Meaningful Use and Hospital Performance on Post-Acute Utilization Indicators.

OBJECTIVES: To examine trends in hospital post-acute utilization indicators and to determine whether improvement in these indicators is associated with attesting to meaningful use (MU). DATA SOURCES: Medicare claims-based, repeated measures on 30-day hospital-wide all-cause readmission and emergency department (ED) utilization rates for 160 short-stay hospitals (2009-2012); Medicare EHR Incentive Program Payments files (2011-2012); and other hospital and market data. STUDY DESIGN: Interrupted time series with concurrent comparison group. PRINCIPAL FINDINGS: Propensity score-weighted multilevel models for change demonstrate that 30-day readmission rates (unadjusted) fell from 13.4 percent in 2009 to 12.1 percent in 2012. Similarly, 30-day ED utilization declined from 18.9 percent to 17.3 percent during the same period. However, MU and non-MU hospitals were indistinguishable vis-à-vis performance. Controlling for hospital and market characteristics, MU was unrelated to 30-day readmission. In contrast, 30-day ED utilization deteriorated. CONCLUSIONS: Hospitals with MU Stage 1 designation did not show significantly higher improvement on post-acute utilization compared to their counterparts without. To achieve gains in quality and safety, potentially associated with EHRs, and to advance care coordination and patient engagement, the regulators should strengthen accountability by linking comprehensive, outcomes-based performance measures to specific MU objectives.

Hospital Postacute Care Referral Networks: Is Referral Concentration Associated with Medicare-Style Bundled Payments?

OBJECTIVE: To evaluate whether Medicare-style bundled payments are lower or higher for beneficiaries discharged from hospitals with postacute care (PAC) referrals concentrated among fewer PAC providers. DATA SOURCE: Medicare Part A and Part B claim (2008-2012) for all beneficiaries residing in any of 17 market areas: the Provider of Service file, the Healthcare Cost Report Information System, and the Dartmouth Atlas. STUDY DESIGN: An observational study in which hospitals were distinguished according to PAC referral concentration, which is the tendency to utilize fewer rather than more PAC providers. We tested the hypothesis that higher referral concentration would be associated with total Medicare bundled payments. DATA COLLECTION/EXTRACTION METHODS: The data represent a convenience sample of market areas that were defined by the locations of grantees from the ONC Beacon Community Program. PRINCIPAL FINDINGS: The four most-used PAC providers accounted for an average of 60 percent of patients discharged from hospitals in the sample. Regression analysis suggested that higher referral concentration was associated with lower Medicare costs per bundle. CONCLUSIONS: Hospitals that tend to use fewer PAC providers may lead to lower costs for payers such as Medicare. The study results reinforce the importance of limited networks for PAC services under bundling arrangements for hospital and PAC payments.

Linking Spending and Quality Indicators to Measure Value and Efficiency in Health Care.

Policy makers and stakeholders have reached a consensus that both quality and spending or resource use indicators should be jointly measured and prioritized to meet the objectives of our health system. However, the relative merits of alternative approaches that combine quality and spending indicators are not well understood. We conducted a literature review to identify different approaches that combine indicators of quality and spending measures to profile provider efficiency in the context of specific applications in health care. Our investigation identified seven alternative models that are either in use or have been proposed to evaluate provider efficiency. We then used publicly available data to profile hospitals using these approaches. Profiles of hospital efficiency using alternative models yielded wide variation in performance, underscoring the importance of model selection. By identifying the current efficiency models and evaluating their trade-offs within specific programmatic contexts, our analysis informs stakeholder and policy maker decisions about how to link quality and spending indicators when measuring efficiency in health care.

Effects of Expanded Coverage for Chiropractic Services on Medicare Costs in a CMS Demonstration.

