Provision of Behavioral Health Services at Community Health Centers and Hospital Emergency Department Visits.

BACKGROUND: Numerous US patients seek the hospital emergency department (ED) for behavioral health care. Community Health Centers (CHCs) offer a potential channel for redirecting many to a more patient-centered, lower cost setting. OBJECTIVE: The aim of this study was to identify unique market areas serviced by CHCs and to examine whether CHCs are effective in offsetting behavioral health ED visits. RESEARCH DESIGN: We identified CHC-year specific service areas using patient origin zip codes. We then estimated random effects models applied to 42 federally qualified CHCs operating in New York State during 2013-2020. The dependent variables were numbers of ED mental health (substance use disorder) visits per capita in a CHC's service area, drawn from HCUP State Emergency Department Databases. Key explanatory variables measured CHC number of mental health (substance use disorder) visits, number of unique mental health (substance use disorder) patients, and mental health (substance use disorder) intensity, obtained from the HRSA Uniform Data System. RESULTS: Controlling for population, we observed small negative effects of CHC behavioral health integration in explaining ED behavioral health utilization. Measures of mental health utilization in CHCs were associated with 1.3%-9.3% fewer mental health emergency department visits per capita in Community Health Centers' service areas. Measures of substance use disorder utilization in Community Health Centers were associated with 1.3%-3.0% fewer emergency department visits per capita. CONCLUSION: Results suggest that behavioral health integration in CHCs may reduce reliance on hospital EDs, but that policymakers explore more avenues for regional coordination strategies that align services between CHCs and local hospitals.

Quality and Cost in Community Health Centers.

BACKGROUND: Quantifying health care quality has long presented a challenge to identifying the relationship between provider level quality and cost. However, growing focus on quality improvement has led to greater interest in organizational performance, prompting payers to collect various indicators of quality that can be combined at the provider level. OBJECTIVE: To explore the relationship between quality and average cost of medical visits provided in US Community Health Centers (CHCs) using composite measures of quality. RESEARCH DESIGN: Using the Uniform Data System collected by the Bureau of Primary Care, we constructed composite measures by combining 9 process and 2 outcome indicators of primary care quality provided in 1331 US CHCs during 2015-2018. We explored different weighting schemes and different combinations of individual quality indicators constructed at the intermediate domain levels of chronic condition control, screening, and medication management. We used generalized linear modeling to regress average cost of a medical visit on composite quality measures, controlling for patient and health center factors. We examined the sensitivity of results to different weighting schemes and to combining individual quality indicators at the overall level compared with the intermediate domain level. RESULTS: Both overall and domain level composites performed well in the estimations. Average cost of a medical visit was negatively associated with quality, although the magnitude of the effect varied across weighting schemes. CONCLUSION: Efforts toward improvement of primary health care quality delivered in CHCs need not involve greater cost.

The Effect of Telehealth Services on Provider Productivity.

BACKGROUND: Telehealth services historically have played a small role in the provision of health care in the United States. However during the coronavirus disease 2019 (COVID-19) pandemic, public and private insurers rapidly expanded access to telehealth in order to reduce exposure and avoid transmission. It is unknown whether telehealth will become a more regular substitute for in-person care beyond the pandemic. OBJECTIVE: Our objective was to provide evidence on the value of telehealth by comparing the productivity of physicians and other specialized clinicians who provide telehealth with the productivity of those who do not. RESEARCH DESIGN: We conducted a retrospective data analysis of 17,705 unique providers in the areas of internal medicine, cardiology, dermatology, psychiatry, psychology, and optometry practicing in the US veterans affairs health care system during the period 2015 to 2018. For each year, we measured individual providers productivity by the total number of relative value units (RVUs) per full-time equivalent (FTE). We estimated the impact of providing telehealth on RVUs/FTE using fixed effects regression models estimated on a panel dataset of 58,873 provider-year observations and controlling for provider and patient characteristics. RESULTS: Overall provider productivity increased in veterans affairs over the period, particularly in cardiology and dermatology. Providers of telehealth had above average productivity by 124 RVUs/FTE, or ∼4% of average total provider productivity. For the highest quartile of telehealth providers, average productivity was 188 RVUs/FTE higher than productivity of other providers. CONCLUSION: Strategies that encourage long-term integration of telehealth into provider practices may contribute to overall health care value.

Hospital Response to CMS Public Reports of Hospital Charge Information.

