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Publications of Note

Potentially Preventable Medicare Spending Concentrated Among Frail Elderly

Researchers summed spending on potentially avoidable emergency department (ED) visits as well as hospital care and postacute care for ambulatory care–sensitive conditions to estimate how much of Medicare spending may be preventable. The answer: roughly 5 percent. The majority (73.8%) was incurred by high-cost patients (defined as those in the highest decile of individual spending). They found high-cost frail elderly beneficiaries, who make up only 4 percent of the Medicare population, accounted for 43.9 percent of total potentially preventable spending (or $6,593 per person). High-cost nonelderly disabled persons accounted for 14.5 percent ($3,421 per person) while beneficiaries with major complex chronic conditions accounted for 11.2 percent ($3,327 per person). J. F. Figueroa, K. E. Joynt Maddox, N. Beaulieu et al., “Concentration of Potentially Preventable Spending Among High-Cost Medicare Subpopulations: An Observational Study,” Annals of Internal Medicine, Nov. 21, 2017 167(10):706–13.

Lessons from Other Countries Implementing Accountable Care Reforms

Researchers analyzed promising accountable care reforms in three countries — Germany, Nepal, and the Netherlands — to extract lessons for providers, payers, and policymakers. After summarizing these efforts, which produced improvements in quality using the same or fewer health care resources, they made several recommendations, among them that policymakers implement payment reform in such a way that encourages providers to shift to a patient-centered focus without adding to administrative burden. They also recommend policymakers develop evidence to guide reforms as this will increase confidence among those asked to adopt and expand new models of care delivery and payment. M. McClellan, K. Udayakumar, A. Thoumi et al., “Improving Care and Lowering Costs: Evidence and Lessons from a Global Analysis of Accountable Care Reforms,”Health Affairs, Nov. 2017 36(11):1920–27.

Low-Cost, Low-Value Services More Costly in Aggregate Than High-Cost, Low-Value Services

An analysis of claims for 44 low-value health services in the Virginia All-Payer Claims Database found more than $586 million in unnecessary costs in 2014. Among these low-value services, those that were low-cost ($100–$538 per service) and very-low-cost (less than $100 per service) were delivered far more frequently than those that were high-cost ($539–$1,315 per service) and very-high-cost (more than $1,315 per service). The authors note the combined costs of the former group were nearly twice those of the latter (65 percent versus 35 percent). J. N. Mafi, K. Russell, B. A. Bortz et al., “Low-Cost, High-Volume Health Services Contribute the Most to Unnecessary Health Spending,” Health Affairs, Oct. 2017 36(10):1701–4.

Coordination Program Reduces Acute Care Among Frequent Emergency Care Users

A study of Bridges to Care (B2C) — a multidisciplinary program designed to help high utilizers of the emergency department (ED) gain access to primary care — found participants had significantly fewer ED visits (a reduction of 27.9%) and significantly more primary care visits (an increase of 114%) compared with the control group during the six months after the intervention was completed. Among patients with mental health comorbidities, they found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 percent) and hospitalizations (30.0 percent), and significantly more primary care visits (an increase of 123.2 percent). R. Capp, G. J. Misky, R. C. Lindrooth et al., “Coordination Program Reduced Acute Care Use and Increased Primary Care Visits Among Frequent Emergency CareUsers,” Health Affairs, Oct. 2017 36(10):1705–11.

Subset of Frequent Emergency Department Users Remain So Over Time

An analysis of frequent emergency department (ED) users in California that sought to measure the persistence of frequent ED use and identify the characteristics of nonelderly adults whose frequent ED use was sustained over time found small percentages (16.5%, 5.7%, and 1.9%) exhibited persistent frequent use for three, six, and 11 consecutive years. The strongest predictor of persistent frequent ED use was the intensity of ED use in the baseline year. Identifying and differentiating persistent frequent users is important, the authors say, as these patients may be candidates for distinct interventions. H. K. Kanzaria, M. J. Niedzwiecki, J. C. Montoy et al., “Persistent Frequent Emergency Department Use: Core Group Exhibits Extreme Levels of Use for More Than a Decade,” Health Affairs, Oct. 2017 36(10):1720–28.

Newly Eligible Medicaid Enrollees Use Less Care Than Those Previously Eligible

A study of the spending and utilization patterns of the nonelderly adults who became newly eligible for Medicaid under the Affordable Care Act found their average monthly expenditures were $180, or 21 percent, less than the $228 average for previously eligible enrollees. They note utilization differences between these groups likely contributed to this differential. P. D. Jacobs, G. M. Kenney, and T. M. Selden, “Newly Eligible Enrollees in Medicaid Spend Less and Use Less Care Than Those Previously Eligible,” Health Affairs, Sept. 2017 36(9):1637–42.

