Obama Weighs in on Health Reform
In a commentary penned for the Journal of the American Medical Association, President Barack Obama outlines the achievements of the Affordable Care Act as he sees them, including the law’s impact on health care access, affordability, and quality, as well as its promotion of new models of payment. To achieve greater benefit, he calls on policymakers to continue to implement delivery system reforms and health insurance marketplaces; increase financial assistance to marketplace enrollees; introduce a public plan option in areas lacking individual market competition; and take action to reduce prescription drug costs. B. Obama, “United States Health Care Reform: Progress to Date and Next Steps,” Journal of the American Medical Association, Aug. 2, 2016 316(5):525–32.
Making a Business Case for Reducing Health Disparities
This commentary outlines several ways public and private payers can incentivize health care providers to address disparities in health outcomes. Among others, they include requiring providers to report clinical data stratified by factors such as race, ethnicity, and socioeconomic status; incorporating equity measures into incentive programs; providing technical and financial support to safety-net institutions; and funding demonstration projects that test new payment and delivery system reforms. Demonstrations, for instance, could help identify the most effective performance measures and risk-adjustment techniques and determine what types and magnitude of incentives are most powerful in influencing behavior for different types of care. M. H. Chin, “Creating the Business Case for Achieving Health Equity,” Journal of General Internal Medicine, July 2016 31(7):792–6.
Documenting the Benefits of Addressing Social Determinants
The authors of this article reviewed the evidence of the effectiveness of various interventions that address the social determinants of health—including programs focused on education and early childhood, housing, income, and employment—by documenting their positive impact on health outcomes, as well as crime rates, violence, and high-risk behaviors that carry significant financial and social costs. They say efforts to reduce disparities should focus on scaling up these evidence-based interventions at the regional, state, and national levels, since interventions focused on the health care sector alone are insufficient to address population-level health disparities. R. L. J. Thornton, C. M. Glover, C. W. Cene et al., “Evaluating Strategies for Reducing Health Disparities by Addressing the Social Determinants of Health,” Health Affairs, August 2016 35(8):1416–23.
Principles for Screening for Social Determinants of Health
In this commentary, the authors outline some challenges associated with screening for food insecurity, lack of access to stable housing, and other social needs. If not handled sensitively and with systems in place to make referrals to community-based services, there is the potential for unintended harm, they say. To minimize the risk, they outline several principles for screening, which include engaging all of a practice’s patients, rather than targeting subgroups by apparent social status, and building on the strengths of patients and families as this practice correlates with positive long-term outcomes. A. Garg, R. Boynton-Jarrett, and P. H. Dworkin, “Avoiding the Unintended Consequences of Screening for Social Determinants of Health,” Journal of the American Medical Association, Aug. 23/30, 2016 316(8):813–4.
Gaps in Research and Translation of Interventions to Reduce Disparities
To guide the development of interventions and policies to reduce health disparities, the authors outline critical gaps in knowledge and call for more research into the relative benefits and interplay of interventions that target individuals; family, friends, and social supports; providers and organizations; and policy and community factors. The authors also profile promising approaches to reducing disparities related to cardiovascular disease and cancer that were developed by the Centers for Population Health and Health Disparities. They also call for greater engagement of patients in developing, testing, and disseminating interventions. T. S. Purnell, E. A. Calhoun, S. H. Golden et al., “Achieving Health Equity: Closing the Gaps in Health Care Disparities, Interventions, and Research,” Health Affairs, Aug. 2016 35(8):1410–5.
Analysis of Medicare Shared Savings Program Finds Modest Savings and Disparate Performance Among ACOs
A study of the Medicare Shared Savings Program found declines in spending were greater among accountable care organizations (ACOs) that joined the program in 2012 compared with those that joined in 2013, suggesting early gains by more advanced ACOs may not be generalizable to less advanced ones or may be slower to develop. Per-beneficiary spending for Part A and B services in the 2012 cohort was estimated to be $144 less than for beneficiaries in the fee-for-service program, a savings of 1.4 percent, but was only $3 per beneficiary less in the 2013 cohort. Moreover, the estimated savings for the 2012 cohort were likely offset by bonus payments and the losses Medicare assumed for some ACOs under the one-sided risk model, resulting in no net savings for Medicare. ACOs in the program also demonstrated improved performance on some quality measures, but for others—including measures that track low-value care—performance was unchanged. The researchers also found independent primary care groups achieved greater savings than ACOs that included both hospitals and physicians, suggesting financial integration between physicians and hospitals is not necessary for success. J. M. McWilliams, L. A. Hatfield, M. E. Chernew et al., “Early Performance of Accountable Care Organizations in Medicare,” New England Journal of Medicine, June 16, 2016 374(24):2357–66
Commentary: CMS Should Jettison ACOs, Pursue Delivery Reforms That Take Advantage of Technology and Lower-Cost Models of Care
In this commentary in the Journal of the American Medical Association, the authors say the accountable care programs introduced by the Affordable Care Act—the Medicare Shared Savings Program and the Pioneer ACO program—have failed to achieve their goals. They point to three recent evaluations that found modest increases in spending or declines that were offset in some cases by incentive payments to participants. The authors also point out that the model has encouraged hospitals to acquire physician practices, allowing them to amass market power that has led to increased prices that health plans have sought to combat with high-deductible products and narrow networks. They urge the Centers for Medicare and Medicaid Services to abandon the ACO model and pursue strategies that encourage physicians to keep patients out of hospitals and away from costly facilities and tests. They also recommend the Center for Medicare and Medicaid Innovation invest in models that take advantage of telemedicine, diagnostic wearable devices, and lower-cost workers as a means of increasing efficiency. K. A. Schulman and B. D. Richman, “Reassessing ACOs and Health Care Reform,” Journal of the American Medical Association, Aug. 16, 2016 316(7):707–8.
