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1.
BMC Health Serv Res ; 19(1): 818, 2019 Nov 08.
Artigo em Inglês | MEDLINE | ID: mdl-31703682

RESUMO

BACKGROUND: While Medicare is a federal health insurance program, managed Medicare limits access to healthcare services to networks within states or territories. However, if a natural disaster requires evacuation, displaced patients are at risk of losing coverage for their benefits. Previous literature has discussed the quality of managed Medicare plans within Puerto Rico but has not addressed the adequacy of this coverage if residents are displaced to the continental United States. We explore Hurricane Maria's impact on a resident of Puerto Rico with chronic health problems, and the challenges he faces seeking healthcare in New York. CASE PRESENTATION: A 59-year-old male with a history of diabetes mellitus type II, coronary artery disease, peripheral vascular disease status post right foot amputation, and end-stage kidney disease on hemodialysis was admitted in October of 2017 for chest pain and swelling of legs for 5 days. The patient had missed his last three dialysis sessions after Hurricane Maria forced him to leave Puerto Rico. In examining this patient's treatment, we observe the effect of Hurricane Maria on the medical management of Puerto Rican residents and identify challenges managed Medicare may pose to patients who cross state or territory lines. CONCLUSIONS: We employ this patient's narrative to frame a larger discussion of Puerto Rican managed Medicare and provide additional recommendations for healthcare providers. Moreover, we consider this case in the context of disaster-related continuity of care for patients with complex medical conditions or treatment regimens. To address the gaps in the care of these patients, this article proposes (1) developing system-based approaches for screening displaced patients, (2) increasing the awareness of Special Enrollment Periods related to Medicare among healthcare providers, and (3) creating policy solutions to assure access to care for patients with complex medical conditions.


Assuntos
Tempestades Ciclônicas , Assistência à Saúde/normas , Desastres , Medicare/normas , Múltiplas Afecções Crônicas/terapia , Hispano-Americanos , Humanos , Seguro Saúde , Masculino , Turismo Médico , Pessoa de Meia-Idade , Múltiplas Afecções Crônicas/etnologia , Cidade de Nova Iorque , Aceitação pelo Paciente de Cuidados de Saúde , Porto Rico/etnologia , Refugiados , Diálise Renal , Estados Unidos
2.
Health Serv Res ; 54(6): 1233-1245, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31576563

RESUMO

OBJECTIVE: To examine between-state differences in the socioeconomic and health characteristics of Medicare beneficiaries dually enrolled in Medicaid, focusing on characteristics not observable to or used by policy makers for risk adjustment. DATA SOURCE: 2010-2013 Medicare Current Beneficiary Survey. STUDY DESIGN: Retrospective analyses of survey-reported health and socioeconomic status (SES) measures among low-income Medicare beneficiaries and low-income dual enrollees. We used hierarchical linear regression models with state random effects to estimate the between-state variation in respondent characteristics and linear models to compare the characteristics of dual enrollees by state Medicaid policies. PRINCIPAL FINDINGS: Between-state differences in health and socioeconomic risk among low-income Medicare beneficiaries, as measured by the coefficient of variation, ranged from 17.5 percent for an index of socioeconomic risk to 20.3 percent for an index of health risk. Between-state differences were comparable among the subset of low-income beneficiaries dually enrolled in Medicare and Medicaid. Dual enrollees with incomes below the Federal Poverty Level were in better health and had higher SES in states that offered Medicaid to individuals with relatively higher incomes. Duals' average incomes were higher in states with Medically Needy programs. CONCLUSIONS: Characteristics of dual enrollees differ substantially across states, reflecting differences in states' low-income Medicare populations and Medicaid policies. Risk-adjustment methods using dual enrollment to proxy for poor health and low SES should account for this state-level heterogeneity.


Assuntos
Elegibilidade Dupla ao MEDICAID e MEDICARE , Definição da Elegibilidade/normas , Medicaid/estatística & dados numéricos , Medicaid/normas , Medicare/estatística & dados numéricos , Medicare/normas , Risco Ajustado/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Socioeconômicos , Governo Estadual , Estados Unidos
3.
Health Serv Res ; 54(5): 971-980, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31506956

RESUMO

OBJECTIVE: To estimate the relationship between breach remediation efforts and hospital care quality. DATA SOURCES: Department of Health and Human Services' (HHS) public database on hospital data breaches and Medicare Compare's public data on hospital quality measures for 2012-2016. MATERIALS AND METHODS: Data breach data were merged with the Medicare Compare data for years 2012-2016, yielding a panel of 3025 hospitals with 14 297 unique hospital-year observations. STUDY DESIGN: The relationship between breach remediation and hospital quality was estimated using a difference-in-differences regression. Hospital quality was measured by 30-day acute myocardial infarction mortality rate and time from door to electrocardiogram. PRINCIPAL FINDINGS: Hospital time-to-electrocardiogram increased as much as 2.7 minutes and 30-day acute myocardial infarction mortality increased as much as 0.36 percentage points during the 3-year window following a breach. CONCLUSION: Breach remediation efforts were associated with deterioration in timeliness of care and patient outcomes. Thus, breached hospitals and HHS oversight should carefully evaluate remedial security initiatives to achieve better data security without negatively affecting patient outcomes.


