how the United States might develop a long-term cost-containment strategy that is both effective and sustainable.

Realigning incentives in fee-for-service Medicare.

This paper proposes Medicare payment reform built on the fee-for-service system, with incentive payments to eligible provider organizations determined by their rate of increase in cost per patient compared to the overall growth rate in the community. By planning and monitoring how care patterns are altered to achieve greater efficiency, policy-makers can align the incentives of Medicare and the provider organization better than using either fee-for-service or capitation alone. This reform, unlike capitation, maintains Medicare's historical role as insurer and focuses providers on managing care.

An examination of factors in the withdrawal of managed care plans from the Medicare+Choice program.

Participation of health maintenance organizations (HMOs) in the Medicare+Choice program, expected to rise rapidly after passage of the Balanced Budget Act of 1997, has gone in just the opposite direction. Because plans have left in such large numbers, Congress has taken remedial measures to remove restrictions and increase payments. To date these efforts have failed. This paper uses plan organizational characteristics, market position, and financial performance to quantify the reasons why some HMOs exited at the end of 1998. The findings suggest HMO participation in Medicare+Choice will continue to fall unless major changes are made to the overall Medicare program and the method of paying HMOs.