The impact of the affordable care act and Medicaid expansion on colorectal cancer screening: Evidence from the 5th year of Medicaid expansion.

BACKGROUND: Colorectal cancer screening rates remain suboptimal, particularly among low-income populations. Our objective was to evaluate the long-term effects of Medicaid expansion on colorectal cancer screening. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed data from 354,384 individuals aged 50-64 with an income below 400% of the federal poverty level (FPL), who participated in the Behavioral Risk Factors Surveillance System from 2010 to 2018. A difference-in-difference analysis was employed to estimate the effect of Medicaid expansion on colorectal cancer screening. Subgroup analyses were conducted for individuals with income up to 138% of the FPL and those with income between 139% and 400% of the FPL. The effect of Medicaid expansion on colorectal cancer screening was examined during the early, mid, and late expansion periods. MAIN OUTCOMES AND MEASURES: The primary outcome was the likelihood of receiving colorectal cancer screening for low-income adults aged 50-64. RESULTS: Medicaid expansion was associated with a significant 1.7 percentage point increase in colorectal cancer screening rates among adults aged 50-64 with income below 400% of the FPL (p < 0.05). A significant 2.9 percentage point increase in colorectal cancer screening was observed for those with income up to 138% the FPL (p < 0.05), while a 1.5 percentage point increase occurred for individuals with income between 139% and 400% of the FPL. The impact of Medicaid expansion on colorectal cancer screening varied based on income levels and displayed a time lag for newly eligible beneficiaries. CONCLUSIONS: Medicaid expansion was found to be associated with increased colorectal cancer screening rates among low-income individuals aged 50-64. The observed variations in impact based on income levels and the time lag for newly eligible beneficiaries receiving colorectal cancer screening highlight the need for further research and precision public health strategies to maximize the benefits of Medicaid expansion on colorectal cancer screening rates.

Impact of performance-based budgeting on quality outcomes in U.S. military health care facilities.

BACKGROUND: Performance-based budgeting (PBB) is a variation of pay for performance that has been used in government hospitals but could be applicable to any integrated system. It works by increasing or decreasing funding based on preestablished performance thresholds, which incentivizes organizations to improve performance. In late 2006, the U.S. Army implemented a PBB program that tied hospital-level funding decisions to performance on key cost and quality-related metrics. PURPOSE: The aim of this study was to estimate the impact of PBB on quality improvement in U.S. Army health care facilities. APPROACH: This study used a retrospective difference-in-differences analysis of data from two Defense Health Agency data repositories. The merged data set encompassed administrative, demographic, and performance information about 428 military health care facilities. Facility-level performance data on quality indicators were compared between 187 Army PBB facilities and a comparison group of 241 non-PBB Navy and Air Force facilities before and after program implementation. RESULTS: The Army's PBB programs had a positive impact on quality performance. Relative to comparison facilities, facilities that participated in PBB programs increased performance for over half of the indicators under investigation. Furthermore, performance was either sustained or continued to improve over 5 years for five of the six performance indicators examined long term. CONCLUSION: Study findings indicate that PBB may be an effective policy mechanism for improving facility-level performance on quality indicators. PRACTICE IMPLICATIONS: This study adds to the extant literature on pay for performance by examining the specific case of PBB. It demonstrates that quality performance can be influenced internally through centralized budgeting processes. Though specific to military hospitals, the findings might have applicability to other public and private sector hospitals who wish to incentivize performance internally in their organizational subunits through centralized budgeting processes.

A taxonomy of hospitals participating in Medicare accountable care organizations.

BACKGROUND: Medicare was an early innovator of accountable care organizations (ACOs), establishing the Medicare Shared Savings Program (MSSP) and Pioneer programs in 2012-2013. Existing research has documented that ACOs bring together an array of health providers with hospitals serving as important participants. PURPOSE: Hospitals vary markedly in their service structure and organizational capabilities, and thus, one would expect hospital ACO participants to vary in these regards. Our research identifies hospital subgroups that share certain capabilities and competencies. Such research, in conjunction with existing ACO research, provides deeper understanding of the structure and operation of these organizations. Given that Medicare was an initiator of the ACO concept, our findings provide a baseline to track the evolution of ACO hospitals over time. METHODOLOGY/APPROACH: Hierarchical clustering methods are used in separate analyses of MSSP and Pioneer ACO hospitals. Hospitals participating in ACOs with 2012-2013 start dates are identified through multiple sources. Study data come from the Centers for Medicare and Medicaid Services, American Hospital Association, and Health Information and Management Systems Society. RESULTS: Five-cluster solutions were developed separately for the MSSP and Pioneer hospital samples. Both the MSSP and Pioneer taxonomies had several clusters with high levels of health information technology capabilities. Also distinct clusters with strong physician linkages were present. We examined Pioneer ACO hospitals that subsequently left the program and found that they commonly had low levels of ambulatory care services or health information technology. CONCLUSION: Distinct subgroups of hospitals exist in both the MSSP and Pioneer programs, suggesting that individual hospitals serve different roles within an ACO. Health information technology and physician linkages appear to be particularly important features in ACO hospitals. PRACTICE IMPLICATIONS: ACOs need to consider not only geographic and service mix when selecting hospital participants but also their vertical integration features and management competencies.

