Transforming Care: Reporting on Health System Improvement

Transforming Care focuses on new models of care, payment approaches, and patient engagement strategies that have the potential to reshape our delivery system to better meet the needs of the nation’s sickest and most vulnerable patients. 

  • December 17, 2015 Issue
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Publications of Note

Insurance Expansion May Lead to Better Management of Chronic Conditions

To gain insight into the health effects of insurance expansion under the Affordable Care Act (ACA), researchers evaluated the relationships between health insurance and the diagnosis and management of diabetes, hypercholesterolemia, and hypertension. They found people with insurance had significantly higher probabilities of diagnosis than uninsured people, by 14 percentage points for diabetes and hypercholesterolemia and 9 percentage points for hypertension. Among those with existing diagnoses, insurance was associated with significantly lower hemoglobin A1c (−0.58 percent), total cholesterol (−8.0 mg/dL), and systolic blood pressure (−2.9 mmHg). If the number of nonelderly Americans without health insurance were reduced by half, the researchers estimate that there would be 1.5 million more people with a diagnosis of one or more of these chronic conditions and 659,000 fewer people with uncontrolled cases. Their findings suggest that the ACA could have significant effects on chronic disease identification and management, but policymakers need to consider the possible implications of those effects for the demand for health care services and spending for chronic disease. D. R. Hogan, G. Danaei, M. Ezzati et al., “Estimating the Potential Impact of Insurance Expansion on Undiagnosed and Uncontrolled Chronic Conditions,” Health Affairs, Sept. 2015 34(9):1554–62.

Incentive Programs Must Also Reflect Patient Values and Goals

The authors of this commentary say value-based purchasing programs that tie incentive payments to quality metrics should include measures that are relevant to people living with frailty or advanced illness. These patients are weighing health care decisions with other critical factors such as being comfortable, controlling finances, having food and shelter, being connected to others, honoring their family and social role, and spiritual commitments—which current metrics do not assess. The authors also recommend that every older patient have a comprehensive assessment and care plan that includes such goals and an assessment of the financial costs of treatment to patients and their families and caregivers. J. Lynn, A. McKethan, and A. K. Jha, “Value-Based Payments Require Valuing What Matters to Patients,” Journal of the American Medical Association, Oct. 13, 2015 314(14):1445–46.

Medicare’s Chronic Care Management Program a Potential Boon to Primary Care Practices

A study designed to estimate the financial impact of new payments for chronic care management (CCM) of Medicare patients found that practices that rely on nonphysician team members to provide these services outside of office visits will likely experience substantial revenue gains but must enroll a sufficient number of eligible patients to recoup the costs. Practices could expect approximately $332 per enrolled patient per year if CCM services were delivered by registered nurses, approximately $372 if services were delivered by licensed practical nurses, and approximately $385 if services were delivered by medical assistants. S. Basu, R. S. Phillips, A. Bitton et al., “Medicare Chronic Care Management Payments and Financial Returns to Primary Care Practices: A Modeling Study,” Annals of Internal Medicine, Oct. 20, 2015 163(8):580–88.

Financial Burden for Patients with Dementia Higher Than with Other Diseases

Researchers examining the financial risks faced by Medicare beneficiaries in the five years before death found that, on average, the total cost for those with dementia ($287,038) was significantly greater than for those who died of heart disease ($175,136), cancer ($173,383), or other causes ($197,286). Although Medicare expenditures were similar across groups, average out-of-pocket spending for patients with dementia was 81 percent higher than that for patients without dementia ($61,522 versus $34,068). A similar pattern held for informal care. Out-of-pocket spending for the dementia group represented 32 percent of wealth measured five years before death compared with 11 percent for the nondementia group. This proportion was greater for black patients (84%), patients with less than a high school education (48%), and unmarried or widowed women (58%). A. S. Kelley, K. McGarry, R. Gorges et al., “The Burden of Health Care Costs for Patients with Dementia in the Last 5 Years of Life,” Annals of Internal Medicine, Nov. 17, 2015 163(10):729–36.

High-Cost Patients More Likely to Switch from Medicare Advantage to Fee-for-Service Medicare Than the Other Way Around

Researchers found high-cost Medicare Advantage members—defined as those who are hospitalized, and/or use home health care services or nursing homes—leave those plans for fee-for-service (FFS) Medicare plans more than the reverse. For those who are hospitalized, the switching rates are 2 percentage points higher (5.3% vs. 3.4%). For those using home care services rates are about 3 percentage points higher (7.5% vs. 3.4%) and for those with long-term nursing home stays the rates were six times higher (17% vs. 3%). The findings are consistent with previous research and raise questions about whether Medicare Advantage payment formulas work for these patients. Another possibility is that Medicare Advantage plans do not have sufficient incentives to pay for better services for these patients, the researchers say. M. Rahman, L. Keohane, A. N. Trivedi et al., “High-Cost Patients Had Substantial Rates of Leaving Medicare Advantage and Joining Traditional Medicare,” Health Affairs, Oct. 2015 34(10):1675–81.

