Traditional fee-for-service (FFS) Medicare's prospective payment systems for postacute care provide little incentive to coordinate care or control costs. In contrast, Medicare Advantage plans pay for ...postacute care out of monthly capitated payments and thus have stronger incentives to use it efficiently. We compared the use of postacute care in skilled nursing and inpatient rehabilitation facilities by enrollees in Medicare Advantage and FFS Medicare after hospital discharge for three high-volume conditions: lower extremity joint replacement, stroke, and heart failure. After accounting for differences in patient characteristics at discharge, we found lower intensity of postacute care for Medicare Advantage patients compared to FFS Medicare patients discharged from the same hospital, across all three conditions. Medicare Advantage patients also exhibited better outcomes than their FFS Medicare counterparts, including lower rates of hospital readmission and higher rates of return to the community. These findings suggest that payment reforms such as bundling in FFS Medicare may reduce the intensity of postacute care without adversely affecting patient health.
Pay-for-performance programs are one strategy used by health plans to improve the efficiency and quality of care delivered to beneficiaries. Under such programs, providers are often compared against ...their peers in order to win bonuses or face penalties in payment. Yet luck has the potential to affect performance assessment through randomness in the sorting of patients among providers or through random events during the evaluation period. To investigate the impact luck can have on the assessment of performance, we investigated its role in assigning penalties under Medicare's Hospital Readmissions Reduction Policy (HRRP), a program that penalizes hospitals with excess readmissions. We performed simulations that estimated program hospitals' 2015 readmission penalties in 1,000 different hypothetical fiscal years. These hypothetical fiscal years were created by: (a) randomly varying which patients were admitted to each hospital and (b) randomly varying the readmission status of discharged patients. We found significant differences in penalty sizes and probability of penalty across hypothetical fiscal years, signifying the importance of luck in readmission performance under the HRRP. Nearly all of the impact from luck arose from events occurring after hospital discharge. Luck played a smaller role in determining penalties for hospitals with more beds, teaching hospitals, and safety-net hospitals.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objective
To understand what patterns of health care use are associated with higher post‐hospitalization spending.
Data Sources
Medicare hospital, skilled nursing, inpatient rehabilitation, and home ...health agency claims, and Medicare enrollment data from 2007 and 2008.
Study Design
For 10 common inpatient conditions, we calculated variation across hospitals in price‐standardized and case mix–adjusted Medicare spending in the 30 days following hospital discharge. We estimated the fraction of spending differences between low‐ and high‐spending hospitals attributable to readmissions versus post‐acute care, and within post‐acute care between inpatient rehabilitation facility (IRF) versus skilled nursing facility (SNF) use. For each service, we distinguished between differences in probability of use and spending conditional on use.
Data Extraction Methods
We identified index hospital claims and examined hospital and post‐acute care occurring within a 30‐day period following hospital discharge. For each Medicare Severity Diagnosis‐Related Group (MS‐DRG) at each hospital, we calculated average price‐standardized Medicare payments for readmissions, SNFs, IRFs, and post‐acute care overall (also including home health agencies and long‐term care hospitals).
Principal Findings
There was extensive variation across hospitals in Medicare spending in the 30 days following hospital discharge. For example, the interquartile range across hospitals ranged from $1,245 for chronic obstructive pulmonary disease to over $4,000 for myocardial infarction MS‐DRGs. The proportion of differences attributable to readmissions versus post‐acute care differed across conditions. For myocardial infarction, 74 to 93 percent of the variation was due to readmissions. For hip and femur procedures and joint replacement, 72 to 92 percent of the variation was due to differences in post‐acute care spending. There was also variation in the relative importance of the type of post‐acute spending. For hip and femur procedures, joint replacement, and stroke, whether patients received IRF was the key driver of variation in post‐acute care spending In contrast, for pneumonia and heart failure, whether patients received SNF care was the key driver of variation in post‐acute spending.
