Changes in Hospital-acquired Conditions and Mortality Associated With the Hospital-acquired Condition Reduction Program.

IMPORTANCE: To improve patient safety, the Centers for Medicare and Medicaid Services announced the Hospital-Acquired Condition Reduction Program (HACRP) in August 2013. The program reduces Medicare payments by 1% for hospitals in the lowest performance quartile related to hospital-acquired conditions. Performance measures are focused on perioperative care. OBJECTIVE: To evaluate changes in HACs and 30-day mortality after the announcement of the HACRP. DESIGN: Interrupted time-series design using Medicare Provider and Analysis Review (MEDPAR) claims data. We estimated models with linear splines to test for changes in HACs and 30-day mortality before the Affordable Care Act (ACA), after the ACA, and after the HACRP. SETTING: Fee-for-service Medicare 2009-2015. PARTICIPANTS: Medicare beneficiaries undergoing surgery and discharged from an acute care hospital between January 2009 and August 2015 (N = 8,857,877). MAIN OUTCOME AND MEASURE: Changes in HACs and 30-day mortality after the announcement of the HACRP. RESULTS: Patients experienced HACs at a rate of 13.39 per 1000 discharges [95% confidence interval (CI), 13.10 to 13.68] in the pre-ACA period. This declined after the ACA was passed and declined further after the HACRP announcement [adjusted difference in annual slope, -1.34 (95% CI, -1.64 to -1.04)]. Adjusted 30-day mortality was 3.69 (95% CI, 3.64 to 3.74) in the pre-ACA period among patients receiving surgery. Thirty-day mortality continued to decline after the ACA [adjusted annual slope -0.04 (95% CI, -0.05 to -0.02)] but was flat after the HACRP [adjusted annual slope -0.01 (95% CI, -0.04 to 0.02)]. CONCLUSIONS AND RELEVANCE: Although hospital-acquired conditions targeted under the HACRP declined at a greater rate after the program was announced, 30-day mortality was unchanged.

Improving Payment for Collaborative Mental Health Care in Primary Care.

BACKGROUND: There is strong evidence supporting implementation of the Collaborative Care Model within primary care. Fee-for-service payment codes, published by Current Procedural Terminology in 2018, have made collaborative care separately reimbursable for the first time. These codes (ie, 99492-99494) reimburse for time spent per month by any member of the care team engaged in Collaborative Care, including behavioral care managers, primary care providers, and consulting psychiatrists. Time-based billing for these codes presents challenges for providers delivering Collaborative Care services. OBJECTIVES: Based on experience from multiple health care organizations, we reflect on these challenges and provide suggestions for implementation and future refinement of the codes. CONCLUSIONS: Further refinements to the codes are encouraged, including moving from a calendar month to a 30-day reimbursement cycle. In addition, we recommend payers adopt the new code proposed by the Centers for Medicare and Medicaid Services to account for smaller increments of time.

Ethical Issues in Physician Billing Under Fee-For-Service Plans.

Medical ethics has become an important and recognized component of physician training. There is one area, however, in which medical students receive little guidance. There is practically no discussion of the financial aspects of medical practice. My objective in this paper is to initiate a discussion about the moral dimension of physician billing practices. I argue that physicians should expand their conception of professional responsibility in order to recognize that their moral obligations toward patients include a commitment to honest and forthright billing practices. I argue that physicians should aspire to a standard of clinical accuracy-not legal adequacy-in describing their activities. More generally, physicians should strive to promote an integrity-based professional culture, first and foremost by stigmatizing rather than celebrating creative billing practices, as well as condemning the misguided sense of solidarity that currently makes it taboo for physicians to criticize each other on this score.

Comparison of treatment of early-stage breast cancer among Nurses' Health Study participants and other Medicare beneficiaries.

