Association of a Care Coordination Model With Health Care Costs and Utilization: The Johns Hopkins Community Health Partnership (J-CHiP).

Importance: The Johns Hopkins Community Health Partnership was created to improve care coordination across the continuum in East Baltimore, Maryland. Objective: To determine whether the Johns Hopkins Community Health Partnership (J-CHiP) was associated with improved outcomes and lower spending. Design, Setting, and Participants: Nonrandomized acute care intervention (ACI) and community intervention (CI) Medicare and Medicaid participants were analyzed in a quality improvement study using difference-in-differences designs with propensity score-weighted and matched comparison groups. The study spanned 2012 to 2016 and took place in acute care hospitals, primary care clinics, skilled nursing facilities, and community-based organizations. The ACI analysis compared outcomes of participants in Medicare and Medicaid during their 90-day postacute episode with those of a propensity score-weighted preintervention group at Johns Hopkins Community Health Partnership hospitals and a concurrent comparison group drawn from similar Maryland hospitals. The CI analysis compared changes in outcomes of Medicare and Medicaid participants with those of a propensity score-matched comparison group of local residents. Interventions: The ACI bundle aimed to improve transition planning following discharge. The CI included enhanced care coordination and integrated behavioral support from local primary care sites in collaboration with community-based organizations. Main Outcomes and Measures: Utilization measures of hospital admissions, 30-day readmissions, and emergency department visits; quality of care measures of potentially avoidable hospitalizations, practitioner follow-up visits; and total cost of care (TCOC) for Medicare and Medicaid participants. Results: The CI group had 2154 Medicare beneficiaries (1320 [61.3%] female; mean age, 69.3 years) and 2532 Medicaid beneficiaries (1483 [67.3%] female; mean age, 55.1 years). For the CI group's Medicaid participants, aggregate TCOC reduction was $24.4 million, and reductions of hospitalizations, emergency department visits, 30-day readmissions, and avoidable hospitalizations were 33, 51, 36, and 7 per 1000 beneficiaries, respectively. The ACI group had 26 144 beneficiary-episodes for Medicare (13 726 [52.5%] female patients; mean patient age, 68.4 years) and 13 921 beneficiary-episodes for Medicaid (7392 [53.1%] female patients; mean patient age, 52.2 years). For the ACI group's Medicare participants, there was a significant reduction in aggregate TCOC of $29.2 million with increases in 90-day hospitalizations and 30-day readmissions of 11 and 14 per 1000 beneficiary-episodes, respectively, and reduction in practitioner follow-up visits of 41 and 29 per 1000 beneficiary-episodes for 7-day and 30-day visits, respectively. For the ACI group's Medicaid participants, there was a significant reduction in aggregate TCOC of $59.8 million and the 90-day emergency department visit rate decreased by 133 per 1000 episodes, but hospitalizations increased by 49 per 1000 episodes and practitioner follow-up visits decreased by 70 and 182 per 1000 episodes for 7-day and 30-day visits, respectively. In total, the CI and ACI were associated with $113.3 million in cost savings. Conclusions and Relevance: A care coordination model consisting of complementary bundled interventions in an urban academic environment was associated with lower spending and improved health outcomes.

Inappropriate Utilization in Fee-for-Service Medicare and Medicare Advantage Plans.

This study uses a national multi-payer claims database to test for differences in potentially inappropriate emergency department (ED) visits and ambulatory care sensitive (ACS) admissions in fee-for-service (FFS) Medicare and Medicare Advantage (MA) plans. Rates of ACS admissions for MA enrollees were approximately one third those of FFS beneficiaries, controlling for covariates, which included the beneficiary's health status as represented by their risk score. This study then compared FFS and MA beneficiaries when they moved from one type of health plan to another. Again, controlling for covariates, potentially inappropriate ED visits and ACS admissions remained at their low baseline values for FFS beneficiaries who switched from FFS Medicare to MA plans, but rose for MA enrollees switching to FFS Medicare.

Two Innovative Cancer Care Programs Have Potential to Reduce Utilization and Spending.

BACKGROUND: Cancer patients often present to the emergency department (ED) and hospital for symptom management, but many of these visits are avoidable and costly. OBJECTIVE: We assessed the impact of 2 Health Care Innovation Awards that used an oncology medical home model [Community Oncology Medical Home (COME HOME)] or patient navigation model [Patient Care Connect Program (PCCP)] on utilization and spending. METHODS: Participants in COME HOME and PCCP models were matched to similar comparators using propensity scores. We analyzed utilization and spending outcomes using Medicare fee-for-service claims with unadjusted and adjusted difference-in-differences models. RESULTS: In the adjusted models, both COME HOME and PCCP were associated with fewer ED visits than a comparison group (15 and 22 per 1000 patients/quarter, respectively; P<0.01). In addition, COME HOME had lower spending ($675 per patient/quarter; P<0.01), and PCCP had fewer hospitalizations (11 per 1000 patients/quarter; P<0.05), relative to the comparison group. Among patients undergoing chemotherapy, fewer COME HOME and PCCP patients had ED visits (18 and 28 per 1000 patients/quarter, respectively; P<0.01) and fewer PCCP patients had hospitalizations (13 per 1000 patients/quarter; P<0.05), than comparison patients. CONCLUSIONS: The oncology medical home and patient navigator programs both showed reductions in spending or utilization. Adoption of such programs holds promise for improving cancer care.

