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Publications of Note

Case Management for Disabled Medicaid Enrollees Improved Access But Didn’t Yield Savings

A study that evaluated the outcomes of a nurse-led care management intervention for disabled Medicaid beneficiaries with high health care costs found the intervention group had higher odds of outpatient mental health service use and higher prescription drug costs than the control group. Participants also had fewer unplanned hospital admissions and lower associated costs, higher odds of long-term-care service use, higher drug/alcohol treatment costs, and lower odds of homelessness. The study found no net cost savings but the results suggest that care management may have the potential to increase access to needed care, slow growth in the number and therefore cost of unplanned hospitalizations, and prevent homelessness. J. F. Bell, A. Krupski, J. M. Joesch et al., “A Randomized Controlled Trial of Intensive Care Management for Disabled Medicaid Beneficiaries with High Health Care Costs,” Health Services Research, June 2015 50(3):663–89.

Patient Navigators More Effective for Older Safety-Net Patients

A study designed to determine if assistance from patient navigators reduced readmissions among high-risk, low-income patients found that it led to a 4.1 percent decrease in readmissions and increased rates of follow-up appointments among older patients. But in the group of patients age 60 or younger, there was a significant increase in readmissions (by 11.8%) with no change in 30-day follow-up. The navigators, who were hospital-based community health workers, provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach. They supported patients for 30 days post-discharge with medication management, scheduling of follow-up appointments, communication with their primary care clinicians, and symptom management. The authors concluded that transition strategies should be evaluated among diverse populations, noting younger high-risk patients may require novel strategies. R. B. Balaban, A. A. Galbraith, M. E. Burns et al., “A Patient Navigator Intervention to Reduce Hospital Readmissions Among High-Risk Safety-Net Patients: A Randomized Controlled Trial,” Journal of General Internal Medicine, July 2015 30(7):907–15.

Revisit Rates to ED More Frequent Than Previously Reported

Researchers studying variation in the rates at which patients return to the emergency department (ED) after an initial visit found that within three days of an initial visit, 8.2 percent of patients returned to an ED—with 32 percent going to different institutions. The rates varied by diagnosis, with skin infections having the highest rates. Among the six states studied, revisit rates varied. In Florida, the only state with complete cost data, revisits were more expensive than on the initial one. The authors note that revisits are more frequent than previously reported, in part because many occur outside of the index institution. R. Duseja, N. S. Bardach, G. A. Lin et al., “Revisit Rates and Associated Costs After an Emergency Department Encounter: A Multistate Analysis,” Annals of Internal Medicine, June 2, 2015 162(11):750–56.

More Than Half of Medicaid Patients Using EDs for Low-Acuity Problems Prefer ED to Primary Care

A study that sought to determine the proportion of adult Medicaid enrollees with low-acuity conditions who were willing to use primary care services rather than an ED if given the choice found that a little less than half (45.3%) in a sample of 95 patients presenting to the ED would have preferred to use their primary care physician if an appointment had been immediately available. Of those preferring the ED, roughly half said they thought the ED had more technology or specialty care services available compared with their PCP’s clinic. A smaller percentage (11.5%) felt the care they received in the ED was better than what they would receive in their primary care clinic. R. Capp, M. Camp-Binford, S. Sobolewski et al., “Do Adult Medicaid Enrollees Prefer Going to Their Primary Care Provider’s Clinic Rather Than Emergency Department (ED) for Low Acuity Conditions?Medical Care, June 2015 53(6):530–33.

Primary Care Continuity Associated with Reduced ED Use and Hospitalizations in California

Given concerns that extending health insurance coverage to millions of previously uninsured Americans would give rise to increased use of ED and hospital services, researchers sought to determine whether continuity with a regular source of primary care was associated with lower use of these services. They relied on data on previously uninsured adults in Orange County, Calif., who, as part of the state’s Health Care Coverage Initiative, gained access to a safety net–based provider network and a defined package of covered benefits beginning in 2007. They found that after the Orange County program required participants to select and use a primary care provider, those who were adherent to the provider had a higher probability of having no ED visits and no hospitalizations compared with those who were never adherent. N. Pourat, A. C. Davis, X. Chen et al., “In California, Primary Care Continuity Was Associated with Reduced Emergency Department Use and Fewer Hospitalizations,” Health Affairs, July 2015 34(7):1113–20.

Medical Home Transformation Linked to Organizational Factors and Change Strategies

A study of the first 132 primary care practices in Minnesota to achieve medical home certification found that 80 percent to 100 percent of these certified clinics had 15 of the 18 organizational factors important for improving care processes and that 60 percent to 90 percent had successfully used 16 improvement strategies. Prioritizing change and use of more strategies were predictive of greater transformation. The authors note clinics contemplating medical home implementation should consider the factors and strategies identified and be sure that such a change is a high priority for them. L. I. Solberg, L. H. Stuck, A. L. Crain et al., “Organizational Factors and Change Strategies Associated with Medical Home Transformation,” American Journal of Medical Quality, July/August 2015 30(4):337–44.

