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Newsletter Article


Publications of Note

Even with Greater Use of Hospice, Care Intensity Increases at End of Life

Researchers reviewing studies on the causes of death and on care patterns among Americans in the last stages of life found dramatic shifts in both the percentage of patients with multiple chronic conditions and the percentage dying of Alzheimer’s disease. The increasing complexity of managing these conditions and symptom burdens may explain one main finding: that both hospice use and intensive medical treatment at the end of life are increasing. The authors say the changing epidemiology of death may compel policymakers to consider whether and how the hospice benefit should be modified to account for patients who need or want concurrent care or who suffer from diseases whose progression is more difficult to predict. M. D. Aldridge and E. H. Bradley, “Epidemiology and Patterns of Care at the End of Life: Rising Complexity, Shifts in Care Patterns and Sites of Death,” Health Affairs, July 2017 36(7):1175–83. 

Less Activated Patients More Likely to Develop Chronic Disease and Be Hospitalized

The developers of the Patient Activation Measure—a tool for assessing the extent to which patients feel competent to navigate the health care system and manage their own health—found it to be a significant predicator of hospital utilization and future diagnoses of chronic disease. The study of nearly 100,000 adults found that less activated patients had significantly higher odds of hospitalization for ambulatory care–sensitive conditions as compared with patients who were more activated, and were more likely to have a new chronic-disease diagnosis over each of the three years observed. J. H. Hibbard, J. Greene, R. M. Sacks, et al., “Improving Population Health Management Strategies: Identifying Patients Who Are More Likely to Be Users of Avoidable Costly Care,” Health Services Research, Aug. 2017 52(4):1297–1309. 

Goals of Care Discussions Improve with Clinician Training

A study of the Serious Illness Care Program—an intervention designed to improve communication between patients with serious illness and their providers about goals, values, and a plan of care—found that patients in the clinics that implemented the program were more likely than those in comparison clinics to have comprehensive discussions and to have the results documented in the medical record. Clinicians who participated also reported high satisfaction with the training they received. The intervention was tested at primary care clinics affiliated with Brigham and Women’s Hospital, in Boston, Mass., that were participating in a high-risk care management program. J. R. Lakin, L. A. Koritsanszky, R. Cunningham, et al., “A Systematic Intervention to Improve Serious Illness Communication in Primary Care,” Health Affairs, July 2017 36(7):1258–64.

A Comprehensive Approach Needed to Spur Investment in and Focus on Palliative Care

The authors of this Health Affairs article call for the development of a national strategy to ensure that patients with serious illnesses, including those living at home, in assisted living facilities, and in nursing homes, have access to high-quality palliative care. Following models like the National HIV/AIDS Strategy or the National Alzheimer’s Project Act, the strategy, they say, should focus on the defined structures and processes for palliative care programs, reimbursement schedules, quality and access standards, health care education, and investment in research. D. E. Meier, A. L. Back, A. Berman, et al., “A National Strategy for Palliative Care,” Health Affairs, July 2017 36(7):1265–73. 

High-Cost Duals Fall into Two Distinct Groups

A study of adults who are dually eligible for Medicare and Medicaid found high combined spending for two distinct groups: older beneficiaries who are nearing the end of life and younger beneficiaries with a sustained need for functional supports. The study found that among high-cost dual-eligibles living in the community, those who are older spend less on home- and community-based services than those who are younger. Such services could provide older beneficiaries with more stable support in the last year or two of life, when illness and functional decline accelerate. J. P. W. Bynum, A. Austin, D. Carmichael, et al., “High-Cost Dual Eligibles’ Service Use Demonstrates the Need for Supportive and Palliative Models of Care,” Health Affairs, July 2017 36(7):1309–17. 

Employment Correlated with Mental Health Outcomes

Combining mental health care and social services may produce improvements in mental health outcomes, researchers concluded after simulating the effects on health outcomes of improved education, employment, and income. Their simulations showed that increased employment was significantly correlated with improvements in mental health outcomes, while increased education and income produced weak or non-significant correlations. They recommend that state and federal agencies as well as insurers provide evidence-based employment services as a standard treatment for people with mental disorders. M. Alegria, R. E. Drake, H. Kang, et al., “Simulations Test Impact of Education, Employment, and Income Improvements on Minority Patients with Mental Illness,” Health Affairs, June 2017 36(6):1024–31. 

