Medicare Durable Medical Equipment Competitive Bidding Program: An Evaluation.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) implemented the Medicare durable medical equipment (DME) Competitive Bidding Program (CBP) in 2011. Since then, concerns have been raised regarding access to equipment and adverse health outcomes. OBJECTIVES: The aim was to evaluate whether the CBP was associated with changes in spending, utilization, and adverse health events (emergency department visits, hospitalizations, and falls). RESEARCH DESIGN: A comparative interrupted time series over 8 years was used to compare Round1 and Round2 bidding to nonbidding areas. Medicare fee for services claims were aggregated at the quarterly Metropolitan Statistical Area (MSA) level from 2009 to 2016. RESULTS: For the 3 evaluated DME (continuous positive airway pressure machines, oxygen supplies, and walkers), we found that implementation of the Medicare CBP was associated with reductions in per capita spending without changes in DME utilization or adverse health outcomes in CBP areas compared with nonbidding areas. For example, the slope change in the proportion of oxygen supplies purchasers in Round1 areas after implementation of Round1 was similar to the slope change in nonbidding areas (-0.0002; 95% CI: -0.0004, 0.0001; P=0.189). The difference in slope changes of emergency department visits and hospitalization in Round1 areas for oxygen supplies were (-0.0004; 95% CI: -0.0016, 0.0008; P=0.514) and (0.0002; 95% CI: -0.0010, 0.0014; P=0.757), respectively. Findings in Round2 areas after implementation of Round2 were similar to findings in Round1 areas. CONCLUSIONS: The Medicare DME CBP lowered Medicare expenditures while not reducing beneficiary access or increasing adverse outcomes.

Association between specialist compensation and Accountable Care Organization performance.

OBJECTIVE: To determine if Medicare Shared Savings Program Accountable Care Organizations (ACOs) using cost reduction measures in specialist compensation demonstrated better performance. DATA SOURCES: National, cross-sectional survey data on ACOs (2013-2015) linked to public-use data on ACO performance (2014-2016). STUDY DESIGN: We compared characteristics of ACOs that did and did not report use of cost reduction measures in specialist compensation and determined the association between using this approach and ACO savings, outpatient spending, and specialist visit rates. PRINCIPAL FINDINGS: Of 160 ACOs surveyed, 26 percent reported using cost reduction measures to help determine specialist compensation. ACOs using cost reduction in specialist compensation were more often physician-led (68.3 vs 49.6 percent) and served higher-risk patients (mean Hierarchical Condition Category score 1.09 vs 1.05). These ACOs had similar savings per beneficiary year (adjusted difference $82.6 [95% CI -77.9, 243.1]), outpatient spending per beneficiary year (-24.0 [95% CI -248.9, 200.8]), and specialist visits per 1000 beneficiary years (369.7 [95% CI -9.3, 748.7]). CONCLUSION: Incentivizing specialists on cost reduction was not associated with ACO savings in the short term. Further work is needed to determine the most effective approach to engage specialists in ACO efforts.

How Do Frail Medicare Beneficiaries Fare Under Bundled Payments?

