Providing Behavioral Health Care in PACE - A Review of Federal and State Manual Regulations.

OBJECTIVES: Present analysis of the federal and state regulations that guide The Program of All-Inclusive Care for the Elderly (PACE) operations and core clinical features for direction on behavioral health (BH). DESIGN: Review and synthesize the federal (Centers for Medicare and Medicaid Services [CMS]) and all publicly available state manuals according to the BH-Serious Illness Care (SIC) model domains. SETTING AND PARTICIPANTS: The 155 PACE organizations operating in 32 states and the District of Columbia. METHODS: A multipronged search was conducted to identify official state and federal manuals guiding the implementation and functions of PACE organizations. The CMS PACE website was used to identify the federal PACE manual. State-level manuals for 32 states with PACE programs were identified through several sources, including official PACE websites, contacts through official websites, the National PACE Association (NPA), and public and academic search engines. The manuals were searched according to the BH-SIC model domains that pertain to integrating BH care with complex care individuals. RESULTS: According to the CMS Manual, the interdisciplinary team is responsible for holistic care of PACE enrollees, but a BH specialist is not a required member. The CMS Manual includes information on BH clinical functions, BH workforce, and structures for outcome measurement, quality, and accountability. Eight of 32 PACE-participating states offer publicly available state PACE manuals; of which 3 offer information on BH clinical functions. CONCLUSIONS AND IMPLICATIONS: Regarding BH, federal and state manual regulations establish limited guidance for comprehensive care service delivery at PACE organizations. The absence of clear directives weakens BH care delivery due to a limiting the ability to develop quality measures and accountability structures. This hinders incentivization and accountability to truly all-inclusive care. Clearer guidelines and regulatory parameters regarding BH care at federal and state levels may enable more PACE organizations to meet rising BH demands of aging communities.

KDOQI US Commentary on the 2020 ISPD Practice Recommendations for Prescribing High-Quality Goal-Directed Peritoneal Dialysis.

The recently published 2020 International Society for Peritoneal Dialysis (ISPD) practice recommendations regarding prescription of high-quality goal-directed peritoneal dialysis differ fundamentally from previous guidelines that focused on "adequacy" of dialysis. The new ISPD publication emphasizes the need for a person-centered approach with shared decision making between the individual performing peritoneal dialysis and the clinical care team while taking a broader view of the various issues faced by that individual. Cognizant of the lack of strong evidence for the recommendations made, they are labeled as "practice points" rather than being graded numerically. This commentary presents the views of a work group convened by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) to assess these recommendations and assist clinical providers in the United States in interpreting and implementing them. This will require changes to the current clinical paradigm, including greater resource allocation to allow for enhanced services that provide a more holistic and person-centered assessment of the quality of dialysis delivered.

Comparative Effectiveness of Rivaroxaban, Apixaban, and Warfarin in Atrial Fibrillation Patients With Polypharmacy.

BACKGROUND AND PURPOSE: Comparative effectiveness and safety of oral anticoagulants in patients with atrial fibrillation and high polypharmacy are unknown. METHODS: We used Medicare administrative data to evaluate patients with new atrial fibrillation diagnosis from 2015 to 2017, who initiated an oral anticoagulant within 90 days of diagnosis. Patients taking ≤3, 4 to 8, or ≥9 other prescription medications were categorized as having low, moderate, or high polypharmacy, respectively. Within polypharmacy categories, patients receiving apixaban 5 mg twice daily, rivaroxaban 20 mg once daily, or warfarin were matched using a 3-way propensity score matching. Study outcomes included ischemic stroke, bleeding, and all-cause mortality. RESULTS: The study cohort included 6985 patients using apixaban, 3838 using rivaroxaban, and 6639 using warfarin. In the propensity-matched cohorts there was no difference in risk of ischemic stroke between the 3 drugs in patients with low and moderate polypharmacy. However, among patients with high polypharmacy, the risk of ischemic stroke was higher with apixaban compared with warfarin (adjusted hazard ratio 2.34 [95% CI, 1.01-5.42]; P=0.05) and similar to rivaroxaban (adjusted hazard ratio, 1.38 [95% CI, 0.67-2.84]; P=0.4). There was no difference in risk of death between the 3 drugs in patients with low and moderate polypharmacy, but apixaban was associated with a higher risk of death compared with rivaroxaban (adjusted hazard ratio, 2.03 [95% CI, 1.01-4.08]; P=0.05) in the high polypharmacy group. Apixaban had lower bleeding risk compared with warfarin in the low polypharmacy group (adjusted hazard ratio, 0.54 [95% CI, 0.32-0.90]; P=0.02), but there was no difference in bleeding between the 3 drugs in the moderate and high polypharmacy groups. CONCLUSIONS: Our study suggests that among patients with significant polypharmacy (>8 drugs), there may be a higher stroke and mortality risk with apixaban compared with warfarin and rivaroxaban. However, differences were of borderline significance.