Factors associated with hospital participation in Centers for Medicare and Medicaid Services' Accountable Care Organization programs.

BACKGROUND: In 2012, the Centers for Medicare and Medicaid Services (CMS) initiated the Medicare Shared Savings Program (MSSP) and Pioneer Accountable Care Organization (ACO) programs. Organizations in the MSSP model shared cost savings they generated with CMS, and those in the Pioneer program shared both savings and losses. It is largely unknown what hospital and environmental characteristics are associated with the development of CMS ACOs with one- or two-sided risk models. PURPOSE: The aim of this study was to assess the organizational and environmental characteristics associated with hospital participation in the MSSP and Pioneer ACOs. METHODOLOGY: Hospitals participating in CMS ACO programs were identified using primary and secondary data. The ACO hospital sample was linked with the American Hospital Association, Health Information and Management System Society, and other data sets. Multinomial probit models were estimated that distinguished organizational and environmental factors associated with hospital participation in the MSSP and Pioneer ACOs. RESULTS: Hospital participation in both CMS ACO programs was associated with prior experience with risk-based payments and care management programs, advanced health information technology, and location in higher-income and more competitive areas. Whereas various health system types were associated with hospital participation in the MSSP, centralized health systems, higher numbers of physicians in tightly integrated physician-organizational arrangements, and location in areas with greater supply of primary care physicians were associated with Pioneer ACOs. Favorable hospital characteristics were, in the aggregate, more important than favorable environmental factors for MSSP participation. CONCLUSION: MSSP ACOs may look for broader organizational capabilities from participating hospitals that may be reflective of a wide range of providers participating in diverse markets. Pioneer ACOs may rely on specific hospital and environmental characteristics to achieve quality and spending targets set for two-sided contracts. PRACTICE IMPLICATIONS: Hospital and ACO leaders can use our results to identify hospitals with certain characteristics favorable to their participation in either one- or two-sided ACOs.

Analysis of Delays in Breast Cancer Treatment and Late-Stage Diagnosis in Kazakhstan

Objective: Although Kazakhstan has made significant investments to improve health and life expectancy of its population, high cancer rates persist, with breast cancer being the most prevalent type. Factors contributing to delays in treatment and late staging for breast cancer patients were assessed. Methods: A retrospective follow-up study with registry data identified 4,248 breast cancer patients in sixteen regions of Kazakhstan in 2014. We used logistic regressions to estimate (i) associations of treatment delays with patient demographics and cancer center regions; and (ii) associations of late-stage (III and IV) cancer diagnosis with patient demographics and cancer center regions, with and without controlling for treatment delays. Results: Breast cancer patients treated in regions located further away from Almaty City had higher risks of treatment delays. However, the risks of late-stage cancer diagnosis were greater for patients treated in Almaty City and those with treatment delays. Conclusion: The main driver of delayed treatment is cancer center region. Residents of Almaty City, a major urban area of Kazakhstan, may have a better access to a tertiary cancer center, resulting in less treatment delays. Referrals of sicker patients from neighboring regions to Almaty City for cancer treatment is likely to increase risks of late-stage diagnosis. New or upgraded cancer centers may reduce treatment delays, but their case-mix is likely to increase.

Diabetes management before and after cancer diagnosis: missed opportunity.