State Leadership in Health Care Transformation: Opportunities and Challenges

In this commentary, the authors describe the increasingly important role states play in health care reform—as purchasers of services through the Medicaid program, as providers of health care services, as collectors of data, as grantees of federal funding for experimentation, and as conveners of business leaders, health care executives, and patient advocates. They note not all states are leveraging the opportunities available and face certain challenges. It can be difficult to align competing goals, for instance, for cost containment, population health, and care of high-need populations. States also need support from the federal government on payment and regulatory issues. Another challenge is ensuring leadership changes in executive and legislative branches of government do not derail reform efforts. A. Hwang, J. M. Sharfstein, and C. F. Koller, “State Leadership in Health Care Transformation: Red and Blue,” Journal of the American Medical Association, July 28, 2015 314(4):349–50.

Consumers Uninterested in Practice-Level Physician Ratings

Researchers studying consumers’ understanding of and interest in practice-level physician quality ratings conducted four focus groups—half with individuals who had a chronic illness and half with individuals who did not. They found most consumers correctly understand the concept of a physician practice, but exhibited little interest in practice-level characteristics, preferring instead information about their personal doctor. They also found that understanding of and interest in practice-level quality does not differ by chronic disease status. The authors recommend additional work to design, develop, and test promotional and educational materials to highlight the relevance of practice-level characteristics for consumer decision-making. B. Smith, W. D. Lynch, C. Markow et al., “Consumers’ Understanding of and Interest in Provider- Versus Practice-Level Quality Characteristics: Findings from a Focus Group Study,” American Journal of Medical Quality, July/August 2015 30(4):367–73.

Ambulatory Care–Sensitive Readmission Rates Vary by Professional Networks

A study that sought to determine whether the rate of ambulatory care–sensitive hospital admissions varies across the provider networks with which a patient’s physician is connected—even networks at the same hospital—found that these rates varied significantly across networks. There was a 46 percent difference in admission rates between networks at the 25th and 75th percentiles. At 95 percent of hospitals with admissions from two networks, the networks had significantly different admission rates. Networks with a higher percentage of primary care physicians and networks in which patients received care from a larger number of primary care physicians had higher rates. The authors note physician networks could be an important focus for understanding variations in medical care and for intervening to improve care. L. P. Casalino, M. F. Pesko, A. M. Ryan et al., “Physician Networks and Ambulatory Care–Sensitive Admissions,” Medical Care, June 2015 53(6):534–41.

Pioneer ACO Beneficiaries Had Lower Spending Increases and Utilization Than Traditional Medicare Beneficiaries

A study found fee-for-service Medicare beneficiaries aligned with accountable care organizations (ACOs) in the Pioneer program had smaller increases in spending and utilization than other fee-for-service beneficiaries while retaining similar levels of care satisfaction in the first two years of the program. Differential changes in spending were approximately −$35.62 per beneficiary per month in 2012 and −$11.18 in 2013, which amounted to aggregate reductions of approximately $280 million in 2012 and $105 million in 2013. Inpatient spending showed the largest differential change of any spending category (−$14.40 per beneficiary per month in 2012 and −$6.46 in 2013). Changes in utilization of physician services, emergency department, and postacute care followed a similar pattern. The study also found little difference in patient experience among beneficiaries aligned with Pioneer ACOs and general Medicare fee-for-service beneficiaries. D. J. Nyweide, W. Lee, T. T. Cuerdon et al., “Association of Pioneer Accountable Care Organizations vs. Traditional Medicare Fee for Service with Spending, Utilization, and Patient Experience,” Journal of the American Medical Association, June 2, 2015 313(21):2152–61.

Medicare Drug Coverage Neither Improved Health Outcomes Nor Increased Efficiency

A study examining the changes in health outcomes and medical services in the Medicare population after implementation of Part D, which provides prescription drug coverage, found no clinically or statistically significant reductions in the prevalence of fair or poor health status or limitations in activities of daily living relative to historical trends. Compared with trends before Part D, no changes in emergency department visits, hospital admissions or days, inpatient costs, or mortality after Part D were seen. B. A. Briesacher, J. M. Madden, F. Zhang et al., “Did Medicare Part D Affect National Trends in Health Outcomes or Hospitalizations? A Time-Series Analysis," Annals of Internal Medicine, June 16, 2015 162(12):825–33.

Hospital Board Management Practices Tied to Performance on Quality Metrics

After studying the relationships among hospital boards, management practices of frontline managers, and the quality of care delivered in nationally representative groups of hospitals in the United States and England, researchers found that hospitals with more effective management practices provided higher-quality care. Higher-rated hospital boards also had superior performance by management staff. Hospitals with boards that paid greater attention to clinical quality had management that better monitored quality performance. Similarly, they found that hospitals with boards that used clinical quality metrics more effectively had higher performance by hospital management staff on target setting and operations. T. C. Tsai, A. K. Jha, A. A. Gawande et al., “Hospital Board and Management Practices Are Strongly Related to Hospital Performance on Clinical Quality Metrics,” Health Affairs, Aug. 2015 34(8):1304–11.

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