PURPOSE: Increasingly epidemiological cohorts are being linked to claims data to provide rich data for healthcare research. These cohorts tend to be different than the general United States (US) population. We will analyze healthcare utilization of Nurses' Health Study (NHS) participants to determine if studies of newly diagnosed incident early-stage breast cancer can be generalized to the broader US Medicare population. METHODS: Analytic cohorts of fee-for-service NHS-Medicare-linked participants and a 1:13 propensity-matched SEER-Medicare cohort (SEER) with incident breast cancer in the years 2007-2011 were considered. Screening leading to, treatment-related, and general utilization in the year following early-stage breast cancer diagnosis were determined using Medicare claims data. RESULTS: After propensity matching, NHS and SEER were statistically balanced on all demographics. NHS and SEER had statistically similar rates of treatments including chemotherapy, breast-conserving surgery, mastectomy, and overall radiation use. Rates of general utilization include those related to hospitalizations, total visits, and emergency department visits were also balanced between the two groups. Total spending in the year following diagnosis were statistically equivalent for NHS and SEER ($36,180 vs. $35,399, p = 0.70). CONCLUSIONS: NHS and the general female population had comparable treatment and utilization patterns following diagnosis of early-stage incident breast cancers with the exception of type of radiation therapy received. This study provides support for the larger value of population-based cohorts in research on healthcare costs and utilization in breast cancer.

Claims-based cardiovascular outcome identification for clinical research: Results from 7 large randomized cardiovascular clinical trials.

BACKGROUND: Medicare insurance claims may provide an efficient means to ascertain follow-up of older participants in clinical research. We sought to determine the accuracy and completeness of claims- versus site-based follow-up with clinical event committee (+CEC) adjudication of cardiovascular outcomes. METHODS: We performed a retrospective study using linked Medicare and Duke Database of Clinical Trials data. Medicare claims were linked to clinical data from 7 randomized cardiovascular clinical trials. Of 52,476 trial participants, linking resulted in 5,839 (of 10,497 linkage-eligible) Medicare-linked trial participants with fee-for-service A and B coverage. Death, myocardial infarction (MI), stroke, and revascularization incidences were compared using Medicare inpatient claims only, site-reported events (+CEC) only, or a combination of the 2. Randomized treatment effects were compared as a function of whether claims-based, site-based (+CEC), or a combined system was used for event detection. RESULTS: Among the 5,839 study participants, the annual event rates were similar between claims- and site-based (+CEC) follow-up: death (overall rate 5.2% vs 5.2%; adjusted κ 0.99), MI (2.2% vs 2.3%; adjusted κ 0.96), stroke (0.7% vs 0.7%; adjusted κ 0.99), and any revascularization (7.4% vs 7.9%; adjusted κ 0.95). Of events detected by claims yet not reported by CEC, a minority were reported by sites but negatively adjudicated by CEC (39% of MIs and 18% of strokes). Differences in individual case concordance led to higher event rates when claims- and site-based (+CEC) systems were combined. Randomized treatment effects were similar among the 3 approaches for each outcome of interest. CONCLUSIONS: Claims- versus site-based (+CEC) follow-up identified similar overall cardiovascular event rates despite meaningful differences in the events detected. Randomized treatment effects were similar using the 2 methods, suggesting claims data could be used to support clinical research leveraging routinely collected data. This approach may lead to more effective evidence generation, synthesis, and appraisal of medical products and inform the strategic approaches toward the National Evaluation System for Health Technology.

Early Health System Experiences with Collaborative Care (CoCM) Billing Codes: a Qualitative Study of Leadership and Support Staff.

BACKGROUND: Although collaborative care (CoCM) is an evidence-based and widely adopted model, reimbursement challenges have limited implementation efforts nationwide. In recent years, Medicare and other payers have activated CoCM-specific codes with the primary aim of facilitating financial sustainability. OBJECTIVE: To investigate and describe the experiences of early adopters and explorers of Medicare's CoCM codes. DESIGN AND PARTICIPANTS: Fifteen interviews were conducted between October 2017 and May 2018 with 25 respondents representing 12 health care organizations and 2 payers. Respondents included dually boarded medicine/psychiatry physicians, psychiatrists, primary care physicians (PCPs), psychologists, a registered nurse, administrative staff, and billing staff. APPROACH: A semi-structured interview guide was used to address health care organization characteristics, CoCM services, patient consent, CoCM operational components, and CoCM billing processes. All interviews were recorded, transcribed, coded, and analyzed using a content analysis approach conducted jointly by the research team. KEY RESULTS: Successful billing required buy-in from key, interdisciplinary stakeholders. In planning for CoCM billing implementation, several organizations hired licensed clinical social workers (LICSWs) as behavioral health care managers to maximize billing flexibility. Respondents reported a number of consent-related difficulties, but these were not primary barriers. Workflow changes required for billing the CoCM codes (e.g., tracking cumulative treatment minutes, once-monthly code entry) were described as arduous, but also stimulated creative solutions. Since CoCM codes incorporate the work of the psychiatric consultant into one payment to primary care, organizations employed strategies such as inter-departmental ledger transfers. When challenges arose from variations in the local payer mix, some organizations billed CoCM codes exclusively, while others elected to use a mixture of CoCM and traditional fee-for-service (FFS) codes. For most organizations, it was important to demonstrate financial sustainability from the CoCM codes. CONCLUSIONS: With deliberate planning, persistence, and widespread organizational buy-in, successful utilization of newly available FFS CoCM billing codes is achievable.

