The Association of Readmission Reduction Activities with Primary Care Practice Readmission Rates.

BACKGROUND: A great deal of research has focused on how hospitals influence readmission rates. While hospitals play a vital role in reducing readmissions, a significant portion of the work also falls to primary care practices. Despite this critical role of primary care, little empirical evidence has shown what primary care characteristics or activities are associated with reductions in hospital admissions. OBJECTIVE: To examine the relationship between practices' readmission reduction activities and their readmission rates. DESIGN, SETTING, AND PARTICIPANTS: A retrospective study of 1,788 practices who responded to the National Survey of Healthcare Organizations and Systems (fielded 2017-2018) and 415,663 hospital admissions for Medicare beneficiaries attributed to those practices from 2016 100% Medicare claims data. We constructed mixed-effects logistic regression models to estimate practice-level readmission rates and a linear regression model to evaluate the association between practices' readmission rates with their number of readmission reduction activities. INTERVENTIONS: Standardized composite score, ranging from 0 to 1, representing the number of a practice's readmission reduction capabilities. The composite score was composed of 12 unique capabilities identified in the literature as being significantly associated with lower readmission rates (e.g., presence of care manager, medication reconciliation, shared-decision making, etc.). MAIN OUTCOMES AND MEASURES: Practices' readmission rates for attributed Medicare beneficiaries. KEY RESULTS: Routinely engaging in more readmission reduction activities was significantly associated (P < .05) with lower readmission rates. On average, practices experienced a 0.05 percentage point decrease in readmission rates for each additional activity. Average risk-standardized readmission rates for practices performing 10 or more of the 12 activities in our composite measure were a full percentage point lower than risk-standardized readmission rates for practices engaging in none of the activities. CONCLUSIONS: Primary care practices that engaged in more readmission reduction activities had lower readmission rates. These findings add to the growing body of evidence suggesting that engaging in multiple activities, rather than any single activity, is associated with decreased readmissions.

Navigating the Shifting Terrain of US Health Care Reform-Medicare for All, Single Payer, and the Public Option.

Policy Points "Medicare for All" is an increasingly common term in US health care reform debates, yet widespread confusion exists over its meaning. The various meanings of Medicare for All and other related terms reflect divergent political and philosophical assumptions about the preferred direction of health care reform, as well as the hybrid structure of the current Medicare program.

Lessons From the Long and Winding Road to Medicare for All.

Recently there has been a surge in political attention to Medicare for all, the latest chapter in a long history of conflict over national health insurance in the United States. This essay places the current Medicare for all debate in historical perspective.My aim is to illuminate past struggles over single-payer reform, explore the genesis and evolution of Medicare, and analyze the implications for contemporary health politics of the public and private insurance arrangements developed by the United States over the past century.The history of US health reform provides critical lessons for understanding the enduring appeal of single-payer models as well as the formidable political obstacles to transforming Medicare for all from an aspiration into a legislative reality.

Impact of Medicare Part D on mental health treatment and outcomes for dual eligible beneficiaries with HIV.

Depression is common among women with HIV and untreated depression can result in poor quality of life and worsen HIV outcomes. Women with HIV who are dually enrolled in Medicaid and Medicare faced a potential disruption in medication access when Medicare Part D was implemented in 2006. The goal of this study was to estimate the effects of Medicare Part D implementation on antidepressant use, depressive symptoms, and hospitalization in Medicaid-Medicare dual eligible women with HIV. This study used 2003-2008 data from the Women's Interagency HIV Study. The effects of Medicare Part D were estimated using a difference-in-differences approach, adjusting for temporal trends using a matched control group of Medicaid-only enrollees. Before Medicare Part D implementation, dual eligibles differed from Medicaid-only enrollees in antidepressant use and hospitalization, despite having identical prescription drug coverage through Medicaid. For dual enrollees, the transition to Medicare Part D was not associated with changes in antidepressant use, depressive symptoms, or hospitalization. We did not find disruptive effects on antidepressant use and related outcomes among dual eligibles in this study. Stable antidepressant use may be due to better access to medical care for dual eligibles through Medicare both before and after Medicare Part D implementation, which may have eclipsed any effects of the transition. It may also signal that classification of antidepressants as a protected drug class under Medicare Part D was effective in preventing psychiatric medication disruption.