BACKGROUND: Moderately convincing evidence supports the benefits of chiropractic manipulations for low back pain. Its effectiveness in other applications is less well documented, and its cost-effectiveness is not known. These questions led the Centers for Medicaid and Medicare Services (CMS) to conduct a two-year demonstration of expanded Medicare coverage for chiropractic services in the treatment of beneficiaries with neuromusculoskeletal (NMS) conditions affecting the back, limbs, neck, or head. METHODS: The demonstration was conducted in 2005-2007 in selected counties of Illinois, Iowa, and Virginia and the entire states of Maine and New Mexico. Medicare claims were compiled for the preceding year and two demonstration years for the demonstration areas and matched comparison areas. The impact of the demonstration was analyzed through multivariate regression analysis with a difference-in-difference framework. RESULTS: Expanded coverage increased Medicare expenditures by $50 million or 28.5% in users of chiropractic services and by $114 million or 10.4% in all patients treated for NMS conditions in demonstration areas during the two-year period. Results varied widely among demonstration areas ranging from increased costs per user of $485 in Northern Illinois and Chicago counties to decreases in costs per user of $59 in New Mexico and $178 in Scott County, Iowa. CONCLUSION: The demonstration did not assess possible decreases in costs to other insurers, out-of-pocket payments by patients, the need for and costs of pain medications, or longer term clinical benefits such as avoidance of orthopedic surgical procedures beyond the two-year period of the demonstration. It is possible that other payers or beneficiaries saved money during the demonstration while costs to Medicare were increased.

Racial/Ethnic disparities in patient experience with communication in hospitals: real differences or measurement errors?

BACKGROUND: An important aspect of medical care is clear and effective communication, which can be particularly challenging for individuals based on race/ethnicity. Quality of communication is measured systematically in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, and analyzed frequently such as in the National Healthcare Disparities Report. Caution is needed to discern differences in communication quality from racial/ethnic differences in perceptions about concepts or expectations about their fulfillment. OBJECTIVES: To examine assumptions about the degree of commonality across racial/ethnic groups in their perceptions and expectations, and to investigate the validity of conclusions regarding racial/ethnic differences in communication quality. METHODS: We used 2007 HCAHPS data from the National CAHPS Benchmarking Database to construct racial/ethnic samples that controlled for other patient characteristics (828 per group). Using multiple-groups confirmatory factor analyses, we tested whether the factor structure and model parameters (ie, factor loadings, intercepts) differed across groups. RESULTS: We identified support for basic tests of equivalence across 7 racial/ethnic groups in terms of equivalent factor structure and loadings. Even stronger support was found for Communication with Doctors and Nurses. However, potentially important nonequivalence was found for Communication about Medicines, including instances of statistically significant differences between non-Hispanic whites and non-Hispanic blacks, Asians, and Native Hawaiian/other Pacific Islanders. CONCLUSIONS: Our results provide strongest support for racial/ethnic comparisons on Communication with Nurses and Doctors, and reason to caution against comparisons on Communication about Medicines due to significant differences in model parameters across groups; that is, a lack of invariance in the intercept.

Images of imaging: how to process and display imaging utilization for large populations.

OBJECTIVE: We propose a method of processing and displaying imaging utilization data for large populations. CONCLUSION: The comprehensive and finely grained picture of imaging utilization yielded by our methods is a first step toward population-based imaging utilization management. We believe that our methods for the categorization and display of imaging utilization will prove to be widely useful.

Association of military deployment of a parent or spouse and changes in dependent use of health care services.

