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Publications of Note: July–September 2019

Secret Shopper Survey Finds Many Buprenorphine Prescribers Do Not Offer New Appointments

To assess real-world access to buprenorphine treatment for uninsured or Medicaid-covered patients, researchers contacted publicly listed prescribers and posed as patients seeking treatment for heroin addiction. In six communities with a high burden of opioid-related mortality (the District of Columbia, Maryland, Massachusetts, New Hampshire, Ohio, and West Virginia), they found clinicians offered new appointments to 54 percent of Medicaid contacts and 62 percent of uninsured (self-pay) contacts. Twenty-seven percent of Medicaid and 41 percent of uninsured contacts were offered an appointment with the possibility of buprenorphine prescription at the first visit. The median wait time to first appointment was six days for Medicaid contacts and five days for uninsured contacts. The median wait time from first contact to possible buprenorphine induction was eight days for Medicaid contacts and seven for the uninsured. The researchers say the short wait times suggest there are opportunities to increase access using the existing prescriber workforce. Tamara Beetham et al., “Access to Office-Based Buprenorphine Treatment in Areas with High Rates of Opioid-Related Mortality: An Audit Study,” Annals of Internal Medicine 171, no. 1 (July 2019):1-9.

 

A Population-Based Intervention Reduces Hospitalizations Among Children

An initiative that aimed to reduce hospitalizations among children living in two high-morbidity, high-poverty neighborhoods in Cincinnati, Ohio, decreased the inpatient bed-day rate by 18 percent from the 2012-15 baseline to the improvement phase (2015-18). Hospitalizations decreased by 20 percent. There was no similar decrease in demographically comparable neighborhoods. The initiative focused on chronic disease management, transitions in care, mitigation of social risk, and use of actionable, real-time data. Andrew F. Beck et al., “Cooling the Hot Spots Where Child Hospitalization Rates Are High: A Neighborhood Approach to Population Health,” Health Affairs 38, no. 9 (September 2019):1433-41.

 

Supportive Services Improve Access to Care, Preventive Services, and Satisfaction Among Health Center Patients

A study of patients served by health centers funded by the Health Resources and Services Administration found in 2014 those who received supportive services that addressed social challenges and barriers to accessing care had 1.92 times more health center visits, an 11.78–percentage-point higher probability of getting a routine check-up, a 16.34–percentage-point higher likelihood of having a flu shot, and a 7.63–percentage-point higher probability of a patient definitely recommending the health center to others. The supportive services included care coordination, health education, transportation, and assistance obtaining food, shelter, and benefits. Dahai Yue et al., “Enabling Services Improve Access to Care, Preventive Services, and Satisfaction Among Health Center Patients,” Health Affairs 38, no. 9 (September 2019):1468-74.

 

Racial Disparities Found in Home and Community-Based Services for Dual Eligibles

A study that compared outcomes for older adults dually eligible for Medicare and Medicaid who received home and community-based services (HCBS) to those receiving institutional care found overall hospitalization rates were similar in both groups even though nursing facility users were generally sicker based on their claims histories. The researchers also found among HCBS users, blacks were more likely to be hospitalized than non-Hispanic whites and the gap widened among blacks and whites with dementia. Medicaid HCBS spending was also higher for whites than for blacks, and higher Medicare and Medicaid hospital spending for blacks and Hispanics did not offset this difference. They concluded that services need to be carefully targeted to avoid adverse outcomes and disparities in access to high-quality care. Rebecca J. Gorges, Prachi Sanghavi, and R. Tamara Konetzka, “A National Examination of Long-Term Care Setting, Outcomes, and Disparities Among Elderly Dual Eligibles,” Health Affairs 38, no. 7 (July 2019):1110-18.

 

AIM Model Significantly Reduces Hospital Days and Expenses for Patients in the Last Month of Life

The Advanced Illness Management (AIM) program at California’s Sutter Health, which informed the development of a new Medicare payment model for serious illness care, reduced hospital days for seriously ill patients in the last month of life by 1,361 per 1,000 Medicare beneficiaries, hospital deaths by 8.2 percent, inpatient payments by $6,127, and the total cost of care by $5,657 per beneficiary. In a Health Affairs article, the developer of the model and current staff describe the lessons they learned changing the focus of care for advanced illness from hospital to home. Brad Stuart, Elizabeth Mahler, and Praba Koomson, “A Large-Scale Advanced Illness Intervention Informs Medicare’s New Serious Illness Payment Model,” Health Affairs 38, no. 6 (June 2019):950-56.

 

ACOs Aren’t Taking Advantage of Serious Illness Programs

A national survey of accountable care organizations (ACOs) found 94 percent at least partially identified seriously ill patients, but only 8 percent to 21 percent widely implemented serious illness initiatives, such as advance care planning or home-based palliative care. The authors selected six ACOs with successful programs for case studies and found common themes. The ACOs saw the need for upfront investment beyond shared savings to build the necessary infrastructure and workforce; the importance of establishing a business case to gain organizational buy-in; and the necessity of using data and information technology to manage populations. The authors also consider how quality measures, risk adjustment, attribution methods, support for rural ACOs, and enhancing timely access to data affect adoption of these models. William K. Bleser et al., “ACO Serious Illness Care: Survey and Case Studies Depict Current Challenges and Future Opportunities,” Health Affairs 38, no. 6 (June 2019):1011-20.