Assuntos
Segurança Computacional/estatística & dados numéricos , Segurança Computacional/normas , Confidencialidade/normas , Registros Eletrônicos de Saúde/normas , Hospitais/normas , Medicare/normas , Qualidade da Assistência à Saúde/normas , Registros Eletrônicos de Saúde/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Humanos , Medicare/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estados Unidos
4.
J Manag Care Spec Pharm ; 25(9): 995-1000, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31456493

RESUMO

The shift to a value-based health care system has incentivized providers to implement strategies that improve population health outcomes while minimizing downstream costs. Given their accessibility and expanded clinical care models, community pharmacists are well positioned to join interdisciplinary care teams to advance efforts in effectively managing the health of populations. In this Viewpoints article, we discuss the expanded role of community pharmacists and potential barriers limiting the uptake of these services. We then explore strategies to integrate, leverage, and sustain these services in a value-based economy. Although community pharmacists have great potential to improve population health outcomes because of their accessibility and clinical interventions that have demonstrated improved outcomes, pharmacists are not recognized as merit-based incentive eligible providers and, as a result, may be underutilized in this role. Additional barriers include lack of formal billing codes, which limits patient access to services such as hormonal contraception; fragmentation of Medicare, which prevents alignment of medical and pharmaceutical costs; and continued fee-for-service payment models, which do not incentivize quality. Despite these barriers, there are several opportunities for continued pharmacist involvement in new care models such as patient-centered medical homes (PCMH), accountable care organizations, and other value-based payment models. Community pharmacists integrated within PCMHs have demonstrated improved hemoglobin A1c, blood pressure control, and immunization rates. Likewise, other integrated, value-based models that used community pharmacists to provide medication therapy management services have reported a positive return on investment in overall health care costs. To uphold these efforts and effectively leverage community pharmacist services, we recommend the following: (a) recognition of pharmacists as providers to facilitate full participation in performance-based models, (b) increased integration of pharmacists in emerging delivery and payment models with rapid cycle testing to further clarify the role and value of pharmacists, and (c) enhanced collaborative relationships between pharmacists and other providers to improve interdisciplinary care. DISCLOSURES: This article was funded by the National Association of Chain Drug Stores. The authors have no potential conflicts of interest to report.


Assuntos
Serviços Comunitários de Farmácia/organização & administração , Serviços Comunitários de Farmácia/normas , Conduta do Tratamento Medicamentoso/organização & administração , Conduta do Tratamento Medicamentoso/normas , Farmacêuticos/organização & administração , Farmacêuticos/normas , Organizações de Assistência Responsáveis/organização & administração , Organizações de Assistência Responsáveis/normas , Redução de Custos/normas , Planos de Pagamento por Serviço Prestado/normas , Custos de Cuidados de Saúde/normas , Humanos , Medicare/organização & administração , Medicare/normas , Equipe de Assistência ao Paciente/organização & administração , Equipe de Assistência ao Paciente/normas , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/normas , Papel Profissional , Estados Unidos
5.
Ann Intern Med ; 171(1): 27-36, 2019 07 02.
Artigo em Inglês | MEDLINE | ID: mdl-31207609

RESUMO

Background: Accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) are associated with modest savings. However, prior research may overstate this effect if high-cost clinicians exit ACOs. Objective: To evaluate the effect of the MSSP on spending and quality while accounting for clinicians' nonrandom exit. Design: Similar to prior MSSP analyses, this study compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics. To further account for selection effects, the share of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as a falsification outcome. The authors also tested for compositional changes among MSSP participants. Setting: Fee-for-service Medicare, 2008 through 2014. Patients: A 20% sample (97 204 192 beneficiary-quarters). Measurements: Total spending, 4 quality indicators, and hospitalization for hip fracture. Results: In adjusted longitudinal models, the MSSP was associated with spending reductions (change, -$118 [95% CI, -$151 to -$85] per beneficiary-quarter) and improvements in all 4 quality indicators. In instrumental variable models, the MSSP was not associated with spending (change, $5 [CI, -$51 to $62] per beneficiary-quarter) or quality. In falsification tests, the MSSP was associated with hip fracture in the adjusted model (-0.24 hospitalizations for hip fracture [CI, -0.32 to -0.16 hospitalizations] per 1000 beneficiary-quarters) but not in the instrumental variable model (0.05 hospitalizations [CI, -0.10 to 0.20 hospitalizations] per 1000 beneficiary-quarters). Compositional changes were driven by high-cost clinicians exiting ACOs: High-cost clinicians (99th percentile) had a 30.4% chance of exiting the MSSP, compared with a 13.8% chance among median-cost clinicians (50th percentile). Limitation: The study used an observational design and administrative data. Conclusion: After adjustment for clinicians' nonrandom exit, the MSSP was not associated with improvements in spending or quality. Selection effects-including exit of high-cost clinicians-may drive estimates of savings in the MSSP. Primary Funding Source: Horowitz Foundation for Social Policy, Agency for Healthcare Research and Quality, and National Institute on Aging.


