Quality of Care for Children With Medical Complexity: An Analysis of Continuity of Care as a Potential Quality Indicator.

OBJECTIVE: To examine the relationship between continuity of care for children with medical complexity (CMC) and emergency department (ED) utilization, care coordination quality, and family effects related to care coordination. METHODS: We measured ED utilization and primary care continuity with the Bice-Boxerman continuity of care index for 1477 CMC using administrative data from Minnesota and Washington state Medicaid agencies. For a subset of 186 of these CMC a caregiver survey was used to measure care coordination quality (using items adapted from the Consumer Assessment of Healthcare Providers and System Adult Health Plan Survey) and family impact (using items adapted from the National Survey of Children with Special Health Care Needs). Multivariable regression was used to examine the relationship between continuity, entered as a continuous variable ranging from 0 to 1, and the outcomes. RESULTS: The median continuity was 0.27 (interquartile range [IQR], 0.12-0.48) in the administrative data cohort and 0.27 (IQR, 0.14-0.43) in the survey cohort. Compared with children with a continuity score of 0, children with a score of 1 had lower odds of having ≥1 ED visit (odds ratio, 0.65; 95% confidence interval [CI], 0.46-0.93; P = .017) and their caregivers reported higher scores for the measure of receipt of care coordination (ß = 35.2 on a 0-100 scale; 95% CI, 11.5-58.9; P = .004). There was no association between continuity and family impact. CONCLUSIONS: Continuity of care holds promise as a quality measure for CMC because of its association with lower ED utilization and more frequent receipt of care coordination.

Impact of Health System Affiliation on Hospital Resource Use Intensity and Quality of Care.

OBJECTIVE: To assess the impact of hospital affiliation, centralization, and managed care plan ownership on inpatient cost and quality. DATA SOURCES: Inpatient discharges from 3,957 community hospitals in 44 states and American Hospital Association Annual Survey data from 2010 to 2012. STUDY DESIGN: We conducted a retrospective longitudinal regression analysis using hierarchical modeling of discharges clustered within hospitals. DATA COLLECTION: Detailed discharge data including costs, length of stay, and patient characteristics from the Healthcare Cost and Utilization Project State Inpatient Databases were merged with hospital survey data from the American Hospital Association. PRINCIPAL FINDINGS: Hospitals affiliated with health systems had a higher cost per discharge and better quality of care compared with independent hospitals. Centralized systems in particular had the highest cost per discharge and longest stays. Independent hospitals with managed care plans had a higher cost per discharge and better quality of care compared with other independent hospitals. CONCLUSIONS: Increasing prevalence of health systems and hospital managed care ownership may lead to higher quality but are unlikely to reduce hospital discharge costs. Encouraging participation in innovative payment and delivery reform models, such as accountable care organizations, may be more powerful options.

Avoiding the Tragedy of the Commons in Health Care: Policy Options for Covering High-Cost Cures.

In this article, Mattke and his colleagues discuss the risk that strategic behavior by health insurers could unravel the market for curative therapies for chronic diseases. Because the cost of these cures is front-loaded but the benefits accrue over time, insurers might attempt to delay treatment or avoid patients who require it, in the hope that they might change insurers. The authors discuss policy options to remedy this potential free-rider problem through alignment of incentives at the patient level, coordination among payers, and government intervention. They present a framework to analyze policy options and real-world case studies. While implementing those policy options is far from easy, stakeholders need to collaborate in order to establish equitable mechanisms that fairly distribute the cost and benefits of high-cost cures.

Provider type and management of common visits in primary care.

OBJECTIVES: Debate continues on whether nurse practitioners (NPs) and physician assistants (PAs) are more likely to order ancillary services, or order more costly services among alternatives, than primary care physicians (PCPs). We compared prescription medication and diagnostic service orders associated with NP/PA versus PCP visits for management of neck or back (N/B) pain or acute respiratory infection (ARI). STUDY DESIGN: Retrospective, observational study of visits from January 2006 through March 2008 in the adult primary care practice of Kaiser Permanente in Atlanta, Georgia. METHODS: Data were obtained from electronic health records. NP/PA and PCP visits for N/B pain or ARI were propensity score matched on patient age, gender, and comorbidities. RESULTS: On propensity score-matched N/B pain visits (n = 6724), NP/PAs were less likely than PCPs to order a computed tomography (CT)/magnetic resonance image (MRI) scan (2.1% vs 3.3%, respectively) or narcotic analgesic (26.9% vs 28.5%) and more likely to order a nonnarcotic analgesic (13.5% vs 8.5%) or muscle relaxant (45.8% vs 42.5%) (all P ≤.05). On propensity score-matched ARI visits (n = 24,190), NP/PAs were more likely than PCPs to order any antibiotic medication (73.7% vs 65.8%), but less likely to order an x-ray (6.3% vs 8.6%), broad-spectrum antibiotic (41.5% vs 42.5%), or rapid strep test (6.3% vs 9.7%) (all P ≤.05). CONCLUSIONS: In the multidisciplinary primary care practice of this health maintenance organization, NP/PAs attending visits for N/B pain or ARI were less likely than PCPs to order advanced diagnostic radiology imaging services, to prescribe narcotic analgesics, and/or to prescribe broad-spectrum antibiotics.