Mapping colocation: Using national provider identified data to assess primary care and behavioral health colocation.

INTRODUCTION: Evidence supports that integrated behavioral health care improves patient outcomes. Colocation, where health and behavioral health providers work in the same physical space, is a key element of integration, but national rates of colocation are unknown. We established national colocation rates and analyzed variation by primary care provider (PCP) type, practice size, rural/urban setting, Health and Human Services region, and state. METHOD: Data were from the Centers for Medicare & Medicaid Services' 2018 National Plan and Provider Enumeration System data set. Practice addresses of PCPs (family medicine, general practitioners, internal medicine, pediatrics, and obstetrician/gynecologists), social workers, and psychologists were geocoded to latitude and longitude coordinates. Distances were calculated; those < 0.01 miles apart were considered colocated. Bivariate and multivariate analyses were conducted, and maps were generated. RESULTS: Of the 380,690 PCPs, > 44% were colocated with a behavioral health provider. PCPs in urban settings were significantly more likely to be colocated than rural providers (46% vs. 26%). Family medicine and general practitioners were least likely to be colocated. Only 12% of PCPs who were the sole PCP at an address were colocated compared with 48% at medium-size practices (11-25 PCPs). DISCUSSION: Although colocation is modestly expanding in the United States, it is most often occurring in large urban health centers. Efforts to expand integrated behavioral health care should focus on rural and smaller practices, which may require greater assistance achieving integration. Increased colocation can improve access to behavioral health care for rural, underserved populations. This work provides a baseline to assist policymakers and practices reach behavioral health integration. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Reflections on a Crisis in Graduate Medical Education: The Closure of Hahnemann University Hospital.

In June 2019, Hahnemann University Hospital (HUH) in Philadelphia became the largest U.S. teaching hospital to announce its closure and the closure of all of its graduate medical education (GME) programs, which displaced more than 550 residents, fellows, and other trainees. In addition to the displaced trainees, the HUH closure involved many stakeholders at both the closing hospital and hospitals willing to accept transferred residents and fellows-program directors and coordinators, designated institutional officials (DIOs), and hospital executives-as well as the Accreditation Council for Graduate Medical Education, the Centers for Medicare and Medicaid Services, the National Resident Matching Program, and other organizations. Given the rarity of such events, those involved had little experience or expertise in dealing with the closure of so many GME programs at one time. In this Invited Commentary, the DIOs of HUH and 4 other area teaching hospitals detail their experiences working to find new training opportunities for the displaced residents and fellows, discussing lessons learned and providing recommendations to prepare for any future teaching hospital closures. Stakeholder organizations should work together to develop a "playbook" for use during future closures so that the chaos that occurred this time can be avoided.

Do Bundled Payment Programs in Joint Replacement Care Hold Promise for Improving Patient Outcomes?