BACKGROUND: U.S. Armed Forces members and spouses report increased stress associated with combat deployment. It is unknown, however, whether these deployment stressors lead to increased dependent medication use and health care utilization. OBJECTIVE: To determine whether the deployment of Army active duty members (sponsors) is associated with changes in dependent health care utilization. DESIGN: A quasi-experimental, pre-post study of health care patterns of more than 55,000 nonpregnant spouses and 137,000 children of deployed sponsors and a comparison group of dependents. MEASURES: Changes in dependent total utilization in the military health system, and separately in military-provided and purchased care services in the year following the sponsors' deployment month for office visit services (generalist, specialist); emergency department visits; institutional stays; psychotropic medication (any, antidepressant, antianxiety, antistimulant classes). RESULTS: Sponsor deployment was associated with net increased use of specialist office visits (relative percent change 4.2% spouses; 8.8% children), antidepressants (6.7% spouses; 17.2% children), and antianxiety medications (14.2% spouses; 10.0% children; P<0.01) adjusting for group differences. Deployment was consistently associated with increased use of purchased care services, partially, or fully offset by decreased use of military treatment facilities. CONCLUSIONS: These results suggest that emotional or behavioral issues are contributing to increased specialist visits and reliance on medications during sponsors' deployments. A shift to receipt of services from civilian settings raises questions about coordination of care when families temporarily relocate, family preferences, and military provider capacity during deployment phases. Findings have important implications for the military health system and community providers who serve military families, especially those with children.

Incidence and cost of pneumonia in medicare beneficiaries.

BACKGROUND: Pneumonia is a frequent and serious illness in elderly people, with a significant impact on mortality and health-care costs. Lingering effects may influence clinical outcomes and medical service use beyond the acute hospitalization. This study describes the incidence and mortality of pneumonia in elderly Medicare beneficiaries based on treatment setting (outpatient, inpatient) and location of origin (health-care associated, community acquired) and estimates short- and long-term direct medical costs and mortality associated with an inpatient episode of pneumonia. METHODS: Administrative claims from a 5% sample of fee-for-service Medicare beneficiaries aged ≥ 65 years from 2005 through 2007 were used. Total direct medical costs for patients during and after hospitalization for pneumonia compared with similar patients without pneumonia (the excess cost of pneumonia) were estimated using propensity score matching. RESULTS: The age-adjusted annual cumulative incidence of any pneumonia was 47.4 per 1,000 beneficiaries (13.3 per 1,000 inpatient primary pneumonia), increasing with age; one-half of pneumonia cases were treated in the hospital. Thirty-day mortality was twice as high among beneficiaries with health-care-associated pneumonia than among those hospitalized with community-acquired pneumonia (13.4% vs 6.4%). Total medical costs for beneficiaries during and 1 year following a pneumonia hospitalization were $15,682 higher than matched control patients without pneumonia. The total annual excess cost of hospital-treated pneumonia as a primary diagnosis in the elderly fee-for-service Medicare population in 2010 is estimated conservatively at > $7 billion. CONCLUSIONS: Pneumonia in elderly people is associated with high acute-care costs and an overall impact on total direct medical costs and mortality during and after an acute episode.

A randomized trial of telemonitoring heart failure patients.

The purpose of this study was to measure the ability of telemonitoring to reduce hospital days and total costs for Medicare managed care enrollees diagnosed with heart failure. Patients were recruited and randomly assigned for six months to either telemonitoring or standard care. Telemonitoring transmitted vital signs and clinical alerts daily to a central nursing station. Utilization of covered services was analyzed for the six-month telemonitoring period to test for hypothesized reductions in hospital days and changes in utilization of the emergency department (ED), urgent care, and primary care. Negative binomial regressions adjusted for gender, age, co-occurring diabetes, co-occurring chronic obstructive pulmonary disease, and residence neighborhood were used to analyze units of service, and two-part (hurdle) multivariable models were used for expenditures. The main finding was a tendency for lower total number of hospital days for patients assigned to telemonitoring. Results for other covered services were generally consistent with hypothesized direction and magnitude; however, statistical power was reduced because of lower-than-expected recruitment rates into the study. Within a managed-care environment, telemonitoring appears to facilitate better ambulatory management of heart failure patients, including fewer ED visits, which were offset by more frequent primary care and urgent care visits.

Emergency department utilization patterns for Medicare beneficiaries with serious mental disorders.