Anesthesia Service Use During Outpatient Gastroenterology Procedures Continued to Increase From 2010 to 2013 and Potentially Discretionary Spending Remained High.

OBJECTIVES: Previous studies have identified an increasing number of gastroenterology (GI) procedures using anesthesia services to provide sedation, with a majority of these services delivered to low-risk patients. The aim of this study was to update these trends with the most recent years of data. METHODS: We used Medicare and commercial claims data from 2010 to 2013 to identify GI procedures and anesthesia services based on CPT codes, which were linked together using patient identifiers and dates of service. We defined low-risk patients as those who were classified as ASA (American Society of Anesthesiologists) physical status class I or II. For those patients without an ASA class listed on the claim, we used a prediction algorithm to impute an ASA physical status. RESULTS: Over 6.6 million patients in our sample had a GI procedure between 2010 and 2013. GI procedures involving anesthesia service accounted for 33.7% in 2010 and 47.6% in 2013 in Medicare patients, and 38.3% in 2010 and 53.0% in 2013 in commercially insured patients. Overall, as more patients used anesthesia services, total anesthesia service use in low-risk patients increased 14%, from 27,191 to 33,181 per million Medicare enrollees. Similarly, we observed a nearly identical uptick in commercially insured patients from 15,871 to 22,247 per million, an increase of almost 15%. During 2010-2013, spending associated with anesthesia services in low-risk patients increased from US$3.14 million to US$3.45 million per million Medicare enrollees and from US$7.69 million to US$10.66 million per million commercially insured patients. CONCLUSIONS: During 2010 to 2013, anesthesia service use in GI procedures continued to increase and the proportion of these services rendered for low-risk patients remained high.

The Impact of Using Mid-level Providers in Face-to-Face Primary Care on Health Care Utilization.

BACKGROUND: There has been concern that greater use of nurse practitioners (NP) and physician assistants (PA) in face-to-face primary care may increase utilization and spending. OBJECTIVE: To evaluate a natural experiment within Kaiser Permanente in Georgia in the use of NP/PA in primary care. STUDY DESIGN: From 2006 through early 2008 (the preperiod), each NP or PA was paired with a physician to manage a patient panel. In early 2008, NPs and PAs were removed from all face-to-face primary care. Using the 2006-2010 data, we applied a difference-in-differences analytic approach at the clinic level due to patient triage between a NP/PA and a physician. Clinics were classified into 3 different groups based on the percentage of visits by NP/PA during the preperiod: high (over 20% in-person primary care visits attended by NP/PAs), medium (5%-20%), and low (<5%) NP/PA model clinics. MEASURES: Referrals to specialist physicians; emergency department visits and inpatient admissions; and advanced diagnostic imaging services. RESULTS: Compared with the low NP/PA model, the high NP/PA model and the medium NP/PA model were associated with 4.9% and 5.1% fewer specialist referrals, respectively (P<0.05 for both estimates); the high NP/PA model and the medium NP/PA model also showed fewer hospitalizations and emergency department visits and fewer advanced diagnostic imaging services, but none of these was statistically significant. CONCLUSIONS: We find no evidence to support concerns that under a physician's supervision, NPs and PAs increase utilization and spending.

Impact of State Reporting Laws on Central Line-Associated Bloodstream Infection Rates in U.S. Adult Intensive Care Units.

OBJECTIVE: To examine the effect of mandated state health care-associated infection (HAI) reporting laws on central line-associated bloodstream infection (CLABSI) rates in adult intensive care units (ICUs). DATA SOURCES: We analyzed 2006-2012 adult ICU CLABSI and hospital annual survey data from the National Healthcare Safety Network. The final analytic sample included 244 hospitals, 947 hospital years, 475 ICUs, 1,902 ICU years, and 16,996 ICU months. STUDY DESIGN: We used a quasi-experimental study design to identify the effect of state mandatory reporting laws. Several secondary models were conducted to explore potential explanations for the plausible effects of HAI laws. PRINCIPAL FINDINGS: Controlling for the overall time trend, ICUs in states with laws had lower CLABSI rates beginning approximately 6 months prior to the law's effective date (incidence rate ratio = 0.66; p < .001); this effect persisted for more than 6 1/2 years after the law's effective date. These findings were robust in secondary models and are likely to be attributed to changes in central line usage and/or resources dedicated to infection control. CONCLUSIONS: Our results provide valuable evidence that state reporting requirements for HAIs improved care. Additional studies are needed to further explore why and how mandatory HAI reporting laws decreased CLABSI rates.