Innovative Oncology Care Models Improve End-Of-Life Quality, Reduce Utilization And Spending.

Three models that received Health Care Innovation Awards from the Centers for Medicare and Medicaid Services (CMS) aimed to reduce the cost and use of health care services and improve the quality of care for Medicare beneficiaries with cancer. Each emphasized a different principle: the oncology medical home, patient navigation, or palliative care. Comparing participants in each model who died during the study period to matched comparators, we found that the oncology medical home and patient navigation models were associated with decreased costs in the last ninety days of life ($3,346 and $5,824 per person, respectively) and fewer hospitalizations in the last thirty days of life (fifty-seven and forty per 1,000 people, respectively). The patient navigation model was also associated with fewer emergency department visits in the last thirty days of life and increased hospice enrollment in the last two weeks of life. These promising results can inform new initiatives for cancer patients, such as the CMS Oncology Care Model.

Innovative Models for High-Risk Patients Use Care Coordination and Palliative Supports to Reduce End-of-life Utilization and Spending.

BACKGROUND AND OBJECTIVES: Care coordination and palliative care supports are associated with reduced anxiety, fewer hospital admissions, and improved quality of life for patients and their families. Early palliative care can result in savings in the end-of-life period, but there is limited evidence that larger-scale models can improve both utilization and the cost of care. Three models that received Health Care Innovation Awards from the Centers for Medicare & Medicaid Services aimed to improve quality of care and reduce cost through the use of innovative care coordination models. This study explores the total cost of care and selected utilization outcomes at the end-of-life for these innovative models, each of which enrolled adults with multiple chronic conditions and featured care coordination with advance care planning as a component of palliative care. These included a comprehensive at-home supportive care model for persons predicted to die within a year and two models offering advance care planning in nursing facilities and during care transitions. RESEARCH DESIGN AND METHODS: We used regression models to assess model impacts on costs and utilization for high-risk Medicare beneficiaries participating in the comprehensive supportive care model (N = 3,339) and the two care transition models (N = 587 and N = 277) who died during the study period (2013-2016), relative to a set of matched comparison patients. RESULTS: Comparing participants in each model who died during the study period to matched comparators, two of the three models were associated with significantly lower costs in the last 90 days of life ($2,122 and $4,606 per person), and the third model showed nonsignificant differences. Two of the three models encouraged early hospice entry in the last 30 days of life. For the comprehensive at-home supportive care model, we observed aggregate savings of nearly $19 million over the study period. One care transition model showed aggregate savings of over $500,000 during the same period. Potential drivers of these cost savings include improved patient safety, timeliness of care, and caregiver support. DISCUSSION AND IMPLICATIONS: Two of the three models achieved significant lower Medicare costs than a comparison group and the same two models also sustained their models beyond the Centers for Medicare & Medicaid Services award period. These findings show promise for achieving palliative care goals as part of care coordination innovation.

PQRS Participation, Inappropriate Utilization of Health Care Services, and Medicare Expenditures.

Medicare's Physician Quality Reporting System (PQRS) is the largest quality-reporting system in the U.S. health care system and a basis for the new value-based modifier system for physician payment. The PQRS allows health care providers to report measures of quality of care that include both the process of care and physiological outcomes. Using a multivariate difference-in-differences model, we examine the relationship of PQRS participation to three claims-computable measures of inappropriate utilization of health care services and risk-adjusted per capita Medicare expenditures. The data are a national random sample of PQRS-participating providers matched to nonparticipating providers by zip code and caseload. We found few significant relationships in the overall analysis. However, the magnitude and statistical significance of the desirable associations increased in subgroups of providers and beneficiaries more prone to overutilization (e.g., males, older beneficiaries, beneficiaries treated in larger medical practices or by nonphysicians, and practices in rural areas), and among beneficiaries with heart conditions, diabetes, and eye problems.

Can data envelopment analysis provide a scalar index of 'value'?

The concept of 'value' typically includes a combination of cost and quality measures. Some approaches to incorporating value into payment systems treat cost and quality as separate dimensions, but policymakers have expressed interest in a single scalar index that combines cost and quality. Treating risk-adjusted cost as an input and multiple measures of quality as outputs, we examine whether data envelopment analysis input efficiency is associated with higher quality and lower cost in a sample of physician practices using 2008 US Medicare claims data from Colorado. The findings suggest that input efficiency might provide a useful scalar measure of value for a value-based payment system for physician services.

Emergency department utilization as a measure of physician performance.

