Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement.

Importance: The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. Objective: To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. Design, Setting, and Participants: This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Exposures: Implementation of the CJR model in 2016. Main Outcomes and Measures: Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. Results: The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Conclusions and Relevance: Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.

A Transitional Care Model Using Faith Community Nurses.

The Medicare mandatory readmission reduction program has hospitals scrambling to reduce 30-day readmissions. A Faith Community Nurse (FCN) Transitional Care Model was developed from systematic literature review of predictive factors of readmission and pre- and postdischarge interventions that decrease readmission. The model presents specific FCN care that occurs pre- and posthospital discharge to support the patient in transitioning from one level of care to another, move toward wholistic health, and avoid unnecessary readmission.

Quality of care for older patients with cancer in the Veterans Health Administration versus the private sector: a cohort study.

BACKGROUND: The Veterans Health Administration (VHA) is the largest integrated health care system in the United States. Studies suggest that the VHA provides better preventive care and care for some chronic illnesses than does the private sector. OBJECTIVE: To assess the quality of cancer care for older patients provided by the VHA versus fee-for-service Medicare. DESIGN: Observational study of patients with cancer that was diagnosed between 2001 and 2004 who were followed through 2005. SETTING: VHA and non-VHA hospitals and office-based practices. PATIENTS: Men older than 65 years with incident colorectal, lung, or prostate cancer; lymphoma; or multiple myeloma. MEASUREMENTS: Rates of processes of care for colorectal, lung, or prostate cancer; lymphoma; or multiple myeloma. Rates were adjusted by using propensity score weighting. RESULTS: Compared with the fee-for-service Medicare population, the VHA population received diagnoses of colon (P < 0.001) and rectal (P = 0.007) cancer at earlier stages and had higher adjusted rates of curative surgery for colon cancer (92.7% vs. 90.5%; P < 0.010), standard chemotherapy for diffuse large B-cell non-Hodgkin lymphoma (71.1% vs. 59.3%; P < 0.001), and bisphosphonate therapy for multiple myeloma (62.1% vs. 50.4%; P < 0.001). The VHA population had lower adjusted rates of 3-dimensional conformal or intensity-modulated radiation therapy for prostate cancer treated with external-beam radiation therapy (61.6% vs. 86.0%; P < 0.001). Adjusted rates were similar for 9 other measures. Sensitivity analyses suggest that if patients with cancer in the VHA system have more severe comorbid illness than other patients, rates for most indicators would be higher in the VHA population than in the fee-for-service Medicare population. LIMITATION: This study included only older men and did not include information about performance status, severity of comorbid illness, or patient preferences. CONCLUSION: Care for older men with cancer in the VHA system was generally similar to or better than care for fee-for-service Medicare beneficiaries, although adoption of some expensive new technologies may be delayed in the VHA system. PRIMARY FUNDING SOURCE: Department of Veterans Affairs.

Integrating mental health parity for homebound older adults under the medicare home health care benefit.

Despite high rates of mental illness, very few homebound older adults receive treatment. Comorbid mental illness exacerbates physical health conditions, reduces treatment adherence, and increases dependency and medical costs. Although effective treatments exist, many home health agencies lack capacity to effectively detect and treat mental illness. This article critically analyzes barriers within the Medicare home health benefit that impede access to mental health treatment. Policy, practice, and research recommendations are made to integrate mental health parity in home health care. In particular, creative use of medical social work can improve detection and treatment of mental illness for homebound older adults.

Integration demonstration. The CMS' latest pay-for-performance initiative will test the power of integrated delivery systems to alter doc practice patterns.

Linda Magno of the CMS says the Medicare Health Care Quality Demonstration project is one of the agency's boldest initiatives yet. She says the project is a chance for providers to "redesign the healthcare system." The project will feature "a lot of latitude" in payment and waivers of Medicare provisions. And the CMS needs a few good volunteer providers to participate.

Quality of care of Medicare patients with diabetes in a metropolitan fee-for-service primary care integrated delivery system.

Diabetes care in the United States is suboptimal. Although closed-panel health maintenance organizations (HMOs) and the Department of Veterans Affairs (VA) report performance superior to national norms, fee-for-service performance is uncertain. To address this issue, 3 outcome and 5 process indicators were measured for 2010 Medicare diabetes patients across 22 sites in a large, fee-for-service primary care group practice. American Diabetes Association standards for glycemic control, low-density lipoprotein cholesterol, and blood pressure were met by 53%, 46%, and 19% of patients, respectively. Diabetes Quality Improvement Project/Alliance poor control markers for the same measures were exceeded by 9%, 20%, and 54% of patients. Chart abstraction demonstrated annual eye examination, foot examination, and nephropathy screening rates of 16%, 49%, and 38%, while Medicare claims showed an annual eye examination rate of 63%. Observed processes and outcomes in this fee-for-service setting were superior to reported national performance and similar to the best performance in staff-model HMOs and the VA.

Medicare P4P demonstration project shows significant QI. Participants improve in all five clinical areas over three-year period.

In demonstration project, Medicare offers bonuses based on how well hospitals meet quality measures. Median performance composite score for all hospitals was up 7.5% in project's first year. Incentives may not have been the only reason for improvement, observers say.

