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Publications of Note: March–June 2018

Alternative Payment Models May Add to Risks for Vulnerable Populations

The author of a commentary in the New England Journal of Medicine cautions that alternative payments models (APMs) may have negative consequences for vulnerable populations because current risk adjustment methods are not sophisticated enough to reliably distinguish between poor-quality care and high medical and social risk. They also fail to fully account for functional status and social support needs. The author outlines several principles policymakers should follow to avoid unnecessary harm to vulnerable populations, including evaluating APM participants on improvement rather than solely on achievement of performance targets to avoid penalizing providers caring for patients with more complex needs. She also recommends APMs reward quality improvements proportionally rather than taking an all-or-nothing approach, and that APMs link payment to measures that examine access to care and reductions in health disparities for vulnerable populations. Karen E. Joynt Maddox, “Financial Incentives and Vulnerable Populations — Will Alternative Payment Models Help or Hurt?New England Journal of Medicine 378, no. 11 (March 15, 2018): 977–79.


Home Food Delivery Programs Reduce Inpatient Admissions, Spending for Medically Vulnerable

A study of medical claims for adults dually eligible for Medicare and Medicaid found those who received home delivery of either medically tailored or non-tailored meals had fewer emergency department visits. Participants in the medically tailored meal program also had fewer inpatient admissions and lower health care spending. Participation in the non-tailored food program in contrast was not associated with reduced inpatient admissions but was associated with lower health care spending. Seth A. Berkowitz et al., “Meal Delivery Programs Reduce the Use of Costly Health Care in Dually Eligible Medicare and Medicaid Beneficiaries,” Health Affairs 37, no. 4 (April 2018): 535–42.


Primary Care Clinic at Recreational Center Lowers Spending, ED Use

A primary care clinic established in a recreational center in a low-income area of Dallas that focused on addressing wellness, prevention, and the social determinants of health reduced emergency department (ED) use by 21.4 percent and inpatient care by 36.7 percent for patients in the year after they first sought care at the clinic. Costs related to both services decreased by 34.5 percent and 54.4 percent, respectively. Residents who joined the Baylor Scott & White Health and Wellness Center completed health risk assessments and were served by multidisciplinary teams that included social workers, nutritionists, and community health workers who assisted with patient education, navigation, and social needs such as transportation and access to healthy food. Members also had access to health and wellness activities including cooking demonstrations, prevention programs for diabetes, and weight management and fitness classes, as well as access to fresh fruit and vegetables. The study sample included patients who had at least one ED or hospitalization in the year before or after receiving care at the center. Donald Wesson et al., Innovative Population Health Model Associated with Reduced Emergency Department Use and Inpatient Hospitalization,” Health Affairs 37, no. 4 (April 2018): 543–50.


Crowdsourcing Platform Leads to Improved Asthma Outcomes and Policy Recommendations

AIR Louisville, a public–private partnership that brought city leaders together with a local nonprofit (the Institute for Healthy Air Water and Soil) and a digital health company focused on improving asthma outcomes (Propeller Health), leveraged information drawn from sensors attached to asthma inhalers to identify hot spots of respiratory disease symptoms and their environmental correlates. They found use of the digital health platform — which captures the data, time, and location of inhaler use and enables users to share records with physicians and access educational material, improved clinical outcomes — reducing inhaler use by 78 percent and increasing by 48 percent the number of symptom-free days users experienced. The data collected from the platform informed the group’s policy recommendations for reducing respiratory risks. These include enhancing tree canopy, promoting tree removal mitigation, zoning for air pollution emission buffers, altering truck routes, and developing a community asthma notification system. Meredith Barrett et al., “AIR Louisville: Addressing Asthma with Technology, Crowdsourcing, Cross-Sector Collaboration, and Policy,” Health Affairs 37, no. 4 (April 2018): 525–34.


Core Components of Community-Based Population Health Strategy Outlined

A journal article that describes five core components of community-based population health strategies illustrated them with Vermont’s multipayer delivery system reform efforts. The five include: an inventory of evidence-based interventions for addressing the social determinants of health; a diverse collection of financial sources to fund the interventions; a selection process that prioritizes interventions according to community needs; the capability to capture and share a portion of savings for reinvestment; and an accountable health community — that is, community infrastructure that can build and maintain a balanced portfolio of interventions to address community needs and adjust as conditions change. James Hester, “A Balanced Portfolio Model for Improving Health: Concept and Vermont’s Experience,” Health Affairs 37, no. 4 (April 2018): 570–78.


U.S. Health Investment Portfolio Requires Rebalancing

In a commentary in Health Affairs, two authors argue a major reason for the poor performance of the nation’s health investments is that too much is spent on health care services and too little on establishing social, economic, and environmental conditions vital to maintaining health and well-being. Their commentary summarizes the evidence for this assertion and outlines opportunities and challenges involved in rebalancing these investments. David A. Kindig and Bobby Milstein, “A Balanced Investment Portfolio for Equitable Health and Well-Being Is an Imperative, and Within Reach,” Health Affairs 37, no. 4 (April 2018): 579–84.


