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Publications of Note: July–September 2018

Bundling Payment for Chronic Conditions Did Not Lower Costs or Produce Better Outcomes

Researchers looking at the performance of hospitals participating in Medicare’s Bundled Payments for Care Improvement (BPCI) initiative for five medical conditions (congestive heart failure, pneumonia, chronic obstructive pulmonary disease, sepsis, and acute myocardial infarction) found no significant difference between the hospitals participating in the program and the control hospitals in terms of what Medicare paid for the care provided, patients’ clinical complexity, average length of hospital stay, emergency department use, hospital readmission, or mortality. The results suggest bundling for medical conditions may require more time, new care strategies and partnerships, or additional incentives. Karen E. Joynt Maddox et al., “Evaluation of Medicare’s Bundled Payments Initiative for Medical Conditions,” New England Journal of Medicine 379, no. 3 (July 19, 2018): 260–69.

 

ACOs That Serve a Disproportionate Share of Vulnerable Patients Achieved Greater Savings

A study of 333 accountable care organizations (ACOs) in the Medicare Shared Savings Program found ACOs with a higher proportion of dual eligible or disabled members had slightly lower quality or similar or higher baseline spending than other ACOs, but achieved greater savings ($212 vs. $51 for high-dual ACOs and $241 vs. $44 for high-disabled). These ACOs were equally or more likely to earn shared savings; just over 30 percent of high-dual ACOs earned shared savings compared with 25 percent of non–high-dual ACOs and 38 percent of high-disabled ACOs. Aditi P. Sen et al., “Performance in the Medicare Shared Savings Program by Accountable Care Organizations Disproportionately Serving Dual and Disabled Populations,” Medical Care 56, no. 9 (Sept. 2018): 805–11.

 

Adjusting for Socioeconomic Status Produced Improvements in Medicare Advantage Plan Quality Rankings

A study found that adjusting for Medicare Advantage members’ socioeconomic and demographic factors would have improved the relative rankings on measures of blood pressure, diabetes, and cholesterol control among plans serving disadvantaged populations. The researchers adjusted for sex, race/ethnicity, dual eligibility, rurality, and neighborhood disadvantage. After adjustment, 20.3 percent, 19.5 percent, and 11.4 percent of plans improved by one or more quintiles in rank on the diabetes, cholesterol, and blood pressure measures, respectively. Shayla N. M. Durfey et al., “Impact of Risk Adjustment for Socioeconomic Status on Medicare Advantage Plan Quality Rankings,” Health Affairs 37, no. 7 (July 2018): 1065–72.

 

Medicaid Expansion Increased Coverage for Substance Abuse Treatment But Didn’t Increase Treatment Rates

Researchers assessed changes in coverage and substance use disorder treatment among low-income adults with the disorder following the expansion of the Medicaid program in 2014. Using data for 2008–15 from the National Survey on Drug Use and Health, they found in expansion states the percentage of low-income residents with substance use disorders who were uninsured decreased from 34.4 percent in 2012–13 to 20.4 percent in 2014–15, while the corresponding decrease among residents of nonexpansion states was from 45.2 percent to 38.6 percent. They also found there was no corresponding increase in receipt of substance use disorder treatment in either expansion or nonexpansion states. They say increasing treatment rates may require the integration of substance use disorder treatment with other medical services and clinical interventions to motivate people to engage in treatment. Mark Olfson et al., “Impact of Medicaid Expansion on Coverage and Treatment of Low-Income Adults with Substance Use Disorders,” Health Affairs 37, no. 8 (Aug. 2018): 1208–15.

 

Collaboration Among Health Care and Social Service Providers May Be a Factor in Lower Health Care Use for Older Americans

A study of U.S. communities in which older residents have lower rates of health care use and lower costs found those communities tend to adopt holistic, collaborative approaches to solving the medical and social problems facing this population. The study, which examined 16 hospital service areas, also found in low-performing communities — those with high rates of care utilization and costs — health care providers struggle to coordinate with social service organizations. Amanda L. Brewster et al., “Patterns of Collaboration Among Health Care and Social Services Providers in Communities with Lower Health Care Utilization and Costs,” Health Services Research 53, no. S1 (Aug. 2018): 2892–909.

 

Variation in Spending at the End of Life Linked to Availability of Physicians, Physician Attitudes Toward Hospice

Using data from the Cancer Care Outcomes Research and Surveillance Consortium study, researchers assessed the extent to which geographic variation in health care spending in the months before death can be explained by patients’ sociodemographic factors, clinical factors, and beliefs; physicians’ beliefs; and the availability of services. They found physicians in higher-spending areas reported less knowledge about and comfort with treating dying patients and less positive attitudes about hospice, compared with those in lower-spending areas. Higher-spending areas also had more physicians and fewer primary care providers (PCPs) and hospices in proportion to their total population than did lower-spending areas. Availability of services and physicians’ beliefs, but not patients’ beliefs, were important in explaining geographic variations in end-of-life spending. They note enhanced training to better equip physicians to care for patients at the end of life and strategic resource allocation may have potential for decreasing unwarranted variation in care. Nancy L. Keating et al., “Factors Contributing to Geographic Variation in End-of-Life Expenditures for Cancer Patients,” Health Affairs 37, no. 7 (July 2018): 1136–43.