The Centers for Medicare and Medicaid Services (CMS) Innovation Center offers two alternative payment models for joint replacement: the voluntary Bundled Payment for Care Improvement (BPCI) model and the mandatory Comprehensive Care for Joint Replacement (CJR) model. As CMS considers methods for cost reduction, research is needed to understand patient-level outcomes and organizational-level success factors. A retrospective cross-sectional study of hospitals was performed, using regression models to evaluate an aggregate patient satisfaction score, complication rates, and operational differences among BPCI, CJR, and nonparticipating hospitals. Results show that BPCI hospitals received significantly better patient satisfaction scores (88.6) than CJR hospitals (86.0), but complication rates were not significantly different between CJR and BPCI hospitals (2.83 and 2.77, respectively). Factors associated with BPCI participation include academic affiliation, a Northeast region locale, and having a higher CMS efficiency score. Thus, requiring more hospitals to participate in CMS-bundled payment programs as a federal policy may not be the optimal way to improve patient satisfaction and outcomes. Rather, the CJR and BPCI programs should be further studied, and the results generalized for use by nonparticipating hospitals to encourage preparation and participation in CMS value-based initiatives.

The Hahnemann University Hospital Closure and What Matters: A Department Chair's Perspective.

The closure of Hahnemann University Hospital, which was announced on June 26, 2019, resulted in the most significant graduate medical education displacement in history, sending over 550 residents to new institutions within a month of the announcement. Over 2,000 physicians, nurses, and staff lost their jobs. While seemingly predictable in retrospect, the closure came as a cataclysmic event to all involved. In this Invited Commentary, a department chair reflects on the lessons learned from these unprecedented circumstances. These lessons cover areas that are not a typical concern for faculty who are focused on teaching their trainees, but are worthy of their attention. Corporate and organizational structure, leadership, and financing of the hospital were critical determining characteristics of the failure. The roles that the Accreditation Council for Graduate Medical Education and the Centers for Medicare and Medicaid Services played in this event were key stabilizers. However, examining their roles in this event offers opportunities to play a more active role in future events and alter how the next massive displacement unfolds, possibly preserving teaching programs. Highly competitive health systems should rethink noncollaborative strategies before allowing struggling institutions to succumb to market forces. Finally, a commitment by a hospital to the mission of academic medicine is a sacred trust with the faculty, trainees, and patients that it serves. It should not be undertaken by any enterprise that is not well resourced and equipped with the knowledge and expertise to meet this most serious of commitments.

The Graduate Medical Education (GME) Gold Rush: GME Slots and Funding as a Financial Asset.

The unprecedented displacement of more than 550 trainees that occurred because of the closure of Hahnemann University Hospital has demonstrated that the medical education community, Centers for Medicare and Medicaid Services, and the Accreditation Council for Graduate Medical Education were unprepared for a graduate medical education (GME) crisis of this scale. The authors offer a first-hand perspective of the chaotic environment that ensued following the announcement of the hospital's closure and of the challenges faced by trainees and program leadership looking to ensure trainees found a landing program that was a good fit for them. The authors review the complexity of GME funding and how the owners of Hahnemann University Hospital leveraged this in an attempt to offset debt. The lessons learned from the authors' experience can help inform the medical education community's response to this type of crisis in the future.

Effects of Integrating Care for Medicare-Medicaid Dually Eligible Seniors in Minnesota.

Individuals dually eligible for Medicare and Medicaid often receive fragmented and inefficient care. Using Minnesota fee-for-service claims, managed care encounters, and enrollment data for 2010-2012, we estimated the likely impact of Minnesota Senior Health Option (MSHO)-seen as the first statewide fully integrated Medicare-Medicaid model-on health care and long-term services and supports use, relative to Minnesota Senior Care Plus (MSC+), a Medicaid-only managed care plan with Medicare fee for service. Estimates suggest that MSHO enrollees had significantly higher use of primary care and, potentially, of community-based services, combined with lower use of hospital-based care than similar MSC+ enrollees. Adopting fully integrated care models like MSHO may have merit in other states.

Value-Based Care Has Not Resulted in Biased Patient Selection: Analysis of a Single Center's Experience in the Care for Joint Replacement Bundle.