Test of Medical Home Model in FQHCs Produces Mixed Results

A study of federally qualified health centers (FQHCs) participating in the Advanced Primary Care Practice Demonstration—a three-year Centers for Medicare and Medicaid Services initiative that provided FQHCs with care management fees and technical assistance to support implementation of the medical home model—found that demonstration sites achieved higher rates of medical home recognition than did comparison sites. The impact on health care utilization and quality was mixed. The researchers found that demonstration sites had higher rates of annual eye examinations and nephropathy tests and smaller decreases in patient visits than did comparison sites, but they also had larger increases in emergency department visits, inpatient admissions, and Medicare Part B expenditures. Participation in the initiative was not associated with relative improvement in most measures of patients’ experiences. They say the care management fees ($6 per beneficiary per month) and the duration of the evaluation may have been a factor, as most demonstration sites required the entire three-year period to achieve recognition and the majority did so in the final quarter of the demonstration. J. W. Timbie, C. M. Setodji, A. Kress, et al., “Implementation of Medical Homes in Federally Qualified Health Centers,” New England Journal of Medicine, July 2017 377(3):246–56. 

Outpatient Visits and Spending Higher in Medical Home Demonstration Sites at FQHCs

The same researchers found that beneficiaries seen in FQHCs participating in the Advanced Primary Care Demonstration had higher numbers of outpatient visits and higher Medicare expenditures as compared with beneficiaries seeking care at less advanced sites. There were no differences in inpatient costs. They noted that expanded access to care, together with slower development of key medical home capabilities, may explain higher Medicare expenditures and other types of utilization. J. W. Timbie, P. S. Hussey, C. M. Setodji, et al., “Association Between Patient-Centered Medical Home Capabilities and Outcomes for Medicare Beneficiaries Seeking Care from Federally Qualified Health Centers,” Journal of General Internal Medicine, Sept. 2017 32(9):997–1004. 

ACA Reduces Disparities Among Mexican-Heritage Latinos with Hypertension

The Affordable Care Act helped reduce some of the disparities in health care access and utilization and in medication use between non-Latino whites and Mexican-heritage Latinos with hypertension in California. Researchers found that the odds of having a usual source of care increased after the full implementation of the law in 2014 for these two groups, and that the gain was more substantial for Mexican-heritage Latinos. The researchers also found that the odds of having any physician visit and taking blood pressure medications decreased among non-Latino whites but increased among Mexican-heritage Latinos. R. M. McKenna, H. E. Alcalá, F. Lê-Scherban, et al., “The Affordable Care Act Reduces Hypertension Treatment Disparities for Mexican-Heritage Latinos,” Medical Care, July 2017 55(7):654–60. 

Better Linkages Between Corrections and Community Health Systems Could Improve Health Equity and Promote More Appropriate Health Care Use

A study of the Transitions Clinic Network, which uses multidisciplinary teams and enhanced primary care to coordinate care for high-risk, chronically ill people as they leave prison, found that referral from correctional systems to the network was associated with fewer emergency department (ED) visits and inpatient stays in the 12 months after release as compared with patients who were referred by community partners. However, early engagement with the program (i.e., within the first month of release) was associated with more acute-care visits. The study also found that patients with food insecurity at the outset had a higher incidence of ED visits and hospitalizations as compared with those without food insecurity. Neither referral from correctional partners nor early engagement in primary care was significantly associated with recidivism. S. Shavit, J. A. Aminawung, N. Birnbaum, et al., “Transitions Clinic Network: Challenges and Lessons in Primary Care for People Released from Prison,” Health Affairs, June 2017 36(6):1006–15. 

Care Transitions Program Produces Differential Results for Those Above and Those Below Age 60

A study of a patient navigator program that relied on community health workers to support high-risk patients during hospital-to-home transitions found that among patients 60 and above, hospital-based utilization was reduced (by 18.7% at 180 days), while outpatient visits increased in the critical first 30 days after discharge. Among younger patients, hospital-based utilization was higher (by 31.7% at 180 days), while outpatient visits experienced no significant changes. The patient navigators provided coaching and assistance with medications, appointments, transportation, communication with primary care providers, and self-care. The study suggests future research is warranted to evaluate care transition programs among different subpopulations and over longer time periods. R. B. Balaban, F. Zhang, C. E. Vialle-Valentin, et al., “Impact of a Patient Navigator Program on Hospital-Based and Outpatient Utilization Over 180 Days in a Safety-Net Health System,” Journal of General Internal Medicine, Sept. 2017 32(9):981–9. 

Value-Based Payment Modifier Program May Disproportionately Penalize Practices Caring for Complex Patients

Researchers found that during the first year of the Medicare Physician Value-Based Payment Modifier Program, physician practices with more socially high-risk patients had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs. These patterns were associated with fewer bonuses and more penalties for practices serving high-risk patients. Practices that served lower-risk populations were more likely to successfully register and report data to the program (thus not triggering an automatic reporting penalty). The researchers note that failure to participate may reflect a lack of infrastructure or technology for reporting. L. M. Chen, A. M. Epstein, E. J. Orav, et al., “Association of Practice-Level Social and Medical Risk with Performance in the Medicare Physician Value-Based Payment Modifier Program,” Journal of the American Medical Association, Aug. 2017 318(5):453–61. 

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