BACKGROUND: In an effort to increase price transparency, the Centers for Medicare and Medicaid Services (CMS) began reporting charges for Medicare inpatients treated in ∼3400 hospitals online in 2013. As of 2019, CMS began to require hospitals themselves to publicize a more comprehensive list of their underlying procedure charges. OBJECTIVE: The objective of this study was to assess the responses of hospitals to broad-scale public reporting of their charges for inpatient services. RESEARCH DESIGN: We used descriptive analysis to examine the trend in CMS charge data for high charge hospitals before and after the 2013 intervention. We also applied difference-in-differences analysis to comprehensive inpatient charge data from New York and Florida for the years 2011-2016, defining the reported high-volume diagnosis-related groups (DRGs) as the intervention group. RESULTS: At the national level, the CMS charge data showed relatively lower growth in high charge hospitals following the intervention. From the state data, we found that after 3 years, the growth in charges for reported DRGs in New York hospitals was 4%-9% lower than for unreported diagnosis-related groups. In Florida, it was 2%-8% lower. CONCLUSION: Public reports of hospital inpatient charges by DRG appear to influence subsequent charges, slowing their growth.

Patient Outcomes Following Total Joint Replacement Surgery: A Comparison of Hospitals and Ambulatory Surgery Centers.

BACKGROUND: For several years, many orthopedic surgeons have been performing total joint replacements in hospital outpatient departments (HOPDs) and more recently in ambulatory surgery centers (ASCs). In a recent shift, the Centers for Medicare and Medicaid Services began reimbursing for total knee replacement surgery in HOPDs. Some observers have expressed concerns over patient safety for the Medicare population particularly if Centers for Medicare and Medicaid Services extends the policy to include total hip replacement surgery and coverage in ASCs. METHODS: This study used a large claims database of non-Medicare patients to examine inpatient and outpatient total knee replacement and total hip replacement surgery performed on a near-elderly population during 2014-2016. We applied propensity score methods to match inpatients with ASC patients and HOPD patients with ASC patients adjusting for risk using the HHS Hierarchical Condition Categories risk adjustment model. We conducted statistical tests comparing clinical outcomes across the 3 settings and examined relative costs. RESULTS: Readmissions, postsurgical complications, and payments were lower for outpatients than for inpatients. Within outpatient settings, readmissions and postsurgical complications were lower in ASCs than in HOPDs but payments for ASC patients were higher than payments for HOPD patients. CONCLUSION: Our findings support the argument that outpatient total joint replacement is appropriate for select patients treated in both HOPDs and ASCs, although in the commercially insured population, the latter services may come at a cost. Until further study of outpatient total joint replacement in the Medicare population becomes available, how this will extrapolate to the Medicare population is unknown.

A Comparison of Ambulatory Surgery Center Production Costs and Medicare Payments: Evidence on Colonoscopy and Endoscopy.

BACKGROUND: Ambulatory surgery centers (ASCs) are freestanding facilities that specialize in surgical and diagnostic procedures that do not require an overnight stay. While it is generally assumed that ASCs are less costly than hospital outpatient surgery departments, there is sparse empirical evidence regarding their relative production costs. OBJECTIVES: To estimate ASC production costs using financial and claims records for procedures performed by surgery centers that specialize in gastroenterology procedures (colonoscopy and endoscopy). RESEARCH DESIGN: We estimate production costs in ASCs that specialize in gastroenterology procedures using financial cost and patient discharge data from Pennsylvania for the time period 2004-2013. We focus on the 2 primary procedures (colonoscopies and endoscopies) performed at each ASC. We use our estimates to predict average costs for each procedure and then compare predicted costs to Medicare ACS payments for these procedures. RESULTS: Comparisons of the costs of each procedure with 2013 national Medicare ASC payment rates suggest that Medicare payments exceed production costs for both colonoscopy and endoscopy. CONCLUSIONS: This study demonstrated that it is feasible to estimate production costs for procedures performed in freestanding surgery centers. The procedure-specific cost estimates can then be compared with ASC payment rates to ascertain if payments are aligned with costs. This approach can serve as an evaluation template for CMS and private insurers who are concerned that ASC facility payments for specific procedures may be excessive.

The cost of hospital readmissions: evidence from the VA.

This paper is an examination of hospital 30-day readmission costs using data from 119 acute care hospitals operated by the U.S. Veterans Administration (VA) in fiscal year 2011. We applied a two-part model that linked readmission probability to readmission cost to obtain patient level estimates of expected readmission cost for VA patients overall, and for patients discharged for three prevalent conditions with relatively high readmission rates. Our focus was on the variable component of direct patient cost. Overall, managers could expect to save $2140 for the average 30-day readmission avoided. For heart attack, heart failure, and pneumonia patients, expected readmission cost estimates were $3432, $2488 and $2278. Patient risk of illness was the dominant driver of readmission cost in all cases. The VA experience has implications for private sector hospitals that treat a high proportion of chronically ill and/or low income patients, or that are contemplating adopting bundled payment mechanisms.

