Post-Acute Care and ACOs — Who Will Be Accountable?

Objective

To determine how the inclusion of post-acute evaluation and management (E&M) services as primary care affects assignment of Medicare beneficiaries to accountable care organizations (ACOs).

Data Sources

Medicare claims for a random 5 percent sample of 2009 Medicare beneficiaries linked to American Medical Association Group Practice data identifying provider groups sufficiently large to be eligible for ACO program participation.

Study Design

We calculated the fraction of community-dwelling beneficiaries whose assignment shifted, as a consequence of including post-acute E&M services, from the group providing their outpatient primary care to a different group providing their inpatient post-acute care.

Principal Findings

Assignment shifts occurred for 27.6 percent of 25,992 community-dwelling beneficiaries with at least one post-acute skilled nursing facility stay, and they were more common for those incurring higher Medicare spending. Those whose assignment shifted constituted only 1.3 percent of all community-dwelling beneficiaries cared for by large ACO-eligible organizations (n = 535,138), but they accounted for 8.4 percent of total Medicare spending for this population.

Conclusions

Under current Medicare assignment rules, ACOs may not be accountable for an influential group of post-acute patients, suggesting missed opportunities to improve care coordination and reduce inappropriate readmissions.     

Favorable Selection,Risk Adjustment,and the Medicare Advantage Program

Objectives

To examine the effects of changes in payment and risk adjustment on (1) the annual enrollment and switching behavior of Medicare Advantage (MA) beneficiaries, and (2) the relative costliness of MA enrollees and disenrollees.

Data

From 1999 through 2008 national Medicare claims data from the 5 percent longitudinal sample of Parts A and B expenditures.

Study Design

Retrospective, fixed effects regression analysis of July enrollment and year-long switching into and out of MA. Similar regression analysis of the costliness of those switching into (out of) MA in the 6 months prior to enrollment (after disenrollment) relative to nonswitchers in the same county over the same period.

Findings

Payment generosity and more sophisticated risk adjustment were associated with substantial increases in MA enrollment and decreases in disenrollment. Claims experience of those newly switching into MA was not affected by any of the policy reforms, but disenrollment became increasingly concentrated among high-cost beneficiaries.

Conclusions

Enrollment is very sensitive to payment levels. The use of more sophisticated risk adjustment did not alter favorable selection into MA, but it did affect the costliness of disenrollees.     

Do Changes in Hospital Outpatient Payments Affect the Setting of Care?

Objective

To examine whether decreases in Medicare outpatient payment rates under the Outpatient Prospective Payment System (OPPS) caused outpatient care to shift toward the inpatient setting.

Data Sources/Study Setting

Hospital inpatient and outpatient discharge files from the Florida Agency for Health Care Administration from 1997 through 2008.

Study Design

This study focuses on inguinal hernia repair surgery, one of the most commonly performed surgical procedures in the United States. We estimate multivariate regressions of inguinal hernia surgery counts in the outpatient setting and in the inpatient setting. The key explanatory variable is the time-varying Medicare payment rate specific to the procedure and hospital. Control variables include time-varying hospital and county characteristics and hospital and year-fixed effects.

Principal Findings

Outpatient hernia surgeries fell in response to OPPS-induced rate cuts. The volume of inpatient hernia repair surgeries did not increase in response to reductions in the outpatient reimbursement rate.

Conclusions

Potential substitution from the outpatient setting to the inpatient setting does not pose a serious threat to Medicare''s efforts to contain hospital outpatient costs.     

Long‐Term Impact of Medicare Payment Reductions on Patient Outcomes

Objective

To examine the long-term impact of Medicare payment reductions on patient outcomes for Medicare acute myocardial infarction (AMI) patients.

Data Sources

Analysis of secondary data compiled from 100 percent Medicare Provider Analysis and Review between 1995 and 2005, Medicare hospital cost reports, Inpatient Prospective Payment System Payment Impact Files, American Hospital Association annual surveys, InterStudy, Area Resource Files, and County Business Patterns.

