Patterns of Postoperative Visits Among Medicare Fee-for-service Beneficiaries.

OBJECTIVE: To describe patterns of postoperative visits reported for Medicare fee-for-service (FFS) patients. BACKGROUND: Payment for most surgical procedures bundles postoperative visits within a global period of either 10 or 90 days after a procedure. There is concern that payments for some procedures are excessive because the number of postoperative visits provided is less than the number of postoperative visits used to help determine payment. To obtain data to inform this concern, Medicare required select surgeons to report on their postoperative visits starting July 1, 2017. METHODS: We analyzed Medicare FFS claims data from surgeons who billed Medicare for 1 or more of the 293 common procedure codes between July 1, 2017 and December 31, 2017 in the 9 states where surgeons were required to report postoperative visits. We examined the share of procedures with any reported postoperative visits and the proportion of expected postoperative visits provided. To address concerns about underreporting, we also examined procedures performed by a subset of surgeons actively reporting postoperative visits. RESULTS: We linked 663,681 procedures to 422,432 postoperative visits. The share of procedures with any postoperative visits was higher for procedures with 90-day global periods (70.1%) than for procedures with 10-day global periods (3.7%). The proportions of expected postoperative visits provided for 90-day global and 10-day global periods were 0.37 and 0.04 respectively. Among surgeons actively reporting postoperative visits, the proportions of expected postoperative visits provided were modestly higher (procedures with 90-day global periods=0.46 and 10-day global periods=0.16). CONCLUSIONS: The proportion of expected postoperative visits that were provided is low. These results support the need for a reassessment of payment for surgical procedures.

Antenatal Admissions Among Women with Opioid-Affected and Non-Opioid-Affected Deliveries.

OBJECTIVES: (1) To compare the prevalence of antenatal admissions and mean length of stay among women with opioid-affected and non-opioid-affected deliveries; (2) examine predictors of admission; and (3) describe the most common discharge diagnoses in each group. METHODS: Using data from seven states in the State Inpatient Databases for varying years between 2009 and 2014, delivery hospitalizations among women 18 years of age and older were identified and classified as opioid-affected or non-opioid-affected. Antenatal admissions were linked to deliveries. The antenatal admission ratio and mean length of stay for each group were calculated; the percentage of deliveries in each group with no, any, one, two, or three or more antenatal admissions were compared with t-tests. Logistic regression models estimated odds of any antenatal admission, stratified by opioid-affected and non-opioid-affected deliveries. Frequencies were tabulated for the ten most common discharge diagnoses in each group. RESULTS: Of 2,684,970 deliveries, 14,765 were opioid-affected. Admissions among women with opioid-affected deliveries were more prevalent (26.4 per 100 deliveries) compared to 6.7 among women with non-opioid-affected deliveries and were associated with a 1.5-day longer mean length of stay. The presence of a behavioral health condition was associated with higher odds of antenatal admission in both groups, with a particularly strong association among women with opioid-affected deliveries. Six of the ten most common diagnoses for admissions prior to opioid-affected deliveries were behavioral health-related. CONCLUSIONS FOR PRACTICE: These results highlight the importance of addressing the large burden of behavioral health conditions among pregnant women, especially those with opioid dependence and abuse.

Veteran Single Parents: Surviving but Not Thriving.

The demographics of the veteran population are changing. Veterans who served after September 11, 2001 (post-9/11 veterans), are more likely to be female and identify as a person of color than their older counterparts. They are also more likely to be raising children, many of them without support from a partner. This study provides a comprehensive look at the financial, physical, and mental health of veteran single parents; explores the differences across these factors by race, ethnicity, and gender; and includes recommendations on policies and programs that can better support veteran single parents and their children.

Impact of socioeconomic adjustment on physicians' relative cost of care.

