Dimick and Ryan talk about observational studies which are commonly used to evaluate the changes in outcomes associated with health care policy implementation. An important limitation in using ...observational studies in this context is the need to control for background changes in outcomes that occur with time. The association between policy changes and subsequent outcomes is often evaluated by pre-post assessments. Outcomes after implementation are compared with those before.
U.S. hospitals caring for more disadvantaged patients fared worse in the first year of Medicare's Hospital Value-Based Purchasing program. Over time, such resource reductions may cause the quality of ...care to deteriorate in hospitals serving more disadvantaged patients.
Financial incentives for improving quality and efficiency have gone mainstream in U.S. health care. After years of small-scale pilot projects, demonstrations, and experiments, the Affordable Care Act mandated that Medicare payment to hospitals and physicians must depend, in part, on metrics of quality and efficiency. The first program to do so is Hospital Value-Based Purchasing (HVBP), which began affecting Medicare payments to acute care hospitals in October 2012.
In the first year of HVBP, hospitals received incentives for performance on clinical-process and patient-experience measures. In subsequent years, hospitals will also receive incentives for performance on outcome-based measures, such as 30-day . . .
Summary Background Introduced in 2004, the UK's Quality and Outcomes Framework (QOF) is the world's largest primary care pay-for-performance programme. We tested whether the QOF was associated with ...reduced population mortality. Methods We used population-level mortality statistics between 1994 and 2010 for the UK and other high-income countries that were not exposed to pay-for-performance. The primary outcome was age-adjusted and sex-adjusted mortality per 100 000 people for a composite outcome of chronic disorders that were targeted by the QOF. Secondary outcomes were age-adjusted and sex-adjusted mortality for ischaemic heart disease, cancer, and a composite of all non-targeted conditions. For each study outcome, we created a so-called synthetic UK as a weighted combination of comparison countries. We then estimated difference-in-differences models to test whether mortality fell more in the UK than in the synthetic UK after the QOF. Findings Introduction of the QOF was not significantly associated with changes in population mortality for the composite outcome (−3·68 per 100 000 population 95% CI −8·16 to 0·80; p=0·107), ischaemic heart disease (−2·21 per 100 000 –6·86 to 2·44; p=0·357), cancer (0·28 per 100 000 –0·99 to 1·55; p=0·679), or all non-targeted conditions (11·60 per 100 000 –3·91 to 27·11; p=0·143). Interpretation Although we noted small mortality reductions for a composite outcome of targeted disorders, the QOF was not associated with significant changes in mortality. Our findings have implications for the probable effects of similar programmes on population health outcomes. The relation between incentives and mortality needs to be assessed in specific disease domains. Funding None.
Hospital–physician vertical integration is on the rise. While increased efficiencies may be possible, emerging research raises concerns about anticompetitive behavior, spending increases, and ...uncertain effects on quality. In this review, we bring together several of the key theories of vertical integration that exist in the neoclassical and institutional economics literatures and apply these theories to the hospital–physician relationship. We also conduct a literature review of the effects of vertical integration on prices, spending, and quality in the growing body of evidence (n = 15) to evaluate which of these frameworks have the strongest empirical support. We find some support for vertical foreclosure as a framework for explaining the observed results. We suggest a conceptual model and identify directions for future research. Based on our analysis, we conclude that vertical integration poses a threat to the affordability of health services and merits special attention from policymakers and antitrust authorities.
The article discusses the findings of a study to evaluate and report interim outcomes from the first year of a bundled payment model for lower extremity joint replacement (LEJR), which revealed that ...in the first year of bundled payment, metropolitan statistical areas (MSAs) covered by the Comprehensive Care for Joint Replacement (CJR) had a significantly lower percentage of discharges to institutional postacute care but no difference in total Medicare spending per LEJR episode.. The findings of another study to evaluate whether hospital Bundled Payments for Care Improvement (BPCI) participation for lower extremity joint replacement (LEJR) was associated with changes in overall volume and case mix, revealed that hospital participation in BCPI was not associated with changes in market-level lower extremity joint replacement volume as well as largely was not associated with changes in hospital case mix.
Aim
The evolutionary interactions between western spadefoot toads (genus Spea) represent a textbook example of character displacement, facilitated by dietary specialization of one Spea species on ...fairy shrimp (Anostraca) when all three co‐occur. The aim of this study is to understand the covariation between predator (Spea) and prey (Anostraca) range shifts in response to climate change oscillations, and whether biotic interactions can be used to project species distribution models on different time scales when studying species with dietary specialization. Taxon: Amphibia: Spea spp. and Crustacea: Anostraca.
Location
North America.