Leap of Faith--Medicare's New Physician Payment System.

Medicare's new payment system reflects the movement toward value-based payment, which is built on the view that we can contain costs only by eliminating fee-for-service payment. But there are important problems with this belief and the reforms it inspires.

Perspectives on Research Participation and Facilitation Among Dialysis Patients, Clinic Personnel, and Medical Providers: A Focus Group Study.

BACKGROUND: Most prospective studies involving individuals receiving maintenance dialysis have been small, and many have had poor clinical translatability. Research relevance can be enhanced through stakeholder engagement. However, little is known about dialysis clinic stakeholders' perceptions of research participation and facilitation. The objective of this study was to characterize the perspectives of dialysis clinic stakeholders (patients, clinic personnel, and medical providers) on: (1) research participation by patients and (2) research facilitation by clinic personnel and medical providers. We also sought to elucidate stakeholder preferences for research communication. STUDY DESIGN: Qualitative study. SETTING & PARTICIPANTS: 7 focus groups (59 participants: 8 clinic managers, 14 nurses/patient care technicians, 8 social workers/dietitians, 11 nephrologists/advanced practice providers, and 18 patients/care partners) from 7 North Carolina dialysis clinics. METHODOLOGY: Clinics and participants were purposively sampled. Focus groups were recorded and transcribed. ANALYTICAL APPROACH: Thematic analysis. RESULTS: We identified 11 themes that captured barriers to and facilitators of research participation by patients and research facilitation by clinic personnel and medical providers. We collapsed these themes into 4 categories to create an organizational framework for considering stakeholder (narrow research understanding, competing personal priorities, and low patient literacy and education levels), relationship (trust, buy-in, and altruistic motivations), research design (convenience, follow-up, and patient incentives), and dialysis clinic (professional demands, teamwork, and communication) aspects that may affect stakeholder interest in participating in or facilitating research. These themes appear to shape the degree of research readiness of a dialysis clinic environment. Participants preferred short research communications delivered in multiple formats. LIMITATIONS: Potential selection bias and inclusion of English-speaking participants only. CONCLUSIONS: Our findings revealed patient interest in participating in research and clinical personnel and medical provider interest in facilitating research. Overall, our results suggest that dialysis clinic research readiness may be enhanced through increased stakeholder research knowledge and alignment of clinical and research activities.

Associations Between Medicare Part D and Out-of-Pocket Spending, HIV Viral Load, Adherence, and ADAP Use in Dual Eligibles With HIV.

BACKGROUND: The implementation of Medicare part D on January 1, 2006 required all adults who were dually enrolled in Medicaid and Medicare (dual eligibles) to transition prescription drug coverage from Medicaid to Medicare part D. Changes in payment systems and utilization management along with the loss of Medicaid protections had the potential to disrupt medication access, with uncertain consequences for dual eligibles with human immunodeficiency virus (HIV) who rely on consistent prescription coverage to suppress their HIV viral load (VL). OBJECTIVE: To estimate the effect of Medicare part D on self-reported out-of-pocket prescription drug spending, AIDS Drug Assistance Program (ADAP) use, antiretroviral adherence, and HIV VL suppression among dual eligibles with HIV. METHODS: Using 2003-2008 data from the Women's Interagency HIV Study, we created a propensity score-matched cohort and used a difference-in-differences approach to compare dual eligibles' outcomes pre-Medicare and post-Medicare part D to those enrolled in Medicaid alone. RESULTS: Transition to Medicare part D was associated with a sharp increase in the proportion of dual eligibles with self-reported out-of-pocket prescription drug costs, followed by an increase in ADAP use. Despite the increase in out-of-pocket costs, both adherence and HIV VL suppression remained stable. CONCLUSIONS: Medicare part D was associated with increased out-of-pocket spending, although the increased spending did not seem to compromise antiretroviral therapy adherence or HIV VL suppression. It is possible that increased ADAP use mitigated the increase in out-of-pocket spending, suggesting successful coordination between Medicare part D and ADAP as well as the vital role of ADAP during insurance transitions.

No Permanent Fix: MACRA, MIPS, and the Politics of Physician Payment Reform.