Vulnerable Patients Have Limited Access to ACOs
A study of physician participation in ACOs found that it varied widely across hospital referral regions—ranging from zero to 85 percent. The researchers also found participation rates were significantly lower in areas where a higher percentage of the population was black, living in poverty, uninsured, or disabled or had only a high school education, suggesting that such vulnerable populations’ access to ACOs is more limited than for other groups, which could exacerbate disparities in health care quality. They suggest several policy interventions, including offering physicians who serve vulnerable populations additional incentives to form an ACO or assistance with startup costs. L. C. Yasaitis, W. Pajerowski, D. Polsky et al., “Physicians’ Participation in ACOs Is Lower in Places with Vulnerable Populations Than in More Affluent Communities,” Health Affairs, Aug. 2016 35(8):1382–90.
High and Persistent Spending at the End of Life Associated with Chronic Conditions
Using Medicare claims data to characterize trajectories of health care spending among beneficiaries in their last year of life, researchers found:
- nearly half (48.7%) had high persistent spending (high initial and steadily increasing spending);
- 29.0 percent had moderate persistent spending (moderate initial spending, followed by a dip and then an increase toward end of life);
- 10.2 percent had progressive spending (relatively low initially but increasing steeply over the year); and
- 12.1 percent had late rise spending (low spending up to four months before death, then increasing exponentially).
They also found high spending over the full year before death was associated with having multiple chronic conditions but not any specific diseases, suggesting spending at the end of life is a marker of patterns set in motion long before death. M. A. Davis, B. J. Nallamothu, M. Banerjee et al., “Identification of Four Unique Spending Patterns Among Older Adults in the Last Year of Life Challenges Standard Assumptions,” Health Affairs, July 2016 35(7):1316–23.
Medical Home Model Lowers Spending for High-Need Patients
A study of Pennsylvania’s statewide patient-centered medical home initiative—which took place from 2008 to 2011—found it was associated with substantial cost savings for Medicaid patients with chronic medical conditions and comorbid psychiatric or substance abuse disorders. Researchers found spending was $4,145.28 less per patient per year for those participating in the Chronic Care Initiative, driven largely by reduced inpatient medical costs. The mean count of emergency department visits and psychiatric hospitalizations also declined (15.6% and 40.7%, respectively). They did not measure quality of care, and thus did not draw conclusions about the initiative’s overall cost-effectiveness. K. V. Rhodes, S. Basseyn, R. Gallop et al., “Pennsylvania’s Medical Home Initiative: Reductions in Healthcare Utilization and Cost Among Medicaid Patients with Medical and Psychiatric Comorbidities,” Journal of General Internal Medicine, published June 25, 2016.
Integration of Primary and Behavioral Health Care Improves Quality, Lowers Utilization, Decreases Reimbursements
A study of patients receiving primary care at Intermountain Healthcare clinics that integrated physical and behavioral health care services found that compared with traditional primary care clinics, the integrated practices performed better on some but not all quality and utilization measures. They found the practices had higher rates of depression screening, greater adherence to a diabetes care bundle, and greater documentation of self-care plans, but a lower proportion of patients with controlled hypertension, and no significant difference in documentation of advanced directives. They also found rates of emergency department (ED) visits, hospital admissions (including admissions for conditions sensitive to ambulatory care), and primary care physician encounters were lower, but there was no significant difference in visits to urgent care facilities or specialists. The program also reduced payments to the health system by $115 per patient per year and cost the system $12.1 million to implement between 2010 and 2013, the period studied. B. Reiss-Brennan, K. D. Brunisholz, C. Dredge et al., “Association of Integrated Team-Based Care with Health Care Quality, Utilization, and Cost,” Journal of the American Medical Association, Aug. 23/30, 2016 316(8):826–34.
Integration of Behavioral Health Care Services into Primary Care Reduces ED Use
This article describes a collaborative care model that UCLA Health introduced to increase access to behavioral health services for its patients, half of whom are covered by risk-based contracts. Modeled on the Improving Mood-Promoting Access to Collaborative Treatment program, the Behavioral Health Services program enhances screening for behavioral health conditions, streamlines referral processes, and encourages collaboration among physicians and behavioral health providers who work together in primary care practices. Since 2012, the program has tripled the number of patients receiving behavioral health services and produced a 13 percent reduction in emergency department use among patients served, the sole measure used to assess impact on acute care services. Reimbursements for services were insufficient to cover program expenses, but UCLA Health hopes that shared savings payments from its ACO contracts will help to make up the difference. R. M. A. Clarke, J. Jeffrey, M. Grossman et al., “Delivering on Accountable Care: Lessons from a Behavioral Health Program to Improve Access and Outcomes,” Health Affairs, Aug. 2016 35(8):1487–93.