BACKGROUND: Bundled reimbursement models for total knee arthroplasty (TKA) by the Center for Medicare and Medicaid Services have resulted in an effort to decrease the cost of care. However, these models may incentivize bias in patient selection to avoid excess cost of care. We sought to determine the impact of the Comprehensive Care for Joint Replacement (CJR) model at a single center. METHODS: This is a retrospective review of primary TKA patients from July 2015 to December 2017. Patients were stratified by whether or not their surgery was performed before or after implementation of the CJR bundle. Patient demographic data including age, sex, and body mass index were collected in addition to Elixhauser comorbidities and American Society of Anesthesiologists score. In-hospital outcomes were then examined including surgery duration, length of stay, discharge disposition, and direct cost of care. RESULTS: A total of 1248 TKA patients (546 Medicare and 702 commercial insurance) were evaluated, with 27.0% undergoing surgery before the start of the bundle. Compared to patients following implementation of the bundle, there was no significant difference in age, gender, or body mass index. However, pre-CJR Medicare patients were more likely to have fewer Elixhauser comorbidities (P < .001), prolonged length of stay (P < .001), and greater discharges to inpatient facilities (P = .019). There was no significant difference in direct hospital costs or operative service time comparing pre-bundle and post-bundle patients. CONCLUSION: Implementation of the bundled reimbursement model did not result in biased patient selection at our institution; importantly, it also did not result in decreased hospital costs despite apparent improvement in value-based outcome metrics. This should be taken into consideration as future adaptations to reimbursement are made by the Center for Medicare and Medicaid Services.

What do women in Medicaid say about enhanced prenatal care? Findings from the national Strong Start evaluation.

BACKGROUND: Medicaid pays for approximately half of United States births, yet little research has explored Medicaid beneficiaries' perspectives on their maternity care. Typical maternity care in the United States has been criticized as too medically focused while insufficiently addressing psychosocial risks and patient education. Enhanced care strives for a more holistic approach. METHODS: The perspectives of participants in the Strong Start for Mothers and Newborns II initiative, which provided enhanced prenatal care to women covered by Medicaid or the Children's Health Insurance Program (CHIP) during pregnancy through Birth Centers, Group Prenatal Care, and Maternity Care Homes, are evaluated. Strong Start intended to improve care quality and birth outcomes while lowering costs. We analyzed data from 133 focus groups with 951 pregnant or postpartum women who participated in Strong Start from 2013 to 2017. RESULTS: The majority of focus group participants said that Strong Start's enhanced care offered numerous important benefits over typical maternity care, including considerably more focus on women's psychosocial risk factors and need for education. They praised increased support; nutrition, breastfeeding, and family planning education; community referrals; longer time with practitioners; and involvement of partners in their care. Maternity Care Home participants, however, occasionally voiced concerns over lack of practitioner continuity and short clinical appointments, whereas Group Prenatal Care participants sometimes said they could not attend visits because of lack of childcare. CONCLUSIONS: Medicaid and CHIP beneficiaries reported positive experiences with Strong Start care. If more Medicaid practitioners could adopt aspects of the prenatal care approaches that women praised most, it is likely that women's risk factors could be more effectively addressed and their overall care experiences could be improved.

Impact of Co-Morbidities on the Cost of Care in Primary Elective Joint Arthroplasty.

BACKGROUND: The Comprehensive Care for Joint Replacement model is the newest iteration of the bundled payment methodology introduced by the Centers for Medicare and Medicaid Services. Comprehensive Care for Joint Replacement model, while incentivizing providers to deliver care at a lower cost, does not incorporate any patient-level risk stratification. Our study evaluated the impact of specific medical co-morbidities on the cost of care in total joint arthroplasty (TJA) patients. METHODS: A retrospective study was conducted on 1258 Medicare patients who underwent primary elective TJA between January 2015 and July 2016 at a single institution. There were 488 males, 552 hips, and the mean age was 71 years. Cost data were obtained from the Centers for Medicare and Medicaid Services. Co-morbidity information was obtained from a manual review of patient records. Fourteen co-morbidities were included in our final multiple linear regression models. RESULTS: The regression models significantly predicted cost variation (P < .001). For index hospital costs, a history of cardiac arrhythmias (P < .001), valvular heart disease (P = .014), and anemia (P = .020) significantly increased costs. For post-acute care costs, a history of neurological conditions like Parkinson's disease or seizures (P < .001), malignancy (P = .001), hypertension (P = .012), depression (P = .014), and hypothyroidism (P = .044) were associated with increases in cost. Similarly, for total episode cost, a history of neurological conditions (P < .001), hypertension (P = .012), malignancy (P = .023), and diabetes (P = .029) were predictors for increased costs. CONCLUSION: The cost of care in primary elective TJA increases with greater patient co-morbidity. Our data provide insight into the relative impact of specific medical conditions on cost of care and may be used in risk stratification in future reimbursement methodologies.