Conclusions
Through initiatives such as bundled payment, hospitals are financially responsible for spending in the post‐hospitalization period. The key driver of variation in post‐hospitalization spending varied greatly across conditions. For some conditions, the key driver was having a readmission, for others it was whether patients receive any post‐acute care, and for others the key driver was the type of post‐acute care. These findings may help hospitals implement strategies to reduce post‐discharge spending.
This article compares patterns of postacute care-including care provided by skilled nursing facilities, inpatient rehabilitation facilities, and home health agencies-under Medicare Advantage and ...traditional Medicare. Overall, Medicare Advantage enrollees received less postacute care, both institutional and home health, than traditional Medicare enrollees did for three common conditions.
To compare direct-to-consumer (DTC) telemedicine and in-person visits in rates of testing, follow-up health care use, and quality for urinary tract infections (UTIs) and sinusitis.
The Minnesota All ...Payer Claims Data provided 2008-2015 administrative claims data.
Using a difference-in-differences approach, we compared episodes of care for UTIs and sinusitis among enrollees of health plans introducing coverage for DTC telemedicine relative to those without DTC telemedicine coverage. Primary outcomes included number of laboratory tests, antibiotics filled, office and outpatient visits, emergency department (ED) visits, and standardized spending, based on standardized prices of health services.
The study sample included non-elderly enrollees of commercial health insurance plans. We constructed 30-day episodes of care initiated by a DTC telemedicine or in-person visit.
The UTI and sinusitis samples were comprised of 215,134 and 624,630 episodes of care, respectively. Following the introduction of coverage for DTC telemedicine, 15.7% of UTI episodes and 8.9% of sinusitis episodes were initiated with DTC telemedicine. Compared to episodes without coverage for DTC telemedicine, UTI episodes with coverage had 0.25 fewer lab tests (95% CI: -0.33, -0.18; p < 0.001), lower standardized spending for the first UTI visit (-$11.18 95% CI: -$21.62, -$0.75; p < 0.05), and no change in office and outpatient visits, ED visits, antibiotics filled, or standardized medical spending. Sinusitis episodes with coverage for DTC telemedicine had fewer antibiotics filled (-0.08 95% CI: -0.14, -0.01; p < 0.05) and a very small increase in ED visits (0.001 95% CI: 0.001, 0.010; p < 0.05), but no change in lab tests, office and outpatient visits, or standardized medical spending.
Among commercially insured patients, coverage of DTC telemedicine was associated with reductions in antibiotics for sinusitis and laboratory tests for UTI without changes in downstream total office and outpatient visits or changes in ED visits.
Background
Experience in trials of implementing quality improvement (QI) programs in nursing homes (NHs) has been variable. Understanding the characteristics of NHs that demonstrate improvements ...during these trials is critical to improving NH care.
Design
Secondary analysis of a randomized controlled trial of implementation of a QI program to reduce hospital transfers.
Participants
Seventy‐one NHs that completed the 12‐month trial
Intervention
Implementation included distance‐learning strategies, involvement of a champion, regular submission of data on hospitalizations and root cause analyses of transfers, and training, feedback and support.
Measurements
Primary outcomes included all‐cause and potentially avoidable hospitalizations and emergency department (ED) visits per 1000 NH resident days, and the percentage of residents readmitted in 30‐days. We compared multiple other variables that could influence effective program implementation in NHs in the highest versus lowest quartile of changes in the primary outcomes.
Results
The 18 high‐performing NHs had significant reductions in hospitalization and ED visits, whereas the 18 NHs in the low‐performing group had increases. The difference in changes in each outcome varied between a reduction of 0.75 and 2.30 events relative to a NH with a census of 100; the absolute difference in 30‐day readmissions was 19%. None of the variables we examined reached significance after adjustment for multiple comparisons between the groups. There was no consistent pattern of differences in nonprofit status, nursing staffing, and quality ratings.