BACKGROUND/OBJECTIVES: Bundled payments are an alternative payment model in which a hospital takes accountability for the costs of a 90-day episode of care. Such models are meant to improve care through better coordination across care settings, but could have adverse consequences for frail adults if they lead to inappropriate cuts in necessary post-acute care. DESIGN: Retrospective claims-based analysis of hospitals' first year of participation in Medicare's Bundled Payments for Care Improvement (BPCI) program. SETTING: US hospitals. PARTICIPANTS: A total of 641 146 Medicare beneficiaries admitted to 688 BPCI programs and 1276 matched control hospitals for myocardial infarction, heart failure, pneumonia, sepsis, chronic obstructive pulmonary disease, or major joint replacement of the lower extremity in 2012 to 2016. INTERVENTION: Participation in BPCI. MEASUREMENTS: Proportion of patients in each quartile of a validated claims-based frailty index, total and setting-specific standardized Medicare payments per episode, days at home, 90-day readmissions, and 90-day mortality. RESULTS: Higher levels of frailty were associated with higher Medicare payments and worse clinical outcomes (for the medical composite, costs per episode were $11 921, $17 348, $22 828, and $29 157 across frailty quartiles; days at home were 70.1, 60.4, 54.3, and 51.5; 90-day readmission rates were 16.0%, 27.0%, 38.2%, and 50.9%; and 90-day mortality rates were 15.4%, 22.5%, 25.1%, 21.3%); patterns were similar for joint replacement. Under the BPCI program, there was no differential change in the proportion of highly frail patients at BPCI vs control hospitals. There were also no differential deleterious changes in payments or clinical outcomes for frail relative to nonfrail patients at BPCI vs non-BPCI hospitals. CONCLUSION: While frail patients had higher costs and worse outcomes in general, there was no evidence of changes in access or worsening clinical outcomes in BPCI hospitals for frail patients relative to the nonfrail in hospitals' first year of participation in the program. These findings may be reassuring for policy makers and clinical leaders. J Am Geriatr Soc 67:2245-2253, 2019.

Inter-hospital transfer and patient outcomes: a retrospective cohort study.

BACKGROUND: Inter-hospital transfer (IHT, the transfer of patients between hospitals) occurs regularly and exposes patients to risks of discontinuity of care, though outcomes of transferred patients remains largely understudied. OBJECTIVE: To evaluate the association between IHT and healthcare utilisation and clinical outcomes. DESIGN: Retrospective cohort. SETTING: CMS 2013 100 % Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data. PARTICIPANTS: Beneficiaries≥age 65 enrolled in Medicare A and B, with an acute care hospitalisation claim in 2013 and 1 of 15 top disease categories. MAIN OUTCOME MEASURES: Cost of hospitalisation, length of stay (LOS) (of entire hospitalisation), discharge home, 3 -day and 30- day mortality, in transferred vs non-transferred patients. RESULTS: The final cohort consisted of 53 420 transferred patients and 53 420 propensity-score matched non-transferred patients. Across all 15 disease categories, IHT was associated with significantly higher costs, longer LOS and lower odds of discharge home. Additionally, IHT was associated with lower propensity-matched odds of 3-day and/or 30- day mortality for some disease categories (acute myocardial infarction, stroke, sepsis, respiratory disease) and higher propensity-matched odds of mortality for other disease categories (oesophageal/gastrointestinal disease, renal failure, congestive heart failure, pneumonia, renal failure, chronic obstructivepulmonary disease, hip fracture/dislocation, urinary tract infection and metabolic disease). CONCLUSIONS: In this nationally representative study of Medicare beneficiaries, IHT was associated with higher costs, longer LOS and lower odds of discharge home, but was differentially associated with odds of early death and 30 -day mortality depending on patients' disease category. These findings demonstrate heterogeneity among transferred patients depending on the diagnosis, presenting a nuanced assessment of this complex care transition.

Has development assistance for health facilitated the rise of more peaceful societies in sub-Saharan Africa?

Growing evidence suggests that health aid can serve humanitarian and diplomatic ends. This study utilised the Fragile States Index (FSI) for the 47 nations of the World Health Organizations' Africa region for the years 2005-2014 and data on health and non-health development aid spending from the United States (US) for those same years. Absolute amounts of health and non-health aid flows from the US were used as predictors of state fragility. We used time-lagged, fixed-effects multivariable regression modelling with change in FSI as the outcome of interest. The highest quartile of US health aid per capita spending (≥$4.00 per capita) was associated with a large and immediate decline in level of state fragility (b = -7.57; 95% CI, -14.6 to -0.51, P = 0.04). A dose-response effect was observed in the primary analysis, with increasing levels of spending associated with greater declines in fragility. Health per-capita expenditures were correlated with improved fragility scores across all lagged intervals and spending quartiles. The association of US health aid with immediate improvements in metrics of state stability across sub-Saharan Africa is a novel finding. This effect is possibly explained by our observations that relative to non-health aid, US health expenditures were larger and more targeted.