OBJECTIVE: This study examined emergency department use among Medicare beneficiaries with serious mental disorders. METHODS: Drawn from the 2004 national 5% sample of Medicare beneficiaries, the sample in this study (N=129,805) included fee-for-service enrollees with primary diagnoses of schizophrenia, major depression, other major affective disorders, or other psychoses. Emergency department use was compared by psychiatric diagnostic category and presence of a claim related to substance use disorder. RESULTS: Having any emergency department visit was common for beneficiaries aged >or=65 years (58.3%) and beneficiaries <65 years who were Medicare eligible because of a disability (48.5%). Emergency department visits with a primary psychiatric diagnosis occurred for 14.8% of disabled beneficiaries and 6.7% of aged beneficiaries. Use varied by diagnosis and was higher for those with any substance-related claims (p<.01). CONCLUSIONS: Emergency department use was common in the sample. Within each eligibility category, use varied by psychiatric diagnostic category and presence of a substance-related claim.

The relationship between Medicare's process of care quality measures and mortality.

Using Medicare inpatient claims and Hospital Compare process of care quality data from the period 2004-2006, we estimate two model specifications to test for the presence of correlational and causal relationships between hospital process of care performance measures and risk-adjusted (RA) 30-day mortality for heart attack, heart failure, and pneumonia. Our analysis indicates that while Hospital Compare process performance measures are correlated with 30-day mortality for each diagnosis, after we account for unobserved heterogeneity, process of care performance is no longer associated with mortality for any diagnosis. This suggests that the relationship between hospital-level process of care performance and mortality is not causal. Implications for pay-for-performance are discussed.

Measuring outcomes and efficiency in medicare value-based purchasing.

The Medicare program may soon adopt value-based purchasing (VBP), in which hospitals could receive incentives that are conditional on meeting specified performance objectives. The authors advocate for a market-oriented framework and direct measures of system-level value that are focused on better outcomes and lower total cost of care. They present a multidimensional framework for measuring outcomes of care and a method to adjust incentive payments based on efficiency. Incremental reforms based on VBP could provoke transformational changes in total patient care by linking payments to value related to the whole patient experience, recognizing shared accountability among providers.

The impact of publicly funded managed care on adolescent substance abuse treatment outcomes.

This study compares the 12-month changes in substance use following admission to substance abuse treatment in Massachusetts between adolescents enrolled in Medicaid managed care and other publicly funded adolescents. Two hundred and fifty-five adolescents were interviewed as they entered substance abuse treatment and at 6 and 12 month follow-ups. Medicaid enrollment data were used to determine the managed care enrollment status. One hundred forty two (56%) adolescents were in the managed care group and 113 (44%) comprise the comparison group. Substance use outcomes include a count of negative consequences of substance use, days of alcohol use, days of cannabis use, and days of any substance use in the previous 30 days. Repeated measures analysis of covariance (ANCOVA) was used to assess change with time of measurement and managed care status as main effects and the interaction of time and managed care included to measure differences between the groups over time. Although several changes across time were detected for all four outcomes, we found no evidence of an impact of managed care for any of the outcomes. The results of our study do not support the fears that behavioral managed care, by imposing limits on services provided, would substantially reduce the effectiveness of substance abuse treatment for adolescents. At the same time, the results do not support those who believe that the continuity of care and improved resource utilization claimed for managed care would improve outcomes.

The precarious pricing system for hospital services.

Over the past twenty-five years, the average ratio of hospital charges for services (gross revenues) to payments received (net revenues) has grown from 1.1 to 2.6. This reflects a transition from predominantly cost- and charge-based payment systems to regulated and negotiated fixed payments. Hospitals have been able to squeeze additional revenues from remaining charge-based payers and services by sharply increasing charges, negatively affecting the uninsured. Although protection of the uninsured seems warranted, it might be difficult to regulate hospital pricing systems in isolation from other controversial issues, such as the acceptability of cross-subsidies and the role of market forces.