The impact of the adoption of a patient rostering model on primary care access and continuity of care in urban family practices in Ontario, Canada.

BACKGROUND: Greater continuity and access to primary care results in improved patient health, satisfaction, and reduced healthcare costs. Although patient rostering is considered to be a cornerstone of a high performing primary care system and is believed to improve continuity and access, few studies have examined these relationships. This study examined the impact of the adoption of a patient rostering enhanced fee-for-service model (eFFS) on continuity, coordination of specialized care, and access. METHOD: A population-based longitudinal study was conducted using health administrative data from urban family practices in Ontario, Canada. Family physicians that transitioned from traditional FFS (tFFS) to eFFS between 2004 and 2013 were followed overtime. Physicians providing comprehensive primary care that had at least 4 years of pre-transition and 2 years of post-transition data were eligible. Patients were attributed to physicians on an annual basis by determining the provider that billed the largest dollar amount over a 2 year period. Outcomes of interest were the usual provider of care index (UPC), a referral index (RI) (% of total primary care referrals for a physician's roster made by the main provider), and emergency department (ED) visits for family practice sensitive conditions (FPSCs). Mixed-effects segmented linear and logistic regressions were used to examine changes in outcomes while controlling for patient and provider contextual factors. RESULTS: Prior to transitioning, UPC was decreasing at a rate of 0.27%/year (95% CI: -0.34 to - 0.21, p < 0.0001). Following the transition, UPC began decreasing by an additional 0.59%/year (95% CI: -0.69 to - 0.49, p < 0.0001) relative to the pre-transition rate. RI decreased by an additional 0.34%/year (95% CI: -0.43 to - 0.24, p < 0.0001) relative to the pre-transition period, where it had been stable. The transition had minimal impact on FPSC ED visits. CONCLUSION: Continuity and coordination of specialized care slightly decreased upon transition from tFFS to eFFS. This is likely due to physicians working in groups and sharing patients following the transition to the eFFS model. Adoption of an enrolment model with after-hours care did not decrease non-urgent ED use, which may reflect the small impact that primary care access has on these types of ED visits.

Impacts of an Integrated Medicaid Managed Care Program for Adults with Behavioral Health Conditions: The Experience of Illinois.

This study assessed the impact of the Integrated Care Program (ICP), a new Medicaid managed care model in Illinois, on health services utilization and costs for adults with behavioral health conditions. Data sources included Medicaid claims, encounter records, and state payment data for 28,127 persons with a behavioral health diagnosis. Difference-in-differences models, in conjunction with propensity score weighting, were used to compare utilization and costs between ICP enrollees and a fee-for-service (FFS) comparison group. The model considered the impact of the SMART Act, which restricted access to care for the comparison group. Before the SMART Act, ICP was associated with 2.8 fewer all-cause primary care visits, 34.6 fewer behavioral health-specific outpatient visits, and 2.5 fewer all-cause inpatient admissions per 100 persons per month, and $228 lower total costs per member per month relative to the FFS group. After the SMART Act, ICP enrollees had increased outpatient and dental services utilization without significantly higher costs. The relative increase in utilization was due primarily to decreased utilization in the restricted FFS group after the SMART Act. By the end of the study period, the ICP group had 13.3 more all-cause primary care visits, 1.5 more emergency department visits, and 1.4 more dental visits per 100 persons per month relative to the FFS program. A fully-capitated, integrated managed care program has the potential to reduce overall Medicaid costs for people with behavioral health conditions without negative effects on service utilization.