Study Design

We used a natural experiment—the Balanced Budget Act (BBA) of 1997—as an instrument to predict cumulative Medicare revenue loss due solely to the BBA, and basing on the predicted loss categorized hospitals into small, moderate, or large payment-cut groups and followed Medicare AMI patient outcomes in these hospitals over an 11-year panel between 1995 and 2005.

Principal Findings

We found that while Medicare AMI mortality trends remained similar across hospitals between pre-BBA and initial-BBA periods, hospitals facing large payment cuts saw smaller improvement in mortality rates relative to that of hospitals facing small cuts in the post-BBA period. Part of the relatively higher AMI mortalities among large-cut hospitals might be related to reductions in staffing levels and operating costs, and a small part might be due to patient selection.

Conclusions

We found evidence that hospitals facing large Medicare payment cuts as a result of BBA of 1997 were associated with deteriorating patient outcomes in the long run. Medicare payment reductions may have an unintended consequence of widening the gap in quality across hospitals.     

The Impact of the Affordable Care Act on Medicare Advantage Plan Availability and Enrollment

Objective

To assess the impact of the Patient Protection and Affordable Care Act''s (ACA) changes in Medicare Advantage (MA) payment rates on the availability of and enrollment in MA plans.

Data Sources

Secondary data on MA plan offerings, contract offerings, and enrollment by state and county, in 2010–2011.

Study Design

We estimated regression models of the change in the number of plans, the number of contracts, and enrollment as a function of quartiles of FFS spending and pre-ACA MA payment generosity. Counties in the lowest quartile of spending are treated most generously by the ACA.

Principal Findings

Relative to counties in the highest quartile of spending, the number of plans in counties in the first, second, and third quartiles rose by 12 percent, 7.6 percent, and 5.4 percent, respectively. Counties with more generous MA payment rates before the ACA lost significantly more plans. We did not find a similar impact on the change in contracts or enrollment.

Conclusions

The ACA-induced MA payment changes reduced the number of plan choices available for Medicare beneficiaries, but they have yet affected enrollment patterns.     

Market Variations in Intensity of Medicare Service Use and Beneficiary Experiences with Care

Objective

Examine associations between patient experiences with care and service use across markets.

Data Sources/Study Setting

Medicare fee-for-service (FFS) and managed care (Medicare Advantage [MA]) beneficiaries in 306 markets from the 2003 Consumer Assessments of Healthcare Providers and Systems (CAHPS) surveys. Resource use intensity is measured by the 2003 end-of-life expenditure index.

Study Design

We estimated correlations and linear regressions of eight measures of case-mix-adjusted beneficiary experiences with intensity of service use across markets.

Data Collection/Extraction

We merged CAHPS data with service use data, excluding beneficiaries under 65 years of age or receiving Medicaid.

Principal Findings

Overall, higher intensity use was associated (p<.05) with worse (seven measures) or no better care experiences (two measures). In higher-intensity markets, Medicare FFS and MA beneficiaries reported more problems getting care quickly and less helpful office staff. However, Medicare FFS beneficiaries in higher-intensity markets reported higher overall ratings of their personal physician and main specialist. Medicare MA beneficiaries in higher-intensity markets also reported worse quality of communication with physicians, ability to get needed care, and overall ratings of care.

Conclusions

Medicare beneficiaries in markets characterized by high service use did not report better experiences with care. This trend was strongest for those in managed care.     

Medicaid Primary Care Physician Fees and the Use of Preventive Services among Medicaid Enrollees

Objective

The Patient Protection and Affordable Care Act (ACA) increases Medicaid physician fees for preventive care up to Medicare rates for 2013 and 2014. The purpose of this paper was to model the relationship between Medicaid preventive care payment rates and the use of U.S. Preventive Services Task Force (USPSTF)–recommended preventive care use among Medicaid enrollees.

Data Sources/Study Session

We used data from the 2003 and 2008 Medical Expenditure Panel Survey (MEPS), a national probability sample of the U.S. civilian, noninstitutionalized population, linked to Kaiser state Medicaid benefits data, including the state Medicaid-to-Medicare physician fee ratio in 2003 and 2008.