BACKGROUND: Few studies have examined the management of comorbidities in cancer patients. This study used population-based data to estimate the guideline concordance rates for diabetes management before and after cancer diagnosis and examined if diabetes management services among cancer patients was associated with characteristics of the hospital where the patient was treated. METHODS: We linked 2005-2009 Medicare claims data to information on 2,707 breast and colorectal cancers patients in state cancer registry files. Multivariate logistic regression models examined hospital characteristics associated with receipt of diabetes management care after cancer diagnosis. RESULTS: The rates of HbAlc testing, LDL-C testing, and retinal eye exam decreased from 72.7%, 79.6%, and 57.9% before cancer diagnosis to 58.3%, 69.5%, and 55.8% after diagnosis. The pre- and post-diagnosis diabetes management care was not significantly different by hospital characteristics in the bivariate analysis except for that the distance between residence and hospital was negatively related to retinal eye exam after diagnosis (P<0.05). The multivariate analysis did not identify any significant differences in diabetes management care after cancer diagnosis by hospital characteristics. CONCLUSIONS: Cancer patients received fewer diabetes management care after diagnosis than prior to diagnosis, even for those who were treated in large comprehensive centers. This may reflect a missed opportunity to connect diabetic cancer patients to diabetes care. This study provides benchmarks to measure improvements in comorbidity management among cancer patients.

Characteristics of all, occasional, and frequent emergency department visits due to ambulatory care-sensitive conditions in Florida.

We studied characteristics of all, occasional, and frequent emergency department (ED) visits due to ambulatory care-sensitive conditions (ACSCs). We used a cross-sectional, split-sample design with multivariate logistic regressions using encounter-level, all-payer ED data from all Florida hospitals for the year of 2005. We evaluated associations of key patient characteristics, characteristics of ED utilization, and availability of primary care physicians in the area, with ED visits for ACSCs. We concluded that factors associated with ED use for ACSCs were similar for occasional and frequent ED users. Therefore, universal strategies for reduction of ED overutilization by increasing access to, timeliness, and quality of primary care for all patients likely to experience ACSCs should be used.

Bypassing the local rural hospital for outpatient procedures.

PURPOSE: To assess the amount of local rural hospital outpatient department (HOPD) bypass for outpatient procedures. METHODS: We analyzed data on colonoscopies and upper gastrointestinal endoscopies performed in the state of Florida over the period 1997-2004. FINDINGS: Approximately, 53% of colonoscopy and 45% of upper gastrointestinal endoscopy patients bypassed their local rural hospital for treatment at either a free-standing ambulatory surgical center (ASC) or a nonlocal hospital outpatient department. Independent predictors of bypass included risk-adjusted severity of the patient's medical condition, insurance status, and race. Patients treated in ASCs were predominately healthier, white and commercially insured. Nonlocal HOPDs tend to treat a sicker cohort of patients who were publicly insured or under managed care. CONCLUSIONS: The results indicate that patients who bypass their local HOPD to an ASC differ from those bypassing to a nonlocal HOPD, and that patient factors influencing bypass for outpatient procedures differ from those influencing inpatient bypass. From a policy perspective, as procedures continue to migrate from the inpatient to the outpatient setting, bypassing the local rural hospital for treatment elsewhere could create conditions that negatively impact rural hospital operations.

Variations in inpatient mortality among hospitals in different system types, 1995 to 2000.

BACKGROUND: Relatively few studies focused on the impact of system formation and hospital merger on quality, and these studies reported typically little or no quality effect. OBJECTIVE: To study associations among 5 main types of health systems--centralized, centralized physician/insurance, moderately centralized, decentralized, and independent--and inpatient mortality from acute myocardial infarction (AMI), congestive heart failure, stroke, and pneumonia. DATA AND METHODS: Panel data (1995-2000) were assembled from 11 states and multiple sources: Agency for Healthcare Research and Quality State Inpatient Database, American Hospital Association Annual Surveys, Area Resource File, HMO InterStudy, and the Centers for Medicare and Medicaid Services. We applied a panel study design with fixed effects models using information on variation within hospitals. RESULTS: We found that centralized health systems are associated with lower AMI, congestive heart failure, and pneumonia mortality. Independent hospital systems had better AMI quality outcomes than centralized physician/insurance and moderately centralized health systems. We found no difference in inpatient mortality among system types for the stroke outcome. Thus, for certain types of clinical service lines and patients, hospital system type matters. Research that focuses only on system membership may mask the impact of system type on the quality of care.

How well does diagnosis-based risk-adjustment work for comparing ambulatory clinical outcomes?

This paper examines the empirical consistency of the Diagnosis Cost Groups/Hierarchical Condition Categories (DCG/HCC) risk-adjustment method for comparing 7-day mortality between hospital-based outpatient departments (HOPDs) and freestanding ambulatory surgery centers (ASCs). We used patient level data for the three most common outpatient procedures provided during the 1997-2004 period in Florida. We estimated base-line logistic regression models without any diagnosis-based risk adjustment and compared them to logistic regression models with the DCG/HCC risk-adjustment, and to conditional logit models with a matched cohort risk-adjustment approach. We also evaluated models that adjusted for primary diagnoses only, and then for all available diagnoses, to assess how the frequently absent secondary diagnoses fields in ambulatory surgical data affect risk-adjustment. We found that risk-adjustment using both diagnosis-based methods resulted in similar 7-day mortality estimates for HOPD patients in comparison with ASC patients in two out of three procedures. We conclude that the DCG/HCC risk-adjustment method is relatively consistent and stable, and recommend this risk-adjustment method for health policy research and practice with ambulatory surgery data. We also recommend using risk-adjustment with all available diagnoses.