Assuntos
Organizações de Assistência Responsáveis/economia , Organizações de Assistência Responsáveis/normas , Redução de Custos , Medicare/economia , Medicare/normas , Idoso , Planos de Pagamento por Serviço Prestado/economia , Fraturas do Quadril/terapia , Hospitalização/estatística & dados numéricos , Humanos , Estudos Longitudinais , Indicadores de Qualidade em Assistência à Saúde , Viés de Seleção , Estados Unidos
6.
BMC Geriatr ; 19(1): 103, 2019 04 11.
Artigo em Inglês | MEDLINE | ID: mdl-30975076

RESUMO

BACKGROUND: Availability of nursing home care has declined and national efforts have been initiated to improve the quality of nursing home care in the U.S. Yet, data are limited on whether there are geographic variations in declines of availability and quality of nursing home care, and whether variations persist over time. We sought to assess geographic variation in availability and quality of nursing home care. METHODS: Retrospective study using Medicaid/Medicare-certified nursing home data from the Centers for Medicare & Medicaid Services, 1996-2016. Outcomes were 1) availability of all nursing home care (1996-2016), measured by the number of Medicaid/Medicare-certified beds for a given county per 100,000 population aged ≥65 years, regardless of nursing home star rating; 2) availability of 5-star nursing home care, measured by the number of Medicaid/Medicare-certified beds provided by 5-star nursing homes; and 3) utilization of nursing home beds, defined as the rate of occupied Medicaid/Medicare-certified beds among the total Medicaid/Medicare-certified beds. RESULTS: From 1999 to 2016, availability of all nursing home care declined from 4882 (standard deviation: 931) to 3480 (912) beds, per 100,000 population aged ≥65 years. Persistent geographic variation in availability of nursing home care was observed; the correlation coefficient of county-specific availabilities from 1996 to 2016 was 0.78 (95% CI 0.77-0.79). From 2011 to 2016, availability of 5-star nursing home beds increased from 658 (303) to 895 (661) per 100,000 population aged ≥65 years. The correlation coefficient for county-specific availabilities from 2011 to 2016 was 0.54 (95% CI 0.51-0.56). Availability and quality of nursing home care were not highly correlated. In 2016, the correlation coefficient for county-specific availabilities between all nursing home and 5-star nursing home beds was 0.33 (95% CI 0.30-0.36). From 1996 to 2016, the utilization of certified beds declined from 78.5 to 72.2%. This decline was consistent across all census divisions, but most pronounced in the Mountain division and less in the South-Atlantic division. CONCLUSION: We observed persistent geographic variations in availability and quality of nursing home care. Availability of all nursing home care declined but availability of 5-star nursing home care increased. Availability and quality of nursing home care were not highly correlated.


Assuntos
Acesso aos Serviços de Saúde/tendências , Instituição de Longa Permanência para Idosos/tendências , Casas de Saúde/tendências , Qualidade da Assistência à Saúde/tendências , Idoso , Idoso de 80 Anos ou mais , /tendências , Feminino , Acesso aos Serviços de Saúde/normas , Instituição de Longa Permanência para Idosos/normas , Humanos , Masculino , Medicaid/normas , Medicaid/tendências , Medicare/normas , Medicare/tendências , Casas de Saúde/normas , Qualidade da Assistência à Saúde/normas , Estudos Retrospectivos , Instituições de Cuidados Especializados de Enfermagem/normas , Instituições de Cuidados Especializados de Enfermagem/tendências , Estados Unidos/epidemiologia
9.
Health Serv Res ; 54(2): 327-336, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30848491

RESUMO

OBJECTIVE: Medicare's Hospital Readmissions Reduction Program (HRRP) does not account for social risk factors in risk adjustment, and this may lead the program to unfairly penalize safety-net hospitals. Our objective was to determine the impact of adjusting for social risk factors on HRRP penalties. STUDY DESIGN: Retrospective cohort study. DATA SOURCES/STUDY SETTING: Claims data for 2 952 605 fee-for-service Medicare beneficiaries with acute myocardial infarction (AMI), congestive heart failure (CHF) or pneumonia from December 2012 to November 2015. PRINCIPAL FINDINGS: Poverty, disability, housing instability, residence in a disadvantaged neighborhood, and hospital population from a disadvantaged neighborhood were associated with higher readmission rates. Under current program specifications, safety-net hospitals had higher readmission ratios (AMI, 1.020 vs 0.986 for the most affluent hospitals; pneumonia, 1.031 vs 0.984; and CHF, 1.037 vs 0.977). Adding social factors to risk adjustment cut these differences in half. Over half the safety-net hospitals saw their penalty decline; 4-7.5 percent went from having a penalty to having no penalty. These changes translated into a $17 million reduction in penalties to safety-net hospitals. CONCLUSIONS: Accounting for social risk can have a major financial impact on safety-net hospitals. Adjustment for these factors could reduce negative unintended consequences of the HRRP.