Study Design

Probit models were used to estimate the probability that eligible individuals received one of five USPSF-recommended preventive services. A difference-in-difference model was used to separate out the effect of changes in the Medicaid payment rate and other factors.

Data Collection/Extraction Methods

Data were linked using state identifiers.

Principal Findings

Although Medicaid enrollees had a lower rate of use of the five preventive services in univariate analysis, neither Medicaid enrollment nor changes in Medicaid payment rates had statistically significant effects on meeting screening recommendations for the five screenings. The results were robust to a number of different sensitivity tests. Individual and state characteristics were significant.

Conclusions

Our results suggest that although temporary changes in primary care provider payments for preventive services for Medicaid enrollees may have other desirable effects, they are unlikely to substantially increase the use of these selected USPSTF-recommended preventive care services among Medicaid enrollees.     

How Successful Is Medicare Advantage?

Context

Medicare Part C, or Medicare Advantage (MA), now almost 30 years old, has generally been viewed as a policy disappointment. Enrollment has vacillated but has never come close to the penetration of managed care plans in the commercial insurance market or in Medicaid, and because of payment policy decisions and selection, the MA program is viewed as having added to cost rather than saving funds for the Medicare program. Recent changes in Medicare policy, including improved risk adjustment, however, may have changed this picture.

Methods

This article summarizes findings from our group''s work evaluating MA''s recent performance and investigating payment options for improving its performance even more. We studied the behavior of both beneficiaries and plans, as well as the effects of Medicare policy.

Findings

Beneficiaries make “mistakes” in their choice of MA plan options that can be explained by behavioral economics. Few beneficiaries make an active choice after they enroll in Medicare. The high prevalence of “zero-premium” plans signals inefficiency in plan design and in the market''s functioning. That is, Medicare premium policies interfere with economically efficient choices. The adverse selection problem, in which healthier, lower-cost beneficiaries tend to join MA, appears much diminished. The available measures, while limited, suggest that, on average, MA plans offer care of equal or higher quality and for less cost than traditional Medicare (TM). In counties, greater MA penetration appears to improve TM''s performance.

Conclusions

Medicare policies regarding lock-in provisions and risk adjustment that were adopted in the mid-2000s have mitigated the adverse selection problem previously plaguing MA. On average, MA plans appear to offer higher value than TM, and positive spillovers from MA into TM imply that reimbursement should not necessarily be neutral. Policy changes in Medicare that reform the way that beneficiaries are charged for MA plan membership are warranted to move more beneficiaries into MA.     

Effects of Payment Changes on Trends in Post-Acute Care

Objective. To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies.
Data Sources. Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data.
Study Design. We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems.
Data Extraction Methods. A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement.
Principal Findings. Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill.
Conclusions. Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites.     

Emerging Lessons From Regional and State Innovation in Value‐Based Payment Reform: Balancing Collaboration and Disruptive Innovation

Policy Points:

• Public and private purchasersmust create a "burning bridge" of countervailing pressure that signals "no turning back" to fee-for-service in order to sustain the momentum for value-based payment.
• Multi-stakeholder coalitions must establish a defined set of quality, outcomes, and cost performance measures and the interoperable information systems to support data collection and reporting of value-based payment schemes.
• Anti-trust vigilance is necessary to find the "sweet spot" of competition and cooperation among health plans and health care providers.
• Provider and health plan transparency of price and quality, supported by all-payer claims data, are critical in driving value-based payment innovation and cost constraint.

Context

In recent decades, practitioners and policymakers have turned to value-based payment initiatives to help contain spending on health care and to improve the quality of care. The Robert Wood Johnson Foundation funded 7 grantees across the country to design and implement value-based, multistakeholder payment reform projects in 6 states and 3 regions of the United States.

Methods

As the external evaluator of these projects, we reviewed documents, conducted Internet searches, interviewed key stakeholders, cross-validated factual and narrative interpretation, and performed qualitative analyses to derive cross-site themes and implications for policy and practice.