Measuring the hospital length of stay/readmission cost trade-off under a bundled payment mechanism.

If patients are discharged from the hospital prematurely, many may need to return within a short period of time. This paper investigates the relationship between length of stay and readmission within 30 days of discharge from an acute care hospitalization. It applies a two-part model to data on Medicare patients treated for heart attack in New York state hospitals during 2008 to obtain the expected cost of readmission associated with length of stay. The expected cost of a readmission is compared with the marginal cost of an additional day in the initial stay to examine the cost trade-off between an extra day of care and the expected cost of readmission. The cost of an additional day of stay was offset by expected cost savings from an avoided readmission in the range of 15% to 65%. Results have implications for payment reform based on bundled payment reimbursement mechanisms.

Diffuse skeletal muscle metastases from sacral chordoma.

Chordomas are rare, slow-growing tumors arising from cellular remnants of the notochord. They account for 1-4% of primary malignant bone tumors and usually occur in the axial skeleton, most commonly the sacrum. Although typically locally recurrent, chordoma metastasis rates as high as 10-42% have been reported. While spread to multiple organ systems has been documented, metastatic disease to skeletal muscle is extremely rare. We present a case of extensive, multifocal skeletal muscle metastases developing in the setting of recurrent sacral chordoma. Our literature search found only one additional case of metastatic chordoma to a single skeletal muscle.

Mental health care provision in community health centers and hospital emergency department utilization.

OBJECTIVES: To examine whether community health centers (CHCs) are effective in offsetting mental health emergency department (ED) visits. DATA SOURCES AND STUDY SETTING: The HRSA Uniform Data System and the HCUP State ED Databases for Florida patients during 2012-2019. STUDY DESIGN: We identified CHC-year-specific service areas using patient origin zip codes. We then estimated panel data models for number of ED mental health visits per capita in a CHC's service area. Models measured CHC mental health utilization as number of visits, unique patients, and intensity (visits per patient). PRINCIPAL FINDINGS: CHC mental health utilization increased approximately 100% during 2012-2019. Increased CHC mental health provision was associated with small reductions in ED mental health utilization. An annual increase of 1000 CHC mental health care visits (5%) was associated with 0.44% fewer ED mental health care visits (p = 0.153), and an increase of 1000 CHC mental health care patients (15%) with 1.9% fewer ED mental health care visits (p = 0.123). An increase of 1 annual mental health visit per patient was associated with 16% fewer ED mental health care visits (p = 0.011). CONCLUSIONS: Results suggest that mental health provision in CHCs may reduce reliance on hospital EDs, albeit minimally. Policies that promote alignment of services between CHCs and local hospitals may accelerate this effect.

Association between physician-hospital integration and inpatient care delivery in accountable care organizations: An instrumental variable analysis.

OBJECTIVE: To investigate the relationship between physician-hospital integration within accountable care organizations (ACOs) and inpatient care utilization and expenditure. DATA SOURCES: The primary data were Massachusetts All-Payer Claims Database (2009-2013). STUDY SETTING: Fifteen provider organizations that entered a commercial ACO contract with a major private payer in Massachusetts between 2009 and 2013. STUDY DESIGN: Using an instrumental variable approach, the study compared inpatient care delivery between patients of ACOs demonstrating high versus low integration. We measured physician-hospital integration within ACOs by the proportion of primary care physicians in an ACO who billed for outpatient services with a place-of-service code indicating employment or practice ownership by a hospital. The study sample comprised non-elderly adults who had continuous insurance coverage and were attributed to one of the 15 ACOs. Outcomes of interest included total medical expenditure during an episode of inpatient care, length of stay (LOS) of the index hospitalization, and 30-day readmission. An inpatient episode was defined as 30, 45, and 60 days from the admission date. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: The study examined 33,535 admissions from patients served by the 15 ACOs. Average medical expenditure within 30 days of admission was $24,601, within 45 days was $26,447, and within 60 days was $28,043. Average LOS was 3.5 days, and 5.4% of patients were readmitted within 30 days. Physician-hospital integration was associated with a 10.6% reduction in 30-day expenditure (95% CI, -15.1% to -5.9%). Corresponding estimates for 45 and 60 days were - 9.7% (95%CI, -14.2% to -4.9%) and - 9.6% (95%CI, -14.3% to -4.7%). Integration was associated with a 15.7% decrease in LOS (95%CI, -22.6% to -8.2%) but unrelated to 30-day readmission rate. CONCLUSIONS: Our instrumental variable analysis shows physician-hospital integration with ACOs was associated with reduced inpatient spending and LOS, with no evidence of elevated readmission rates.