BACKGROUND: Ongoing efforts to profile physicians on their relative cost of care have been criticized because they do not account for differences in patients' socioeconomic status (SES). The importance of SES adjustment has not been explored in cost-profiling applications that measure costs using an episode of care framework. OBJECTIVES: We assessed the relationship between SES and episode costs and the impact of adjusting for SES on physicians' relative cost rankings. RESEARCH DESIGN: We analyzed claims submitted to 3 Massachusetts commercial health plans during calendar years 2004 and 2005. We grouped patients' care into episodes, attributed episodes to individual physicians, and standardized costs for price differences across plans. We accounted for differences in physicians' case mix using indicators for episode type and a patient's severity of illness. A patient's SES was measured using an index of 6 indicators based on the zip code in which the patient lived. We estimated each physician's case mix-adjusted average episode cost and percentile rankings with and without adjustment for SES. RESULTS: Patients in the lowest SES quintile had $80 higher unadjusted episode costs, on average, than patients in the highest quintile. Nearly 70% of the variation in a physician's average episode cost was explained by case mix of their patients, whereas the contribution of SES was negligible. After adjustment for SES, only 1.1% of physicians changed relative cost rankings >2 percentiles. CONCLUSIONS: Accounting for patients' SES has little impact on physicians' relative cost rankings within an episode cost framework.

A Needs Assessment of Women Veterans in Western Pennsylvania: Final Report to Adagio Health.

Women make up an increasingly large share of the U.S. veteran population, and their numbers continue to grow while the overall number of veterans is on the decline. Yet programs designed to support veterans' health and well-being have largely focused on men. Women's military experiences and postservice needs often differ from those of men, and women veterans also differ in significant ways from their nonveteran counterparts. Few studies have explored these variations, and this has translated to potentially missed opportunities to improve support for women during and after their transition from military to civilian life. Adagio Health, a provider of health, wellness, and nutrition services based in Western Pennsylvania, has taken steps to improve care for women veterans in its service area. To identify opportunities to further expand and enhance Adagio Health's efforts to support women veterans' health and wellness, the authors quantitatively and qualitatively assessed the needs of women veterans in the Adagio Health service area. The assessment provides a clearer picture of this often-underserved population, available services and resources, gaps in support, barriers to access, and areas to prioritize to provide the best support possible for the health and well-being of women who served. With the approaches recommended in this assessment, Adagio Health can continue increasing its capacities and capabilities for supporting its women veteran patients and making progress toward its goal of advancing their health and well-being.

An Evaluation of a Multisite, Health Systems-Based Direct Care Worker Retention Program: Key Findings and Recommendations.

The U.S. direct care workforce employs nearly 4.6 million people and represents one of the fastest growing occupations in the United States. Direct care workers, or "caregivers," include nursing assistants, home care workers, and residential care aides, all of whom provide basic care to older adults and individuals with disabilities in various health care settings. Despite a growing need for caregivers, supply has not kept up with demand due to high turnover and low wages. In addition, caregivers often face high levels of workplace stress, limited training and growth opportunities, and personal stressors. Ranging from 35 to 90 percent, depending on the health care setting, the turnover rates of direct care workers pose a major challenge for health systems, as well as care recipients and workers themselves. In 2019, the Ralph C. Wilson Jr. Foundation funded three health systems to support the implementation of a new program: Transformational Healthcare Readiness through Innovative Vocational Education (THRIVE). This 12-month program was designed to help address barriers that entry-level caregivers experience and reduce turnover through a comprehensive risk assessment, training, and one-on-one coaching. Researchers from RAND conducted a process and outcome evaluation to determine whether THRIVE was meeting its goals of improving retention and achieving a positive return on investment (ROI). They also examined potential areas for program improvement.

Virtual Behavioral Health for Army Soldiers: Soldier Perspectives and Patterns of Treatment.