Organized medicine long yearned for the demise of Medicare's Sustainable Growth Rate (SGR) formula for updating physician fees. Congress finally obliged in 2015, repealing the SGR as part of the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA established value-based metrics for physician payment and financial incentives for doctors to join alternative delivery models like patient-centered medical homes. Throughout the law's initial implementation, the politics of accommodation prevailed, with federal officials crafting final rules that made MACRA more favorable for physicians. However, the era of accommodation could be short-lived. The discretion that the Centers for Medicare and Medicaid Services had during the first two years of implementation is ending. Additionally, euphoria over the SGR's repeal has given way to concerns over the new program's value-based purchasing arrangements and uncertainty over their sustainability. MACRA eliminated the SGR, but not the politics of physician payment.

Collision course? Donald Trump, Paul Ryan, and the fate of Medicare.

The election of Donald Trump as president of the United States raises questions about the future of Medicare. How will Medicare fare under Republican-led government? There are several compelling reasons that the Trump administration and Congressional Republicans might avoid Medicare reform, including the political risks of taking on a popular program, the difficulties the party has encountered in trying to dismantle the Patient Protection and Affordable Care Act (ACA), the importance of older Americans to the GOP coalition, and President Trump's views about Medicare. However, because of fiscal pressures and the commitment of Speaker of the House Paul Ryan and other Republicans to entitlement reform, the GOP nonetheless could end up attempting to make major changes in Medicare. Alternatively, Republican efforts to repeal and undermine the ACA could unintentionally enhance the political fortunes of proposals to expand Medicare. Consequently, the fate of Medicare during the Trump administration remains highly uncertain.

Dialysis Patient Perspectives on CKD Advocacy: A Semistructured Interview Study.

BACKGROUND: Health advocacy groups provide education, raise public awareness, and engage in legislative, scientific, and regulatory processes to advance funding and treatments for many diseases. Despite a high burden of chronic kidney disease (CKD) in the United States, public awareness and research funding lag behind those for other disease states. We undertook this study of patients receiving maintenance dialysis to describe knowledge and beliefs about CKD advocacy, understand perceptions regarding advocacy participation, and elicit ideas for generating more advocacy in the dialysis community. STUDY DESIGN: Qualitative study. SETTING & PARTICIPANTS: 48 patients (89% response rate) receiving in-center hemodialysis (n=39), home hemodialysis (n=4), and peritoneal dialysis (n=5) from 14 US states. METHODOLOGY: Semistructured interviews. ANALYTICAL APPROACH: Transcripts were thematically analyzed. RESULTS: 5 themes describing patient perspectives on CKD advocacy were identified: (1) advocacy awareness (advocacy vs engagement knowledge, concrete knowledge, CKD publicity), (2) willingness to participate (personal qualities, internal efficacy, external efficacy), (3) motivations (altruism, providing a purpose, advancement of personal health, self-education), (4) resource availability (time, financial and transportation, health status), and (5) mobilization experience (key figure, mobilization network). Participants displayed operational understanding of advocacy but generally lacked knowledge about specific opportunities for participation. Personal qualities and external efficacy were perceived as important for advocacy participation, as were motivating factors such as altruism and self-education. Resources factored heavily into perceived participation ability. Most participants identified a key figure who invited them to participate in advocacy. In-person patient-delivered communication about advocacy opportunities was identified as critical to enhancing CKD advocacy among patients living on dialysis therapy. LIMITATIONS: Potential selection bias and inclusion of only English-speaking participants may limit generalizability. CONCLUSIONS: Overall, our results suggest that there may be untapped advocacy potential within the dialysis community and highlight the need for local in-person patient-led initiatives to increase patient involvement in CKD advocacy.

Implementing the Affordable Care Act: The Promise and Limits of Health Care Reform.

The Obama administration has confronted a formidable array of obstacles in implementing the Affordable Care Act (ACA). The ACA has overcome those obstacles to substantially expand access to health insurance, though significant problems with its approach have emerged. What does the ACA's performance to date tell us about the possibilities and limits of health care reform in the United States? I identify key challenges in ACA implementation-the inherently disruptive nature of reform, partisan polarization, the limits of "near universal" coverage, complexity, and divided public opinion-and analyze how these issues have shaped its evolution. The article concludes by exploring the political and policy challenges that lie ahead for the ACA.