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. 

  • June 29, 2016 Issue
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Publications of Note

Functional Limitations and Geriatric Syndromes Key to Identifying Health Risks in Older Adults 
A study of U.S. adults age 50 and older that sought to identify the combinations of chronic conditions, functional limitations, and geriatric syndromes that predict poor health outcomes found that functional limitations such as difficulty walking several blocks and geriatric syndromes such as visual impairment were more important than chronic conditions in predicting outcomes, self-ratings of health, and mortality. To identify these subgroups of patients, the authors recommend providers use such instruments as the Comprehensive Geriatric Assessment. S. M. Koroukian, N. Schiltz, D. F. Warner et al., “Combinations of Chronic Conditions, Functional Limitations, and Geriatric Syndromes that Predict Health Outcomes,"Journal of General Internal Medicine, June 2016 31(6):630–7. 

CMS May Need to Move Slowly When Changing ACO Benchmarks
To address concerns that the Medicare Shared Savings Program rewards accountable care organizations (ACOs) that are more inefficient and offers little incentive for high-performing ACOs to continue to reduce costs, the Centers for Medicare and Medicaid Services (CMS) is considering revising its benchmarking formula. Rather than assessing an ACO’s performance largely on its past spending, ACOs would be judged by how their spending compares with that of  other providers in their region. To understand the impact of this change, researchers looked at how spending varies among ACOs in a given region and between ACO and non–ACO providers. They found wide differences and concluded that in areas where there is great variation, CMS may need to move slowly to avoid discouraging participation by higher-cost providers and to ensure ACOs are not penalized for serving sicker patients. S. Rose, A. M. Zaslavsky, and J. M. McWilliams, “Variation in Accountable Care Organization Spending and Sensitivity to Risk Adjustment: Implications for Benchmarking,” Health Affairs, March 2016 35(3):440–8.

Lower Patient Activation Scores Linked to Higher Spending
Using data from a large health system in Minnesota, researchers found that high-risk patients who had the lowest scores on a patient activation measure made the greatest use of hospital and emergency department care. The measure, which assesses patients’ knowledge, skills, and confidence in managing their health, also accurately predicted the use of these costly services three years later. The authors say adding a behavioral assessment to risk-scoring models will help identify high-need patients who would benefit from additional support. J. H. Hibbard, J. Greene, R. Sacks et al., “Adding a Measure of Patient Self-Management Capability to Risk Assessment Can Improve Prediction of High Costs,” Health Affairs, March 2016 35(3):489–94.

Improved Depression Care May Lower Mortality Risk Among Patients with Comorbid Conditions
A study designed to determine whether evidence-based depression care management would reduce long-term mortality risk among adults with increasing levels of medical comorbidity found that it mitigated the combined effect of comorbidity and depression. In the usual care group, patients with the highest level of medical comorbidity were at increased risk of mortality compared with depressed patients with minimal comorbidity. In contrast, patients in the intervention group with the highest level of medical comorbidity and depression were not at significantly increased risk compared with depressed patients with minimal comorbidity. As part of the intervention, a depression care manager worked with primary care physicians to provide care—including offering psychotherapy, increasing antidepressant use if indicated, and monitoring symptoms, medication adverse effects, and treatment adherence. J. J. Gallo, S. Hwang, J. H. Joo et al., “Multimorbidity, Depression, and Mortality in Primary Care: Randomized Clinical Trial of an Evidence-Based Depression Care Management Program on Mortality Risk,” Journal of General Internal Medicine, April 2016 31(4):380–6.

Depression Care Lacking in Primary Care Practices
Researchers found large primary care practices in the U.S. used significantly fewer care management processes for depression than for other chronic illnesses, including asthma, congestive heart failure, and diabetes. On average, they used less than one of five depression care management processes, while small and medium-sized practices appeared to be using few care management processes overall. They also found no significant increase in the use of depression care management processes between 2006 and 2013. The authors say the findings indicate that U.S. primary care practices may not be well equipped to manage depression as a chronic illness, despite the high proportion of depression care they provide, and incentive programs may be necessary to spur their use. T. F. Bishop, P. P. Ramsay, L. P. Casalino et al., “Care Management Processes Used Less Often for Depression Than for Other Chronic Conditions in U.S. Primary Care Practices,” Health Affairs, March 2016 35(3):394–400. 

Greater Attention to Measure the Quality of Behavioral Health Care Needed to Spur Improvement
In this article the authors provide an overview of current measures of behavioral health, identify priorities for measure development, and outline the most significant challenges. They note that although there are more than 500 measures related to behavioral health, only 5 percent are used in quality-reporting programs and only 10 percent have been endorsed by the National Quality Forum. Quality reporting so far also appears to have had limited effect on behavioral health: based on Healthcare Effectiveness Data and Information Set (HEDIS) reports from commercial health plans, patients receive recommended behavioral health care less than half the time, with slow improvement in recent years. In terms of measure development, the authors identify five priorities: expanded outcomes measurement; structural measures, such as accreditation programs for health homes; recognition of efforts to integrate physical and behavioral health care; attention to psychosocial interventions; and attention to substance use disorders. H. A. Pincus, S. H. Scholle, B. Spaeth-Rublee et al., “Mental Health and Substance Abuse: Gaps, Opportunities, and Challenges,” Health Affairs, June 2016 35(6):1000–8.

