Social Determinants of Health, Quality of Public Health Data, and Health Equity in the United States.

In recent years, increasing attention has been paid to the impact social determinants of health (SDOH) can have on health equity in the United States. In this essay, we provide a framework for considering the upstream structural factors that affect the distribution of SDOH as well as the downstream consequences for individuals and groups. Improving health equity in the United States will require multiple policy streams, each requiring comprehensive data for policy development, implementation, and evaluation. Although much progress has been made in improving these data, there remain considerable gaps and opportunities for improvement. (Am J Public Health. 2023;113(12):1301-1308. https://doi.org/10.2105/AJPH.2023.307423).

Medicare Durable Medical Equipment Competitive Bidding Program: An Evaluation.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) implemented the Medicare durable medical equipment (DME) Competitive Bidding Program (CBP) in 2011. Since then, concerns have been raised regarding access to equipment and adverse health outcomes. OBJECTIVES: The aim was to evaluate whether the CBP was associated with changes in spending, utilization, and adverse health events (emergency department visits, hospitalizations, and falls). RESEARCH DESIGN: A comparative interrupted time series over 8 years was used to compare Round1 and Round2 bidding to nonbidding areas. Medicare fee for services claims were aggregated at the quarterly Metropolitan Statistical Area (MSA) level from 2009 to 2016. RESULTS: For the 3 evaluated DME (continuous positive airway pressure machines, oxygen supplies, and walkers), we found that implementation of the Medicare CBP was associated with reductions in per capita spending without changes in DME utilization or adverse health outcomes in CBP areas compared with nonbidding areas. For example, the slope change in the proportion of oxygen supplies purchasers in Round1 areas after implementation of Round1 was similar to the slope change in nonbidding areas (-0.0002; 95% CI: -0.0004, 0.0001; P=0.189). The difference in slope changes of emergency department visits and hospitalization in Round1 areas for oxygen supplies were (-0.0004; 95% CI: -0.0016, 0.0008; P=0.514) and (0.0002; 95% CI: -0.0010, 0.0014; P=0.757), respectively. Findings in Round2 areas after implementation of Round2 were similar to findings in Round1 areas. CONCLUSIONS: The Medicare DME CBP lowered Medicare expenditures while not reducing beneficiary access or increasing adverse outcomes.

Understanding Medicare ACO Adoption in the Context of Market Factors.

Medicare Accountable Care Organizations (ACOs) have achieved high-quality performance and recent cost savings, but little is known about how local market conditions influence provider adoption. The authors describe physician practice participation in Medicare ACOs at the county level and use adjusted logistic regression to assess the association between ACO presence and 3 characteristics hypothesized to influence ACO formation: physician market concentration, Medicare Advantage (MA) penetration, and commercial health insurance market concentration. Analyses are repeated on urban and rural county subgroups to examine geographic differences in ACO adoption. Practice participation in ACOs grew 19% nationally from 5.4% to 6.4% of practices between 2015 to 2017, but participation lagged in the West and rural counties, the latter of which had relatively concentrated physician markets and low MA penetration. After controlling for urban location, population density, and other covariates, ACO presence in a county was independently associated with less concentrated physician markets and moderate MA penetration but not commercial insurance concentration. The evidence suggests that Medicare ACO programs have continued appeal to physician practices, but additional engagement strategies may be needed to expand adoption in rural areas. In addition, greater practice competition and MA experience may facilitate ACO adoption. These insights into the relationship between market conditions and ACO participation have important implications for policy efforts to accelerate Medicare payment transformation.

The Five-Star Skilled Nursing Facility Rating System and Care of Disadvantaged Populations.