Does a provider payment method affect membership retention in a health insurance scheme? a mixed method study of Ghana's capitation payment for primary care.

BACKGROUND: Ghana introduced a National Health Insurance Scheme (NHIS) in 2003 applying fee-for-service method for paying NHIS-credentialed health care providers. The National Health Insurance Authority (NHIA) later introduced diagnosis-related-grouping (DRG) payment to contain cost without much success. The NHIA then introduced capitation payment, a decision that attracted complaints of falling enrolment and renewal rates from stakeholders. This study was done to provide evidence on this trend to guide policy debate on the issue. METHODS: We applied mixed method design to the study. We did a trend analysis of NHIS membership data in Ashanti, Volta and Central regions to assess growth rate; performed independent-sample t-test to compare sample means of the three regions and analysed data from individual in-depth interviews to determine any relationship between capitation payment and subscribers' renewal decision. RESULTS: Results of new enrolment data analysis showed differences in mean growth rates between Ashanti (M = 30.15, SE 3.03) and Volta (M = 40.72, SE 3.10), p = 0.041; r = 0. 15; and between Ashanti and Central (M = 47.38, SE6.49) p = 0.043; r = 0. 42. Analysis of membership renewal data, however, showed no significant differences in mean growth rates between Ashanti (M = 65.47, SE 6.67) and Volta (M = 69.29, SE 5.04), p = 0.660; r = 0.03; and between Ashanti and Central (M = 50.51, SE 9.49), p = 0.233. Analysis of both new enrolment and renewal data also showed no significant differences in mean growth rates between Ashanti (M = - 13.76, SE 17.68) and Volta (M = 5.48, SE 5.50), p = 0.329; and between Ashanti and Central (M = - 6.47, SE 12.68), p = 0.746. However, capitation payment had some effect in Ashanti compared with Volta (r = 0. 12) and Central (r = 0. 14); but could not be sustained beyond 2012. Responses from the in-depth interviews did not also show that capitation payment is a key factor in subscribers' renewal decision. CONCLUSION: Capitation payment had a small but unsustainable effect on membership growth rate in the Ashanti region. Factors other than capitation payment may have played a more significant role in subscribers' enrolment and renewal decisions in the Ashanti region of Ghana.

VALUE AND PERFORMANCE OF ACCOUNTABLE CARE ORGANIZATIONS: A COST-MINIMIZATION ANALYSIS.

OBJECTIVES: Determine the relationship between quality of an accountable care organization (ACO) and its long-term reduction in healthcare costs. METHODS: We conducted a cost minimization analysis. Using Centers for Medicare and Medicaid cost and quality data, we calculated weighted composite quality scores for each ACO and organization-level cost savings. We used Markov modeling to compute the probability that an ACO transitioned between different quality levels in successive years. Considering a health-systems perspective with costs discounted at 3 percent, we conducted 10,000 Monte Carlo simulations to project long-term cost savings by quality level over a 10-year period. We compared the change in per-member expenditures of Pioneer (early-adopters) ACOs versus Medicare Shared Savings Program (MSSP) ACOs to assess the impact of coordination of care, the main mechanism for cost savings. RESULTS: Overall, Pioneer ACOs saved USD 641.24 per beneficiary and MSSP ACOs saved USD 535.59 per beneficiary. By quality level: (a) high quality organizations saved the most money (Pioneer: USD 459; MSSP: USD 816); (b) medium quality saved some money (Pioneer: USD 222; MSSP: USD 105); and (c) low quality suffered financial losses (Pioneer: USD -40; MSSP: USD -386). CONCLUSIONS: Within the existing fee-for-service healthcare model, ACOs are a mechanism for decreasing costs by improving quality of care. Higher quality organizations incorporate greater levels of coordination of care, which is associated with greater cost savings. Pioneer ACOs have the highest level of integration of services; hence, they save the most money.

Payment system of urban family physician programme in the Islamic Republic of Iran: is it appropriate?