Differences in Patient Experience Between Hispanic and Non-Hispanic White Patients Across U.S. Hospitals.

INTRODUCTION: Despite the increased emphasis on patient experience, little is known about whether there are meaningful differences in hospital satisfaction between Hispanic and non-Hispanic whites. METHODS: To determine if satisfaction differs, we used Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data (2009-2010) reported by hospitals to compare responses between Hispanic and non-Hispanic white patients. Clustered logistic regression models identified within-hospital and between-hospital differences in satisfaction. RESULTS: Of the 3,864,938 respondents, 6.2% were Hispanics, who were more often younger and females and less likely to have graduated from high school. Hispanics were overall more likely to recommend their hospital (74.1% vs. 70.9%, p < .001) and to rate it 9 or 10 (72.5% vs. 65.9%, p < .001) than whites. Increased satisfaction among Hispanics was more pronounced when compared with whites within the same hospitals, with significantly higher ratings on all HCAHPS measures. However, hospitals serving a higher percentage of Hispanics had lower satisfaction scores for both Hispanic and white patients than other hospitals. CONCLUSION: There were significant but only modest-sized differences in patient experience between Hispanic and white patients across U.S. hospitals. Hispanics tended to be more satisfied with their care but received care at lower-performing hospitals.

Characteristics of adult psychiatric patients with stays of 24 hours or more in the emergency department.

OBJECTIVE: This study identified characteristics of adult psychiatric patients who remained for 24 or more hours in the emergency departments of general hospitals in Massachusetts. METHODS: Data were collected starting in June 2008 on a prospective cohort of 1,076 patients who presented for emergency psychiatric evaluation at one of five hospitals. RESULTS: A total of 90 patients (8%) stayed 24 or more hours (median=31 hours). More than 90% (N=1,018) of all patients had health insurance. Characteristics associated with extended stays included homelessness, transfer to another hospital, public insurance, and use of restraints or sitters (p<.05). The two academic medical centers had higher proportions of extended-stay patients than the three community hospitals (12% and 15% versus 1%, 7%, and 7%, respectively; p<.001). CONCLUSIONS: Despite overall high rates of health insurance coverage, publicly insured patients waited longer than those with private insurance. Future reforms of Massachusetts' mandatory health insurance program should consider treatment capacity as well.

Evaluation of the contributions of an electronic web-based reporting system: enabling action.

BACKGROUND: Incident reporting represents a key tool in safety improvement. Electronic voluntary reporting systems have been perceived as advantageous compared to paper approaches and are increasingly being implemented. OBJECTIVES: To evaluate the rate, content, ease of use, reporters' profile, and the follow-up and actions resulting from reports submitted to a Web-based electronic reporting system. METHODS: Analysis of the submitted reports to a commercial Web-based reporting system at a tertiary care academic hospital for 31 months between May 2004 and November 2006. RESULTS: During the study period, 14,179 reports were submitted. The leading incident categories were labs (30%), followed by medication issues (17%), falls (11%), and blood bank (10%). Of the reported incidents, 24% were near misses, 61% were adverse events that caused no harm, 14% caused temporary harm, 0.4% caused permanent harm, and 0.1% caused death. Of the eligible staff, 29% submitted a report during the study period. Physicians submitted only 2.9% of the reports; most reports were submitted by nurses, pharmacists, and technicians. Physicians tended to report on more severe cases and focused on different topics than other professionals. Overall, 84% of the reports came from the inpatient setting. On average, it took 14 minutes to submit a report. In following up on reports, first manager review was completed within a median of 22 hours, and a mean of 4 people reviewed each report. A large array of actions followed the reports. CONCLUSIONS: This application effectively captured incidents, actions, and follow-up. Ease of data manipulation facilitated descriptive statistical analysis, and the ability to use branching algorithms may have helped in decision making about actions and follow-up.