OBJECTIVES: To examine characteristics and locations of high- and low-quality skilled nursing facilities (SNFs) and whether certain vulnerable individuals were differentially discharged to facilities with lower quality ratings. DESIGN: Retrospective observational study. SETTING: Medicare-certified SNFs providing postacute care. PARTICIPANTS: SNF stays (N=1,195,166) of Medicare beneficiaries aged 65 and older admitted to 14,033 SNFs within 2 days of hospital discharge. MEASUREMENTS: We used Medicare claims from October 2013 to September 2014 and SNF 5-star ratings published on Nursing Home Compare. We describe the characteristics and populations of facilities according to quality, and the location of low (1 star) and high (5 stars) quality facilities. We used logistic regression models to estimate odds of admission to a low-quality facility after hospital discharge according to race, ethnicity, dual Medicare-Medicaid enrollment, functional status, discharge from a safety-net or low-quality hospital, and residence in a county with more low-quality SNFs. RESULTS: More than one-fifth (22.2%) of the facilities had a 5-star (high quality) rating, and 15.9% had a one-star (low quality) rating. Low-quality facilities were more likely to be in the south (44%), for profit (85%), and larger (>70 beds (86%)). Dual enrollment was the strongest predictor of admission to a 1-star facility (odds ratio (OR) = 1.53, 95% confidence interval (CI) = 1.51-1.55), although racial or ethnic minority status (black: OR = 1.25, 95% CI = 1.22-1.28; Hispanic: OR = 1.10, 95% CI = 1.06-1.14) and geographic prevalence of facilities (for a 10% increase in 1-star beds located in the county of individual's residence: OR = 1.27, 95% CI = 1.26-1.27) were also significant predictors. CONCLUSION: Vulnerable groups are more likely to be discharged to lower-quality facilities for postacute care. Policy-makers should monitor disparities in SNF quality. J Am Geriatr Soc 67:108-114, 2019.

Effect of a Hospital-wide Measure on the Readmissions Reduction Program.

BACKGROUND: The Hospital Readmissions Reduction Program penalizes hospitals that have high 30-day readmission rates across specific conditions. There is support for changing to a hospital-wide readmission measure to broaden hospital eligibility and provide incentives for improvement across more conditions. METHODS: We used Medicare claims from 2011 through 2013 to evaluate the number of hospitals that were eligible for penalties, in that they met a volume threshold of 25 admissions over a 3-year period for a specific condition or 25 admissions over a 1-year period for the cohorts included in the hospital-wide measure. We estimated the expected effects that changing from the condition-specific readmission measures to a hospital-wide measure would have on average penalties for safety-net hospitals (i.e., hospitals that treat a large proportion of low-income patients) and other hospitals. RESULTS: Our sample included 6,807,899 admissions for the hospital-wide measure and 4,392,658 admissions for the condition-specific measures. Of 3443 hospitals, 688 were considered to be safety-net hospitals. Changing to the hospital-wide measure would result in 76 more hospitals being eligible to receive penalties. The hospital-wide measure would increase penalties (mean [±SE] Medicare payment reductions across all hospitals) from 0.42±0.01% to 0.89±0.01% of Medicare base diagnosis-related-group payments. It would also increase the disparity in penalties between safety-net hospitals and other hospitals from -0.03±0.02 to 0.41±0.06 percentage points. CONCLUSIONS: A transition to a hospital-wide readmission measure would only modestly increase the number of hospitals eligible for penalties and would substantially increase the penalties for safety-net hospitals.

Elements of Program Design in Medicare's Value-based and Alternative Payment Models: a Narrative Review.

Increasing emphasis on value in health care has spurred the development of value-based and alternative payment models. Inherent in these models are choices around program scope (broad vs. narrow); selecting absolute or relative performance targets; rewarding improvement, achievement, or both; and offering penalties, rewards, or both. We examined and classified current Medicare payment models-the Hospital Readmissions Reduction Program (HRRP), Hospital Value-Based Purchasing Program (HVBP), Hospital-Acquired Conditions Reduction Program (HACRP), Medicare Advantage Quality Star Rating program, Physician Value-Based Payment Modifier (VM) and its successor, the Merit-Based Incentive Payment System (MIPS), and the Medicare Shared Savings Program (MSSP) on these elements of program design and reviewed the literature to place findings in context. We found that current Medicare payment models vary significantly across each parameter of program design examined. For example, in terms of scope, the HRRP focuses exclusively on risk-standardized excess readmissions and the HACRP on patient safety. In contrast, HVBP includes 21 measures in five domains, including both quality and cost measures. Choices regarding penalties versus bonuses are similarly variable: HRRP and HACRP are penalty-only; HVBP, VM, and MIPS are penalty-or-bonus; and the MSSP and MA quality star rating programs are largely bonus-only. Each choice has distinct pros and cons that impact program efficacy. Unfortunately, there are scant data to inform which program design choice is best. While no one approach is clearly superior to another, the variability contained within these programs provides an important opportunity for Medicare and others to learn from these undertakings and to use that knowledge to inform future policymaking.

