Affordable, quality health care. For everyone.

Publications of Note: January–March 2019

Patient Engagement Linked to Lower Health Care Spending on High-Risk Patients

A study focusing on the degree to which changes in the Patient Activation Measure (PAM) — a tool for measuring a patient’s confidence in managing his or her health — influence health care spending found the tool is predictive of health care costs among high-risk patients. The study found an increase in one PAM level was associated with 8.3 percent lower follow-up costs. The study relied on data from a Center for Medicare and Medicaid Innovation–funded intervention used by three medical groups to improve patient activation and care coordination among high-risk patients. The measure assigns patients to one of four levels on a continuum that ranges from very passive to very proactive. Ann Lindsay et al., “Patient Activation Changes as a Potential Signal for Changes in Health Care Costs: Cohort Study of US High-Cost Patients,” Journal of General Internal Medicine 33, no. 12 (Dec. 2018): 2106–12.


Promoting Better Coordination Through New CMS Billing Codes

A commentary in the Journal of the American Medical Association proposes strategies for ensuring new fee-for-service billing codes introduced by the Centers for Medicare and Medicaid Services to reimburse for virtual care (e.g., e-consults, remote physiologic monitoring, and video and image review) promote coordinated care. Among the strategies, Medicare should develop and refine separate payments for services that promote coordination to create a roadmap for other payers, which account for the majority of payments to most clinicians. Medicare could also consider removing copays that could be an impediment for some patients. Joshua M. Liao, Amol S. Navathe, and Matthew J. Press, “Medicare’s Approach to Paying for Services That Promote Coordinated Care,” Journal of the American Medical Association 321, no. 2 (Jan. 15, 2019):147–48.


High Utilizers of Health Care Services Also High Users of Public Services in Minnesota

A study of service use patterns among newly insured Medicaid members in Hennepin County, Minn., quantified their engagement in four public sectors (health care, human services, housing, and criminal justice) and, using clustering techniques, produced six utilization archetypes. They are: a low-contact class (33.9%) that had little involvement in any public sector; a primary care class (26.3%) that had moderate, stable health care utilization; a health and human services class (15.3%) that had high rates of health care and cash assistance utilization; a minimal criminal history class (11.0%) that had less serious criminal justice involvement; a cross-sector class (7.8%) that had elevated emergency department use, involvement in all four sectors, and the highest prevalence of behavioral health conditions; and an extensive criminal history class (5.7%) that had serious criminal justice involvement. The three most expensive classes (health and human services, cross-sector, and extensive criminal history) had the highest rates of behavioral health conditions. Together, they comprised 29 percent of enrollees and 70 percent of total public costs. The authors conclude that Medicaid expansion enrollees with behavioral health conditions deserve special attention because of the potential to reduce spending across public sectors by coordinating their services and better addressing their needs. Peter J. Bodurtha et al., “Identification of Cross-Sector Service Utilization Patterns Among Urban Medicaid Expansion Enrollees,” Medical Care 57, no. 2 (Feb. 2019): 123–30.


Challenges to Implementing the Behavioral Health Home Model Include Engaging PCPs

Staff who established behavioral health homes within community mental health programs in Maryland reported facing a number of barriers, including difficulty engaging primary care providers in care coordination. Other challenges included difficulty juggling the goals of population health management and direct clinical care. The authors conclude that to improve health outcomes for individuals with serious mental illnesses, multiple strategies are needed, including formalized treatment protocols, training for staff, changes to financing mechanisms, and health information technology improvements. Gail L. Daumit et al., “Care Coordination and Population Health Management Strategies and Challenges in a Behavioral Health Home Model,” Medical Care 57, no. 1 (Jan. 2019): 79–84.


Mandatory Bundled Payment Program for Joint Replacement Reduces Spending Modestly

An evaluation of Medicare’s bundled payment program for hip and knee replacements found in the first two years the program produced a modest reduction in spending per episode without an increase in rates of complications. Hospitals involved in the Comprehensive Care for Joint Replacement program receive bonuses or pay penalties based on spending during the hospitalization and in the 90 days after discharge. The reduction was driven largely by a 5.9 percent relative decrease in the percentage of episodes in which patients were discharged to post–acute care facilities. The program did not have a significant effect on the composite rate of complications or on the percentage of joint-replacement procedures performed among high-risk patients. Michael L. Barnett et al., “Two-Year Evaluation of Mandatory Bundled Payments for Joint Replacement,” New England Journal of Medicine 380, no. 3 (Jan. 2019): 252–62.


Medical Homes Improve Quality of Care for People with Multiple Chronic Conditions

A study examining the association between medical home enrollment and receipt of recommended care for Medicaid beneficiaries with multiple chronic conditions found enrollment in patient-centered medical homes (PCMHs) was associated with an increased likelihood of receiving eight recommended mental and physical health services, including hemoglobin A1c testing for persons with diabetes, lipid profiles for persons with diabetes and/or hyperlipidemia, and psychotherapy for persons with major depression or schizophrenia. PCMH enrollment was also associated with overuse of short-acting medications among beneficiaries with asthma. Karen E. Swietek et al., “Do Medical Homes Improve Quality of Care for Persons with Multiple Chronic Conditions?Health Services Research 53, no. 6 (Dec. 2018): 4667–81.