Using information to guide managed behavioral health care.

This evaluation of substance abuse and mental health treatment services in Arizona discusses and illustrates the use of data already collected by the State to manage and monitor the public behavioral health sector. The authors utilize a framework that focuses on rate-setting and financial incentives; provider profiling and education; and monitoring of data quality and system-wide performance. Information and analysis can contribute to key management activities and forces that guide behavior in the system toward optimal system performance. Using data from 33,208 Medicaid-covered and uninsured adults, service mix varied substantially by region; for example, spending on residential care ranged from 0% to 40% for substance abuse treatment clients. By focusing on a smaller group of client with functional assessments, it also appears that regional spending levels varied considerably, for reasons not explained by client demographics or clinical measures. Finally, longitudinal data show that the regional managed care organizations are moving in different directions with regard to client mix and spending priorities. All of this variation suggests that there may be considerable latitude to guide and improve system-wide performance.

Escalating health care spending: is it desirable or inevitable?

This study analyzes changing trends in U.S. health spending and concludes that although the long-term growth trend has been a good predictor of future spending, periodic differences in the growth trend are important. Of particular concern is the rapid acceleration in health spending beginning in 1998. If left unchecked, the current growth rate will result in almost 24 percent of GDP spent on health by 2011. The authors question whether such unconstrained spending levels are either desirable or inevitable, and they offer a guide to how the United States might develop a long-term cost-containment strategy that is both effective and sustainable.

Realigning incentives in fee-for-service Medicare.

This paper proposes Medicare payment reform built on the fee-for-service system, with incentive payments to eligible provider organizations determined by their rate of increase in cost per patient compared to the overall growth rate in the community. By planning and monitoring how care patterns are altered to achieve greater efficiency, policy-makers can align the incentives of Medicare and the provider organization better than using either fee-for-service or capitation alone. This reform, unlike capitation, maintains Medicare's historical role as insurer and focuses providers on managing care.

Prevalence and costs of major depression among elderly claimants with diabetes.

OBJECTIVE: To compare the odds of major depression among Medicare claimants with and without diabetes and to test whether annual medical payments are greater for those with both diabetes and major depression than for those with diabetes alone. RESEARCH DESIGN AND METHODS: This retrospective analysis relies on claims data from the 1997 Medicare 5% Standard Analytic Files. Using these data, we statistically determined whether the odds of major depression are greater among elderly claimants with diabetes after controlling for age, race/ethnicity, and sex. We then used regression analysis on a sample of over 220,000 elderly claimants with diabetes to test whether payments for non-mental health-related services are greater for those with both diabetes and major depression (n = 4,203) than for those with diabetes alone. RESULTS: Our findings indicate that the odds of major depression are significantly greater among elderly Medicare claimants with diabetes than among those without diabetes (OR 1.58 +/- 0.05). We also found that elderly claimants with both diabetes and major depression seek treatment for more services and spend more time in inpatient facilities, and as a result incur higher medical costs than claimants with diabetes but without major depression. These results hold even after excluding services related to mental health treatment. CONCLUSIONS: This analysis suggests that treatment for major depression among claimants with diabetes may reduce total medical costs if treatment results in a decrease in utilization for general medical services in the future.

An examination of factors in the withdrawal of managed care plans from the Medicare+Choice program.

Participation of health maintenance organizations (HMOs) in the Medicare+Choice program, expected to rise rapidly after passage of the Balanced Budget Act of 1997, has gone in just the opposite direction. Because plans have left in such large numbers, Congress has taken remedial measures to remove restrictions and increase payments. To date these efforts have failed. This paper uses plan organizational characteristics, market position, and financial performance to quantify the reasons why some HMOs exited at the end of 1998. The findings suggest HMO participation in Medicare+Choice will continue to fall unless major changes are made to the overall Medicare program and the method of paying HMOs.