 

Study Finds Readmissions Reductions Continue at Safety-Net Hospitals, But Disparities Persist at Non-Safety–Net Hospitals

A study that examined disparities in rates of 30-day readmissions for three conditions following the 2010 passage the law creating the Hospital Readmission Reduction Program found disparities in readmission rates among blacks and whites were already decreasing prior to implementation. The reductions were largest at safety-net hospitals. They found in 2007, blacks had 13 percent higher odds of readmission if treated in safety-net hospitals, compared with 5 percent higher odds in 2010; this trend continued following implementation of the penalties under the readmission reduction program. By contrast, racial disparities continue to persist at non-safety–net hospitals, which face much lower penalties under the program. The study examined readmissions for acute myocardial infarction, congestive heart failure, or pneumonia at hospitals in five states (Arizona, Florida, Nebraska, New York, and Washington State). Cameron M. Kaplan, Michael P. Thompson, and Teresa M. Waters, “How Have 30-Day Readmission Penalties Affected Racial Disparities in Readmissions? An Analysis from 2007 to 2014 in Five States,” Journal of General Internal Medicine 34, no. 5 (June 2019):878-83.

 

Improvements to the Hospital Readmissions Reduction Program Recommended

The authors of a New England Journal of Medicine commentary describe ways of addressing the limitations and unintended consequences of the Hospital Readmissions Reduction Program, including the tendency of hospitals to rely on observation stays to avoid readmissions, the program’s failure to factor in risk of death, and inadequate risk adjustment to allow fair comparisons of hospitals. They suggest using a “return-to-hospital” metric to capture emergency department visits and observation stays, which could strengthen hospitals’ incentive to focus on improving care transitions and post-discharge care. They recommend creating an outcome measure that combines hospital returns with deaths within 30 days to ensure there are financial incentives to reduce mortality. They also suggest adding data on prior hospital utilization, functional status, and frailty to improve risk models and using revenue generated from the program to help resource-poor hospitals improve. Rishi Wadhera, Robert W. Yeh, and Karen E. Joynt Maddox, “The Hospital Readmissions Reduction Program — Time for a Reboot,” New England Journal of Medicine 380, no. 24 (June 2019):2289-91.

 

ACOs in Rural and Underserved Areas Lowered Medicare Spending

A study of accountable care organizations (ACOs) in rural and underserved areas that received upfront investment from the Centers for Medicare and Medicaid Services (CMS) as part of the ACO Investment Model (AIM) found they reduced total Medicare spending by $28.21 per Medicare beneficiary per month or $131 million in aggregate, relative to a comparison group of beneficiaries in markets where providers did not participate. Over this period, CMS made $76.2 million in prepayments to the ACOs and paid an additional $6.2 million in shared savings. After accounting for these costs, the aggregate net reduction was $48.6 million, or $10.46 per beneficiary per month. Decreases in the number of hospitalizations and use of institutional post-acute care contributed to the observed reduction in overall spending. As part of the AIM program, eligible ACOs participating in the Medicare Shared Savings Program received prepayment of shared savings. Matthew J. Trombley et al., “Early Effects of an Accountable Care Organization Model for Underserved Areas,” New England Journal of Medicine 381, no. 6 (August 2019):543-51.

 

Analysis of Medicare Claims Data Using Machine Learning Identifies Subgroups of High-Need, High-Cost Patients

Using an open-source, machine learning method to describe subgroups of high-need, high-cost (HNHC) patients covered by Medicaid found the largest subgroups were characterized by mental and behavioral health conditions. The researchers also found marked heterogeneity in patient costs across subgroups. An unexpected HNHC patient population they identified: patients with pregnancy-related complications. The study examined the clinical characteristics of patients of Mount Sinai Health System in New York City. Sudhakar V. Nuti et al., “Characterizing Subgroups of High-Need, High-Cost Patients Based on Their Clinical Conditions: A Machine Learning-Based Analysis of Medicaid Claims Data,” Journal of General Internal Medicine 34, no. 8 (August 2019):1406-8.

 

Interdisciplinary Transitional Care Reduces ED Visits, Hospitalizations, and Readmissions for Medicaid Beneficiaries

A study examining the effect of SafeMed — an intensive, interdisciplinary transitional care program that emphasized medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients — found participation was associated with 7 percent fewer hospitalizations, 31 percent fewer 30-day readmissions, and reduced medical expenditures over six months. Improvements were limited to Medicaid patients, who experienced statistically significant decreases of 39 percent in emergency department visits, 25 percent declines in hospitalizations, and 79 percent reductions in 30-day readmissions. Medication adherence was unchanged. James E. Bailey et al., “Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study,” Journal of General Internal Medicine 34, no. 9 (September 2019):1815-24.

 

Disadvantaged Neighborhoods, Safety-Net Hospital Status Are Independent Predictors of Readmission Risk

Researchers found living in a disadvantaged neighborhood in Maryland and being discharged from a hospital that treats a significant number of such patients are independently associated with 30-day hospital readmission rates. The study found, in 2015, patients living in neighborhoods in the 90th percentile of the area disadvantage index — a composite of income, employment, education, and housing measures — had a readmission rate of 14.1 percent, compared with 12.5 percent for similar patients living in neighborhoods at the 10th percentile. The researchers also calculated a “safety-net index,” based on the mean disadvantage of discharged patients from a given hospital. They found hospitals in the 90th percentile on the safety-net index had a readmission rate of 14.8 percent compared with 11.6 percent of patients discharged from hospitals in the 10th percentile. The association of readmission risk with the hospital’s safety-net index was approximately twice the observed association with the patient’s neighborhood disadvantage status. Stephen F. Jencks et al., “Safety-Net Hospitals, Neighborhood Disadvantage, and Readmissions Under Maryland’s All-Payer Program: An Observational Study,” Annals of Internal Medicine 171, no. 2 (July 16, 2019):91-98.

Publication Details

Publication Date: October 1, 2019