Anesthesia Service Use and the Uptake of Screening Colonoscopies.

BACKGROUND: The Center for Medicare & Medicaid Services recently defined "screening colonoscopy" to include separately furnished anesthesia services. OBJECTIVE: To examine the relationship between anesthesia service use and the uptake of screening colonoscopies. STUDY DESIGN: We correlated metropolitan statistical area (MSA) level anesthesia service use rates, derived from the 2008, 2010, and 2012 Medicare and MarketScan claims data, with the presence of individual level guideline concordant screening colonoscopy using the Behavioral Risk Factor Surveillance System data for the same years. MEASURES: Proportion of colonoscopies with anesthesia service was calculated at the MSA level. A guideline concordant screening colonoscopy was defined as a colonoscopy received within the past 10 years. RESULTS: The average MSA level anesthesia service use rate in colonoscopy significantly increased from 25.34% in 2008 to 44.25% in 2012; but only a moderate increase in the rate of guideline concordant colonoscopies was observed, from 57.36% in 2008 to 65.32% in 2012. After adjusting for patient characteristics, we found a nonsignificant negative association between anesthesia service use rate and colonoscopy screening rate, with an odds ratio of 0.90 for receiving a guideline concordant colonoscopy for each percentage point increase in anesthesia service use rate (P=0.27). The relationship between anesthesia service use and the overall colorectal cancer screening rate followed the same pattern and was also not statistically significant. CONCLUSIONS: No significant association between anesthesia service use and colonoscopy screening or colorectal cancer screening rates was found, suggesting that more evidence is needed to support the Center for Medicare & Medicaid Services rule change.

Is More Always Better in Designing Workplace Wellness Programs?: A Comparison of Wellness Program Components Versus Outcomes.

OBJECTIVE: Assess whether adding more components to a workplace wellness program is associated with better outcomes by measuring the relationship of program components to one another and to employee participation and perceptions of program effectiveness. METHODS: Data came from a 2014 survey of 24,393 employees of 81 employers about services offered, leadership, incentives, and promotion. Logistic regressions were used to model the relationship between program characteristics and outcomes. RESULTS: Components individually are related to better outcomes, but this relationship is weaker in the presence of other components and non-significant for incentives. Within components, a moderate level of services and work time participation opportunities are associated with higher participation and effectiveness. CONCLUSIONS: The "more of everything" approach does not appear to be advisable for all programs. Programs should focus on providing ample opportunities for employees to participate and initiatives like results-based incentives.

Understanding the Relationship Between Incentive Design and Participation in U.S. Workplace Wellness Programs.

PURPOSE: We aimed to understand how employer characteristics relate to the use of incentives to promote participation in wellness programs and to explore the relationship between incentive type and participation rates. DESIGN: A cross-sectional analysis of nationally representative survey data combined with an administrative business database was employed. SETTINGS/SUBJECTS: Random sampling of U.S. companies within strata based on industry and number of employees was used to determine a final sample of 3000 companies. Of these, 19% returned completed surveys. MEASURES: The survey asked about employee participation rate, incentive type, and gender composition of employees. Incentive types included any incentives, high-value rewards, and rewards plus penalties. ANALYSIS: Logistic regressions of incentive type on employer characteristics were used to determine what types of employers are more likely to offer which type of incentives. A generalized linear model of participation rate was used to determine the relationship between incentive type and participation. RESULTS: Employers located in the Northeast were 5 to 10 times more likely to offer incentives. Employers with a large number of employees, particularly female employees, were up to 1.25 times more likely to use penalties. Penalty and high-value incentives were associated with participation rates of 68% and 52%, respectively. CONCLUSION: Industry or regional characteristics are likely determinants of incentive use for wellness programs. Penalties appear to be effective, but attention should be paid to what types of employees they affect.

Medical Device Innovation in the Era of the Affordable Care Act: The End of Sexy.

In this article, the authors explore why medical device innovation has traditionally been geared so thoroughly toward improving performance, with little regard to cost. They argue that the changing incentives in the health care sector and the move to value-based payment models, accelerated by the implementation of the Affordable Care Act, will force device manufacturers to redirect investments from the spectacular toward the prudent, which they dub "the end of sexy." The authors explore consequences for manufacturers, investors, and policymakers.

Incentives, Program Configuration, and Employee Uptake of Workplace Wellness Programs.