A Comparison of Telemedicine and Office Visit Payments in a Commercially Insured Population.

In recent years, commercial insurers have been slowly advancing coverage for telemedicine, raising questions regarding payment. Many states now have laws that address telemedicine reimbursement and as of 2019, 10 required full payment parity. Using a large commercial insurance claims database, this study conducted two natural experiments to better understand whether payment parity is effective in driving more telemedicine provision. Payments for common outpatient procedures provided by telemedicine and in offices during 2018-2019 were examined according to whether the service was subject to payment parity. For medical visits, evidence of payment incentives in promoting telemedicine was limited, and for psychotherapy telemedicine payments were comparable or greater than office visit payments. As telemedicine escalated during the COVID-19 peak and continues to grow beyond the pandemic, a valuable message is that payment parity laws may be a less effective strategy for encouraging telemedicine use than presumed by many state policymakers.

Safety-net hospital performance under Comprehensive Care for Joint Replacement.

OBJECTIVE: To investigate the relative progress of safety-net hospitals (SNHs) under Medicare's Comprehensive Care for Joint Replacement (CJR) mandatory bundled payment model over 2016-2020 and to identify the contributors to SNHs' realization of success under the program. DATA SOURCES/STUDY SETTING: Secondary data on all CJR hospitals were collected from the Centers for Medicare and Medicaid Services (CMS) public use files and from the American Hospital Association. STUDY DESIGN: We addressed whether SNHs can achieve progress in financial performance under CJR by focusing on the relative change in reconciliation payments or the difference between episode spending and target prices. We applied the method of dominance analysis to ordinary least squares regression to determine the relative importance of predictors of change in reconciliation payments over time. PRINCIPAL FINDINGS: Compared to CJR hospitals overall, SNHs were less successful in meeting episode spending targets. Hospital factors dominated socioeconomic factors in explaining progress among SNHs, but not among non-SNHs. The contribution of nurse staffing was negligible across all CJR hospitals. CONCLUSIONS: The formula used by CMS to determine spending targets may not be sufficient to address disparities in SNH financial performance under mandatory bundled payment.

Use of abdominopelvic computed tomography in emergency departments and rates of urgent diagnoses in Crohn's disease.

BACKGROUND & AIMS: In the United States, the use of abdominopelvic computed tomography (APCT) by emergency departments for patients with abdominal pain has increased, despite stable admission rates and diagnosis requiring urgent intervention. We proposed that trends would be similar for patients with Crohn's disease (CD). METHODS: We conducted a retrospective study of data from 648 adults with CD who presented at 2 emergency departments (2001-2009; 1572 visits). Trends in APCT use were assessed with Spearman correlation coefficient. We compared patient characteristics and APCT findings during 2001-2003 and 2007-2009. RESULTS: APCT use increased from 2001 (used for 47% of encounters) to 2009 (used for 78% of encounters; P = .005), whereas admission rates were relatively stable at 68% in 2001 and 71% in 2009 (P = .06). The overall proportion of APCTs with findings of intestinal perforation, obstruction, or abscess was 29.0%; 34.9% of APCTs were associated with urgent diagnoses, including those unrelated to CD. Between 2001-2003 and 2007-2009, the proportions of APCTs that detected intestinal perforation, obstruction, or abscess were similar (30% vs 29%, P = .92), as were the proportions used to detect any diagnosis requiring urgent intervention, including those unrelated to CD (36% vs 34%, P = .91). CONCLUSIONS: Despite the increased use of APCT by emergency departments for patients with CD, there were no significant changes in admission rates between the periods of 2001-2003 and 2007-2009. The proportion of APCTs that detected intestinal perforation, obstruction, abscess, or other urgent conditions not related to CD remained high.

The association between serious psychological distress and emergency department utilization among young adults in the USA.