Findings

The nature of payment reform and its momentum closely reflects the environmental context of each project. Federal legislation such as the Patient Protection and Affordable Care Act and federal and state support for the development of the patient-centered medical home and accountable care organizations encourage value-based payment innovation, as do local market conditions for payers and providers that combine a history of collaboration with independent innovation and experimentation by individual organizations.Multistakeholder coalitions offer a useful facilitating structure for galvanizing payment reform. But to achieve the objectives of reduced cost and improved quality, multistakeholder payment innovation must overcome such barriers as incompatible information systems, the technical difficulties and transaction costs of altering existing billing and payment systems, competing stakeholder priorities, insufficient scale to bear population health risk, providers’ limited experience with risk-bearing payment models, and the failure to align care delivery models with the form of payment.

Conclusions

From the evidence adduced in this article, multistakeholder, value-based payment reform requires a trusted, widely respected “honest broker” that can convene and maintain the ongoing commitment of health plans, providers, and purchasers. Change management is complex and challenging, and coalition governance requires flexibility and stable leadership, as market conditions and stakeholder engagement and priorities shift over time. Another significant facilitator of value-based payment reform is outside investment that enables increased investment in human resources, information infrastructure, and care management by provider organizations and their collaborators. Supportive community and social service networks that enhance population health management also are important enablers of value-based payment reform. External pressure from public and private payers is fueling a “burning bridge” between the past of fee-for-service payment models and the future of payments based on value. Robust competition in local health plan and provider markets, coupled with an appropriate mix of multistakeholder governance, pressure from organized purchasers, and regulatory oversight, has the potential to spur value-based payment innovation that combines elements of “reformed” fee-for-service with bundled payments and global payments.     

Organizational Status of Dialysis Facilities and Patient Outcome: Does Higher Injectable Medication Use Mediate Increased Mortality?

Objective

Examine the mediating effect of injectable drugs in the relationship between dialysis facility organizational status and patient mortality.

Study Setting

Medicare dialysis population.

Study Design

Data from the U.S. Renal Data System (USRDS) were used to identify 3,884 freestanding dialysis facilities and 37,942 Medicare patients incident to end-stage renal disease (ESRD) in 2006. The role of injectable medications was evaluated during a 2-year follow-up period by mediational analyses using mixed-effect regression models.

Data Collection

USRDS data were matched with Dialysis Facility Report data from Centers for Medicare and Medicaid Services (CMS) and census data.

Principal Findings

There was a strong association found between organizational status and use of injectable drugs. Large for-profit chains used significantly higher injectable medications compared with nonprofit chains and independent facilities. However, the relationship between facility organizational status and patient mortality was not found to be mediated through the higher use of injectable drugs.

Conclusions

Large for-profit chain facilities administered higher IV epoetin, iron, and vitamin D dosages, but this did not result in improved survival. Given the associated costs and lack of a survival benefit, the overuse of injectable medications among the U.S. dialysis patients will likely end under the recent bundling of injectable medications without jeopardizing patient outcomes.     

Effects of the Ten Percent Cap in Medicare Home Health Care on Treatment Intensity and Patient Discharge Status

Objective

To estimate the effect of the 10 percent cap introduced to Medicare home health care on treatment intensity and patient discharge status.

Data Sources

Medicare Denominator, Medicare Home Health Claims, and Medicare Provider of Services Files from 2008 through 2010.

Study Design

We used agency-level variation in the proportion of outlier payments prior to the implementation of the 10 percent cap to identify how home health agencies adjusted the number of home health visits and patient discharge status under the new law.

Principal Findings

Under the 10 percent cap, agencies dramatically decreased the number of service visits. Agencies also dropped relatively healthy patients and sent sicker patients to nursing homes.

Conclusions

The drastic reduction in the number of service visits and discontinuation of relatively healthy patients from home health care suggest that the 10 percent cap improved the efficiency of home health services as intended. However, the 10 percent cap increased other types of health care expenditures by pushing sicker patients to use more expensive health services.     

Higher Medicare SNF Care Utilization by Dual-Eligible Beneficiaries: Can Medicaid Long-Term Care Policies Be the Answer?

Objective

To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patients who are admitted to skilled nursing facility (SNF) care and whether differences in outcomes are related to states'' Medicaid long-term care policies.