OBJECTIVES: The aim of this study was to determine the effect of wellness program configurations and financial incentives on employee participation rate. METHODS: We analyze a nationally representative survey on workplace wellness programs from 407 employers using cluster analysis and multivariable regression analysis. RESULTS: Employers who offer incentives and provide a comprehensive set of program offerings have higher participation rates. The effect of incentives differs by program configuration, with the strongest effect found for comprehensive and prevention-focused programs. Among intervention-focused programs, incentives are not associated with higher participation. CONCLUSIONS: Wellness programs can be grouped into distinct configurations, which have different workplace health focuses. Although monetary incentives can be effective in improving employee participation, the magnitude and significance of the effect is greater for some program configurations than others.

Does Targeting Higher Health Risk Employees or Increasing Intervention Intensity Yield Savings in a Workplace Wellness Program?

OBJECTIVE: This article aims to test whether a workplace wellness program reduces health care cost for higher risk employees or employees with greater participation. METHODS: The program effect on costs was estimated using a generalized linear model with a log-link function using a difference-in-difference framework with a propensity score matched sample of employees using claims and program data from a large US firm from 2003 to 2011. RESULTS: The program targeting higher risk employees did not yield cost savings. Employees participating in five or more sessions aimed at encouraging more healthful living had about $20 lower per member per month costs relative to matched comparisons (P = 0.002). CONCLUSIONS: Our results add to the growing evidence base that workplace wellness programs aimed at primary prevention do not reduce health care cost, with the exception of those employees who choose to participate more actively.

Central line-associated blood stream infections in pediatric intensive care units: Longitudinal trends and compliance with bundle strategies.

BACKGROUND: Knowing the temporal trend central line-associated bloodstream infection (CLABSI) rates among U.S. pediatric intensive care units (PICUs), the current extent of central line bundle compliance, and the impact of compliance on rates is necessary to understand what has been accomplished and can be improved in CLABSI prevention. METHODS: This is a longitudinal study of PICUs in National Healthcare Safety Network hospitals and a cross-sectional survey of directors and managers of infection prevention and control departments regarding PICU CLABSI prevention practices, including self-reported compliance with elements of central line bundles. Associations between 2011-2012 PICU CLABSI rates and infection prevention practices were examined. RESULTS: Reported CLABSI rates decreased during the study period, from 5.8 per 1,000 line days in 2006 to 1.4 in 2011-2012 (P < .001). Although 73% of PICUs had policies for all central line prevention practices, only 35% of those with policies reported ≥95% compliance. PICUs with ≥95% compliance with central line infection prevention policies had lower reported CLABSI rates, but this association was statistically insignificant. CONCLUSION: There was a nonsignificant trend in decreasing CLABSI rates as PICUs improved bundle policy compliance. Given that few PICUs reported full compliance with these policies, PICUs increasing their efforts to comply with these policies may help reduce CLABSI rates.

Dementia Care Management in an Underserved Community: The Comparative Effectiveness of Two Different Approaches.

OBJECTIVES: To compare the effectiveness and costs of telephone-only approach to in-person plus telephone for delivering an evidence-based, coordinated care management program for dementia. METHODS: We randomized 151 patient-caregiver dyads from an underserved predominantly Latino community to two arms that shared a care management protocol but implemented in different formats: in-person visits at home and/or in the community plus telephone and mail, versus telephone and mail only. We compared between-arm caregiver burden and care-recipient problem behaviors (primary outcomes) and patient-caregiver dyad retention, care quality, health care utilization, and costs (secondary outcomes) at 6- and 12-months follow-up. RESULTS: Care quality improved substantially over time in both arms. Caregiver burden, care-recipient problem behaviors, retention, and health care utilization did not differ across arms but the in-person program cost more to deliver. DISCUSSION: Dementia care quality improved regardless of how care management was delivered; large differences in effectiveness or cost offsets were not detected.

Quantitative Evaluation of the Impact of the Healthy Communities Initiative in Cincinnati.

Metropolitan Cincinnati residents have traditionally had among the highest health care costs in the United States, yet little evidence exists that residents are getting their money's worth, especially in terms of preventive and primary care. Recently, large employers, health plans, and health care providers in the Cincinnati area joined with community organizations in an effort to improve health care and population health, as well as reduce health care costs by focusing on five priority areas: coordinated primary care, health information exchange, quality improvement, public reporting and consumer engagement, and payment innovations. Spearheaded by General Electric (GE) Cincinnati, the resulting Healthy Communities Initiative in Cincinnati was implemented in 2009. In 2012, GE asked RAND Health Advisory Services to assess progress over the first three years of the initiative. Overall, the findings were largely inconclusive because of a concomitant marketwide shift to high-deductible health policies (which are known to have profound effects on care-seeking behavior) and the early stage of the intervention. However, there were some encouraging signs that better care coordination bears fruit, such as less illness-related work loss and fewer avoidable hospital admissions and readmissions. These early impacts suggest that the initiative may succeed in improving care, lowering cost, and improving health status if given sufficient time.