Integrating Health System Preparedness and Community Resilience: Using the CMS Preparedness Rule as a Focusing Event.

This commentary discusses the prospect and value of using the preparedness rule developed and implemented by the Centers for Medicare and Medicaid Services as a focal point for better integrating health system preparedness into broader community resilience efforts, whether at the local or international level. Much attention has been given to the idea that community resilience requires extensive collaboration and coordination between actors across sectors, elements that are vital to effective emergency preparedness in health care as well. To facilitate improved fiscal sustainability, the federal government has since 2012 been encouraging healthcare coalitions to pursue nonprofit status. Building such organizations for the long term will require coalitions to become more proactive in involving organizations outside of the health sector. The preparedness rule has done much to encourage more dialogue between health system actors, and we argue that this momentum should be carried forward to generate a broader discussion of the importance of health preparedness to community resilience. The value of embedding preparedness planning into larger community resilience initiatives is discussed.

Hip Fracture Does Not Belong in the Elective Arthroplasty Bundle: Presentation, Outcomes, and Service Utilization Differ in Fracture Arthroplasty Care.

BACKGROUND: Center for Medicare and Medicaid Services reimbursement is the same for hip arthroplasty performed electively for arthritis and urgently for femoral neck fracture. METHODS: An analytic report of hip arthroplasty for a 5-hospital network identified 2362 cases performed from January 2014 to May 2016. Resource utilization was determined using 90-day charges. RESULTS: The fracture population (623 hips) was older (P < .01), had more medical comorbidities (28.3% vs 3.8%, P < .01), and was more likely to be anemic and malnourished (P < .01), and had longer hospital stay (5.7 vs 3.0 days, P < .0001), more frequent intensive care unit admission (4.5% vs 0.5%, P < .01), less frequent discharge to home (16.2% vs 83.6%, P < .01), more emergency department visits (26.5% vs 10.7%, P < .01), and more readmissions after hospital discharge (25.2% vs 12.2%, P < .01). Utilization of services ($50,875 vs $38,705, P < .0001) and the standard deviation of these services ($22,509 vs $9,847, P < .0001), from 90-day charges, were significantly greater in the fracture population. CONCLUSION: This study supports exclusion of fracture care from the Comprehensive Care for Joint Replacement bundled payment program.

The Hyperbaric Oxygen Therapy Registry: Driving quality and demonstrating compliance.

OBJECTIVE: To provide an update on the status of provider participation in the US Wound Registry (USWR) and its specialty registry the Hyperbaric Oxygen Therapy Registry (HBOTR), which provide much-needed national benchmarking and quality measurement services for hyperbaric medicine. METHODS: Providers can meet many requirements of the Merit-Based Incentive Payment System (MIPS) and simultaneously participate in the HBOTR by transmitting Continuity of Care Documents (CCDs) directly from their certified electronic health record (EHR) or by reporting hyperbaric quality measures, the specifications for which are available free of charge for download from the registry website as electronic clinical quality measures for installation into any certified EHR. Computerized systems parse the structured data transmitted to the USWR. Patients undergoing hyperbaric oxygen (HBO2) therapy are allocated to the HBOTR and stored in that specialty registry database. The data can be queried for benchmarking, quality reporting, public policy, or specialized data projects. RESULTS: Since January 2012, 917,758 clinic visits have captured the data of 199,158 patients in the USWR, 3,697 of whom underwent HBO2 therapy. Among 27,404 patients with 62,843 diabetic foot ulcers (DFUs) captured, 9,908 DFUs (15.7%) were treated with HBO2 therapy. Between January 2016 and September 2018, the benchmark rate for the 1,000 DFUs treated with HBO2 was 7.3%, with an average of 28 treatments per patient. There are 2,100 providers who report data to the USWR by transmitting CCDs from their EHR and 688 who submit quality measure data, 300 (43.6%) of whom transmit HBO2 quality data.