Hospital staffing decisions: does financial performance matter?

This study assesses the impact of changes in hospitals' financial conditions on changes in hospitals' staffing decisions. The sample consisted of community hospitals operating between 1995 and 2000. The analysis employed a generalized method of moments (GMM) estimator for its dynamic panel data. Cash flow and patient margin were used to measure financial condition. We estimated the effect of changing financial condition on the number of full-time equivalent personnel (FTEs), registered nurses (RNs), and licensed practical nurses (LPNs) per 1,000 adjusted patient days. Our results suggest that declining financial performance led to cutbacks in LPN FTEs per adjusted patient day, but the effects on total hospital FTEs and RN FTEs were mixed.

Is there a relationship between physician and facility volumes of ambulatory procedures and patient outcomes?

This study explores associations between patient outcomes (7- and 30-day hospitalization and mortality) and healthcare provider (physician and facility) volumes of outpatient colonoscopy, cataract removal, and upper gastrointestinal endoscopy performed in outpatient surgical settings in Florida. Findings indicate that patients treated by high-volume physicians or facilities had lower adjusted odds ratios for hospitalizations and mortality. When physician and facility volume were assessed simultaneously, physician volume accounted for larger effects than facility volume in hospitalization models. When assessing both physician and facility volume together for mortality, facility volume was a stronger predictor of mortality outcomes at 30 days. Further examinations of associations of outpatient physician and facility volumes and patient outcomes are suggested.

A comparative study of quality outcomes in freestanding ambulatory surgery centers and hospital-based outpatient departments: 1997-2004.

RESEARCH OBJECTIVE: To compare quality outcomes from surgical procedures performed at freestanding ambulatory surgery centers (ASCs) and hospital-based outpatient departments (HOPDs). DATA SOURCES: Patient-level ambulatory surgery (1997-2004), hospital discharge (1997-2004), and vital statistics data (1997-2004) for the state of Florida were assembled and analyzed. STUDY DESIGN: We used a pooled, cross-sectional design. Logistic regressions with time fixed-effects were estimated separately for the 12 most common ambulatory surgical procedures. Our quality outcomes were risk-adjusted 7-day and 30-day mortality and 7-day and 30-day unexpected hospitalizations. Risk-adjustment for patient demographic characteristics and severity of illness were calculated using the DCG/HCC methodology adjusting for primary diagnosis only and separately for all available diagnoses. PRINCIPAL FINDINGS: Although neither ASCs nor HOPDs performed better overall, we found some difference by procedure that varied based on the risk-adjustment approach used. CONCLUSIONS: There appear to be important variations in quality outcomes for certain procedures, which may be related to differences in organizational structure, processes, and strategies between ASCs and HOPDs. The study also confirms the importance of risk-adjustment for comorbidities when using administrative data, particularly for procedures that are sensitive to differences in severity.

Does the patient's payer matter in hospital patient safety?: a study of urban hospitals.

BACKGROUND: Previous studies have documented that hospitals decrease costs in response to reimbursement cutbacks. However, research concerning how this may affect quality of care has produced mixed results. Until recently, the ability to study changes in patient safety and payment has been limited. OBJECTIVE: The objective of the study was to determine whether changes in 4 hospital patient safety indicator (PSI) rates are related to changes in the generosity of payers over time. DATA AND METHODS: Study data are drawn from 1995-2000 hospital discharges in 11 states in the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project State Inpatient Database. Following the same organizations over time, we estimate hospital fixed-effects regression models of the association of payer-specific time and post Balanced Budget Act (BBA) payment changes with risk-adjusted hospital PSI rates controlling for patient, organizational, and market characteristics. Four PSIs relevant to a large number of patients and hospitals that reflect general care processes are studied. RESULTS: The time trend during 1995-2000 is consistently significantly positive for private and Medicare hospital PSI rates. Thus, after controlling for patient characteristics and organizational and market factors, performance worsened. The trend is less consistent for Medicaid and does not exist for self-pay hospital PSI rates. After adjusting for multiple comparisons, we also find that the Medicare trend is fairly consistently higher than that of the other payers. In contrast, there is a less consistent BBA effect, especially for Medicare.