Assuntos
Medicare/organização & administração , Readmissão do Paciente/estatística & dados numéricos , Risco Ajustado/organização & administração , Provedores de Redes de Segurança/organização & administração , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Pessoas com Deficiência/estatística & dados numéricos , Economia Hospitalar , Feminino , Disparidades nos Níveis de Saúde , Insuficiência Cardíaca/epidemiologia , Humanos , Revisão da Utilização de Seguros/estatística & dados numéricos , Masculino , Medicaid/estatística & dados numéricos , Medicare/normas , Infarto do Miocárdio/epidemiologia , Readmissão do Paciente/economia , Pneumonia/epidemiologia , Melhoria de Qualidade/organização & administração , Características de Residência/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Provedores de Redes de Segurança/normas , Fatores Socioeconômicos , Estados Unidos
10.
Value Health ; 22(3): 284-292, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30832966

RESUMO

BACKGROUND: For patients with hepatocellular carcinoma (HCC) not eligible for surgical resection, radiofrequency ablation (RFA) is a promising technique that reduces the risk of disease progression. OBJECTIVES: To evaluate whether the trend of image guidance for RFA is moving toward the more expensive computed tomography (CT) technology and to determine the clinical benefits of CT guidance over the ultrasound (US) guidance. METHODS: A cohort of 463 patients was identified from the Surveillance, Epidemiology, and End Results and Medicare-linked database. The temporal trends in use of image guidance were assessed using the Cochrane-Armitage test. The associations between modality of image guidance and survival, complications, and costs were assessed using the Cox regression model, the logistic regression model, and the generalized linear model, respectively. RESULTS: The use of CT-guided RFA increased sharply, from 20.7% in 2002 to 75.9% in 2011. Compared with CT-guided RFA, those who received US-guided RFA had comparable risk of periprocedural and delayed postprocedural complications. Stratified analyses by tumor size also showed no statistically significant difference. In adjusted survival analysis, no statistically significant difference was observed in overall and cancer-specific survival. Nevertheless, the cost of CT-guided RFA ($2847) was higher than that of US-guided RFA ($1862). CONCLUSIONS: Despite its rapid adoption over time, CT-guided RFA incurred higher procedural costs than US-guided RFA but did not significantly improve postprocedural complications and survival. Echoing the American Board of Internal Medicine's Choosing Wisely campaign and the American Society of Clinical Oncology's Value of Cancer Care initiative, findings from our study call for critical evaluation of whether CT-guided RFA provides high-value care for patients with HCC.


Assuntos
Carcinoma Hepatocelular/diagnóstico por imagem , Neoplasias Hepáticas/diagnóstico por imagem , Medicare/normas , Ablação por Radiofrequência/normas , Tomografia Computadorizada por Raios X/normas , Ultrassonografia de Intervenção/normas , Idoso , Idoso de 80 Anos ou mais , Carcinoma Hepatocelular/epidemiologia , Carcinoma Hepatocelular/cirurgia , Estudos de Coortes , Feminino , Humanos , Neoplasias Hepáticas/epidemiologia , Neoplasias Hepáticas/cirurgia , Masculino , Pontuação de Propensão , Ablação por Radiofrequência/métodos , Estudos Retrospectivos , Programa de SEER/normas , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Ultrassonografia de Intervenção/métodos , Estados Unidos/epidemiologia
11.
JAMA Cardiol ; 4(2): 110-118, 2019 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30624549

RESUMO

Importance: Following negative randomized clinical trials, US guidelines downgraded support for routine manual aspiration thrombectomy (AT) during primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI). However, some PCI operators continue to endorse a clinical benefit with AT use despite the lack of supportive data. Objective: To examine temporal trends and comparative outcomes of AT use during pPCI for STEMI. Design, Setting, and Participants: Retrospective cohort study of the National Cardiovascular Data Registry (NCDR) CathPCI Registry from July 1, 2009, to June 30, 2016, to assess temporal trends and in-hospital outcomes associated with AT use. To evaluate outcomes through 180 days, a subanalysis was conducted among Centers for Medicare and Medicaid Services-linked patients from July 1, 2009, through December 31, 2014. The comparative effectiveness analysis was performed using instrumental variable analyses to account for treatment selection bias. The instrumental variable was operator's preference to use AT during pPCI. Data were analyzed between February 1, 2017, and April 1, 2018. Exposures: Aspiration thrombectomy use during pPCI for STEMI. Main Outcomes and Measures: Primary outcomes included in-hospital stroke and death. Secondary outcomes included heart failure, stroke, all-cause rehospitalization, and death through 180 days of follow-up. Results: Among all pPCIs performed (683 584), the mean (SD) age of patients was 61.7 (12.8) years, 489 257 were male (71.6%), and 596 384 were white (87.2%). Among patients undergoing pPCI, AT use increased from 2009 through 2011, with peak use of 13.8%. This was followed by a decline of more than 9%, reaching 4.7% by mid-2016. Overall, AT was used in 10.8% of pPCIs (lowest operator group median, 0%; highest operator group median, 33.8%). After instrumental variable analysis, AT use was associated with no difference in in-hospital death (adjusted absolute risk difference, -0.18%; 95% CI, -0.53% to 0.16%; P = .29) and a small increase in in-hospital stroke (adjusted RD, 0.14%; 95% CI, 0.01%-0.30%; P = .03). Among Centers for Medicare and Medicaid Services-linked patients, AT use was not associated with differences in death, heart failure, stroke, or rehospitalization at 180 days. Conclusions and Relevance: In this large, nationwide analysis, AT use during STEMI pPCI declined by more than 50% since 2011, with use as of mid-2016 at less than 5%. Selective AT use was associated with a small excess risk of in-hospital stroke and no difference in other outcomes through 180 days of follow-up.