Delivery of high-quality behavioral health (BH) care is essential to supporting the readiness of the U.S. armed forces and their families. The coronavirus disease 2019 (COVID-19) pandemic led to a dramatic expansion of virtual behavioral health (VBH) care: remote patient access to BH care using technology such as a computer or cellular phone. The U.S. Army asked RAND Arroyo Center to examine the use of VBH to inform recommendations on the role of VBH care in the future of BH care in the Military Health System. The authors analyzed administrative data on VBH and in-person BH care from prior to the pandemic through March 2022 and surveyed soldiers who received BH care to assess their perceptions of VBH care. Administrative data analyses showed that direct care providers were less likely to deliver VBH care than private-sector providers and relied heavily on audio rather than video VBH. In addition, soldiers who received VBH care typically received a mix of VBH and in-person visits. Survey respondents who used VBH care had similar perceptions of the quality of their care and more-positive views of VBH than respondents who did not use VBH care. Few respondents had declined VBH care in favor of in-person care. Using these findings, the authors make recommendations on the role of VBH care in overall BH delivered by the military.

A new estimate of the impact of OSHA inspections on manufacturing injury rates, 1998-2005.

BACKGROUND: A prior study indicated that the effect of OSHA inspections on lost workday injuries had declined from 1979 through 1998. This study provides an updated estimate for 1998-2005. METHODS: Injury data from the Pennsylvania workers' compensation program were linked with employment data from unemployment compensation records to calculate lost-time rates for single-establishment manufacturing firms with more than 10 employees. These rates were linked to OSHA inspection findings. The RAND Human Subjects Protection Committee determined that this study was exempt from review. RESULTS: Inspections with penalties reduced injuries by an average of 19-24% annually in the 2 years following the inspection. These effects were not found for workplaces with fewer than 20 or more than 250 employees or for inspections without penalties. CONCLUSIONS: These findings should be generalizable to the 29 states where federal OSHA directly enforces standards. They suggest that the impact of inspections has increased from the 1990s.

A mixed-method approach to understanding the experiences of non-deployed military caregivers.

Given the unprecedented operational tempo of the Afghanistan and Iraq wars and the heavy involvement of the Reserve and National Guard, the stress that military families are exposed to is distinct from stress in earlier conflicts, with little empirical data to inform the impact on non-deployed military caregivers or "home caregivers." The study seeks to examine the experiences of home caregivers during deployments, with a focus on the impact of deployment on the caregiver's well-being. We conducted 50 qualitative interviews and 1,337 survey interviews with home caregivers who experienced at least one deployment. The structured qualitative interview focused on caregiver experiences during deployment. The quantitative data centered on caregiver well-being and household and relationship hassles. The qualitative interview notes were the unit of analysis and traditional methods were used to analyze the data. The quantitative data were analyzed using regression models. The qualitative data revealed key deployment-related household challenges that caregivers experience and the effect of those challenges on caregivers. Multivariate analyses of the quantitative data explored differences in caregivers' emotional well-being, household and relationship hassles. The results showed important component and deployment experience differences. Caregivers affiliated with the National Guard and those with more months of deployment reported significantly poorer emotional well-being, and more household and relationship hassles. Given the important role that maternal well-being has on child and family functioning, it is critical to understand how the stress of deployment is affecting mothers in their daily routines, especially during potentially high stress periods.

Variation in Estimated Surgical Procedure Times Across Patient Characteristics and Surgeon Specialty.

