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. 

  • March 24, 2016 Issue
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Publications of Note

Supportive Housing Leads to Lower Health Care Costs

A study that measured health care expenditures for formerly homeless people who were living in a supportive housing facility in Oregon between 2010 and 2014 found their health care spending fell significantly after they obtained housing. The expenditure changes were driven primarily by reductions in emergency and inpatient care. Respondents reported improved access to care, stronger primary care connections, and better subjective health outcomes as well. B. J. Wright, K. B. Vartanian, H.-F. Li et al., “Formerly Homeless People Had Lower Overall Health Care Expenditures After Moving into Supportive Housing,” Health Affairs, Jan. 2016 35(1):20–27. 

Study Finds Home Visit Programs Reduced Institutional Care

A study of UnitedHealth Group’s HouseCalls program, which has been offered to Medicare Advantage plan members in five states since 2008, found that compared with non–HouseCalls Medicare Advantage plan members and fee-for-service beneficiaries, HouseCalls participants had reductions in admissions to hospitals (1 percent and 14 percent, respectively) and lower risk of nursing home admission (0.67 percent and 1.3 percent, respectively). In addition, participants’ numbers of office visits—chiefly to specialists—increased 2 percent to 6 percent (depending on the comparison group). The program combines a comprehensive geriatric assessment by a clinician during a home visit with referrals to community providers and health plan resources to address uncovered issues. S. Mattke, D. Han, A. Wilks et al., “Medicare Home Visit Program Associated with Fewer Hospital and Nursing Home Admissions, Increased Office Visits,” Health Affairs, Dec. 2015 34(12):2138–46. 

Multistakeholder Collaborative Had Limited Effect on Patient Experience Measures

This study sought to determine whether chronically ill adults from communities participating in the Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q) initiative, a community-level quality improvement effort, reported greater improvement on four domains: care coordination, patient satisfaction, provider interaction and support, and receipt of recommended care for diabetes. It found that, relative to a national comparison group, those communities reported modestly greater improvement on patient satisfaction and receipt of recommended care for diabetes, suggesting that the magnitude of the effect of multistakeholder alliances may be limited. M. McHugh, J. B. Harvey, R. Kang et al., “Community-Level Quality Improvement and the Patient Experience for Chronic Illness Care,” Health Services Research, Feb. 2016 51(1):76–97. 

Spread of PCMH Processes Not More Rapid in AF4Q Communities

Researchers studying whether the adoption of patient-centered medical home processes spread more rapidly in 14 Aligning Forces for Quality (AF4Q) communities found no difference in the overall spread of these processes in these communities than in others, even though these multistakeholder health care alliances made up of payers, purchasers, providers, and consumers had promoted their use. They did, however, observe improvement on measures of care coordination in the AF4Q communities. M. McHugh, Y. Shi, P. P. Ramsay et al., “Patient-Centered Medical Home Adoption: Results from Aligning Forces for Quality,” Health Affairs, Jan. 2016 35(1):141–49. 

Using Behavioral Economics to Influence Physician Behavior

The authors outline nine behavioral economics principles that could be used to influence physicians’ practice patterns and performance—among them, loss aversion, choice overload, and relative social ranking. Such principles have been harnessed to alter retirement planning and savings decisions but are infrequently applied to health care, despite their potential to redirect physicians’ and patients’ behavior. E. J. Emanuel, P. A. Ubel, J. B. Kessler et al., “Using Behavioral Economics to Design Physician Incentives That Deliver High-Value Care,” Annals of Internal Medicine, Jan. 19, 2016 164(2):114–19. 

Medicare’s Bundled Payment Programs Likely to Evolve

This commentary from the Centers for Medicare and Medicaid Services (CMS) discusses the agency’s new bundled payment programs, which provide one fee that covers services provided by clinicians, facilities, and other health care entities during an episode of care. While CMS has been bundling some payments for decades, these new programs expand the length of the episodes and the array of clinical services covered. The piece also describes how the programs are likely to evolve by, among other things, rewarding clinicians for outcomes that matter to patients and revising pricing, including the risk adjustment that underpins it. M. J. Press, R. Rajkumar, and P. H. Conway, “Medicare’s New Bundled Payments: Design, Strategy, and Evolution,” Journal of the American Medical Association, Jan. 12, 2016 315(2):131–32. 