Assuntos
Intervenção Coronária Percutânea/efeitos adversos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Trombectomia/efeitos adversos , Idoso , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/etiologia , Mortalidade Hospitalar/tendências , Humanos , Masculino , Medicare/normas , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Intervenção Coronária Percutânea/tendências , Ensaios Clínicos Controlados Aleatórios como Assunto , Sistema de Registros , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Trombectomia/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
12.
J Arthroplasty ; 34(4): 613-618, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30630648

RESUMO

BACKGROUND: Nursing Home Compare (NHC) ratings, created and maintained by Medicare, are used by both hospitals and consumers to aid in the skilled nursing facility (SNF) selection process. To date, no studies have linked NHC ratings to actual episode-based outcomes. The purpose of this study was to evaluate whether NHC ratings are valid predictors of 90-day complications, readmission, and bundle costs for patients discharged to an SNF after primary total joint arthroplasty (TJA). METHODS: All SNF-discharged primary TJA cases in 2017 at a multihospital academic health system were queried. Demographic, psychosocial, and clinical variables were manually extracted from the health record. Medicare NHC ratings were then collected for each SNF. For patients in the Medicare bundle, postacute and total bundle cost was extracted from claims. RESULTS: Four hundred eighty-eight patients were discharged to a total of 105 unique SNFs. In multivariate analysis, overall NHC rating was not predictive of 90-day readmission/major complications, >75th percentile postacute cost, or 90-day bundle cost exceeding the target price. SNF health inspection and quality measure ratings were also not predictive of 90-day readmission/major complications or bundle performance. A higher SNF staffing rating was independently associated with a decreased odds for >75th percentile 90-day postacute spend (odds ratio, 0.58; P = .01) and a 90-day bundle cost exceeding the target price (odds ratio = 0.69; P = .02) but was similarly not predictive of 90-day readmission/complications. CONCLUSION: Results of our study suggest that Medicare's NHC tool is not a useful predictor of 90-day costs, complications, or readmissions for SNFs within our health system.


Assuntos
Artroplastia de Quadril/reabilitação , Artroplastia do Joelho/reabilitação , Medicare/normas , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Instituições de Cuidados Especializados de Enfermagem/normas , Idoso , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/economia , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/economia , Custos e Análise de Custo , Feminino , Humanos , Masculino , Medicare/economia , Razão de Chances , Pacotes de Assistência ao Paciente/economia , Alta do Paciente , Readmissão do Paciente/economia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Estados Unidos/epidemiologia
13.
Health Serv Res ; 54(1): 106-116, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30520027

RESUMO

OBJECTIVE: To assess the relationship between the 2007 Medicare regulation enforcing quality standards for transplant centers and trends in kidney transplantation. DATA SOURCES: Transplant centers' biannual reports and the national registry for kidney transplantation from 2003 to 2010. STUDY DESIGN: Non-compliant (low-performing) centers were compared with centers in compliance with quality standards according to: number of transplants, waiting-list registrations, and rates of graft failures, transfers, and deaths. Multivariate regressions were estimated to evaluate the association between the regulation and transplantation outcomes. DATA EXTRACTION METHODS: Patient characteristics and outcomes were aggregated to six-month periods and linked to centers' reports. PRINCIPAL FINDINGS: Relative to average-performing centers, 12 percent of transplants shifted away from low-performing centers and high-performing centers captured 6 percent of this decline. Low-performing centers experienced a 2-percentage point per period decline in 1-year graft failure rates and a 15-percent decrease in registrations post-regulation, whereas high-performing centers incurred a 5-percent decrease in registrations relative to average-performing centers. CONCLUSIONS: Government oversight in kidney transplantation was associated with a small downward shift in overall kidney transplants. Reductions in graft failure rates at low-performing centers may imply an increase in quality or a decline in transplantation of either marginal organs or riskier patients; whereas reductions in registrations may indicate risk aversion toward high-risk patients. Policy makers should consider making less punitive requirements for programs, which employ new transplantation techniques to expand access.


