A Medicaid Benefit for Health-Related Social Needs.

This Viewpoint explores a recent advancement to improve outcomes and reduce costs within state Medicaid programs, Section 1115 demonstration waivers.

Financial Performance of Hospitals in the Appalachian Region Under the Hospital Readmissions Reduction Program and Hospital Value-Based Purchasing Program.

PURPOSE: The Hospital Readmission and Reduction Program (HRRP) and Hospital Value-Based Purchasing Program (HVBP) propose to improve quality of patient care by either rewarding or penalizing hospitals through inpatient reimbursement. This study analyzes the effect of both programs on profitability of hospitals located in the Appalachian Region (AR) compared to hospitals in Appalachian states and the rest of the United States. METHODS: This study used a retrospective research design with a longitudinal unbalanced panel dataset from 2008 to 2015. Hospitals participating in both HRRP and HVBP during this time frame were included in the study. A difference-in-difference model with hospital-level fixed effects, controlling for hospital and market characteristics, was used to determine effects of both programs on profitability of hospitals serving the AR, Appalachian states, and the rest of the United States. FINDINGS: After implementation of HRRP and HVBP, only hospitals located in Appalachian states experienced a significant decrease in operating margin (-1.14 percentage points). Unexpectedly, during the same time period, total margin increased significantly for hospitals located in the AR (1.05 percentage points), Appalachian states (1.71 percentage points), and the rest of the United States (2.38 percentage points). CONCLUSIONS: HRRP and HVBP financially incentivize hospitals to focus efforts on improving patient care. The programs may not have the anticipated results. Increases in total margin for all hospitals during the study period indicate access to nonpatient revenues, offsetting the financial penalties from both programs. This revenue source may undermine the program's objectives of delivering value and achieving quality outcomes.

Risk-based contracting for high-need Medicaid beneficiaries: The Arkansas PASSE program.

The high cost of health care for people with behavioral health (BH) conditions or intellectual and developmental disabilities (IDD) in the United States led one state to implement the Provider-led Arkansas Shared Savings Entity (PASSE) program. PASSE is a managed care model that puts provider-led organizations at risk for the highest need people with BH conditions or IDD in Medicaid, a public health insurance program for low-income residents. Drawing on key informant interviews and payment models across the United States, we describe the PASSE program, how it compares with state Medicaid programs for similar populations, and prospects for the program. Key informants cited several PASSE features as promising mechanisms to improve beneficiary outcomes: expanded care coordination, service flexibility, incentives for community investments, accountability for cost and quality across physical health, behavioral health, and long-term care, quality target accountability, fostered competition, and provider ownership. Informants worry that PASSE features will be insufficient to catalyze changes in provider behavior. Efforts may be targeted to control costs primarily through service reductions with uncertain effects on quality of care. PASSE hinges on improved care coordination and increased efforts to address social determinants of health. Success or failure in these areas will likely determine whether PASSE leads to improved outcomes for two of the most costly and vulnerable populations.

Improving quality of life assessments for high-need adult Medicaid service users with mental health conditions.

PURPOSE: There is a lack of consensus on how to evaluate health and social service programs for people with mental health (MH) conditions. Having service users be the primary decision makers in selecting outcome measures can inform a meaningful evaluation strategy. We sought to identify the quality of life (QoL) survey preferences of high-need adult service users with MH conditions. METHODS: A systematic review identified generic, self-reported QoL surveys with evidence of validity in MH populations of interest. An advisory panel selected the most promising surveys to assess the success of programs like Medicaid for MH service users. Three groups of high-need, adult service users with MH conditions and one group of direct care staff ranked the surveys from the advisory panel, and generated and ranked characteristics that were desirable or undesirable in a QoL survey. RESULTS: Twenty-two surveys met the inclusion criteria. Of the six surveys selected by the advisory panel, groups of service users and direct care staff most preferred the Warwick-Edinburg Mental Well-being Scale (WEMWBS). The WEMWBS best embodied the features prioritized by the groups: to have a user-friendly format and positive focus, to be clearly worded and brief, and to avoid presumptive or unrealistic items. Service user groups appreciated survey topics most amenable to self-report, such as satisfaction with relationships. CONCLUSION: Using QoL surveys that service users prefer can reduce the chance that deteriorating QoL is going unchecked, and increase the chance that decisions based on survey findings are meaningful to service users.

Financial Performance of Hospitals in the Mississippi Delta Region Under the Hospital Readmissions Reduction Program and Hospital Value-based Purchasing Program.

BACKGROUND: Previous studies showed that the Hospital Readmissions Reduction Program (HRRP) and the Hospital Value-based Purchasing Program (HVBP) disproportionately penalized hospitals caring for the poor. The Mississippi Delta Region (Delta Region) is among the most socioeconomically disadvantaged areas in the United States. The financial performance of hospitals in the Delta Region under both HRRP and HVBP remains unclear. OBJECTIVE: To compare the differences in financial performance under both HRRP and HVBP between hospitals in the Delta Region (Delta hospitals) and others in the nation (non-Delta hospitals). RESEARCH DESIGN: We used a 7-year panel dataset and applied difference-in-difference models to examine operating and total margin between Delta and non-Delta hospitals in 3 time periods: preperiod (2008-2010); postperiod 1 (2011-2012); and postperiod 2 (2013-2014). RESULTS: The Delta hospitals had a 0.89% and 4.24% reduction in operating margin in postperiods 1 and 2, respectively, whereas the non-Delta hospitals had 1.13% and 1% increases in operating margin in postperiods 1 and 2, respectively. The disparity in total margins also widened as Delta hospitals had a 1.98% increase in postperiod 1, but a 0.30% reduction in postperiod 2, whereas non-Delta hospitals had 1.27% and 2.28% increases in postperiods 1 and 2, respectively. CONCLUSIONS: The gap in financial performance between Delta and non-Delta hospitals widened following the implementation of HRRP and HVBP. Policy makers should modify these 2 programs to ensure that resources are not moved from the communities that need them most.