Readmissions, Observation, and the Hospital Readmissions Reduction Program.

BACKGROUND: The Hospital Readmissions Reduction Program, which is included in the Affordable Care Act (ACA), applies financial penalties to hospitals that have higher-than-expected readmission rates for targeted conditions. Some policy analysts worry that reductions in readmissions are being achieved by keeping returning patients in observation units instead of formally readmitting them to the hospital. We examined the changes in readmission rates and stays in observation units over time for targeted and nontargeted conditions and assessed whether hospitals that had greater increases in observation-service use had greater reductions in readmissions. METHODS: We compared monthly, hospital-level rates of readmission and observation-service use within 30 days after hospital discharge among Medicare elderly beneficiaries from October 2007 through May 2015. We used an interrupted time-series model to determine when trends changed and whether changes differed between targeted and nontargeted conditions. We assessed the correlation between changes in readmission rates and use of observation services after adoption of the ACA in March 2010. RESULTS: We analyzed data from 3387 hospitals. From 2007 to 2015, readmission rates for targeted conditions declined from 21.5% to 17.8%, and rates for nontargeted conditions declined from 15.3% to 13.1%. Shortly after passage of the ACA, the readmission rate declined quickly, especially for targeted conditions, and then continued to fall at a slower rate after October 2012 for both targeted and nontargeted conditions. Stays in observation units for targeted conditions increased from 2.6% in 2007 to 4.7% in 2015, and rates for nontargeted conditions increased from 2.5% to 4.2%. Within hospitals, there was no significant association between changes in observation-unit stays and readmissions after implementation of the ACA. CONCLUSIONS: Readmission trends are consistent with hospitals' responding to incentives to reduce readmissions, including the financial penalties for readmissions under the ACA. We did not find evidence that changes in observation-unit stays accounted for the decrease in readmissions.

Hospice Use, Hospitalization, and Medicare Spending at the End of Life.

OBJECTIVES: Prior studies associate hospice use with reduced hospitalization and spending at the end of life based on all Medicare hospice beneficiaries. In this study, we examine the impact of different lengths of hospice care and nursing home residency on hospital use and spending prior to death across 5 disease groups. METHODS: We compared inpatient hospital days and Medicare spending during the last 6 months of life using hospice versus propensity matched non-hospice beneficiaries who died in 2010, were enrolled in fee for service Medicare throughout the last 2 years of life, and were in at least 1 of 5 disease groups. Comparisons were based on length of hospice use and whether the decedent was in a nursing home during the seventh month prior to death. We regressed a categorical measure of hospice days on outcomes, controlling for observed patient characteristics. RESULTS: Hospice use over 2 weeks was associated with decreased hospital days (1-5 days overall, with greater decreases for longer hospice use) for all beneficiaries; spending was $900-$5,000 less for hospice use of 31-90 days for most beneficiaries not in nursing homes, except beneficiaries with Alzheimer's. Overall spending decreased with hospice use for beneficiaries in nursing homes with lung cancer only, with a $3,500 reduction. DISCUSSION: The Medicare hospice benefit is associated with reduced hospital care at the end of life and reduced Medicare expenditures for most enrollees. Policies that encourage timely initiation of hospice and discourage extremely short stays could increase these successes while maintaining program goals.

Explaining variation in hospice visit intensity for routine home care.