Assuntos
Transplante de Rim/normas , Medicare/normas , Qualidade da Assistência à Saúde/normas , Obtenção de Tecidos e Órgãos/normas , Feminino , Humanos , Transplante de Rim/estatística & dados numéricos , Masculino , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Estados Unidos
14.
JAMA Intern Med ; 179(2): 161-166, 2019 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30575846

RESUMO

Importance: An estimated 4 to 5 million Americans have Alzheimer disease or another dementia. Objective: To determine the health care utilization and cost outcomes of a comprehensive dementia care program for Medicare fee-for-service beneficiaries. Design, Setting, and Participants: In this case-control study, we used a quasiexperimental design to compare health care utilization and costs for 1083 Medicare fee-for-service beneficiaries enrolled in the University of California Los Angeles Health System Alzheimer and Dementia Care program between July 1, 2012, and December 31, 2015, with those of 2166 similar patients with dementia not participating in the program. Patients in the comparison cohort were selected using the zip code of residence as a sampling frame and matched with propensity scores, which included demographic characteristics, comorbidities, and prior-year health care utilization. We used Medicare claims data to compare utilization and cost outcomes for the 2 groups. Interventions: Patients in the dementia care program were comanaged by nurse practitioners and physicians, and the program consisted of structured needs assessments of patients and their caregivers, creation and implementation of individualized dementia care plans with input from primary care physicians, monitoring and revising care plans, referral to community organizations for dementia-related services and support, and access to a clinician for assistance and advice 24 hours per day, 7 days per week. Main Outcomes and Measures: Admissions to long-term care facilities; average difference-in-differences per quarter over the 3-year intervention period for all-cause hospitalization, emergency department visits, 30-day hospital readmissions, and total Medicare Parts A and B costs of care. Program costs were included in the cost estimates. Results: Program participants (n = 382 men, n = 701 women; mean [SD] age, 82.10 [7.90] years; age range 54-101 years) were less likely to be admitted to a long-term care facility (hazard ratio, 0.60; 95% CI, 0.59-0.61) than those not participating in the dementia care program (n = 759 men, n = 1407 women; mean [SD] age, 82.42 [8.50] years; age range, 34-103 years). There were no differences between groups in terms of hospitalizations, emergency department visits, or 30-day readmissions. The total cost of care to Medicare, excluding program costs, was $601 less per patient per quarter (95% CI, -$1198 to -$5). After accounting for the estimated program costs of $317 per patient per quarter, the program was cost neutral for Medicare, with an estimated net cost of -$284 (95% CI, -$881 to $312) per program participant per quarter. Conclusions and Relevance: Comprehensive dementia care may reduce the number of admissions to long-term care facilities, and depending on program costs, may be cost neutral or cost saving. Wider implementation of such programs may help people with dementia stay in their communities.


Assuntos
Serviços de Saúde Comunitária/economia , Demência/economia , Demência/terapia , Assistência de Longa Duração/economia , Medicare/economia , Idoso , Idoso de 80 Anos ou mais , California , Estudos de Casos e Controles , Serviços de Saúde Comunitária/normas , Assistência Integral à Saúde , Análise Custo-Benefício , Planos de Pagamento por Serviço Prestado/economia , Feminino , Humanos , Assistência de Longa Duração/normas , Masculino , Medicare/normas , Pessoa de Meia-Idade , Qualidade da Assistência à Saúde/economia , Estados Unidos
15.
Spine J ; 19(1): 8-14, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30010045

RESUMO

BACKGROUND CONTEXT: The impact of Accountable Care Organizations (ACOs) on healthcare quality and outcomes, including morbidity, mortality, and readmissions, has not been substantially investigated, especially following spine surgery. PURPOSE: To evaluate the impact of ACO formation on postoperative outcomes in the 90-day period following spine surgery. STUDY DESIGN: Retrospective review of national Medicare claims data (2009-2014). PATIENT SAMPLE: Patients who underwent one of four lumbar spine surgical procedures in an ACO or non-ACO. OUTCOME MEASURES: The development of in-hospital mortality, complications or hospital readmission within 90 days of the surgical procedure. METHODS: The primary outcome measures included postsurgical complications and readmissions at 90 days following surgery. In-hospital mortality and 30-day outcomes were considered secondarily. The primary predictor variable consisted of ACO enrollment designation. Multivariable logistic regression analysis was utilized to adjust for confounders and determine the independent effect of ACO enrollment on postsurgical outcomes. The multivariable model included a propensity score adjustment that accounted for factors associated with the preferential enrollment of patients in ACOs, namely, sociodemographic characteristics, medical co-morbidities, hospital teaching status, bed size, and location. RESULTS: In all, there were 344,813 patients identified for inclusion in this analysis with 97% (n = 332,890) treated in non-ACOs and 3% (n = 11,923) in an ACO. Although modest changes were apparent across both ACOs and non-ACOs over the time-period studied, improvements were slightly more dramatic in non-ACOs leading to statistically significant differences in both 90-day complications and readmissions. Specifically, in the period 2012-2014, ACOs demonstrated an 18% increase in the odds of 90-day complications and a 14% elevation in the odds of 90-day readmissions when compared to non-ACOs. There was no difference in hospital mortality between ACOs and non-ACOs. CONCLUSIONS: Our study of Medicare data from 2009 to 2014 failed to demonstrate superior reductions in postoperative morbidity, mortality, and readmissions for beneficiaries treated in ACOs as compared to non-ACOs. These results indicate that meaningful changes in postoperative outcomes should not be anticipated based on organizational participation in ACOs at present.