Methods
Using multiple modelling techniques, we first estimated the potential distribution of central and western North American fairy shrimp species (Crustacea: Anostraca) and two western spadefoot toad species (Spea bombifrons and Spea multiplicata). We then created a shrimp species richness map by aggregating individual species estimates. Third, we studied the relationship between the probability of spadefoot toad presence and fairy shrimp species richness during the present and Last Glacial Maximum conditions. Finally, we estimated the strength and direction of the co‐occurrence between spadefoot toads and fairy shrimp sampled at the level of entire predicted range and at the regional level (allopatric and sympatric).
Results
First, the same abiotic environmental variables shape spadefoot toad and fairy shrimp species' distributions in central and western North America across time. Second, areas of sympatry of Spea bombifrons and Spea multiplicata correspond with dry conditions and higher shrimp richness. Finally, the spatial patterns of predator–prey co‐occurrence are highly variable across geography, forming a spatial mosaic over the species' ranges.
Main Conclusion
Predator–prey relationships form a spatial mosaic across geography and species ranges. Including biotic interactions into species distribution estimates for organisms with dietary specialization is highly recommended. Biotic interactions can be projected across different time frames for organisms with dietary specialization as they are likely conserved.
How Much of an “Advantage” Is Medicare Advantage? Meyers, David J; Ryan, Andrew M; Trivedi, Amal N
JAMA : the journal of the American Medical Association,
12/2022, Letnik:
328, Številka:
21
Journal Article
Recenzirano
In 2023, the majority of Medicare beneficiaries will be enrolled in a private Medicare Advantage plan, and nearly 7 in 10 beneficiaries will be members in Medicare Advantage by 2030. Medicare ...Advantage plans differ from traditional Medicare as they are paid on a capitated basis to cover the health care needs of enrollees each year. Medicare Advantage plans may cover additional benefits unavailable in traditional Medicare, such as dental and fitness benefits, and face incentives to coordinate care and reduce health care spending. To lower costs, Medicare Advantage typically constrains the network of available physicians and implements prior authorization requirements. Roughly 1.5% of the nation's gross domestic product and 5% of the federal budget is spent on payments to Medicare Advantage. With the program's recent rapid growth, it is imperative to understand the implications of its expansion for patient outcomes and medical spending.
Reducing unplanned readmissions is a major focus of current hospital quality efforts. In order to avoid unfair penalization, administrators and policymakers use prediction models to adjust for the ...performance of hospitals from healthcare claims data. Regression-based models are a commonly utilized method for such risk-standardization across hospitals; however, these models often suffer in accuracy. In this study we, compare four prediction models for unplanned patient readmission for patients hospitalized with acute myocardial infarction (AMI), congestive health failure (HF), and pneumonia (PNA) within the Nationwide Readmissions Database in 2014. We evaluated hierarchical logistic regression and compared its performance with gradient boosting and two models that utilize artificial neural networks. We show that unsupervised Global Vector for Word Representations embedding representations of administrative claims data combined with artificial neural network classification models improves prediction of 30-day readmission. Our best models increased the AUC for prediction of 30-day readmissions from 0.68 to 0.72 for AMI, 0.60 to 0.64 for HF, and 0.63 to 0.68 for PNA compared to hierarchical logistic regression. Furthermore, risk-standardized hospital readmission rates calculated from our artificial neural network model that employed embeddings led to reclassification of approximately 10% of hospitals across categories of hospital performance. This finding suggests that prediction models that incorporate new methods classify hospitals differently than traditional regression-based approaches and that their role in assessing hospital performance warrants further investigation.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Current State of Value-Based Purchasing Programs Chee, Tingyin T; Ryan, Andrew M; Wasfy, Jason H ...
Circulation (New York, N.Y.),
2016-May-31, 2016-05-31, 20160531, Letnik:
133, Številka:
22
Journal Article
Recenzirano
Odprti dostop
The US healthcare system is rapidly moving toward rewarding value. Recent legislation, such as the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act, solidified the role of ...value-based payment in Medicare. Many private insurers are following Medicare’s lead. Much of the policy attention has been on programs such as accountable care organizations and bundled payments; yet, value-based purchasing (VBP) or pay-for-performance, defined as providers being paid fee-for-service with payment adjustments up or down based on value metrics, remains a core element of value payment in Medicare Access and CHIP Reauthorization Act and will likely remain so for the foreseeable future. This review article summarizes the current state of VBP programs and provides analysis of the strengths, weaknesses, and opportunities for the future. Multiple inpatient and outpatient VBP programs have been implemented and evaluated; the impact of those programs has been marginal. Opportunities to enhance the performance of VBP programs include improving the quality measurement science, strengthening both the size and design of incentives, reducing health disparities, establishing broad outcome measurement, choosing appropriate comparison targets, and determining the optimal role of VBP relative to alternative payment models. VBP programs will play a significant role in healthcare delivery for years to come, and they serve as an opportunity for providers to build the infrastructure needed for value-oriented care.
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