Importance: The time involved in performing a procedure is a key factor in determining physician payments by Medicare. However, there are long-standing concerns regarding the accuracy of the time estimates generated by the American Medical Association/Specialty Society Relative Value Scale Update Committee surveys that are used in the valuation process, and there have been calls to use other data sources to estimate procedure times. Objective: To compare estimated procedure times that come from claims with the times used in Medicare's valuation process. Design and Setting: Building off prior work using Medicare fee-for-service claims, procedure times were estimated from linked anesthesia claims data for 1349 different Current Procedure Terminology codes that are typically performed with anesthesia. All procedures in the nation performed in 2018 for Medicare fee-for-service beneficiaries were included in the analysis. These estimated times were compared with the times used in the valuation process. Analysis took place from February to November 2021. Main Outcomes and Measures: Estimated procedure times using anesthesia claims were compared with the procedure time used in valuation by calculating an estimated-to-valuation procedure time ratio for each code. The valuation procedure time is publicly reported by Medicare. The mean and median ratio are presented over all procedures and for select high-volume codes as well as by patient characteristics (age, sex, and risk score) and specialty of the physician performing the procedure. Results: Across 4.9 million procedures in this analysis, the mean estimated procedure time was 27% lower than the time used in the valuation process. There were notable exceptions, for which the mean estimated procedure time equaled or exceeded the valuation time including total hip arthroplasty (5% longer) and total knee arthroplasty (equal duration). Within a given code, older patients and those with more illness had longer procedure times. There was substantial variation across specialties in the percent difference between mean estimated and valuation procedure times ranging from gastroenterology (36% shorter) and ophthalmology (35% shorter) to cardiac surgery (2% longer) and thoracic surgery (7% longer). Conclusions and Relevance: Claims-based procedure times could be used to improve the accuracy of valuations for procedures.

Trends in Department of Defense Disability Evaluation System Ratings and Awards for Posttraumatic Stress Disorder and Traumatic Brain Injury, 2002-2017.

Since 2001, more than 3 million service members have deployed in support of multiple combat operations in Afghanistan, Iraq, and other theaters. Many have been diagnosed with the ""signature wounds"" of these conflicts: posttraumatic stress disorder (PTSD) and/or traumatic brain injury (TBI). During the intervening years, the process by which service members are evaluated for disability has evolved significantly, including a complete overhaul of the Disability Evaluation System (DES) beginning in 2007. Meanwhile, the Department of Defense (DoD) and the services made policy changes and initiated other efforts to improve screening for PTSD and TBI, encourage service members to seek treatment, improve quality of care, and reduce the stigma associated with treatment for these conditions. To explore these changes, as well as their potential effects on the numbers and characteristics of service members who are evaluated through DES, the authors identify and assess trends in DES outcomes for PTSD and TBI between 2002 and 2017.

Claims-Based Reporting of Post-Operative Visits for Procedures with 10- or 90-Day Global Periods: Updated Results Using Calendar Year 2018 Data.

Medicare payments for most surgical procedures cover both procedures and post-operative visits occurring within a global period of either ten or 90 days following procedures. There have been concerns that fewer post-operative visits are provided than the number of post-operative visits considered when the procedure was valued. To help inform accurate valuation of procedures with global periods, the Centers for Medicare & Medicaid Services (CMS) required select practitioners to report on post-operative visits after select procedures with 10- or 90-day global periods. The authors of this article summarize patterns of post-operative visits for procedures furnished during calendar year 2018, building on prior research that analyzed data for procedures with July 1, 2017, through June 30, 2018, service dates. During calendar year 2018, 96.5 percent of procedures with 10-day global periods did not have an associated post-operative visit. Approximately two-thirds of procedures with 90-day global periods had an associated post-operative visit; however, the ratio of observed to expected post-operative visits provided for 90-day global period procedures was only 0.38. Underreporting of post-operative visits might be driving these low rates. However, in sensitivity analyses limited to practitioners who were actively reporting their post-operative visits, post-operative patterns were largely similar to the main analysis. Collectively, these findings suggest that a large share of expected post-operative visits are not delivered, and that underreporting is unlikely to fully explain the low ratio of expected post-operative visits provided.

Claims-Based Reporting of Post-Operative Visits for Procedures with 10- or 90-Day Global Periods: Updated Results Using Calendar Year 2019 Data.