Intensive Primary Care Interventions Show Mixed Results

A review of studies assessing the effectiveness of intensive primary care programs that target patients with complex needs found varying degrees of effectiveness at reducing hospitalizations and limited evidence that these interventions were associated with changes in mortality compared with usual primary care services. A total of 18 studies were reviewed: these included studies of programs that replaced traditional primary care (some using home settings and others clinics) and primary care “augmentation” programs that added an interdisciplinary team to existing primary care services. Most studies showed no impact on emergency department use while the effectiveness in reducing hospitalizations varied. No adverse events were reported. The researchers note further work is needed to identify program features that may be associated with improved outcomes. S. T. Edwards, K. Peterson, B. Chan et al., “Effectiveness of Intensive Primary Care Interventions: A Systematic Review,” Journal of General Internal Medicine, Dec. 2017 32(12):1377–86.

Biggest Drivers of Health Care Spending Increase Were Service Price and Intensity

Researchers seeking to quantify how changes in U.S. health care spending relate to population size, population aging, disease prevalence or incidence, service utilization, and service price and intensity found increases in spending from 1996 through 2013 were largely related to increases in health care service price and intensity (e.g., mean spending per visit, hospital day, etc.) but were also positively associated with population growth and aging and negatively associated with disease prevalence or incidence. They say understanding these factors and their variability across health conditions and types of care may inform policy efforts to contain health care spending. J. L. Dieleman, E. Squires, A. L. Bui et al., “Factors Associated with Increases in U.S. Health Care Spending, 1996–2013,” Journal of the American Medical Association, Nov. 7, 2017 318(17):1668–78.

Care Models Reduce ED Visits and Hospitalizations for Cancer Patients

A study of two innovative cancer care programs — an oncology medical home and a patient navigator program — found both produced reductions in spending or utilization. The Community Oncology Medical Home (COME HOME) and the Patient Care Connect Program (PCCP) were associated with fewer emergency department (ED) visits. Patients in the COME HOME model had lower spending ($675 per patient per quarter) than a comparison group, while those in the PCCP had fewer hospitalizations (11 per 1,000 patients per quarter) relative to the comparison group. Among patients undergoing chemotherapy, fewer COME HOME and PCCP patients had ED visits (18 and 28 per 1,000 patients per quarter, respectively) and fewer PCCP patients had hospitalizations (13 per 1,000 patients per quarter) than comparison patients. E. M. Colligan, E. Ewald, N. L. Keating et al., “Two Innovative Cancer Care Programs Have Potential to Reduce Utilization and Spending,” Medical Care, Oct. 2017 55(10):873–78.

Measuring Investment in Primary Care as a Means of Focusing Public Attention and Policy Action

The authors of this commentary recommend using the nation’s primary care spending rate, defined as the proportion of all medical spending devoted to primary care, to assess the health system’s orientation toward high-value care. The measure would include clinician incomes, performance payments, case management activities, and health information technologies. They note that, compared with peer countries, the U.S. has fewer primary care clinicians than specialists and larger income disparities between the two groups. They also point out that while the Affordable Care Act introduced a number of incentives to invest in primary care, these incentives have not been sufficient to fix problems tied to this imbalance. C. F. Koller and D. Khullar, “Primary Care Spending Rate — A Lever for Encouraging Investment in Primary Care,” New England Journal of Medicine, Nov. 2, 2017 377(18):1709–11.

Medicare Advantage Plans Outperform Fee-for-Service Medicare on Some Measures

Researchers who compared the performance of Medicare Advantage (MA) plans and fee-for-service (FFS) Medicare on clinical quality and patient experience measures found MA plans outperformed the FFS program on all 16 quality measures. The differences were large for HEDIS measures and small for Part D measures, they said. They also found that while MA enrollees reported better experiences overall, FFS beneficiaries reported better access to care. Performance gaps were wider for HMOs than PPOs. The study included 9.9 million beneficiaries living in California, New York, and Florida. J. W. Timbie, A. Bogart, C. L. Damberg et al., “Medicare Advantage and Fee-for-Service Performance on Clinical Quality and Patient Experience Measures: Comparisons from Three Large States,” Health Services Research, Dec. 2017 52(6):2038–60.

For Patients with Severe Mental Illnesses, Medical Homes Increase Access and Spending

A study assessing the impact of medical homes on utilization and spending for Medicaid beneficiaries with severe mental illnesses found positive associations with access to primary care, specialty mental health care, and medication adherence. It also found patients served by medical homes had lower emergency department use but greater medical expenditures overall. The sample included all adults with diagnoses of schizophrenia, bipolar disorder, or major depression who were not dually enrolled in Medicare or in a nursing facility. M. E. Domino, M. Kilany, R. Wells et al., “Through the Looking Glass: Estimating Effects of Medical Homes for People with Severe Mental Illness,” Health Services Research, Oct. 2017 52(5):1858–80.

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