Moving Toward High-Value Health Care: Integrating Delivery System Reform into 2020 Policy Proposals.

Issue: Delivery system reform has been a focus of regulatory and legislative policy to date, but it is unclear how policymakers will integrate reforms into their plans for 2020 and beyond. Goal: To present and evaluate options for integrating delivery system reform into upcoming legislative proposals. Methods: Literature review. Findings and Conclusions: Policymakers should integrate delivery system reform into their 2020 plans to continue driving value in the health care system. Several options exist for promoting delivery system reform either through a state-based block grant approach or federal public plan approach. We identify three main principles that are critical for success of reform efforts: information sharing and infrastructure, flexibility to innovate, and alignment and stability of efforts.

Age-dependent cost-utility of pediatric cochlear implantation.

OBJECTIVES: Cochlear implantation (CI) has become the mainstay of treatment for children with severe-to-profound sensorineural hearing loss (SNHL). Yet, despite mounting evidence of the clinical benefits of early implantation, little data are available on the long-term societal benefits and comparative effectiveness of this procedure across various ages of implantation-a choice parameter for parents and clinicians with high prognostic value for clinical outcome. As such, the aim of the present study is to evaluate a model of the consequences of the timing of this intervention from a societal economic perspective. Average cost utility of pediatric CI by age at intervention will be analyzed. DESIGN: Prospective, longitudinal assessment of health utility and educational placement outcomes in 175 children recruited from six U.S. centers between November 2002 and December 2004, who had severe-to-profound SNHL onset within 1 year of age, underwent CI before 5 years of age, and had up to 6 years of postimplant follow-up that ended in November 2008 to December 2011. Costs of care were collected retrospectively and stratified by preoperative, operative, and postoperative expenditures. Incremental costs and benefits of implantation were compared among the three age groups and relative to a nonimplantation baseline. RESULTS: Children implanted at <18 months of age gained an average of 10.7 quality-adjusted life years (QALYs) over their projected lifetime as compared with 9.0 and 8.4 QALYs for those implanted between 18 and 36 months and at >36 months of age, respectively. Medical and surgical complication rates were not significantly different among the three age groups. In addition, mean lifetime costs of implantation were similar among the three groups, at approximately $2000/child/year (77.5-year life expectancy), yielding costs of $14,996, $17,849, and $19,173 per QALY for the youngest, middle, and oldest implant age groups, respectively. Full mainstream classroom integration rate was significantly higher in the youngest group at 81% as compared with 57 and 63% for the middle and oldest groups, respectively (p < 0.05) after 6 years of follow-up. After incorporating lifetime educational cost savings, CI led to net societal savings of $31,252, $10,217, and $6,680 for the youngest, middle, and oldest groups at CI, respectively, over the child's projected lifetime. CONCLUSIONS: Even without considering improvements in lifetime earnings, the overall cost-utility results indicate highly favorable ratios. Early (<18 months) intervention with CI was associated with greater and longer quality-of-life improvements, similar direct costs of implantation, and economically valuable improved classroom placement, without a greater incidence of medical and surgical complications when compared to CI at older ages.

Medicare And Telehealth: Delivering On Innovation's Promise For Equity, Quality, Access, And Sustainability.

The COVID-19 pandemic profoundly changed health care. Policy makers and health care leaders must evaluate the lessons learned from the pandemic and leverage telehealth innovations with an eye toward how such changes can advance health equity; drive high-quality, high-value, person-centered care; and promote affordability and sustainability.

Reexamining Health-Care Coalitions in Light of COVID-19.

The national response to the coronavirus disease 2019 (COVID-19) pandemic has highlighted critical weaknesses in domestic health care and public health emergency preparedness, despite nearly 2 decades of federal funding for multiple programs designed to encourage cross-cutting collaboration in emergency response. Health-care coalitions (HCCs), which are funded through the Hospital Preparedness Program, were first piloted in 2007 and have been continuously funded nationwide since 2012 to support broad collaborations across public health, emergency management, emergency medical services, and the emergency response arms of the health-care system within a geographical area. This commentary provides a SWOT (strengths, weaknesses, opportunities, and threats) analysis to summarize the strengths, weaknesses, opportunities, and threats related to the current HCC model against the backdrop of COVID-19. We close with concrete recommendations for better leveraging the HCC model for improved health-care system readiness. These include better evaluating the role of HCCs and their members (including the responsibility of the HCC to better communicate and align with other sectors), reconsidering the existing framework for HCC administration, increasing incentives for meaningful community participation in HCC preparedness, and supporting next-generation development of health-care preparedness systems for future pandemics.

