CMMI’s Early Innovation Models Demonstrated Benefits and Challenges of Rapid Testing
The authors of an article summarizing five innovative payment and delivery system models tested in the initial years of the Center for Medicare and Medicaid Innovation (CMMI) say while CMMI created an organizing framework for iterative testing and learning, the expedited timetable for demonstrating cost savings and system transformation may have been too ambitious. They recommend instituting more realistic time frames to demonstrate impact on cost and quality and say greater integration and coordination of existing models is needed. R. J. Perla, H. Pham, R. Gilfillan et al., “Government as Innovation Catalyst: Lessons from the Early Center for Medicare and Medicaid Innovation Models,” Health Affairs, Feb. 2018 37(2):213–21.
Tracing the Stages of Innovation Diffusion Through Health Leads
A case study of Health Leads, a nonprofit that partners with health care institutions and communities to address patients’ basic resource needs, traced five stages of its development to draw lessons about the diffusion of innovation. The authors found having a clear aim and constancy of purpose made the strategic and operational adjustments required for diffusion easier to see and act upon. Investing in model testing and standardization also enabled Health Leads to be responsive to the market. Ceding control of the model as early as possible after testing and standardization also accelerated broad adoption. R. D. Onie, R. Lavizzo-Mourey, T. H. Lee et al., “Integrating Social Needs into Health Care: A Twenty-Year Case Study of Adaptation and Diffusion,” Health Affairs, Feb. 2018 37(2):240–47.
Two Approaches to Supporting Patients Proved Effective in Behavioral Health Homes
As part of a multiyear effort to transform community mental health centers into behavioral health homes for patients with serious mental illnesses, Community Care Behavioral Health Organization, a managed care plan, and the Behavioral Health Alliance of Rural Pennsylvania offered mental health centers supports designed to enhance their capacity to promote healthy lifestyles, disease prevention, and health education. The initiative tested two approaches: one that relied on nurses to educate staff about common medical conditions and develop tailored wellness plans, as well as support patients, and another that provided patients with access to wellness coaches and online educational content tailored to their needs and goals. The study found both approaches led to a nearly two-point increase in patient activation scores and a 36-percent increase in primary care or specialty care use for patients. J. Schuster, C. Nikolajski, J. Kogan et al., “A Payer-Guided Approach to Widespread Diffusion of Behavioral Health Homes in Real-World Settings,” Health Affairs, Feb. 2018 37(2):248–56.
Primary Care Collaborative Targets Ambulatory Care–Sensitive Conditions, Reduces Hospitalizations
The Better Health Partnership, a primary care–led regional health improvement collaborative operating in Cuyahoga County, Ohio, that focused on disseminating best practices for care of patients with diabetes, heart failure, and hypertension, averted almost 6,000 hospitalizations over a six-year period, producing an estimated $40 million in savings. Estimated savings were greatest for congestive heart failure, followed by diabetes-related conditions, pneumonia, and hypertension. The partnership engaged primary care providers who provide care for roughly three-quarters of adults with chronic medical conditions in the county and used a positive deviance approach to identify, disseminate publicly, and accelerate adoption of best practices. J. Tanenbaum, R. D. Cebul, M. Votruba et al., “Association of a Regional Health Improvement Collaborative with Ambulatory Care–Sensitive Hospitalizations,” Health Affairs, Feb. 2018 37(2):266–74.
Counties Where AAAs Partner with a Broad Array of Organizations Had Lower Readmissions
Researchers studying cross-sector partnerships between Area Agencies on Aging (AAAs) and other social service and health care organizations found that counties where AAAs maintained informal partnerships with a broad range of organizations had significantly lower hospital readmission rates compared with counties whose AAAs had informal partnerships with fewer types of organizations. Counties where AAAs had programs to divert older adults from nursing home placement also had significantly lower avoidable nursing home use. A. L. Brewster, S. Kunkel, J. Straker et al., “Cross-Sectoral Partnerships by Area Agencies on Aging: Associations with Health Care Use and Spending,” Health Affairs, Jan. 2018 37(1):15–21.
Mental Health and Substance Use Disorders Common in Medicaid Expansion Population
A study of public spending on childless adults in the Medicaid expansion population in Hennepin County, Minnesota, found those who had high health care utilization relative to other new enrollees were disproportionately American Indian, younger, and significantly more likely than other expansion enrollees to have mental health (88.1 percent versus 48.0 percent) or substance use diagnoses (79.2 percent versus 29.6 percent). Total cross-sector public spending was nearly four times higher for high health care users ($25,337 versus $6,786) and non–health care expenses were 2.4 times higher ($7,476 versus $3,108). The authors say collaboration across sectors may result in cost savings. K. D. Vickery, P. Bodurtha, T. N. A. Winkelman et al., “Cross-Sector Service Use Among High Health Care Utilizers in Minnesota After Medicaid Expansion,” Health Affairs, Jan. 2018 37(1):62–69.