BACKGROUND: Medicare pays a flat per diem rate by level of hospice service without case-mix adjustment, although previous research shows that visit intensity varies considerably over the course of hospice episodes. Concerns pertain to the inherent financial incentives for routine home care, the most frequently used level, and whether payment efficiency can be improved using case-mix adjustment. OBJECTIVES: The aim of this study was to assess variation in hospice visit intensity during hospice episodes by patient, hospice, and episode characteristics to inform policy discussions regarding hospice payment methods. RESEARCH DESIGN: This observational study used Medicare claims for hospice episodes in 2010. Multiple observations were constructed per episode phase (eg, days 1-14, 15-30, etc.). Episode phase and observed characteristics were regressed on average routine home care visit intensity per day; patient and hospice fixed effects controlled for unobserved characteristics. MEASURES: Visit intensity was constructed using national wages to weight visits by provider type. Observed patient characteristics included age, sex, race, diagnoses, venue of care, use of other hospice levels of care, and discharge status; hospice characteristics included ownership, affiliation, size, and urban/state location. RESULTS: Visit intensity varied substantially by episode phase. This pattern was largely invariant to observed patient and hospice characteristics, which explained <4% of variation in visit intensity per day after adjusting for episode phase. Unobserved patient characteristics explained approximately 85% of remaining variation. CONCLUSIONS: These results show that case-mix adjustment based on commonly observed factors would only minimally improve hospice payment methodology.

Perceived reactions to race and health status in the Massachusetts Behavioral Risk Factor Surveillance System Survey.

OBJECTIVES: Evaluate the relationship between race, perceptions of personally mediated racism and health outcomes in the Massachusetts Behavioral Risk Factor Surveillance System (BRFSS). METHODS: Regression analysis of 8,266 respondents to the Reactions to Race module in 2006 and 2008. Questions assessing personally mediated racism were combined to measure perceptions of reactions to race. OUTCOME MEASURES: Adjusted odds ratios and 95% CI of perceived personally mediated racism, self-reported overall health, life satisfaction, health risks (smoking status, obesity, binge and heavy drinking), and preventive services (colonoscopy, flu vaccine). RESULTS: Black non-Hispanic respondents are 10.4 times (95% CI: 6.3-17.3; P<.001) and Hispanics 5.8 times (95% CI: 3.6-9.4; P<.001) more likely to report being treated worse than other races compared to White non-Hispanic respondents. Respondents of all races reporting being treated worse than other races are 3.2 times (95% CI: 1.9-5.4; P<.001) more likely to have fair/poor health and 4.1 times (95% CI: 2.1-7.9; P<.001) more likely to report life dissatisfaction than those treated the same or better than other races. There is no statistically significant association between perceived personally mediated racism and health risks or preventive services tested. CONCLUSIONS: Perceptions of personally mediated racism are significantly associated with fair/poor overall health and life dissatisfaction, but none of the health risks or preventive services tested.

Forty years of secondhand smoke research: the gap between discovery and delivery.

CONTEXT: Public health initiatives often focus on the discovery of risk factors associated with disease and death. Although this is an important step in protecting public health, recently the field has recognized that it is critical to move along the continuum from discovery of risk factors to delivery of interventions, and to improve the quality and speed of translating scientific discoveries into practice. EVIDENCE ACQUISITION: To understand how public health problems move from discovery to delivery, citation network analysis was used to examine 1877 articles on secondhand smoke (SHS) published between 1965 and 2005. Data were collected and analyzed in 2006-2007. EVIDENCE SYNTHESIS: Citation patterns showed discovery and delivery to be distinct areas of SHS research. There was little cross-citation between discovery and delivery research, including only nine citation connections between the main paths. A discovery article was 83.5% less likely to cite a delivery article than to cite another discovery article (OR=0.165 [95% CI=0.139, 0.197]), and a delivery article was 64.3% less likely (OR=0.357 [95% CI=0.330, 0.386]) to cite a discovery article than to cite another delivery article. Research summaries, such as Surgeon General reports, were cited frequently and appear to bridge the discovery-delivery gap. CONCLUSIONS: There was a lack of cross-citation between discovery and delivery, even though they share the goal of understanding and reducing the impact of SHS. Reliance on research summaries, although they provide an important bridge between discovery and delivery, may slow the development of a field.