Data Sources/Collection

We used national Medicare enrollment data and claims, and the Minimum Data Set for 890,922 community-residing Medicare fee-for-service beneficiaries who were discharged to an SNF from a general hospital between July 2008 and June 2009.

Study Design

We estimated the effect of dual eligibility on the likelihood of 30-day rehospitalization, becoming a long-stay nursing home resident, and 180-day survival while controlling for clinical, demographic, socio-economic, residential neighborhood characteristics, and SNF-fixed effects. We estimated the differences in outcomes by dual eligibility status separately for each state and showed their relationship with state policies: the average Medicaid payment rate; presence of nursing home certificate-of-need (CON) laws; and Medicaid home and community-based services (HCBS) spending.

Principal Findings

Dual-eligible patients are equally likely to experience 30-day rehospitalization, 12 percentage points more likely to become long-stay residents, and 2 percentage points more likely to survive 180 days compared to Medicare-only patients. This longer survival can be attributed to longer nursing home length of stay. While higher HCBS spending reduces the length-of-stay gap without affecting the survival gap, presence of CON laws reduces both the length-of-stay and survival gaps.

Conclusions

Dual eligibles utilize more SNF care and experience higher survival rates than comparable Medicare-only patients. Higher HCBS spending may reduce the longer SNF length of stay of dual eligibles without increasing mortality and may save money for both Medicare and Medicaid.     

Clinical Quality Performance in U.S. Health Centers

Objective

To describe current clinical quality among the nation''s community health centers and to examine health center characteristics associated with performance excellence.

Data Sources

National data from the 2009 Uniform Data System.

Data Collection/Extraction Methods

Health centers reviewed patient records and reported aggregate data to the Uniform Data System.

Study Design

Six measures were examined: first-trimester prenatal care, childhood immunization completion, Pap tests, low birth weight, controlled hypertension, and controlled diabetes. The top 25 percent performing centers were compared with lower performing (bottom 75 percent) centers on these measures. Logistic regressions were utilized to assess the impact of patient, provider, and institutional characteristics on health center performance.

Principal Findings

Clinical care and outcomes among health centers were generally comparable to national averages. For instance, 67 percent of pregnant patients received timely prenatal care (national = 68 percent), 69 percent of children achieved immunization completion (national = 67 percent), and 63 percent of hypertensive patients had blood pressure under control (national = 48 percent). Depending on the measure, centers with more uninsured patients were less likely to do well, while centers with more physicians and enabling service providers were more likely to do well.

Conclusions

Health centers provide quality care at rates comparable to national averages. Performance may be improved by increasing insurance coverage among patients and increasing the ratios of physicians and enabling service providers to patients.     

Peer Reviewed: Physician Visits and Colorectal Cancer Testing Among Medicare Enrollees in North Carolina and South Carolina, 2005

Introduction

Many Medicare enrollees do not receive colorectal cancer tests at recommended intervals despite having Medicare screening coverage. Little is known about the physician visits of Medicare enrollees who are untested. Our study objective was to evaluate physician visits of enrollees who lack appropriate testing to identify opportunities to increase colorectal cancer testing.

Methods

We used North Carolina and South Carolina Medicare data to compare type and frequency of physician visits for Medicare enrollees with and without a colorectal cancer test in 2005. Type of physician visit was defined by the physician specialty as primary care, mixed specialty (more than 1 specialty, 1 of which was primary care), and nonprimary care. We used multivariate modeling to assess the influence of type and frequency of physician visits on colorectal cancer testing.

Results

Approximately half (46.5%) of enrollees lacked appropriate colorectal cancer testing. Among the untested group, 19.8% had no physician visits in 2005. Enrollees with primary care visits were more likely to be tested than those without a primary care visit. Many enrollees who had primary care visits remained untested. Enrollees with visits to all physician types had a greater likelihood of having colorectal cancer testing.

Conclusions

We identified 3 categories of Medicare enrollees without appropriate colorectal cancer testing: those with no visits, those who see primary care physicians only, and those with multiple visits to physicians with primary and nonprimary care specialties. Different strategies are needed for each category to increase colorectal cancer testing in the Medicare population.     

