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Publications of Note

Home Visits by Nurses and Lay Health Workers Help Lower Total Cost of Care

Researchers studying five models of home-based care funded by the Center for Medicare and Medicaid Innovation (CMMI) found visits led by practice extenders including nurses and lay health workers were associated with reductions in costs, hospitalizations, and emergency department use. The five models emphasized care coordination and patient and consumer engagement and sought to strengthen connections to primary and palliative care. Two models achieved significant reductions in Medicare expenditures, and three reduced utilization of emergency department (ED) visits and hospitals or both relative to comparison groups. The researchers say additional research is needed to determine whether programs led by clinicians other than physicians/nurse practitioners offer particular benefits for high-need populations. S. Ruiz, L. P. Snyder, C. Rotondo et al., “Innovative Home Visit Models Associated with Reductions in Costs, Hospitalizations, and Emergency Department Use,” Health Affairs, March 2017 36(3):42532.

Specialty Medical Homes and Patient Navigation Reduce Costs for Cancer Patients at the End of Life

A study of innovative models of care for Medicare beneficiaries with cancer found one that established medical homes for oncology patients and another that deployed lay navigators who fostered end-of-life care discussions and identified palliative care needs were associated with decreased costs in the last 90 days of life ($3,346 and $5,824 per person, respectively) as well as fewer hospitalizations in the last 30 days (57 and 40 per 1,000 people, respectively). The navigation model, which also focused on helping patients assess and manage symptom flare-ups, was associated with fewer ED visits in the last 30 days of life and increased hospice enrollment in the last two weeks of life. E. M. Colligan, E. Ewald, S. Ruiz et al., “Innovative Oncology Care Models Improve End-Of-Life Quality, Reduce Utilization and Spending,” Health Affairs, March 2017 36(3): 43340.

ACA Narrows But Does Not Close Income– and Race–Based Disparities in Care

Researchers found that lack of insurance is one factor that contributes to worse health outcomes among lower-income Americans and racial and ethnic minorities but only explained a small to moderate portion of the disparities. Through a national survey of 8,000 Americans, they found lower-income families and racial and ethnic minorities experienced more cost-related barriers to care, worse perceived health care quality, and had more difficulty obtaining appointments than white and higher-income patients. Cost-related delays in care and use of emergency departments due to lack of available appointments were twice as common in the lowest income group and less than 40 percent of these disparities were related to insurance. They also found quality of care was worse among blacks and Latinos, with 16 percent to 70 percent explained by insurance. At the same time, lower-income and minority groups were generally more likely than whites and higher-income adults to say the Affordable Care Act was helping them and that quality and/or affordability had improved. B.D. Sommers, C. L. McMurthy, R. J. Blendon et al., “Beyond Health Insurance: Remaining Disparities in U.S. Health Care in the Post-ACA Era,” Milbank Quarterly, March 2017 95(1):43–69.

Among Early CMMI Programs, Savings Appear to Be Larger for Those Targeting Clinically Fragile Patients

An analysis of ambulatory care innovations funded by CMMI in the first round its awards program found those that used health information technology or community health workers achieved the greatest cost savings (estimated savings exceeded $150 per beneficiary per quarter for both). Savings closer to $100 were found for medical home and behavioral health programs and even greater savings were found for programs that targeted clinically complex populations at risk for disease progression. They say the results should be interpreted cautiously because of wide confidence intervals for many of the effects. Meta-analyses of a larger number of delivery system innovations will be necessary to clearly establish their potential for cost savings, they say. K. W. Smith, A. Bir, N. L. B. Freeman et al., “Impact of Health Care Delivery System Innovations in Total Cost of Care,” Health Affairs, March 2017 36(3):50915.

Integrated Care Management Program Appears to Drive One ACO’s Savings

Researchers found patient participation in a Pioneer accountable care organization (ACO) had a modest effect on spending while participation in its care management program was associated with substantial reductions in hospitalizations and ED visits, as well as Medicare spending. They note ED visits decreased relatively quickly, particularly for conditions amenable to outpatient care, while hospitalization rates increased initially before decreasing. Rates of ED visits and hospitalizations were reduced by 6 percent and 8 percent, respectively, and Medicare spending was reduced by 6 percent. They conclude targeting beneficiaries with modifiable high risks and shifting care away from the ED represent viable mechanisms for altering spending within ACOs. J. Hsu, M. Price, C. Vogeli et al., “Bending the Spending Curve by Altering Care Delivery Patterns: The Role of Care Management Within a Pioneer ACO,” Health Affairs, May 2017 36(5):87684. 

Recommendations for Promoting Care Process Innovation Within Health Systems

The authors of this article describe successful models of supporting care process innovation in academic health systems—among them the Cleveland Clinic, Mayo Clinic, University of Pittsburgh, University of Pennsylvania, and Geisinger Health System—and draw lessons for other health systems and practices. Requisites for success include making sufficient resources of money and space available; offering coordination and consultation regarding intellectual property and licensing, and enabling access to engineers, software developers, and behavioral scientists. Other lessons include: making providers and patients available to innovators, having a sufficiently long-term view, and insulating the innovation group from operational demands. D. W. Bates, A. Sheikh, and D. A. Asch, “Innovative Environments in Health Care: Where and How New Approaches to Care Are Succeeding,” Health Affairs, March 2017 36(3):4007.

