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Publications of Note

Transitional Care Program Prevents Readmissions for One-Third of High-Risk Patients
A study of North Carolina's statewide transitional care initiative, which was designed to prevent recurrent hospitalizations among high-risk Medicaid recipients with complex chronic conditions, found that among patients hospitalized during 2010 and 2011, those who received transitional care were 20 percent less likely to experience a readmission during the subsequent year, compared with clinically similar patients who received usual care. The authors found the benefits of the intervention were greatest among patients with the highest readmission risk: one readmission was averted for every six patients who received transitional care services and one for every three of the highest-risk patients. The authors conclude that locally embedded, targeted care coordination interventions may be effective in reducing rehospitalizations for high-risk populations. C. T. Jackson, T. K. Trygstad, D. A. DeWalt et al., "Transitional Care Cut Hospital Readmissions for North Carolina Medicaid Patients with Complex Chronic Conditions," Health Affairs, Aug. 2013 32(8):1407–15.

Patients Sicker in High-Cost Regions of the U.S.
Researchers studying geographic variations in medical spending among Medicare beneficiaries found that most geographic cost variation was attributable to disease burden rather than physician practice patterns. They found a consistent pattern of higher acute and chronic disease burden in high-cost areas, even for conditions that appear to be insensitive to diagnostic and coding patterns. For example, acute conditions unlikely to be affected by diagnostic practices—hip fracture, traumatic amputation, stroke, and heart attack—are 1.73 to 1.91 time more prevalent in high-cost areas compared with low-cost ones. Based on these findings, the authors caution that variations in spending among different regions in the U.S. may not be as strongly related to geography and local practice patterns as Dartmouth Atlas of Health Care researchers have suggested. J. D. Reschovsky, J. Hadley, and P. S. Romano, "Geographic Variation in Fee-for-Service Medicare Beneficiaries' Medical Costs Is Largely Explained by Disease Burden," Medical Care Research and Review, Oct. 2013 70(5):542–63.

Reference-Based Pricing Effective in Steering CalPERS Patients to Low-Cost Facilities
After the California Public Employees' Retirement System (CalPERS) limited the amount it would pay for some medical treatments (a practice known as reference-based pricing), the use of low-price facilities increased by 21.2 percent among patients receiving knee and hip replacement surgeries in the first year of implementation, according to a study that also found the use of high-price facilities by such patients decreased by 34.3 percent. Use of reference-based pricing produced $2.8 million in savings related to orthopedic surgery for CalPERS and led to $0.3 million lower cost-sharing for CalPERS members. J. C. Robinson and T. T. Brown, "Increases in Consumer Cost Sharing Redirect Patient Volumes and Reduce Hospital Prices for Orthopedic Surgery," Health Affairs, Aug. 2013 32(8):1392–97. 

Over Past Two Decades Life Expectancy Increased While Years Lived with Disability Remains Stable
A study that measured the burden of diseases, injuries, and leading risk factors in the U.S. from 1990 to 2010 found that over those decades, life expectancy at birth increased (75.2 in 1990 to 79.2 years in 2010), as did healthy life expectancy (65.8 years to 68.1 years), while the all-cause death rate for all ages decreased. Age-specific rates of years lived with disability remained stable; however, morbidity and chronic disability now account for nearly half of the U.S. health burden. Further, improvements in population health have not kept pace with those achieved in other wealthy nations. The researchers noted that diseases and injuries with the largest number of years of life lost in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury, while age-standardized years of life lost because of premature mortality increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls. The diseases with the largest number of years lived with disability in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders. C. J. L. Murray, J. Abraham, M. K. Ali et al., "The State of U.S. Health, 1990–2010: Burden of Diseases, Injuries, and Risk Factors," Journal of the American Medical Association, Aug. 14, 2013 310(6):591–608.

ED Use Following Discharge Could Serve as an Indicator of Poorly Coordinated Care
A study that examined emergency department (ED) visits by Medicare patients within 30 days of discharge for six common inpatient surgeries found extensive (as much as fourfold) variation across facilities, which the authors note may signify an upstream failure to coordinate care. The study found 17.3 percent of these patients were seen in the ED at least once, while 4.4 percent had multiple visits. The authors suggest that ED use following discharge may be a useful quality indicator. Such visits also represent an opportunity to ensure care is well coordinated—the "last best chance to avoid preventable readmissions." K. E. Kocher, B. K. Mollamothu, J. D. Birkmeyer et al., "Emergency Department Visits After Surgery Are Common for Medicare Patients, Suggesting Opportunities to Improve Care," Health Affairs, Sept. 2013 32(9):1600–7. 