Assuntos
Organizações de Assistência Responsáveis/estatística & dados numéricos , Medicare/estatística & dados numéricos , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Coluna Vertebral/cirurgia , Organizações de Assistência Responsáveis/normas , Humanos , Medicare/normas , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/normas , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Estados Unidos
16.
Am J Manag Care ; 24(12): e399-e403, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-30586489

RESUMO

OBJECTIVES: To (1) compare the 2015 hospital grades reported on Medicare's Hospital Compare website for heart failure (HF) and acute myocardial infarction (AMI) readmissions with the HF- and AMI-specific scores for excess readmissions used to assess Medicare readmission penalties and (2) assess how often hospitals were penalized for excess readmissions in only 1 or 2 conditions, given that hospitals received a penalty impacting all Medicare payments based on an overall readmission score calculated from 5 conditions (HF, AMI, pneumonia, chronic obstructive pulmonary disease, and total hip/knee arthroplasty). STUDY DESIGN: Retrospective secondary data analysis. METHODS: Descriptive analyses of hospital-specific, condition-specific grades and excess readmission scores and hospital-level penalties downloaded from Hospital Compare. RESULTS: Of the 2956 hospitals that had publicly reported HF grades on Hospital Compare, 91.9% (2717) were graded as "no different" than the national rate for HF readmissions, which included 48.6% that were scored as having excessive HF admissions, and 87% received an overall readmission penalty. Of 120 (4.1%) hospitals graded as "better" than the national rate for HF, none were scored as having excessive HF readmissions and 50% were penalized. AMI data yielded similar results. Among 2591 hospitals penalized for overall readmissions, 26.6% had only 1 condition with excess readmissions and 27.5% had 2 conditions. CONCLUSIONS: Many hospitals with an HF and AMI readmission grade of "no different" than the national rate on Hospital Compare received penalties for excessive readmissions under the Hospital Readmissions Reduction Program. The value signal to consumers and hospitals communicated by grades and penalties is therefore weakened because the methods applied to the same hospital data produce conflicting messages of "average grades" yet "bad enough for penalty."


Assuntos
Hospitais/normas , Medicare , Seguro de Saúde Baseado em Valor , Artroplastia de Quadril/economia , Artroplastia de Quadril/normas , Artroplastia do Joelho/economia , Artroplastia do Joelho/normas , Insuficiência Cardíaca/terapia , Humanos , Medicare/economia , Medicare/organização & administração , Medicare/normas , Infarto do Miocárdio/terapia , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Pneumonia/economia , Pneumonia/terapia , Doença Pulmonar Obstrutiva Crônica/economia , Doença Pulmonar Obstrutiva Crônica/terapia , Estudos Retrospectivos , Estados Unidos , Seguro de Saúde Baseado em Valor/economia
18.
Med Decis Making ; 38(8): 983-993, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30403580

RESUMO

BACKGROUND: The Medicare Health Outcomes Survey (HOS), a nationwide annual survey of Medicare beneficiaries, includes the Centers for Disease Control and Prevention's HRQOL-4 questionnaire and Veterans RAND 12-item Health Survey (VR-12). This study compared EQ-5D scores derived from the HRQOL-4 (dEQ-5D) to SF-6D scores derived from VR-12. METHODS: Data were from Medicare HOS Cohort 15 (2012 baseline; 2014 follow-up). We included participants aged 65+ ( n = 105,473). We compared score distributions, evaluated known-groups validity, assessed each index as a predictor for mortality, and estimated quality-adjusted life years (QALYs) using the dEQ-5D and SF-6D. RESULTS: Compared to the SF-6D, the dEQ-5D had a higher mean score (0.787 v. 0.691) and larger standard deviation (0.310 v. 0.101). The decreases in estimated scores associated with chronic conditions were greater for the dEQ-5D than for the SF-6D. For example, dEQ-5D scores for persons with depression decreased 0.456 points compared to 0.141 points for the SF-6D. The dEQ-5D strongly predicted mortality, as adjusted hazard ratios for the first to fourth quintiles, relative to the fifth quintile, were 2.2, 1.7, 1.8, and 1.5, respectively, while the association between SF-6D and mortality was weaker or nonexistent (adjusted hazard ratios were 1.3, 1.1, 1.0, and 0.6, respectively). Compared to the SF-6D, QALYs estimated using the dEQ-5D were higher overall (5.6 v. 4.9 years), higher for persons with less debilitating conditions (e.g., hypertension, 5.0 v. 4.4 years), and lower for more debilitating conditions (e.g. depression, 2.5 v. 2.8 years). CONCLUSIONS: Compared to the SF-6D, the dEQ-5D was better able to measure individuals' overall health; detect the differential impact of chronic conditions, particularly among persons in poorer health; and predict mortality. The HRQOL-4 questionnaire may be valuable for monitoring and improving health outcomes for the Medical HOS data set.