The relationship of membership in research networks to compliance with treatment guidelines for early-stage breast cancer.

BACKGROUND: Research has shown that older women with breast cancer are less likely than younger women to receive treatment in accordance with accepted guidelines. Cancer-related research networks (eg, Comprehensive Cancer Centers) have been funded by the National Cancer Institute to increase the dissemination of new treatment strategies, but little is known about their relationship to cancer treatment patterns. OBJECTIVES: We used a 3-level hierarchical regression model to examine the relationship of treating facilities' memberships in cancer research networks to compliance with guidelines for primary treatment of early stage breast cancer, controlling for patient and facility factors. RESEARCH DESIGN: We analyzed data from a database linking SEER registry data and Medicare claims in patients aged 65 years of age or older with early-stage breast cancer to data on the treating facility, including variables that indicate membership(s) in cancer research networks. SUBJECTS: A total of 16,600 women with stage I or stage II breast cancer, diagnosed between 1990 and 1994, and who received treatment in one of 423 facilities were studied. MEASURES: The key independent variable in this analysis was membership in NCI-funded cancer research networks. The outcome measure is a 3-category variable defined as (1) mastectomy (MAST), (2) breast-conserving surgery plus radiation therapy (BCS+RT), or (3) BCS alone. RESULTS: Patients treated at facilities that were members of 2 or more cancer research networks were more likely to receive guideline-concordant treatment (ie, MAST or BCS+RT) than similar patients treated at non-member facilities. CONCLUSIONS: Organizational factors may influence compliance with treatment guidelines and be useful in improving the quality of care.

Significance of functional status data for payment and quality.

To date, the Medicare Program has used functional status information (FSI) in patient assessment tools, performance assessment, payment mechanisms, and--most recently--in quality measures to inform consumer choice. This article explores the rationale for the collection of functional status data to promote innovative models of care and examines issues related to data collection for quality improvement, performance measurement, and payment. In this issue of the Health Care Financing Review, articles focus on collection and classification of functional status for payment and quality purposes.

Racial differences in the receipt of bowel surveillance following potentially curative colorectal cancer surgery.

OBJECTIVE: To investigate racial differences in posttreatment bowel surveillance after colorectal cancer surgery in a large population of Medicare patients. DATA SOURCES: We used a large population-based dataset: Surveillance, Epidemiology, and End Results (SEER) linked to Medicare data. STUDY DESIGN: This is a retrospective cohort study. We analyzed data from 44,768 non-Hispanic white, 2,921 black, and 4,416 patients from other racial/ethnic groups, aged 65 and older at diagnosis, who had a diagnosis of local or regional colorectal cancer between 1986 and 1996, and were followed through December 31, 1998. Cox Proportional Hazards models were used to investigate the relation of race and receipt of posttreatment bowel surveillance. DATA COLLECTION: Sociodemographic, hospital, and clinical characteristics were collected at the time of diagnosis for all members of the cohort. Surgery and bowel surveillance with colonoscopy, sigmoidoscopy, and barium enema were obtained from Medicare claims using ICD-9-CM and CPT-4 codes. PRINCIPAL FINDINGS: The chance of surveillance within 18 months of surgery was 57 percent, 48 percent, and 45 percent for non-Hispanic whites, blacks, and others, respectively. After adjusting for sociodemographic, hospital, and clinical characteristics, blacks were 25 percent less likely than whites to receive surveillance if diagnosed between 1991 and 1996 (RR = 0.75, 95 percent CI = 0.70-0.81). CONCLUSIONS: Elderly blacks were less likely than non-Hispanic whites to receive posttreatment bowel surveillance and this result was not explained by measured racial differences in sociodemographic, hospital, and clinical characteristics. More research is needed to explore the influences of patient- and provider-level factors on racial differences in posttreatment bowel surveillance.

Implementing a clinical pathway for the treatment of Medicare patients with cardiac chest pain.

BACKGROUND: A small urban hospital identified angina pectoris (DRG 140) as a high-cost and low-reimbursement DRG. Variation in the process of care for patients with cardiac chest pain was related to the timing of decisions on stress tests and whether inpatient GI workups were performed. Underutilization of aspirin was identified as a quality of care issue. In collaboration with Texas Medical Foundation (TMF), the Quality Improvement Organization (QIO) for Texas, this became the initial Health Care Quality Improvement Program (HCQIP) project and the first effort by the hospital at pathway development. INTERVENTION: A team effort lead by physicians, including other healthcare groups at the hospital, identified elements considered essential to providing ideal care for patients with cardiac chest pain, formulating these elements into a clinical pathway. RESULTS: Emergency room physicians, an essential stakeholder group, had not been included in the initial pathway development, which proved to be a critical factor to effective implementation. Pathway implementation was associated with increased administration of aspirin by 45.7% (p < 0.001), reduced length of stay by 1.0 days (p = 0.064), and reduced total charges by an average of $1710.20 (p = 0.039). DISCUSSION: These results suggest that process of care improvement, i.e., clinical pathway implementation, in collaboration with a QIO, contributed to reduced variation in the process of care. Participation by all stakeholders from the beginning in process of care improvement is essential.