Patient-Centric Outcome Measures Needed to Spur Value-Based Care

Value in health care is often defined by the outcomes achieved relative to the costs, but measuring value has been slowed by the limited number of outcome measures that matter to patients. The authors of this commentary say to unlock the potential of value-based health care, the country needs a sufficient set of outcomes for every major medical condition—with well-defined methods for their collection and risk adjustment—that are then standardized. They recommend that providers, payers, patient advocacy groups, and regulators come together to create a process to agree on this measure set. M. E. Porter, S. Larsson, and T. H. Lee, “Standardizing Patient Outcomes Measurement,” New England Journal of Medicine, Feb. 11, 2016 374(6):504–6. 

Oregon’s Medicaid CCOs Possible Template for Medicaid Reform

This commentary describes Oregon’s efforts to reform its Medicaid program to improve health care access and population health and slow increases in spending. The state has established 16 “coordinated care organizations,” or CCOs, to provide comprehensive care for its Medicaid population. Each is locally governed; accountable for access, quality, and health spending; and emphasizes the use of primary care medical homes. The CCOs have reduced inpatient and outpatient spending while increasing screening and treatment for substance abuse. While the results are promising, it remains to be seen whether they will continue as improvement goals become harder to achieve, the author says. K. J. McConnell, “Oregon’s Medicaid Coordinated Care Organizations,” Journal of the American Medical Association, March 1, 2016 315(9):869–70. 

ACO Performance Related to Organizational Characteristics

A study examining the first-year results of accountable care organizations (ACOs) in the Medicare Shared Savings and Pioneer programs found ACOs in these programs lagged providers treating Medicare beneficiaries under fee-for-service arrangements on the majority of measures related to disease prevention and wellness screening, the two domains the researchers focused on. ACOs with relatively more specialists or fewer primary care physicians generally performed worse than their counterparts. However, having more Medicare ACO beneficiaries per primary care provider was associated with significantly better performance on composite scores related to disease prevention and wellness screening. B. B. Albright, V. A. Lewis, J. S. Ross et al., “Preventive Care Quality of Medicare Accountable Care Organizations: Associations of Organizational Characteristics with Performance,” Medical Care, March 2016 54(3):326–35. 

Using Implementation Science to Advance Innovation

In this commentary, the authors recommend using the field of implementation science to determine which technological, policy, and organizational changes are most effective at improving care. The field is devoted to understanding how change takes place by looking at variables such as incentives, modes of delivery, and market structure. They note that applying such a framework to analyze the adoption of innovations will require much better and more timely information, including whether innovations are actually being used and how innovations affect care quality, outcomes, and costs. E. S. Fisher, S. M. Shortell, and L. A. Savitz, “Implementation Science: A Potential Catalyst for Delivery System Reform,” Journal of the American Medical Association, Jan. 26, 2016 315(4):339–40. 

Safe Harbors May Spur Innovation in Quality Measurement and Improvement

The authors of this commentary point out that while public reporting on quality has become widespread, it has had some unintended consequences including discouraging innovation by providers and health plans out of concern that innovation in the early phases may dampen publicly reported outcomes. To encourage innovation, they suggest creating safe harbors for high-performing organizations to test new approaches to measurement, care delivery, or both. The designation would allow organizations to suspend measurement in areas in which they are performing well in return for pursuing innovations that could improve performance measurement methods for an existing clinical area; developing measurement approaches in clinical areas not currently monitored; and/or testing new approaches using different data sources and types of incentives. E. A. McGlynn and E. A. Kerr, “Creating Safe Harbors for Quality Measurement Innovation and Improvement,” Journal of the American Medical Association, Jan. 12, 2016 315(2):129–30. 

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