BACKGROUND: The payment system is pivotal in implementing policies in the health sector. Equitable access to healthcare is the main principle of the payment system. AIMS: This study aimed to investigate aspects of the payment system in the urban family physician programme (FPP) in the Islamic Republic of Iran. METHODS: This was a qualitative study. We obtained data from key informants and both formal and grey literature. We used content analysis for data analysis. RESULTS: A range of concepts was explored related to the payment system of the FPP. By merging similar expressions, we categorized the findings into four main themes including: payment method, payment criteria and incentives, payment process and amount of payment. CONCLUSIONS: FPP is required to follow convenient implementation methods. The mechanisms of payment in the health sector are weak and have no transparency. A blurred combination of criteria makes an unclear process for determining the payment mechanisms. It is recommended that the opinions of key stakeholders be taken into consideration prior to developing payment mechanisms and financial incentives.

Getting Paid for Clinical Services.

Increasingly, pharmacists are providing advanced, patient-centered clinical services. However, pharmacists are not currently included in key sections of the Social Security Act, which determines eligibility to bill and be reimbursed by Medicare. Many state and private health plans also cite the omission from Medicare as the rationale for excluding reimbursement of pharmacists for clinical services. This has prompted forward-thinking pharmacists to seek opportunities for reimbursement in other ways, allowing them to provide value to the health care system, while carving out unique niches for pharmacists to care for patients.

Long-term Effects of Managed Care.

Managed care (MC) plans have been introduced to curb the ever increasing health care costs. Many previous studies on effectiveness lacked a long-term perspective; hence, the sustainability of (possible) savings remains unclear. Moreover, because of their incentives, MC plans are susceptible to under-provision of care. Most of these possibly negative effects can only be observed in the long-term. This paper analyzes the long-term effects of MC plans on cost savings, mortality, and the use of service, using administrative data from a large Swiss health insurer. The identification is based on a propensity-score matching approach, where individuals who enter an MC plan are compared over 10 years to individuals who remain in a standard fee-for-service plan. Cost savings are substantial and sustainable, and the mortality rate is lower in MC plans. Cost savings are driven by fewer consultations and fewer days in hospital care, although the probability of visiting a provider at least once per year is similar or even higher for persons in MC plans. Copyright © 2016 John Wiley & Sons, Ltd.

Dental care for the elderly through a Capped-fee funding model: Optimising outcomes for primary government dental services.

OBJECTIVE: The objectives of this study were to (i) compare a Capped Payment formula for adults, to the fee-for-service model and the New South Wales Government services payment model; (ii) identify the presenting oral health needs of a 65+ years of age cohort during the period January 2011 to March 2015. BACKGROUND DATA DISCUSSING THE PRESENT STATUS OF THE FIELD: Australia faces an ageing population with the vast majority accessing free market dental care, whilst the poor access Government services. This cohort retains most of their dentition increasing demand on Government services. MATERIALS AND METHODS: The analysis of New South Wales Government adult de-identified patients' record unit data was from 2011 to 2015, for the three payment models and undertaken in three stages; (i) development of the Capped Payment Model; (ii) evaluation of twenty (20) case studies of adults 65+ years of age; (iii) analyse the cost efficiency of the three payment models. RESULTS: This study found that the Government model was the most cost effective. The Capped-fee model performed less efficiently, particularly in the 75+ age group, with the fee-for-service model generally more costly. It was $2580 (85%) more costly for the 65-74 age cohort, and $4619 (66%) for the 75+ age cohort. CONCLUSION: Policy makers in partnership with Government and private service providers should seek to develop partnerships with Government, private services and universities, scope opportunities in applying a Capped-fee funding model, and one that helps address the oral needs of the elderly.

Fee-for-Service Is Dead. Long Live Fee for Service?

The move to a value-based payment system was supposed to end perverse incentives that pay doctors more for delivering often unnecessary services. But things are changing slowly and the market is still 95% fee for service. There's talk of reworking the Medicare fee schedule so docs are paid more for the things that work, and less for those that don't.

The Impact of Hospital Payment Schemes on Healthcare and Mortality: Evidence from Hospital Payment Reforms in OECD Countries.

In this study, aggregate-level panel data from 20 Organization for Economic Cooperation and Development countries over three decades (1980-2009) were used to investigate the impact of hospital payment reforms on healthcare output and mortality. Hospital payment schemes were classified as fixed-budget (i.e. not directly based on activities), fee-for-service (FFS) or patient-based payment (PBP) schemes. The data were analysed using a difference-in-difference model that allows for a structural change in outcomes due to payment reform. The results suggest that FFS schemes increase the growth rate of healthcare output, whereas PBP schemes positively affect life expectancy at age 65 years. However, these results should be interpreted with caution, as results are sensitive to model specification. Copyright © 2015 John Wiley & Sons, Ltd.