Visits to the emergency department (ED) are costly, and because some of them are potentially avoidable, some types of ED visits also may be indicative of poor care management, inadequate access to care, or poor choices on the part of beneficiaries. Billings and colleagues developed an algorithm to analyze ED visits and assign probabilities that each visit falls into several categories of appropriateness. The algorithm has been used previously to assess the appropriateness of ED visits at the community or facility level. In this analysis, the authors explain how the Billings algorithm works and how it can be applied to individual physician practices. The authors then present illustrative data from 2 years of Medicare claims data from 5 states. About one third of ED visits are deemed appropriate, and about half could have been treated in a primary care outpatient setting. Another 15% were deemed preventable or avoidable.

Value-based purchasing for physician services.

Growth in Medicare expenditures has forced legislators and policymakers to look for ways to slow spending and get more value for their money. This article reviews previous federal efforts to control Medicare costs as well as current ones required by the Patient Protection and Affordable Care Act. It also describes a proposal for value-based purchasing that the authors developed under contract to the Centers for Medicare and Medicaid Services. This approach uses two measurement systems-one for physicians who practice primarily in outpatient settings and one for physicians who practice primarily in the hospital.

Does home- and community-based care affect nursing home use?

A study was conducted to assess change in numbers, expenditures, and case mix of nursing home residents as Medicaid investment in home- and community-based services (HCBS) 1915(c) waivers increased in seven states. The seven states provided Medicaid expenditure and utilization data from 2001 to 2005, including waiver and state plan utilization. The Minimum Data Set was used for nursing home residents. For three states, community assessment data were also used. In six states, the number of nursing home clients decreased as the numbers of HCBS clients grew. However, in most states, the number of additional waiver clients often greatly exceeded reductions in nursing home residents. Nursing home payments decreased moderately, but this decrease was offset by increases in HCBS waiver and state plan expenditures, leading to a net increase in long-term support services (LTSS) expenditures from 2001 to 2005. Increases in waiver expenditures outpaced increases in waiver clients, indicating expansion of services on top of expansion in clients. States that showed substantial increases in HCBS showed only modest increases in nursing home case mix. The case mix for nursing home residents was more acute than that for HCBS users. The expectation that greater HCBS use would siphon off less severe LTSS users and hence lead to a higher case mix in nursing homes was partially met. The more acute case mix in nursing homes suggests that HCBS serves some individuals who were previously cared for in nursing homes but many who were not. Efforts to promote substitution of HCBS for institutional care will require more proactive strategies such as diversion.

Diagnosed prevalence and health care expenditures of mental health disorders among dual eligible older people.

PURPOSE: Little is known about mental health disorders (MHDs) and their associated health care expenditures for the dual eligible elders across long-term care (LTC) settings. We estimated the 12-month diagnosed prevalence of MHDs among dual eligible older adults in LTC and non-LTC settings and calculated the average incremental effect of MHDs on medical care, LTC, and prescription drug expenditures across LTC settings. METHODS: Participants were fee-for-service dual eligible elderly beneficiaries from 7 states. We obtained their 2005 Medicare and Medicaid claims data and LTC program participation data from federal and state governments. We grouped beneficiaries into non-LTC, community LTC, and institutional LTC groups and identified enrollees with any of 5 MHDs (anxiety, bipolar, major depression, mild depression, and schizophrenia) using the International Classification of Diseases Ninth Revision codes associated with Medicare and Medicaid claims. We obtained medical care, LTC, and prescription drug expenditures from related claims. RESULTS: Thirteen percent of all dual eligible elderly beneficiaries had at least 1 MHD diagnosis in 2005. Beneficiaries in non-LTC group had the lowest 12-month prevalence rates but highest percentage increase in health care expenditures associated with MHDs. Institutional LTC residents had the highest prevalence rates but lowest percentage increase in expenditures. LTC expenditures were less affected by MHDs than medical and prescription drug expenditures. IMPLICATIONS: MHDs are prevalent among dual eligible older persons and are costly to the health care system. Policy makers need to focus on better MHD diagnosis among community-living elders and better understanding in treatment of MHDs in LTC settings.

Effect of long-term care use on Medicare and Medicaid expenditures for dual eligible and non-dual eligible elderly beneficiaries.

BACKGROUND: Dual eligible Medicare and Medicaid beneficiaries consume disproportionate shares of both programs. OBJECTIVES: To compare Medicare and Medicaid expenditures of elderly dual eligible beneficiaries with non-dual eligible beneficiaries based on their long-term care (LTC) use. RESEARCH DESIGN: Secondary analysis of linked MAX and Medicare data in seven states. SUBJECTS: Dual eligible adults (65+) receiving LTC in institutions, in the community, or not at all; and Medicare non-dual eligibles. MEASURES: Medicaid acute medical and LTC expenditures per beneficiary year, Medicare expenditures. RESULTS: Among dual eligibles and non-dual eligibles, the average number of diseases and case mix scores are higher for LTC users. Adjusting for case mix virtually eliminates the difference for medical costs, but not for LTC expenditures. Adjusting for LTC status reduces the difference in LTC costs, but increases the difference in medical costs. CONCLUSIONS: Efforts to control costs for dual eligibles should target those in LTC while better coordinating medical and LTC expenditures.