The CMS Strategy to Promote Equity in Quality and Value Programs.

This Viewpoint discusses the CMS approach to incentivize excellent care for underserved populations.

The effect of cuts in medicare reimbursement on hospital mortality.

OBJECTIVE: To determine if patients treated at hospitals under different levels of financial strain from the Balanced Budget Act (BBA) of 1997 had differential changes in 30-day mortality, and whether vulnerable patient populations such as the uninsured were disproportionately affected. DATA SOURCE: Hospital discharge data from all general acute care hospitals in Pennsylvania from 1997 to 2001. STUDY DESIGN: A multivariate regression analysis was performed retrospectively on 30-day mortality rates, using hospital discharge data, hospital financial data, and death certificate information from Pennsylvania. DATA COLLECTION: We used 370,017 hospital episodes with one of four conditions identified by the Agency for Healthcare Research and Quality as inpatient quality indicators were extracted. PRINCIPAL FINDINGS: The average magnitude of Medicare payment reduction on overall net revenues was estimated at 1.8 percent for hospitals with low BBA impact and 3.6 percent for hospitals with a high impact in 1998, worsening to 2 and 4.8 percent, respectively, by 2001. Operating margins decreased significantly over the time period for all hospitals (p<.05). While unadjusted mortality rates demonstrated a disproportionate rise in mortality for patients from high impact hospitals from 1997 to 2000, adjusted analyses show no consistent, significant difference in the rate of change in mortality between high-impact and low-impact hospitals (p=.04-.94). Similarly, uninsured patients did not experience greater increases in mortality in high-impact hospitals relative to low-impact hospitals. CONCLUSIONS: An analysis of hospitalizations in the Commonwealth of Pennsylvania did not find an adverse impact of increased financial strain from the BBA on patient mortality either among all patients or among the uninsured.

A longitudinal study of the effects of age and time to death on hospital costs.

Recent studies indicate that approaching death, rather than age, may be the main demographic driver of health care costs. Using a 29-year longitudinal English dataset, this paper uses more robust methods to examine the effects of age and proximity to death on hospital costs. A random effects panel data two-part model shows that approaching death affects costs up to 15 years prior to death. The large tenfold increase in costs from 5 years prior to death to the last year of life overshadows the 30% increase in costs from age 65 to 85. Hence, expenditure projections must consider remaining life expectancy in the populations.

Health care expenditures and ageing: an international comparison.

This study examines national health expenditure trends for Japan, Canada, Australia, and England and Wales (combined) to assess the impact of changing demographics and changing age-specific per capita expenditure on national health expenditure. Age-specific expenditure data were obtained from each country's department of health. We calculated changes in age-specific per capita expenditure, population demographics and the share of expenditures used by the different age groups over time. We then determined the extent to which isolated changes in population growth, demographic shifts and changes in age-specific per capita expenditure could predict observed increases in health expenditure. For Japan, Canada and Australia per capita health expenditure increased fastest among those aged 65 and over, at up to twice the increase of those aged 45-64. In England and Wales, on the other hand, those aged 65 and over experienced one-third of the cost increase of those aged 45-64. Hence, the proportion of national health expenditures used by the population aged 65 and over decreased from 40% to 35% in England and Wales, while increasing in the other countries by up to 10 percentage points. Demographic shifts and population growth predicted only 18% of the observed increases in health care expenditures in England and Wales, compared to 68%, 44% and 34% for Japan, Canada and Australia respectively. These differential changes in costs for older age groups over time invite future research into the driving forces behind these costs.

Prevalence of complications from adult tonsillectomy and impact on health care expenditures.