The Economics of Provider Payment Reform: Are Accountable Care Organizations the Answer?

A remarkable consensus has developed that the fee-for-service (FFS) approach for paying medical providers must be replaced. This payment approach is said to increase the volume of services without improving care coordination. In response to these calls, Medicare and private payers are experimenting with payment systems that combine the basic element of FFS - a fee for each service - with arrangements that allow providers to share the savings if they hold total spending per patient below a targeted amount. Medicare's accountable care organizations (ACOs) embody the shared savings approach to payment reform. Private payers have introduced total cost of care contracting (TCOC) in several locations. This article questions the consensus that FFS must go. If the fees are too high, then someone needs to "bite the bullet" and reduce fees in key areas. Hoping to control overspending by investment in ACOs is wishful thinking. I describe the theory and practice of shared savings payment systems and summarize recent TCOC contracting initiatives in the private sector. Medicare's shared savings approach is likely to be less effective than private contracts. Cutting providers' fees would be more efficient. Finally, the new payment models in the Affordable Care Act will not ease the problem of high prices for private payers.

Insights from a pilot program to integrate medical and social services.

This study examines lessons learned from the design, implementation, and early results of an integrated managed care pilot program linking member benefits of a Medicare-Medicaid health care plan with community services and supports. The health plan's average monthly costs for members receiving an assessment and services declined by an economically meaningful, statistically significant amount in the postintervention period relative to the preintervention period compared with those who did not accept an assessment or services. The results along with the lesson learned from the pilot are viewed by the parties as supportive of further program development.

Patient-reported access to primary care in Ontario: effect of organizational characteristics.

OBJECTIVE: To describe patient-reported access to primary health care across 4 organizational models of primary care in Ontario, and to explore how access is associated with patient, provider, and practice characteristics. DESIGN: Cross-sectional survey. SETTING: One hundred thirty-seven randomly selected primary care practices in Ontario using 1 of 4 delivery models (fee for service, established capitation, reformed capitation, and community health centres). PARTICIPANTS: Patients included were at least 18 years of age, were not severely ill or cognitively impaired, were not known to the survey administrator, had consenting providers at 1 of the participating primary care practices, and were able to communicate in English or French either directly or through a translator. MAIN OUTCOME MEASURES: Patient-reported access was measured by a 4-item scale derived from the previously validated adult version of the Primary Care Assessment Tool. Questions were asked about physician availability during and outside of regular office hours and access to health information via telephone. Responses to the scale were normalized, with higher scores reflecting greater patient-reported access. Linear regressions were used to identify characteristics independently associated with access to care. RESULTS: Established capitation model practices had the highest patient-reported access, although the difference in scores between models was small. Our multilevel regression model identified several patient factors that were significantly (P = .05) associated with higher patient-reported access, including older age, female sex, good-to-excellent self-reported health, less mental health disability, and not working. Provider experience (measured as years since graduation) was the only provider or practice characteristic independently associated with improved patient-reported access. CONCLUSION: This study adds to what is known about access to primary care. The study found that established capitation models outperformed all the other organizational models, including reformed capitation models, independent of provider and practice variables save provider experience. This suggests that the capitation models might provide better access to care and that it might take time to realize the benefits of organizational reforms.

Assessing care integration for dual-eligible beneficiaries: a review of quality measures chosen by states in the financial alignment initiative.

Caring for the 9 million low-income elderly or disabled adults who are eligible for full benefits under both Medicare and Medicaid can be extremely costly. As part of the federal Financial Alignment Initiative, states have the opportunity to test care models for dual-eligibles that integrate acute care, behavioral health and mental health services, and long-term services and supports, with the goals of enhancing access to services, improving care quality, containing costs, and reducing administrative barriers. One of the challenges in designing these demonstrations is choosing and applying measures that accurately track changes in quality over time­essential for the rapid identification of effective innovations. This brief reviews the quality measures chosen by eight demonstration states as of December 2013. The authors find that while some quality domains are well represented, others are not. Quality-of-life measures are notably lacking, as are informative, standardized measures of long-term services and supports.