Subgroups of High-Cost Adult Patients Identified

A study that sought to define recognizable subgroups of high-cost patients based on clinical conditions and describe their survival and future spending identified seven clinically distinct subgroups of patients. These included patients with end-stage renal disease (12% of the high-cost population), cardiopulmonary conditions (17%), diabetes with multiple comorbidities (8%), acute illness superimposed on chronic conditions (11%), conditions requiring highly specialized care (14%), neurologic and catastrophic conditions (5%), and patients with few comorbidities (the largest class, 33%). Over four years of follow-up, 31 percent of the patients died, and survival in the classes ranged from 43 percent to 88 percent. Spending regressed to the mean in all classes except the end-stage renal disease and diabetes with multiple comorbidities groups. The study was based on data on 2.7 million adult patients in a large integrated delivery system. Anna C. Davis et al., “Segmentation of High-Cost Adults in an Integrated Healthcare System Based on Empirical Clustering of Acute and Chronic Conditions,” Journal of General Internal Medicine 33, no. 12 (Dec. 2018): 2171–79.


Mental Illness and Substance Use Remain Primary Drivers of Acute Hospitalization of the Homeless

A study of patterns of acute illness among homeless individuals in three states (Massachusetts, Florida, and California) found from 2007 to 2013, hospitalizations increased (from 294 to 420 hospitalizations per 1,000 homeless residents in Massachusetts, from 161 to 240 per 1,000 in Florida, and from 133 to 164 per 1,000 in California). Homeless patients were on average 46 years of age, often male (76.1%), white (62%), and either uninsured (41.9%) or insured by Medicaid (31.7%). Compared with hospitalizations among people who were not homeless, hospitalizations for the homeless were more frequently for mental illness and substance use disorder (52% vs. 18%). Homeless patients also had lower in-hospital mortality rates (0.9% vs. 1.2% for non-homeless patients), longer mean length of stay (6.5 vs. 5.9 days), and lower mean costs per day ($1,535 vs. $1,834). The authors suggest policy efforts address barriers to the use of ambulatory care services, and behavioral health services in particular, to help reduce acute care use and improve the long-term health of homeless individuals. Rishi J. Wadhera et al., “Trends, Causes, and Outcomes of Hospitalizations for Homeless Individuals,” Medical Care 57, no. 1 (Jan. 2019): 21–27.


Proposal for Protecting CMS Payments for Primary Care

The author of a commentary in the New England Journal of Medicine suggests ways of ensuring the Centers for Medicare and Medicaid Services’ methods for valuing evaluation and management services do not unfairly penalize primary care providers and favor specialists. The problem the author seeks to address stems in part from the Congressional requirement that increases in payment for work associated with new technologies and procedures be offset with reductions in payment elsewhere to achieve budget neutrality. One solution would be to balance spending on primary care and specialty care services separately. B. E. Landon, “A Step Toward Protecting Payments for Primary Care,” New England Journal of Medicine 380, no. 6 (Feb. 7, 2019): 507–10.


Persistently High-Cost Medicare Patients Younger, More Likely to be Minorities and/or Dual Eligibles

A study that sought to identify the characteristics and spending patterns of Medicare beneficiaries who remained persistently high-cost over time (i.e., in the top 10 percent of spending each year) found on average that persistently high-cost patients were younger, more likely to be members of racial/ethnic minority groups, eligible for Medicare based on having end-stage renal disease, and dually eligible for Medicaid, compared with transiently and never high-cost patients. The study also found 28.1 percent of high-cost fee-for-service beneficiaries remained so over three years. Persistently high-cost patients had greater relative spending on outpatient care and medications while very little of the spending was related to preventable hospitalizations. Jose F. Figueroa, Xiner Zhou, and Ashish K. Jha, “Characteristics and Spending Patterns of Persistently of High-Cost Medicare Patients,” Health Affairs 38, no. 1 (Jan. 2019): 107–14.


Economic Deprivation Linked to Poor Control of Chronic Conditions

A study assessing the relationship between a composite measure of neighborhood disadvantage — the Area Deprivation Index (ADI) — and control of blood pressure, diabetes, and cholesterol in the Medicare Advantage population found the ADI to be a strong, independent predictor of diabetes and cholesterol control and a moderate predictor of blood pressure control. Compared with enrollees residing in the least disadvantaged neighborhoods, enrollees in the most disadvantaged neighborhoods were 5 percentage points less likely to have controlled blood pressure, 6.9 percentage points less likely to have controlled diabetes, and 9.9 percentage points less likely to have controlled cholesterol. Shayla N. M. Durfey et al., “Neighborhood Disadvantage and Chronic Disease Management,” Health Services Research 54, no. 1.2 (Feb. 2019): 206–16.


Evidence Base Suggests Digital Health Companies Are Having Little Impact on High-Need, High-Cost Conditions

A review of peer-reviewed publications describing the products and services of the 20 top-funded, private digital health companies in the U.S. found these publications focused on only a small number of companies, many of which specialized in artificial intelligence and big data. Few studies involved high-need populations or measured the impact of interventions on outcomes, cost, or access to care. The authors recommend fostering an environment that encourages the development of evidence-based, high-impact products for high-need populations. Kyan Safavi et al., “Top-Funded Digital Health Companies and Their Impact on High-Burden, High-Cost Conditions,” Health Affairs 38, no. 1 (Jan. 2019): 115–23.

Publication Details

Publication Date: March 21, 2019