Medical Homes Appear to Improve Access to Mental Health Services

Adults with mental health disorders who are aligned with patient-centered medical homes (PCMHs) were significantly more likely than those with no usual provider to have experienced a primary care mental health visit and to have received psychiatric medication than similar patients without a usual primary care provider or practice. Participants with a PCMH were additionally more likely than those with no usual provider to visit a mental health specialist and receive mental health counseling. A. L. Jones, S. D. Cochran, A. Leibowitz et al., “Usual Primary Care Provider Characteristics of a Patient-Centered Medical Home and Mental Health Service Use,” Journal of General Internal Medicine, Dec. 1, 2015 30(12):1828–36.

Functional Status Predictive of Readmissions in Medically Complex Patients

Researchers found readmission models based on functional status consistently outperformed models based on medical comorbidities. This approach, based on gender and functional status, was developed to predict the odds of three-, seven-, and 30-day readmission from inpatient rehabilitation facilities to acute-care hospitals. The researchers compared this approach to six other predictive models—three of which combined comorbidity and functional status measures and three that excluded functional status and relied on gender and a comorbidity measure. S. L. Shih, P. Gerrard, R. Goldstein et al., “Functional Status Outperforms Comorbidities in Predicting Acute Care Readmissions in Medically Complex Patients,” Journal of General Internal Medicine, Nov. 2015 30(11):1688–95.

Black Nursing Facility Patients Disproportionately Likely to Be Rehospitalized

Researchers found that when compared with white residents of skilled nursing facilities (SNFs), black SNF residents are more likely to be rehospitalized even after adjusting for patient risk factors. Black–white disparities, especially in potentially preventable rehospitalizations, are largely the result of black residents tending to be admitted to the small number of SNFs with very high rehospitalization rates. The 30-day all-cause and potentially avoidable rehospitalization rates were 21.9 percent and 8.8 percent, respectively, for black residents, and 17.7 percent and 7.9 percent for white residents. Black residents and white residents admitted to SNFs with high proportions of black admissions (>25%) were 31 percent and 19 percent, respectively, more likely to be rehospitalized than white residents admitted to SNFs caring for only a small percentage of black postacute residents (<3%). Y. Li, X. Cai, and L. G. Glance, “Disparities in 30-Day Rehospitalization Rates Among Medicare Skilled Nursing Facility Residents by Race and Site of Care,” Medical Care, Dec. 2015 53(12):1058–65.

Progress with Maryland’s Global Hospital Budget Program

The authors of this commentary describe Maryland’s Global Hospital Budget program, through which hospitals receive a fixed annual amount for inpatient and outpatient services. Six months into the program, which was launched in January 2014, hospitals had agreed to move more than 90 percent of the state’s aggregate hospital revenue into global budgets. The initial cost results have been promising, the authors note: per capita hospital costs decreased by 1.08 percent in Maryland in 2014, compared with an increase of 1.07 percent nationally. Quality of care also improved in many areas. Maryland’s rate of hospital admissions and per capita spending for Medicare patients are still among the highest in the country, however. A. Patel, R. Rajkumar, J. M. Colmers et al., “Maryland’s Global Hospital Budgets—Preliminary Results from an All-Payer Model,” New England Journal of Medicine, Nov. 12, 2015 373(20):1899–1901.

Paying for the Value of Physician Services in Medicare

This commentary explores the potential benefits and challenges of the Merit-Based Incentive Payment System (MIPS), which will be phased in over five years beginning in 2018. The payment methodology moves Medicare toward value-based purchasing by tying physician payment to individual or group-level measures of cost and quality. Performance will be judged by quality of care, resource use, meaningful use of electronic medical records, and participation in clinical practice improvement activities. The poorest performers will face fee cuts of 4 percent in 2019, 5 percent in 2020, 7 percent in 2021, and 9 percent in 2022. A key challenge, the author notes, will be measuring quality at the level of the individual physician. M. B. Rosenthal, “Physician Payment After the SGR—The New Meritocracy,” New England Journal of Medicine, Sept. 24, 2015 373(13):1187–89.

The Pitfalls of Hospital Consolidation

In this commentary the authors consider the implications of hospital consolidation, which has increased substantially in the past five years. They say many of the potential benefits, including improved quality and outcomes, can be achieved through collaborations among hospitals, interoperable electronic medical records, and better transparency. After citing research on the negative impact of mergers on utilization, price, and access to services, they suggest that as consolidation continues, there be greater emphasis on quality reporting and transparency. T. Xu, A. W. Wu, and M. A. Makary, “The Potential Hazards of Hospital Consolidation: Implications for Quality, Access, and Price,” Journal of the American Medical Association, Oct. 6, 2015 314(13):1337–38.

PCPs Needed to Meet Medicaid Demand

If all states were to expand Medicaid, researchers say the U.S. would need 2,114 additional primary care providers, an estimate somewhat lower than recent forecasts. The estimate assumes that adults with Medicaid coverage at any point in the year have an average of 1.32 visits per year to primary care providers, 0.45 more than low-income adults without Medicaid. Because some counties have fewer primary care providers per capita, the authors suggest that efforts to expand capacity focus on where providers practice rather than simply training more providers. E. T. Roberts and D. J. Gaskin, “Projecting Primary Care Use in the Medicaid Expansion Population: Evidence for Providers and Policy Makers,” Medical Care Research and Review, Oct. 2015 72(5):515–61.

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