Use of Care Guides in Primary Care Practices Increases Attainment of Care Goals
A study designed to test whether patients with hypertension, diabetes, or heart failure working with layperson "care guides"—whose job was to help patients and providers achieve recommended goals of care—would achieve more evidence-based goals than patients receiving usual care found the percentage of goals met increased in both groups (changes from baseline were 10% and 3.9%, respectively). However, patients who received help from care guides achieved more goals than those receiving usual care (82.6% vs. 79.1%). Patients working with care guides also reduced the number of unmet goals by 30.1 percent compared with 12.06 percent among those receiving usual care. The authors suggest that adding care guides to primary care teams may be a low-cost way of improving care. R. Adair, D. R. Wholey, J. Christianson et al., "Improving Chronic Disease Care by Adding Laypersons to the Primary Care Team: A Parallel Randomized Trial," Annals of Internal Medicine, Aug. 6, 2013 159(3):176–84.

Success of ACOs Depends on Rapid Spread of Shared Savings Programs by Public and Private Payers
The authors of this commentary contend that for accountable care organizations (ACOs) to succeed, value-based payment incentives that reward clinicians and health care organizations for providing value to patients must spread rapidly to other payers. Otherwise, the delivery systems that are improving cost and quality may drop out of these experiments. They argue that strong federal–state and public–private partnerships are needed to coordinate all payers in each region to ensure that high-value care is rewarded consistently. J. Toussaint, A. Milstein, and S. Shortell, "How the Pioneer ACO Model Needs to Change: Lessons from Its Best-Performing ACO," Journal of the American Medical Association, Oct. 2, 2013 310(13):1341–42.

IOM: Variation in Medicare Spending Largely Due to Post–Acute Care
A commentary by the chairs of the Institute of Medicine (IOM) committee that explored geographic variation in per-beneficiary Medicare spending found much of the variation in Medicare was related to post–acute care, including services provided by home health agencies, skilled nursing facilities, and long-term care hospitals. The report notes that if there were no variation in spending on post-acute services, geographic variation in Medicare spending would decline by an estimated 73 percent, even though these services account for only 13 percent of Medicare spending. J. P. Newhouse and A. M. Garber, "Geographic Variation in Health Care Spending in the United States: Insights from an Institute of Medicine Report," Journal of the American Medical Association, Sept. 25, 2013 310(12):1227–28.

Efforts to Promote Care Coordination Should Preserve Competition in Health Care Markets
The authors of this commentary argue that current efforts to increase the value of care delivered in the U.S. health care system that focus on improved coordination—from accountable care programs to bundled payments—may unintentionally be at odds with strategies for improving value because these approaches may reduce competition in health care markets by creating incentives for provider consolidation. The authors suggest that current policies for addressing the weaknesses of the health care system strike a balance between both goals— coordination among providers as well as competition. They also suggest that the courts and regulatory agencies focus on this trade-off when they examine health care markets. Finally, they suggest policymakers consider the effects an initiative in one sector will have on consumers in another and on providers overall. K. Baicker and H. Lev, "Coordination Versus Competition in Health Care Reform," New England Journal of Medicine, Aug. 29, 2013 369(9):789–91.

AHRQ Reports Finds Barriers to Care Remained in 2009 While Quality Improved in Some Areas
The new National Healthcare Quality Report and National Healthcare Disparities Report, published annually by the Agency for Healthcare Research and Quality (AHRQ), found that on average, more than one-fourth (26%) of Americans reported that they faced a barrier in gaining access to care in 2009 while performance on half of the care processes and outcomes measured improved. The report also found that more than 80 percent of the measures that track treatment of acute illness or injury saw gains, but only 40 percent of those related to chronic disease management did so. C. M. Clancy, "Acute Care Quality Improves While Barriers to Access Remain: AHRQ's 2012 Healthcare Quality and Disparities Reports," American Journal of Medical Quality, Sept./Oct. 2013 28(5):443–45.

High Degree of Inaccuracy in Reported Rates of High-Risk Prescribing by Medicare Advantage Plans
A study that compared the calculated and reported rates of high-risk prescribing among 172 Medicare Advantage plans found that the mean rate of high-risk prescribing derived from Part D claims was 26.9 percent compared with the mean plan-reported rate of 21.1 percent. The study also found 95 percent of the plans underreported rates and that the plans that most accurately reported rates had lower quality rankings when reported rates rather than calculated rates were used. The authors note that routine audits may be necessary to ensure the validity of publicly reported quality measures. A. L. Cooper, L. E. Kazis, D. D. Dore et al., "Underreporting High-Risk Prescribing Among Medicare Advantage Plans: A Cross-Sectional Analysis," Annals of Internal Medicine, Oct. 1, 2013 159(7):456–62.

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