Readmissions Reduction Program Narrowed Health Disparities

A study of the effect of the Hospital Readmissions Reduction Program on racial disparities compared trends in 30-day readmission rates for congestive heart failure, acute myocardial infarction, and pneumonia among non-Hispanic whites and non-Hispanic blacks and among minority-serving hospitals and others. It found during the penalty-free implementation period (Apr. 2010–Sept. 2012), readmission rates improved over pre-implementation trends (Jan. 2007–Mar. 2010) for both whites and blacks, with a significantly greater decline among blacks than among whites. In the period  from October 2012 through December 2014, after penalties began, readmission improvements slowed for both races. Following a similar pattern, minority-serving hospitals saw greater reductions in readmissions than other hospitals did. The authors say it remains to be seen whether new policy efforts will narrow these gaps and reduce the disproportionately high penalties that minority-serving hospitals face. Jose F. Figueroa et al., “Medicare Program Associated with Narrowing Hospital Readmission Disparities Between Black and White Patients,” Health Affairs 37, no. 4 (April 2018): 654–61.


Zip Code Changes, Missed Clinic Visits Predictive of Hospitalization, Emergency Department Use

Researchers using readily available clinical and administrative data successfully identified risk of future “super-utilization” of inpatient and emergency services for both uninsured and insured patients at NYC Health + Hospitals, a large safety-net health system. Proxies such as zip code changes, payer flux, and missed clinic visits represented poorly documented social determinants of health. Such a payer-agnostic approach to risk scoring may increase clinician buy-in, the authors say, because it covers a provider’s full panel of patients and improves targeting of resource-intensive interventions. Jeremy Ziring et al., “An All-Payer Risk Model for Super-Utilization in a Large Safety Net System,” Journal of General Internal Medicine 33, no. 5 (May 2018): 596–98.


Pennsylvania Launches a Global Payment Program for Rural Hospitals

A commentary in the Journal of the American Medical Association describes the Pennsylvania Rural Health Model, a global budget payment method that is intended to improve population health outcomes and lower health care spending in rural communities. The program provides rural hospitals with a global budget based on historic net revenues with the expectation that hospitals will use a portion of the budget to invest in community health, which could include working with community-based organizations like the United Way, Area Agencies on Aging, and drug and alcohol treatment facilities to address local needs. To support the program, which engages six hospitals in the first year and will expand to 30 within three years, the Centers for Medicare and Medicaid Services is providing $25 million, which funds a Rural Health Redesign Center that will provide technical assistance to the hospitals. The program is expected to save Medicare a minimum of $35 million over five years. The hospitals will retain a significant portion of savings in the first three years as an incentive to engage in practice transformation. Karen M. Murphy, Lauren S. Hughes, and Patrick Conway, “A Path to Sustain Rural Hospitals,” Journal of the American Medical Association 319, no. 12 (March 27, 2018): 1193–94.


Readmissions Higher for Homeless Patients Discharged to the Community After Surgery

A study assessing the risk of readmission for homeless veterans following inpatient surgery found they were more likely to be readmitted to the hospital than non-homeless patients. They were also younger, more likely to have psychiatric comorbidities, and less likely to have other medical comorbidities such as hypertension. Discharge destination other than community, recent alcohol abuse, and elevated American Society of Anesthesiologists classification were significant risk factors associated with readmissions within the homeless cohort. The study examined inpatient general, vascular, and orthopedic surgeries occurring in the Veterans Health Administration between 2008 and 2014. Ashley Titan et al., “Homeless Status, Postdischarge Health Care Utilization, and Readmission After Surgery, Medical Care 56, no. 6 (June 2018): 460–69.


Medicare ACOs Underused Primary Care Physicians

An analysis of claims and enrollment data for Medicare beneficiaries enrolled in accountable care organizations (ACOs) through the Medicare Shared Savings Program in 2013 found many ACOs underutilized primary care physicians for chronic disease management. The study found nearly 40 percent of evaluation and management visits for patients with one or more of eight chronic conditions (asthma, chronic kidney disease, chronic obstructive pulmonary disease, depression, diabetes, high cholesterol, high blood pressure, and osteoarthritis) were provided by specialists rather than primary care physicians (PCPs). The rate of PCP use ranged from 34 percent to 81 percent across the 219 ACOs. The share of visits made to PCPs was higher in ACOs that had a higher proportion of PCPs and lower in communities with a higher proportion of white or college-educated patients. Evan S. Cole, Cassandra Leighton, and Yuting Zhang, “Distribution of Visits for Chronic Conditions Between Primary Care and Specialist Providers in Medicare Shared Savings Accountable Care Organizations,” Medical Care 56, no. 5 (May 2018): 424–29.


More Refined Methods Needed to Identify Patients Who Are Appropriate for Care Management

A study that asked care managers working in an intensive care management program to categorize patients who were referred for services into three groups — those who were good candidates for care management, those who were not, and those who needed more than traditional care management could provide — found less than two-thirds (62%) were deemed to be good candidates. Nineteen percent were classified as needing more services. Compared with the other two categories, “good candidates” were older, prescribed more medications, and had more prior year outpatient visits. Based on their findings the authors recommend the systematic collection of information on social supports, patient motivation, and information on recent nonmedical life changes (e.g., a divorce) to better identify patients who could benefit from care management. The study involved nearly 1,200 patients treated in outpatient medical centers within Kaiser Permanente Northern California. Maria E. Garcia et al., “Which Complex Patients Should Be Referred for Intensive Case Management? A Mixed-Methods Analysis,” Journal of General Internal Medicine, published online ahead of print, May 24, 2018.

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