FQHCs with Strong PCMH Capability Share Certain Characteristics
In this study of federally qualified health centers (FQHCs), patient-centered medical home (PCMH) capability appeared to be enhanced by having an electronic medical record system (EMR), being located in a state with state-supported PCMH initiatives, having access to more types of financial incentive programs, and having more hospital-health center affiliations. Researchers also found that the percentage of minority patients was negatively associated with PCMH capability, suggesting that health centers serving a larger proportion of minority patients need additional support. Because EMRs are widely in place in FQHCs, the authors suggest improvement efforts focus on providing more types of financial incentives, supporting hospital-health center affiliations, and implementing state-level PCMH initiatives. Y. Gao, R. S. Nocon, K. E. Gunter et al., “Characteristics Associated with Patient-Centered Medical Home Capability in Health Centers: A Cross-Sectional Analysis,” Journal of General Internal Medicine, Published online May 23, 2016.

Payment Reform and More Public Reporting May Advance ACA’s Mission

This commentary outlines some of the key accomplishments of the Affordable Care Act (ACA), including reducing the number of uninsured Americans, and suggests ways of promoting further reform such as increasing the use of bundled payments (particularly for spine surgery and cardiac procedures, and for treatment of common medical conditions such as congestive heart failure or asthma); reining in escalating drug costs, perhaps by predicating payment upon value; and making public comparisons of physician practices on such measures as total hospital days for ambulatory care–sensitive conditions and number of hospital days in the last six months of life. E. J. Emanuel, “How Well Is the Affordable Care Act Doing? Reasons for Optimism,” Journal of the American Medical Association, April 2016 315(13):1331–2. 

Commentary: Reform Efforts Need Alignment
The authors of this commentary say two competing reform efforts—encouraging physicians, hospitals, and others to improve the way they deliver care and making consumers more price-sensitive by increasing cost sharing—must be aligned to ensure they do not undermine one another. If not, the success of the provider-focused reform strategies, which depend on engaging patients with care teams and increasing preventive and chronic disease care, may be undercut by substantial or poorly targeted cost sharing that may discourage patients from such care. California, as a purchaser of health care services and through its exchange, offers an example of how to minimize the conflict, they say. The state has standardized the design of deductibles, copayments, and other cost sharing for health plans, helping to ensure patients can obtain primary care without being subject to a deductible. At the same time the state is encouraging plans to support medical home and accountable care organization models. E. S. Fisher and P. V. Lee. “Toward Lower Costs and Better Care—Averting a Collision Between Consumer- and Provider-Focused Reforms," New England Journal of Medicine, March 2016 374(10):903–6.

Renewed Focus on Community Benefit Spending Practices Could Lead to Greater Investment in Public Health
The author of this commentary describes the reasons for renewed attention to tax-exempt hospitals’ community benefit spending practices, which include an intensifying focus on the social determinants of health, payment reforms that encourage collaboration among public health and hospitals, and recent clarification from the IRS about what constitutes acceptable practices. The author notes that amendments to the Affordable Care Act specify that tax-exempt hospitals undertake triennial community health assessments with public health and community input. Even a modest increase in hospital spending on community health improvement could lead to significant investment in public health initiatives, she says. S. Rosenbaum, “Hospital Community Benefit Spending: Leaning In on the Social Determinants of Health,” Milbank Quarterly, June 2016 94(2): 251–54.

The Benefits and Possible Pitfalls of Global Payment for Oncology Care 
This commentary describes the Centers for Medicare and Medicaid Services’ new Oncology Care Model, which combines key features of global payment, medical homes, and pay-for-performance programs in an effort to encourage providers to improve the quality and lower the cost of cancer care. The authors describe how provider payment is structured in the program and note some of its potential pitfalls including the fact that opportunities to achieve savings will vary widely by cancer type and across patients. Its success may also hinge on convincing physicians and private payers to participate in the initiative. Z. Song and C. H. Colla, “Specialty-Based Global Payment: A New Phase in Payment Reform,” Journal of the American Medical Association, June 2016 315(21):2271–2.

Transitional Care Intervention Significantly Reduced Readmission Rates
A study of the Bridge Model, a social work–based transitional care intervention, found it produced a 20 percent relative reduction in all-cause 30-day admission rates for Medicare fee-for-service beneficiaries discharged from an urban medical center. The authors note the model, which links patients to existing community resources, may be of interest to organizations that are accountable for the care of patients with complex social needs, such as individuals who are dually eligible for Medicare and Medicaid or newly eligible for Medicaid coverage. M. E. Boutwell, M. B. Johnson, and R. Watkins, “Analysis of a Social Work–Based Model of Transitional Care to Reduce Hospital Readmissions: Preliminary Data,” Journal of the American Geriatrics Society, May 2016 64(5):1104–7.

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