OBJECTIVE: To provide information on the prevalence of common complications of adult tonsillectomy and associated health care utilization and expenditures. STUDY DESIGN: Retrospective analysis of a large insurance database. SETTING: Data from the MarketScan Commercial Claims and Encounters Database. SUBJECTS AND METHODS: Treated prevalence rates for post-tonsillectomy complications were calculated for 36,210 patients with employer-sponsored insurance who had an outpatient tonsillectomy between 2002 and 2007. The relationships with various patient characteristics were examined using multivariate logistic regression. Postoperative emergency department (ED) visits and hospitalizations and total per capita health care expenditures were analyzed. RESULTS: This analysis suggests that of adult patients who undergo a tonsillectomy, 20% will have a complication, 10% will visit an ED, and approximately 1.5% will be admitted to a hospital within 14 days of the tonsillectomy. Six percent were treated for postoperative hemorrhage, 2% for dehydration, and 11% for ENT pain within 14 days of surgery. Patients with comorbidities, prior peritonsillar abscess, or an increased number of antibiotic prescriptions in the past year were significantly more likely to develop complications. Three out of 4 patients with postoperative hemorrhage went to the ED (4.63% of all patients), and 50% had a procedural intervention (3.09% overall). The average cost associated with a tonsillectomy was $3832 if no complication. If there was a complication within 14 days, hemorrhage was the most expensive ($6388 vs $5753 for dehydration and $4708 for ENT pain). CONCLUSIONS: Complications of adult outpatient tonsillectomies are common and may be associated with significant morbidity, health care utilization, and expenditures.

Atypical carcinoid of the larynx and potential complications of the carcinoid syndrome: a case report.

A 47-year-old man with a history of allergic rhinitis presented with a several-month history of nasal symptoms and gastroesophageal reflux disease. He also had clinical depression, for which he had been taking a selective serotonin reuptake inhibitor (SSRI). During evaluation, flexible laryngoscopy incidentally detected a left interarytenoid polyp. Biopsy identified the lesion as a moderately differentiated neuroendocrine carcinoma. In addition to conducting a metastatic workup, we determined that it was necessary to evaluate the functional status of the tumor prior to excision because the SSRI could precipitate a carcinoid syndrome. We discuss the characteristics and management of different neuroendocrine carcinomas of the larynx, and we review the potential complications of the carcinoid syndrome.

Did postoperative mortality increase after the implementation of the Medicare Balanced Budget Act?

BACKGROUND: The Balanced Budget Act (BBA) of 1997 was a cost-saving measure designed to reduce Medicare reimbursements by $116.4 billion from 1998 to 2002. Resulting financial strain could adversely affect the quality of patient care in hospitals. OBJECTIVE: We sought to determine whether 30-day mortality rates for surgical patients who developed complications changed at different rates in hospitals under different levels of financial strain from the BBA. METHODS: Pennsylvania hospital discharge data, financial data, and death certificate data from 1997 to 2001 were obtained. A retrospective multivariate analysis examined whether 30-day mortality rates from 8 postoperative complications varied based on degree of hospital financial strain. RESULTS: The average magnitude of Medicare payment reduction on overall hospital net revenues was estimated at 1.8% for hospitals with low BBA impact and 3.5% for hospitals with high impact in 1998, worsening to 2.0% and 4.8%, respectively, by 2001. Mortality rates changed at similar rates for high- and low-impact hospitals from 1997 to 1999, but from 1997 to 2000 mortality rates increased more among patients in high-impact compared with low-impact hospitals (P<0.05). From 2000 to 2001, mortality rates among impact groups converged. There were no statistically significant differences based on BBA impact in changes in nursing staff or length of stay. CONCLUSIONS: The mortality of surgical patients who developed postoperative complications increased to a greater degree in the short term in hospitals affected more by BBA. Measuring the quality impact of reimbursement cuts is necessary to understand cost-quality tradeoffs that may accompany cost-saving reforms.

Cymetra injections to treat leakage around a tracheoesophageal puncture.