 

Evidence Suggests PCMHs for Low-Income Populations Produce Better Outcomes, Lower Utilization of EDs

A study examining what elements of patient-centered medical homes (PCMHs) are typically provided to low-income populations and whether PCMHs improve health behaviors, experiences, and outcomes for low-income groups found PCMH interventions were usually composed of five of the six recommended components. PCMH patients also had better clinical outcomes, higher adherence to recommended treatment, and lower use of emergency departments. The study relied on existing literature on PCMH utilizations among health care organizations serving low-income populations; the authors note there were some limitations in the quality of the studies, including in some instances no assessment for confounding variables. Carissa van den Berk-Clark et al., “Do Patient-Centered Medical Homes Improve Health Behaviors, Outcomes, and Experiences of Low-Income Patients? A Systematic Review and Meta Analysis,Health Services Research 53, no. 3 (June 2018): 1777–98.

 

Vulnerable Patients Less Likely to Disagree with or Change Doctors

Researchers found Medicare beneficiaries who were older, less educated, and had lower incomes were least inclined to express disagreement with or change doctors. Compared with non-Hispanic whites, Asian/Pacific Islander and Hispanic beneficiaries said they would be less likely, and black beneficiaries more likely, to express disagreement. Asian/Pacific Islander, Hispanic, and American Indian/Alaska Native beneficiaries were less inclined than non-Hispanic whites to change doctors. They concluded that reductions in health care disparities might be achieved if doctors and advocates encouraged vulnerable patients to express their concerns and perspectives and if communities and caregivers provide support for changing providers when care is poor. Steven C. Martino et al., “Speaking Up and Walking Out: Are Vulnerable Patients Less Likely to Disagree with or Change Doctors?Medical Care 56, no. 9 (Sept. 2018): 749–54.

 

Intensive Management Program for High-Risk Patients Shifted Spending from Inpatient to Outpatient Care Without Dramatic Cost Changes

A study assessing whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk patients found the intervention increased outpatient costs ($2,636), driven by greater use of primary care, home care, telephone care, and telehealth services. This expense was mostly offset by a reduction in mean inpatient costs (−$2,164). The study, conducted at five V.A. medical centers, involved primary care patients at high risk for hospitalization who had a recent acute-care episode. They received locally tailored intensive management programs providing care coordination, goals assessment, health coaching, medication reconciliation, and home visits through an interdisciplinary team, including a physician or nurse practitioner, a nurse, and psychosocial experts. Jean Yoon et al., “Impact of Primary Care Intensive Management on High-Risk Veterans’ Costs and Utilization: A Randomized Quality Improvement Trial,” Annals of Internal Medicine 168, no. 12 (June 19, 2018): 846–54.

 

ACO Patients with Comorbid Physical and Mental Health Diagnoses Report Better Physical Functioning When Practices Have Patient-Centered Cultures

A study assessing the extent to which practices with patient-centered cultures, greater shared decision-making strategies, and better coordination among team members have better patient-reported outcomes for patients with diabetes and/or cardiovascular and comorbid mental health diagnoses found patients receiving care from these practices reported better physical functioning and slightly better emotional functioning compared with less patient-centered practices. More activated patients reported better outcomes. Susan Ivey et al., “Patient Engagement in ACO Practices and Patient-Reported Outcomes Among Adults with Co-Occurring Chronic Disease and Mental Health Conditions,” Medical Care 56, no. 7 (July 2018): 551–56.

 

Homeless Veterans Benefit from Primary Care Teams That Specialize in Serving Them

A study assessing the differences in primary care experiences between homeless and nonhomeless veterans receiving care at Veterans Health Administration facilities with homeless-tailored primary care teams and those without, found facilities with these programs appear to offer a better primary care experience for homeless versus nonhomeless veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness. Audrey L. Jones et al., “Differences in Experiences with Care Between Homeless and Nonhomeless Patients in Veterans Affairs Facilities with Tailored and Nontailored Primary Care Teams,” Medical Care 56, no. 7 (July 2018): 610–18.

 

The Potential and Risk Associated with the CHRONIC Care Act

The authors of this commentary describe the promise and pitfalls of the recently enacted CHRONIC Care Act, which gives Medicare Advantage plans opportunities to increase the flexibility of their benefit offerings in 2020. The act allows plans to offer nonmedical supplementary benefits to address the needs of patients with chronic conditions and eliminates the requirement that plans provide uniform benefits to all members. The change may enable plans to offer a wider range of benefits, including long-term services and supports (LTSS) such as assistive devices, meal and transportation services, and personal care services. Whether Medicare beneficiaries will see the true benefits of this change remains to be seen. That may be dependent on ensuring plans are not adversely affected by risk selection that may occur if the sickest beneficiaries who require the costliest care switch from traditional Medicare to Medicare Advantage plans, without adjustment in payment to account for nonmedical needs. The authors offer an alternative approach: the development of integrated care organizations that would operate like ACOs but have broader responsibility for meeting LTSS needs. Amber Willink and Eva H. DuGoff, “Integrating Medical and Nonmedical Services — The Promise and Pitfalls of the CHRONIC Care Act,” New England Journal of Medicine 378, no. 23 (June 7, 2018): 2153–55.

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Publication Date: September 27, 2018