Medicare payments for most surgical procedures cover both procedures and post-operative visits occurring within a global period of either 10 or 90 days following procedures. There have been concerns that fewer post-operative visits are provided than the number of post-operative visits considered when the procedure was valued. To help inform accurate valuation of procedures with global periods, the Centers for Medicare & Medicaid Services (CMS) required select practitioners to report on post-operative visits after select procedures with 10- or 90-day global periods. The authors of this article summarize patterns of post-operative visits for procedures furnished during calendar year 2019, building on prior research that analyzed data for procedures furnished from July 1, 2017, through June 30, 2018, and for the entire 2018 calendar year. During calendar year 2019, 96.5 percent of procedures with 10-day global periods did not have an associated post-operative visit. Approximately two-thirds of procedures with 90-day global periods had an associated post-operative visit; however, the ratio of observed to expected post-operative visits provided for 90-day global period procedures was only 0.38. Underreporting of post-operative visits might be driving these low rates. However, in sensitivity analyses limited to practitioners who were actively reporting their post-operative visits, post-operative patterns were largely similar to the main analysis. Collectively, these findings suggest that many expected post-operative visits are not delivered and that underreporting is unlikely to fully explain the low ratio of expected post-operative visits provided.

Assessing Health and Human Services Needs to Support an Integrated Health in All Policies Plan for Prince George's County, Maryland.

With evolving demographics and a changing health system landscape, the Prince George's County Council, acting as the County Board of Health, is considering its future policy approaches and resource allocations related to health and well-being. To inform this path forward, the authors of this study used primary and secondary data to describe both the health needs of county residents and drivers of health within the county, inclusive of the social, economic, built, natural, and health service environments. This study integrates these findings, an analysis of budget documents, and a review of promising practices from other communities to situate recommendations in a Health in All Policies framework to foster aligned and integrated planning and budgeting across the county to promote health and well-being. Findings from the assessment indicate a shared interest among leaders and residents to embrace a holistic strategy for health and well-being in the county. Inefficient uses of the health care system are identified, highlighting a need to rebalance investments in health care use and drivers of health. Additionally, challenges in navigating health and human services and inequities in drivers of health across communities are noted, signaling broader concerns related to residents' access to health and human services that influence health and well-being outcomes. Recommendations are provided for several paths forward for the county to pursue a more integrated policy approach to influence health and well-being outcomes.

Using Claims-Based Estimates of Post-Operative Visits to Revalue Procedures with 10- and 90-Day Global Periods: Updated Results Using Calendar Year 2019 Data.

Medicare payment for many health care procedures covers not only the procedure itself but also most post-operative care over a fixed period of time (the ""global period""). The Centers for Medicare & Medicaid Services (CMS) sets payment rates assuming that a certain number and type of post-operative visits specific to each procedure typically occur. This article describes how CMS might use claims-based data on the number of post-operative visits to adjust valuation for procedures with 10- and 90-day global periods. There are links between the number of bundled post-operative visits and the components of valuation addressed in this study: work, practice expense (PE), and malpractice relative value units (RVUs). There is some ambiguity regarding how a reduction in post-operative visits translates into changes in work RVUs. In contrast, a reduction in post-operative visits has clear implications on physician time and direct PE. Changes in physician work, physician time, and direct PE will, in turn, affect the allocation of pools of PE and malpractice RVUs to individual services. The idiosyncrasies of the resource-based relative value scale system used to determine payment for Medicare services result in some ambiguity about how procedures should be revalued to reflect reductions in post-operative visits. These results may inform further policy development around revaluation for global procedures.

Assessing the Quality of Outpatient Pain Care and Opioid Prescribing in the Military Health System.

Pain conditions are the leading cause of disability among active-duty service members. Given the significant implications for force readiness and service member well-being, the Military Health System (MHS) has made it a strategic priority to provide service members with the highest-quality treatment for pain conditions. RAND researchers assessed MHS outpatient care for acute and chronic pain, including opioid prescribing. The assessment involved developing a set of 14 quality measures designed to assess aspects of outpatient care for pain, including care associated with dental and ambulatory procedures, acute low back pain, chronic pain, opioid prescribing, and medication treatment for opioid use disorder. This research offers the most comprehensive examination to date of the quality and safety of pain care in the MHS and its alignment with evidence-based clinical practice guidelines. It identifies several areas of strength in pain care delivery, along with some areas for improvement, and provides recommendations to support the MHS in continuing to improve pain care for service members.