Tracheoesophageal puncture (TEP) is a commonly used method of voice restoration following total laryngectomy, but leakage around the prosthesis is prevalent. Several treatments for leakage have been proposed in the literature, but with varying success. This paper examines the efficacy of Cymetra to help shrink the TEP site and stop leakage. Six patients with leaking TEP sites refractory to downsizing and/or cautery were selected for the study. Injection sites were determined based on the primary sites of leakage. Cymetra was rehydrated with 1.0 % lidocaine saline solution and injected via a 23-gauge needle a few millimeters deep to the mucosa, approximately 2 mm from the edge. The patients were followed for up to 13 months. Following 1 trial of Cymetra injection, 4 patients achieved successful results. Only 1 patient has not yet achieved full resolution of leakage. Cymetra may provide a safer and more effective option for resolution of leakage than other methods currently employed.

The impact of ageing on expenditures in the National Health Service.

BACKGROUND: health policy makers in many countries have expressed concern over the pressures that increased numbers of older people will exert on health care costs. Previous studies have shown that, in addition to increasing size of older populations, per capita expenditures have risen disproportionately among the old compared to the middle age groups. Documentation of such trends is essential for more accurate projection of health expenditures. OBJECTIVE: we examined detailed national age-specific expenditure trends for England and Wales, comparing findings with Canada, Japan, and Australia. METHODS: we obtained total health expenditures for each age group from the UK Department of Health for time periods 1985-87 to 1996-99. We examined changes in age-specific per capita expenditure, population demographics, and the allocation of national expenditures to the different age groups. We then determined the association of changes in population, age structure, and age-specific per capita expenditure to increases in national health care expenditure for England and Wales, comparing results to Canada, Japan, and Australia. RESULTS: per capita health expenditures in England and Wales increased by 8% for ages 65 and over, compared to 31% for ages 5-64. Hence the proportion of total expenditures allocated to the population aged 65 and over decreased from 40% to 35%, a trend most noticeable for non-acute hospital costs. Demographic shifts and population growth accounted for only 18% of the observed increases in health care expenditures in England and Wales, compared to 68%, 44%, and 34% in Japan, Canada, and Australia respectively. CONCLUSIONS: in contrast to other countries, England and Wales had slower rises in per capita costs and a decreasing proportion of national expenditures allocated to older people. These differences invite future research into the actual demand drivers of these costs.

Ageing and health-care expenditure: the red herring argument revisited.

Zweifel and colleagues have previously proposed that proximity to death is a more important influence on health-care costs than age, suggesting that demographic change per se will not have a large impact on future aggregate health expenditure. However, issues of econometric methodology have led to challenges of the robustness of these findings. This paper revisits the analysis. Using a longitudinal hospital data set from Oxfordshire, England, the two-step Heckman model from the Zweifel study is first replicated, to find that neither age nor proximity to death have a significant effect on hospital costs. Econometric problems with the model are demonstrated, and instead a two-part model shows both age and proximity to death to have significant effects on quarterly hospital costs. Cost predictions, calculated with bootstrapped 95% confidence intervals, further demonstrate that while age may significantly affect quarterly costs, these cost changes are small compared to the tripling of quarterly costs that occurs with approaching death in the last year of life. The analyses show the importance of model selection to properly assess the determinants of health-care expenditures.

Time to death and health expenditure: an improved model for the impact of demographic change on health care costs.

BACKGROUND: Obtaining well-founded estimates of the effect of demographic change on future health expenditures is a pressing issue in all developed countries. Thus far, expenditure projections have examined the effect of age on health care costs, but fail to account for the influence of remaining life expectancy on costs. OBJECTIVE: This paper seeks to create a more accurate projection model that considers the concentration of costs towards the end of life, and to compare this model with the more traditional approach that holds age- and sex-specific per capita expenditures constant. METHODS: We used a longitudinal hospital dataset which followed 90 929 patients aged 65 and older from 1970 to death, to create an economic model of hospital costs based on patient age and time remaining to death. We then applied the model to England population projections to predict the effect of demographic changes on hospital expenditures from 2002 to 2026. RESULTS: The decline in age-specific mortality rates over time postpones death to later ages, pushing back death-related costs. Accounting for this in expenditure projections gave a predicted annual growth rate of 0.40%-half of the rate predicted with a traditional method. CONCLUSIONS: Using richer data and more refined methods than have hitherto been employed, this study strongly confirms that the pressure of population increases and ageing demographic structure on hospital expenditures will be partially countered by the postponement of death-related hospital costs to later in life-a finding consistent with emerging epidemiological evidence, and heartening for policy makers and physicians alike.