Conclusion
Our experience and reviews of other NH trials suggest that key factors contributing to successful implementation QI programs in NHs remain unclear. To improve NH care, implementation trials should account for intervention fidelity and factors that have not been examined in detail, such as degree and nature of leadership support, financial and regulatory incentives, quality measures, resident and family perspectives, and the availability of onsite high‐quality medical care and support of the medical director.
Objectives
To determine whether degree of implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) program is associated with number of hospitalizations and emergency department ...(ED) visits of skilled nursing facility (SNF) residents.
Design
Secondary analysis from a randomized controlled trial.
Setting
SNFs from across the United States (N=264).
Participants
Two hundred of the SNFs from the randomized trial that provided baseline and intervention data on INTERACT use.
Interventions
During a 12‐month period, intervention SNFs received remote training and support for INTERACT implementation; control SNFs did not, although most control facilities were using various components of the INTERACT program before and during the trial on their own.
Measurements
INTERACT use data were based on monthly self‐reports for SNFs randomized to the intervention group and pre‐ and postintervention surveys for control SNFs. Primary outcomes were rates of all‐cause hospitalizations, potentially avoidable hospitalizations (PAHs), ED visits without admission, and 30‐day hospital readmissions.
Results
The 65 SNFs (32 intervention, 33 control) that reported increases in INTERACT use had reductions in all‐cause hospitalizations (0.427 per 1,000 resident‐days; 11.2% relative reduction from baseline, p<.001) and PAHs (0.221 per 1,000 resident‐days; 18.9% relative reduction, p<.001). The 34 SNFs (12 intervention, 22 control) that reported consistently low or moderate INTERACT use had statistically insignificant changes in hospitalizations and ED visit rates.
Conclusion
Increased reported use of core INTERACT tools was associated with significantly greater reductions in all‐cause hospitalizations and PAHs in both intervention and control SNFs, suggesting that motivation and incentives to reduce hospitalizations were more important than the training and support provided in the trial in improving outcomes. Further research is needed to better understand the most effective strategies to motivate SNFs to implement and sustain quality improvement programs such as INTERACT.
Medicare covers home health benefits for homebound beneficiaries who need intermittent skilled care. While home health care can help prevent costlier institutional care, some studies have suggested ...that traditional Medicare beneficiaries may overuse home health care. This study compared home health use in Medicare Advantage and traditional Medicare, as well as within Medicare Advantage by beneficiary cost sharing, prior authorization requirement, and plan type. In 2016 Medicare Advantage enrollees were less likely to use home health care than traditional Medicare enrollees were, had 7.1 fewer days per home health spell, and were less likely to be admitted to the hospital during their spell. Among Medicare Advantage plans, those that imposed beneficiary cost sharing or prior authorization requirements had lower rates of home health use. Qualitative interviews suggested that Medicare Advantage payment and contracting approaches influenced home health care use. Therefore, changes in traditional Medicare home health payment policies implemented in 2020 may reduce these disparities in home health use and spell length.
In recent years state and federal policies have encouraged the use of telemedicine by formalizing payments for it. Telemedicine has the potential to expand access to timely care and reduce costs, ...relative to in-person care. Using information from the Minnesota All Payer Claims Database, we conducted a population-level analysis of telemedicine service provision in the period 2010-15, documenting variation in provision by coverage type, provider type, and rurality of patient residence. During this period the number of telemedicine visits increased from 11,113 to 86,238, and rates of use varied extensively by coverage type and rurality. In metropolitan areas telemedicine visits were primarily direct-to-consumer services provided by nurse practitioners or physician assistants and covered by commercial insurance. In nonmetropolitan areas telemedicine use was chiefly real-time provider-initiated services delivered by physicians to publicly insured populations. Recent federal and state legislation that expanded coverage and increased provider reimbursement for telemedicine services could lead to expanded use of telemedicine, including novel approaches in new patient populations.
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