Older Americans Fare Worse Where Education, Income Levels Are Low
Researchers identified 820 U.S. counties where Medicare beneficiaries had persistently elevated mortality rates relative to the rest of the country. Over the 16-year study period, risk-standardized mortality rates decreased from 5.52 percent to 4.61 percent in these areas, compared with 5.16 percent to 4.11 percent in other areas. The areas with higher mortality rates tended to include more residents who were non-Hispanic and had lower education levels and income. They also had more people participating in the nation’s Supplemental Nutrition Assistance Program and to have higher unemployment rates. In addition, they also had more income inequality, a higher proportion of dually eligible residents, and residents who had poor or fair health daily despite a higher proportion of health-related spending. They also had higher rates of physical inactivity, diabetes, and obesity. The authors say these counties are ideal venues for testing communitywide interventions targeted at improving the health of older adults. H. M. Krumholz, S.-L. T. Normand, and Y. Wang, “Geographical Health Priority Areas for Older Americans,” Health Affairs, Jan. 2018 37(1):104–10.
MSSP Savings Not Tied to Preventable Hospitalizations or Concentrated Among High-Risk Patients
A study of spending and hospitalization rates of Medicare beneficiaries attributed to accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) suggests spending reductions were not concentrated among high-risk patients. Reductions for high-risk patients accounted for only 38 percent of total reductions for ACOs entering the program in 2012; among 2013 entrants savings were concentrated among lower-risk patients. In addition, participation in the MSSP was associated with some increases in hospitalizations for ambulatory care–sensitive conditions. The findings suggest that care coordination and care management efforts focused on ambulatory care–sensitive conditions and high-risk patients may not have been major drivers of early savings. Because strategies to improve quality may be distinct from those that lower spending, and efforts to improve management of chronic conditions for ACO patients have not been associated with reductions in hospitalizations, it may be necessary to decouple rewards for quality improvement from the achievement of savings, the authors say. J. M. McWilliams, M. E. Chernew, and B. E. Landon, “Medicare ACO Program Savings Not Tied to Preventable Hospitalizations or Concentrated Among High-Risk Patients,” Health Affairs, Dec. 2017 36(12):2085–93.
Uninsured and Privately Insured Use E.D.s at Same Rate
A study comparing emergency department use by uninsured and privately insured people ages 19 to 64 found a high rate of visits for both groups for conditions that are likely nonemergent (roughly 20% of visits) and might be amenable to treatment in other settings (roughly one-third of visits). Contrary to conventional wisdom, the researchers also found that the uninsured use the E.D. much less than those with Medicaid coverage. They also found the uninsured use other types of care (e.g., outpatient or hospital care) much less than the insured, consistent with prior research showing insurance increases access to and use of health care. R. A. Zhou, K. Baicker, S. Taubman et al., “The Uninsured Do Not Use the Emergency Department More — They Use Other Care Less,” Health Affairs, Dec. 2017 36(12):2115–22.
Low-Income Patients with Co-occurring Chronic and Behavioral Health Conditions Have Higher Average Annual Spending Than High-Income Patients
A study examining the prevalence, severity, and health care costs of co-occurring chronic and behavioral health conditions found comorbid behavioral health conditions are more common among low-income patients with chronic conditions compared with higher-income patients. They also found among patients with co-occurring chronic and behavioral problems, average annual spending was greater among low-income patients ($9,472) compared with high-income patients ($7,457). They conclude higher costs among low-income patients with co-occurring conditions reflect poorer mental and physical health relative to higher-income patients. P. J. Cunningham, T. L. Green, and R. T. Braun, “Income Disparities in the Prevalence, Severity, and Costs of Co-Occurring Chronic and Behavioral Health Conditions,” Medical Care, Feb. 2018 56(2):139–45.
PCMH Initiative in Safety-Net Clinics Produces Modest Improvements in Patient Experience of Chronic Illness Care
A study that examined whether patient-centered medical home (PCMH) transformation improved patients’ experiences with chronic illness care found improvement in medical home capability was only marginally associated with improvement, while higher absolute PCMH capability was significantly associated with better patient experiences. In the latter group, they found higher scores on the Patient Assessment of Chronic Illness Care in four of five areas (patient activation, delivery system design, contextual care, and follow-up/coordination). The study relied on data from the Safety Net Medical Home Initiative, a five-year effort to transform safety-net clinics into medical homes. E. L. Tung, Y. Gao, M. E. Peek et al., “Patient Experience of Chronic Illness Care and Medical Home Transformation in Safety Net Clinics,” Health Services Research, Feb. 2018 53(1):469–88, published online May 30, 2017.