Assuntos
Inquéritos Epidemiológicos/normas , Medicare/normas , Anos de Vida Ajustados por Qualidade de Vida , Idoso , Idoso de 80 Anos ou mais , Doença Crônica/mortalidade , Análise Custo-Benefício , Feminino , Comportamentos Relacionados com a Saúde , Humanos , Masculino , Psicometria , Qualidade de Vida , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Fatores Socioeconômicos , Inquéritos e Questionários/normas , Análise de Sobrevida , Estados Unidos
19.
Health Serv Res ; 53 Suppl 3: 5201-5218, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30206936

RESUMO

OBJECTIVE: It remains unknown whether high-functioning teams can compensate for poor continuity of care to support important patient outcomes. DATA SOURCE: Linked VA administrative and Medicare claims data to measure the relationship of team-based care and continuity of care with high-cost utilization. STUDY DESIGN: Retrospective cohort study of 1.2 million VA-Medicare dual eligible Veterans assigned to a VA primary care provider (PCP) in 2012. Continuity was the proportion of primary care visits to the assigned VA provider of care. Clinics were categorized as low, average, or high-team functioning based on survey data. Our primary outcomes were the number of all-cause hospitalizations, ambulatory care sensitive (ACSC) hospitalizations, and emergency department (ED) visits in 2013. PRINCIPAL FINDINGS: A 10-percentage point increase in continuity with a VA PCP was associated with 4.5 fewer hospitalizations (p < .001), 3.2 fewer ACSC hospitalizations (p < .001), and 2.6 more ED visits (p = .07) per 1,000 patients. Team-based care was not significantly associated with any high-cost utilization category. Associations were heterogeneous across VA-reliant and nonreliant Veterans. Finally, the interaction results demonstrated that the quality of team-based care functioning could not compensate for poor continuity on hospitalizations, ACSC hospitalizations, or ED visits. CONCLUSIONS: In Veterans who were reliant on the VA for services, increasing continuity with a VA PCP and high-functioning team-based care clinics was associated with fewer ED visits and hospitalizations. Furthermore, leveraging combined data from VA and Medicare allowed to better measure continuity and assess high-cost utilization among Veterans who are and are not reliant on the VA for services.


Assuntos
Continuidade da Assistência ao Paciente/organização & administração , Medicare/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Assistência Centrada no Paciente/organização & administração , United States Department of Veterans Affairs/organização & administração , Fatores Etários , Idoso , Assistência Ambulatorial/estatística & dados numéricos , Grupos de Populações Continentais , Continuidade da Assistência ao Paciente/normas , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicare/normas , Medicare/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Equipe de Assistência ao Paciente/normas , Assistência Centrada no Paciente/normas , Assistência Centrada no Paciente/estatística & dados numéricos , Estudos Retrospectivos , Fatores Sexuais , Fatores Socioeconômicos , Estados Unidos , United States Department of Veterans Affairs/normas , United States Department of Veterans Affairs/estatística & dados numéricos
20.
J Gerontol Nurs ; 44(9): 9-14, 2018 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-30148527

RESUMO

Hearing loss (HL) becomes increasingly common with age and can lead to multiple negative outcomes, including isolation, falls, depression, altered social relationships, and altered cognitive functioning. HL also can affect patient-provider communication and lead to misunderstandings. Despite the negative effects that HL has on multiple domains, less than 20% to 25% of individuals who might benefit from amplification devices and/or hearing aids own them. Barriers to use include stigma, cost, and access. Nurses can play a critical role in promoting appropriate care for individuals with HL and providing access for those who need hearing aids. The current article (a) briefly reviews how history and policies, especially Medicare and Medicaid, but also those defining the practice of audiology and dispensing of hearing aids, affect insurance coverage for hearing care; (b) reviews how a combination of forces brought the need for accessible and affordable hearing care to national attention and resulted in the Over-the-Counter (OTC) Hearing Aid Act; and (c) discusses the implications of the OTC Act for nurses and nursing practice. [Journal of Gerontological Nursing, 44(9), 9-14.].


Assuntos
Auxiliares de Audição/economia , Auxiliares de Audição/estatística & dados numéricos , Perda Auditiva/enfermagem , Cobertura do Seguro/normas , Medicaid/normas , Medicare/normas , Cuidados de Enfermagem/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Política de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
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