PURPOSE: Psychological problems could lead to several adverse health outcomes and were strongly correlated with cigarette smoking and alcohol consumption. In addition, patients treated in EDs were vulnerable to psychological problems. We therefore examined the population-level association between serious psychological distress (SPD) and emergency department (ED) use among young adults in the USA. We also studied the additive effects of SPD, cigarette smoking, and alcohol consumption on the ED presentation. METHODS: The study sample contains 16,873 individuals, using data from the National Health Interview Survey, from 2004 to 2006. Bivariate analyses with chi-square tests and logistic regression analyses are performed. RESULTS: Young adults having SPD were 2.05 times more likely to go to an ED. People having SPD and being a current smoker were 2.52 times more likely to use services in an ED. However, people having SPD and being a heavy drinker did not have a significantly elevated risk of ED use. CONCLUSION: An association between SPD and ED use among US young adults is established in this study. Attempts to decrease excess ED use and the development of strategies to improve mental health among young adults are needed to improve patient health and reduce the health-care burden of high costs and deteriorating ED care quality.

Evolving role of FDG PET imaging in assessing joint disorders: a systematic review.

Assessing joint disorders has been a relatively recent and evolving application of 18F-2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) imaging. FDG is taken up by inflammatory cells, particularly when they are active as part of an ongoing inflammatory process. Hence FDG PET has been employed to assess a wide array of arthritic disorders. FDG PET imaging has been investigated in various joint diseases for diagnostic purposes, treatment monitoring, and as a prognostic indicator as in other disorders. In some of the diseases the ancillary findings in FDG PET have provided important clues about the underlying pathophysiology and pathogenesis processes. While substantial promise has been demonstrated in a number of studies, it is clear that the potential utility of PET in this clinical realm far outweighs that which has been established to date.

Measuring the cost of hospital adverse patient safety events.

This paper estimates the excess cost of hospital inpatient care due to adverse safety events in the U.S. Department of Veterans Affairs (VA) hospitals during fiscal year 2007. We measured adverse events according to the Patient Safety Indicator (PSI) algorithms of the Agency for Healthcare Research and Quality. Patient level cost regression analyses were performed using generalized linear modeling techniques. Accounting for the heavily skewed distribution of costs among patients having adverse safety events, results suggested that the excess cost of nine different PSIs for VA patients are much higher than previously estimated. We tested sensitivity of results to whether costs were measured by VA's Decision Support System (DSS) that uses local costs of specific inputs, or by the average costing system developed by VA's Health Economics Resource Center. DSS costing appeared to better characterize the high cost patients.

Hospital competition and financial performance: the effects of ambulatory surgery centers.

Ambulatory surgery centers (ASCs), limited-service alternatives for treating surgery patients not requiring an overnight stay, are a health-care service innovation that has proliferated in the U.S. and other countries in recent years. This paper examines the effects of ASC competition on revenues, costs, and profit margins of hospitals that also provided these services as a subset of their general services in Arizona, California, and Texas during the period 1997-2004. We identified all ASCs operating during the period in the 49 Dartmouth Hospital Referral Regions in the three states. The results of fixed effects models suggested that ASCs are meaningful competitors to general hospitals. We found downward pressure on revenues, costs, and profits in general hospitals associated with ASC presence.

Do accountable care organizations differ according to physician-hospital integration?: A retrospective observational study.

ABSTRACT: Physician-hospital integration among accountable care organizations (ACOs) has raised concern over impacts on prices and spending. However, characteristics of ACOs with greater integration between physicians and hospitals are unknown. We examined whether ACOs systematically differ by physician-hospital integration among 16 commercial ACOs operating in Massachusetts.Using claims data linked to information on physician affiliation, we measured hospital integration with primary care physicians for each ACO and categorized them into high-, medium-, and low-integrated ACOs. We conducted cross-sectional descriptive analysis to compare differences in patient population, organizational characteristics, and healthcare spending between the three groups. In addition, using multivariate generalized linear models, we compared ACO spending by integration level, adjusting for organization and patient characteristics. We identified non-elderly adults (aged 18-64) served by 16 Massachusetts ACOs over the period 2009 to 2013.High- and medium-integrated ACOs were more likely to be an integrated delivery system or an organization with a large number of providers. Compared to low-integrated ACOs, higher-integrated ACOs had larger inpatient care capacity, smaller composition of primary care physicians, and were more likely to employ physicians directly or through an affiliated hospital or physician group. A greater proportion of high-/medium-integrated ACO patients lived in affluent neighborhoods or areas with a larger minority population. Healthcare spending per enrollee in high-integrated ACOs was higher, which was mainly driven by a higher spending on outpatient facility services.This study shows that higher-integrated ACOs differ from their counterparts with low integration in many respects including higher healthcare spending, which persisted after adjusting for organizational characteristics and patient mix. Further investigation into the effects of integration on expenditures will inform the ongoing development of ACOs.