Beta‐Binomial Regression and Bimodal Utilization

Objective

To illustrate how the analysis of bimodal U-shaped distributed utilization can be modeled with beta-binomial regression, which is rarely used in health services research.

Data Sources/Study Setting

Veterans Affairs (VA) administrative data and Medicare claims in 2001–2004 for 11,123 Medicare-eligible VA primary care users in 2000.

Study Design

We compared means and distributions of VA reliance (the proportion of all VA/Medicare primary care visits occurring in VA) predicted from beta-binomial, binomial, and ordinary least-squares (OLS) models.

Principal Findings

Beta-binomial model fits the bimodal distribution of VA reliance better than binomial and OLS models due to the nondependence on normality and the greater flexibility in shape parameters.

Conclusions

Increased awareness of beta-binomial regression may help analysts apply appropriate methods to outcomes with bimodal or U-shaped distributions.     

The Importance of a High‐Performance Work Environment in Hospitals

Objective

To examine the benefits of a high-performance work environment (HPWE) for employees, patients, and hospitals.

Study Setting

Forty-five adult, medical-surgical units in nine hospitals in upstate New York.

Study Design

Cross-sectional study.

Data Collection

Surveys were collected from 1,527 unit-based hospital providers (68.5 percent response rate). Hospitals provided unit turnover and patient data (16,459 discharge records and 2,920 patient surveys).

Principal Findings

HPWE, as perceived by multiple occupational groups on a unit, is significantly associated with desirable work processes, retention indicators, and care quality.

Conclusion

Our findings underscore the potential benefits for providers, patients, and health care organizations of designing work environments that value and support a broad range of employees as having essential contributions to make to the care process and their organizations.     

Total Cost of Care Lower among Medicare Fee‐for‐Service Beneficiaries Receiving Care from Patient‐Centered Medical Homes

Objective

To compare health care utilization and payments between NCQA-recognized patient-centered medical home (PCMH) practices and practices without such recognition.

Data Sources

Medicare Part A and B claims files from July 1, 2007 to June 30, 2010, 2009 Census, 2007 Health Resources and Services Administration and CMS Utilization file, Medicare''s Enrollment Data Base, and the 2005 American Medical Association Physician Workforce file.

Study Design

This study used a longitudinal, nonexperimental design. Three annual observations (July 1, 2008–June 30, 2010) were available for each practice. We compared selected outcomes between practices with and those without NCQA PCMH recognition.

Data Collection Methods

Individual Medicare fee-for-service (FFS) beneficiaries and their claims and utilization data were assigned to PCMH or comparison practices based on where they received the plurality of evaluation and management services between July 1, 2007 and June 30, 2008.

Principal Findings

Relative to the comparison group, total Medicare payments, acute care payments, and the number of emergency room visits declined after practices received NCQA PCMH recognition. The decline was larger for practices with sicker than average patients, primary care practices, and solo practices.

Conclusions

This study provides additional evidence about the potential of the PCMH model for reducing health care utilization and the cost of care.     

Serious Mental Illness and Nursing Home Quality of Care

Objective

To estimate the effect of a nursing home''s share of residents with a serious mental illness (SMI) on the quality of care.

Data Sources

Secondary nursing home level data over the period 2000 through 2008 obtained from the Minimum Data Set, OSCAR, and Medicare claims.

Study Design

We employ an instrumental variables approach to address the potential endogeneity of the share of SMI residents in nursing homes in a model including nursing home and year fixed effects.

Principal Findings

An increase in the share of SMI nursing home residents positively affected the hospitalization rate among non-SMI residents and negatively affected staffing skill mix and level. We did not observe a statistically significant effect on inspection-based health deficiencies or the hospitalization rate for SMI residents.

Conclusions

Across the majority of indicators, a greater SMI share resulted in lower nursing home quality. Given the increased prevalence of nursing home residents with SMI, policy makers and providers will need to adjust practices in the context of this new patient population. Reforms may include more stringent preadmission screening, new regulations, reimbursement changes, and increased reporting and oversight.