Medicaid Payment and Fluoride Varnish Application During Pediatric Medical Visits.

All Medicaid programs pay for fluoride varnish applications during medical visits for infants and toddlers, but receipt of care varies considerably across states. Using 2006-2014 Medicaid data from 22 states, this study examined the association between Medicaid payment and receipt of fluoride varnish during pediatric medical visits. Among 3,393,638 medical visits, fewer than one in 10 visits included fluoride varnish. Higher Medicaid payment was positively associated with receipt of fluoride varnish during pediatric medical visits. As policymakers consider strategies for increasing young children's access to preventive oral health services, as well as consider strategies for balancing budgets, attention should be paid to the effects of provider payment on access to pediatric oral health services.

New York State 1115 Demonstration Independent Evaluation: Interim Report.

The broad goals of New York State's Medicaid Section 1115 Waiver are to enroll a majority of Medicaid beneficiaries into managed care, increase access and service quality, and expand coverage to more low-income New Yorkers. The RAND Corporation was competitively selected as the independent evaluator to assess two components under this 1115 Demonstration Waiver: the Managed Long-Term Care (MLTC) program and the 12-month continuous eligibility policy, which guarantees enrollees Medicaid coverage regardless of changes in income in the 12 months after eligibility determination and enrollment. This final interim evaluation examines whether these two components have helped achieve the program's goals. The RAND team's analyses show that the Demonstration has expanded access to managed care through mandatory MLTC enrollment and 12-month continuous eligibility. The team found no evidence of a significant change in patient safety or quality of care. The authors note that, although this means that there is no evidence the Demonstration achieved the goal of improving quality of care, increasing access without compromising quality of care is a success in its own right.

Trends In Home Care Versus Nursing Home Workforce Sizes: Are States Converging Or Diverging Over Time?

There is strong preference among people with disabling conditions to receive care at home rather than in an institutional setting. Differences in state policies may make this more feasible in some states than others. Yet no study to date has examined trends in the long-term care workforce across states. Using state-level data on direct care workers from the period 2009-20, we examine trends in the sizes of the nursing home and home care workforces. We show that since 2009 most states have increased the size of their home care workforces and decreased the size of their nursing home workforces, but there is substantial variation across states in the magnitude of these changes. In addition, the gap between leading and lagging states in home care workforce size has grown over time. This suggests that more targeted efforts may be needed to ensure that people with disabling conditions can have their needs met in their desired setting across the nation.

The Pennsylvania certified safety committee program: an evaluation of participation and effects on work injury rates.

BACKGROUND: Since 1994, Pennsylvania, like several other states, has provided a 5% discount on workers' compensation insurance premiums for firms with a certified joint labor management safety committee. This study explored the factors affecting program participation and evaluated the effect of this program on work injuries. METHODS: Using Pennsylvania unemployment insurance data (1996-2006), workers' compensation data (1998-2005), and the safety committee audit data (1999-2007), we conducted propensity score matching and regression analysis on the program's impact on injury rates. RESULTS: Larger firms, firms with higher injury rates, firms in high risk industries, and firms without labor unions were more likely to join the safety committee program and less likely to drop out of the program. The injury rates of participants did not decline more than the rates for non-participants; however, rates at participant firms with good compliance dropped more than the rates at participant firms with poor compliance. CONCLUSIONS: Firm size and prior injury rates are key predictors of program participation. Firms that complied with the requirement to train their safety committee members did experience reductions in injuries, but non-compliance with that and other requirements was so widespread that no overall impact of the program could be detected.