Meta-Analysis Finds PCMHs Not Achieving Intended Effects

Researchers found use of patient-centered medical homes (PCMHs) had an effect on screening for breast and cervical cancer and two utilization measures—producing reductions in specialty care visits and total cost of care excluding pharmacy spending—but no effect on other utilization measures, including those assessing primary care, ambulatory caresensitive inpatient care, and ED visits. They say further research is needed to understand the contextual features that make some PCMH initiatives more successful and identify the extent to which PCMH activities have differential impacts across patients groups. A. D. Sinaiko, M. B. Landrum, D. J. Meyers et al., “Synthesis of Research on Patient-Centered Medical Homes Brings Systematic Differences into Relief,Health Affairs, March 2017 36(3):5008.

Tiered Health Plan Designs Reduce Total Health Care Spending

An evaluation of a tiered-network health plan designed to steer patients toward higher-quality, more efficient providers found it reduced total health care spending, including inpatient, outpatient, and outpatient radiology spending for nonelderly enrollees. The tiered network was associated with $43.36 lower total adjusted medical spending per member per quarter ($830.07 versus $873.43), representing a roughly 5 percent decrease in spending relative to enrollees in similar plans without a tiered network. Similar levels of spending reductions were found for outpatient (4.6 percent) and outpatient radiology spending (6.5 percent). A. D. Sinaiko, M. B. Landrum, and M. E. Chernew, “Enrollment in a Health Plan With a Tiered Provider Network Decreased Medical Spending by 5 Percent,” Health Affairs, May 2017 35(5):8705.

Oregon’s CCOs Slow Health Care Spending Relative to Neighboring State

A study of Oregon’s coordinated care organizations (CCOs), which assume financial risk and responsibility for the medical, behavioral health, and dental care of Medicaid enrollees across geographic regions, found that relative to Washington State the CCOs produced savings of 7 percent across five service areas: evaluation and management, imaging, procedures, tests, and inpatient facility care. The largest reductions were observed in inpatient hospitalization. Both states saw reductions in avoidable ED visits, while primary care visits declined in Oregon, an area of concern given that its CCOs emphasize the medical home model, the researchers say. They say this differential may reflect tightening primary care capacity in Oregon. K. J. McConnell, S. Renfro, R. C. Lindrooth et al., “Oregon’s Medicaid Reform and Transition to Global Budgets Were Associated with Reductions in Expenditures,” Health Affairs, March 2017 36(3):4519.

Exercise and Diet Intervention Reduces Hospitalizations and ED Use

A study of a diabetes prevention program run by the YMCA and funded by CMMI found it reduced total medical costs for fee-for-service Medicare participants by $278 per quarter for the first three years of the intervention. Total decreases in inpatient admissions and ED visits were significant for participants in program, which focused on helping patients lose weight and increase physical activity. The study found there were 9 fewer inpatient stays and nine fewer ED visits per 1,000 participants per quarter. M. L. Alva, T. J. Hoerger, R. Jeyaraman et al., “Impact of the YMCA of the USA Diabetes Prevention Program on Medicare Spending and Utilization,” Health Affairs, March 2017 36(3):41724.

Practices with Higher Proportions of High-Need Patients Had Lower Spending

In medical practices with a substantial proportion of high-need patients (more than 10% of the practice panel) and in those with a moderate proportion (2% to 10%), high-need patients incurred less spending than those in practices with a minimal proportion of high-need patients (less than 2%). High-need patients in those practices were also less likely to be admitted to the hospital or to visit the ED. Composite quality-of-care scores for practices with a substantial proportion of high-need patients were significantly worse than for practices with a moderate proportion. Small practices with one or two physicians also had worse scores compared with large practices. High-need patients were defined as those with two or more chronic physical, mental, or behavioral health conditions that generate significant health care use. D. A. Cross, G. R. Cohen, C. H. Lemak et al., “Outcomes for High-Needs Patients: Practices with a Higher Proportion of These Patients Have an Edge,” Health Affairs, March 2017 36(3):47684.

Researchers Find Readmission Penalties Are Persistent Over Time

Researchers studying the characteristics of hospitals that received penalties during the first five years of the federal Hospital Readmissions Reduction Program found more than half of participating hospitals were penalized by the Centers for Medicare and Medicaid Services in all five years of the program. They found the penalty burden was greater in hospitals that were urban, major teaching, large, or for-profit and for those that treated larger shares of Medicare or socioeconomically disadvantaged patients. They also found hospitals treating greater proportions of medically complex Medicare patients had a lower cumulative penalty burden compared with those treating fewer proportions of these patients. Because persistent penalization may limit hospitals’ capacity to respond, they say alternate penalty structures may be needed. M. P. Thompson, T. M. Waters, C. M. Kaplan et al., “Most Hospitals Received Annual Penalties for Excess Readmissions, But Some Fared Better Than Others,” Health Affairs, May 2017 36(5):893901.

Weak Relationship Between Physician Practice Pricing and Quality and Efficiency

To examine the relationship between physician practice prices for outpatient services and the practices’ quality and efficiency of care, researchers linked national data from the Consumer Assessment of Healthcare Providers and Systems survey to claims for Medicare beneficiaries. They found compared with low-price practices, high-price practices were much larger and received 36 percent higher prices. Patients of high-price practices reported significantly higher scores on some measures of care coordination and management but did not differ meaningfully in their overall care ratings, other domains of patient experiences (including physician ratings and access to care), receipt of preventive services, acute care use, or total Medicare spending. E. T. Roberts, A. Mehrotra, and J. M. McWilliams, “High-Price and Low-Price Physician Practices Do Not Differ Significantly on Care Quality or Efficiency,” Health Affairs, May 2017 36(5):85564.

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