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Abstract With ongoing efforts to improve the value of health care in the United States and reduce wasteful spending, we examine empirically the value trade-offs involved in an additional day in a skilled nursing facility (SNF) after hospital discharge. To control for potential endogeneity, we use the percentage of Medicare beneficiaries enrolled in Medicare Advantage in each county-year as an instrument for individuals' SNF length of stay among Traditional Medicare beneficiaries, as local Medicare Advantage penetration puts downward pressure on SNF length of stay for all SNF patients but does not directly affect utilization management of those enrolled in Traditional Medicare. We also test for heterogeneity in treatment effect across patients by clinical complexity and two non-health-related factors, marital status and nursing home profit status. We find that one additional day in a SNF lowers short-term readmission rates, but this effect is small and heterogeneous across patient types. The most clinically complex patients (those with the longest predicted SNF stays) benefit the most from an additional SNF day, as do patients whose stays are shorter because of non-health-related factors. The cost savings from reduced readmission rates are small and do not offset the additional SNF costs. [ABSTRACT FROM AUTHOR]

Rationale: Increasing intensive care unit (ICU) beds and the critical care workforce are often advocated to address an aging and increasingly medically complex population. However, reducing potentially preventable ICU stays may be an alternative to ensure adequate capacity.Objectives: To determine the proportions of ICU admissions meeting two definitions of being potentially preventable using nationally representative U.S. claims databases.Methods: We analyzed claims from 2006 to 2015 from all Medicare Fee-for-Service (FFS) beneficiaries and from a large national payer offering a private insurance (PI) plan and a Medicare Advantage (MA) plan. Potentially preventable hospitalizations were identified using existing definitions for ambulatory care sensitive conditions (ACSCs) and life-limiting malignancies (LLMs).Results: We analyzed 420,369,434 person-years of insurance coverage, during which there were 99,793,416 acute inpatient hospitalizations, of which 16,646,977 (16.7%) were associated with an ICU admission. Of these, the proportions with an ACSC were 12.9%, 12.7%, and 15.8%, and with an LLM were 5.2%, 5.4%, and 6.4%, among those with PI, MA, and FFS, respectively. Over 10 years, the absolute percentages of ACSC-associated ICU stays declined (PI = -1.1%, MA -6.4%, FFS -6.4%; all P < 0.001 for all trends). Smaller changes were noted among LLM-associated ICU stays, declining in the MA cohort (-0.8%) and increasing in the FFS (+0.3%) and PI (+0.2%) populations (P < 0.001 for all trends).Conclusions: An appreciable proportion of U.S. ICU admissions may be preventable with community-based interventions. Investment in the outpatient infrastructure required to prevent these ICU admissions should be considered as a complementary, if not alternative, strategy to expanding ICU capacity to meet future demand. [ABSTRACT FROM AUTHOR]

Objective: To investigate the impact of Medicare's skilled nursing facility (SNF) copayment policy, with a large increase in the daily copayment rate on the 20th day of a benefit period, on length of stay, patient outcomes, and costs.Data Sources and Study Setting: Retrospective cohort study from 2012 to 2016 using Medicare claims and SNF assessment data, including SNF admissions for Medicare fee-for-service beneficiaries.Study Design: We first estimate how changes in Medicare's SNF copayment on the 21st day of a patient's benefit period affect length of SNF stay. We then use benefit day on admission as an instrumental variable to estimate the impact of SNF length of stay related to the copayment policy on readmission and Medicare payment.Principal Findings: From 2012 to 2016, we examined 291 134 SNF admissions. Higher benefit day on SNF admission was strongly associated with shorter SNF stays. A 1-day shorter SNF stay was associated with higher readmission rate within 30 days of hospital discharge (1.5 percentage points; 95% CI 1.4-1.6, P < .001) and within 30 days of SNF discharge (0.9 percentage points; 95% CI 0.8-1.0), lower total Medicare payment for the 90-day episode after hospital discharge ($396; 95% CI 361-431, P < .001), but $179 higher payment for the 90 days after SNF discharge (95% CI 149-210, P < .001), offsetting the lower payment for the shorter index SNF stay.Conclusions: Medicare's SNF copayment policy is associated with shorter lengths of stay and worse patient outcomes, suggesting the copayment policy has unintended and negative effects on patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: It remains unknown whether high-functioning teams can compensate for poor continuity of care to support important patient outcomes.Data Source: Linked VA administrative and Medicare claims data to measure the relationship of team-based care and continuity of care with high-cost utilization.Study Design: Retrospective cohort study of 1.2 million VA-Medicare dual eligible Veterans assigned to a VA primary care provider (PCP) in 2012. Continuity was the proportion of primary care visits to the assigned VA provider of care. Clinics were categorized as low, average, or high-team functioning based on survey data. Our primary outcomes were the number of all-cause hospitalizations, ambulatory care sensitive (ACSC) hospitalizations, and emergency department (ED) visits in 2013.Principal Findings: A 10-percentage point increase in continuity with a VA PCP was associated with 4.5 fewer hospitalizations (p < .001), 3.2 fewer ACSC hospitalizations (p < .001), and 2.6 more ED visits (p = .07) per 1,000 patients. Team-based care was not significantly associated with any high-cost utilization category. Associations were heterogeneous across VA-reliant and nonreliant Veterans. Finally, the interaction results demonstrated that the quality of team-based care functioning could not compensate for poor continuity on hospitalizations, ACSC hospitalizations, or ED visits.Conclusions: In Veterans who were reliant on the VA for services, increasing continuity with a VA PCP and high-functioning team-based care clinics was associated with fewer ED visits and hospitalizations. Furthermore, leveraging combined data from VA and Medicare allowed to better measure continuity and assess high-cost utilization among Veterans who are and are not reliant on the VA for services. [ABSTRACT FROM AUTHOR]

Background: While early evidence suggests that Medicare accountable care organizations (ACOs) may reduce post-acute care (PAC) utilization for attributed beneficiaries, whether these effects spill over to all beneficiaries admitted to hospitals participating in ACOs stray is unknown.Objective: The objective of this study was to evaluate whether changes in PAC use and Medicare spending spill over to all beneficiaries admitted to hospitals participating in the Medicare Shared Savings Program (MSSP).Design: Observational study using a difference-in-differences design comparing changes in PAC utilization and spending among beneficiaries admitted to ACO-participating hospitals before and after the start of the ACO contracts, compared to those admitted to non-ACO hospitals.Setting: A total of 233 hospitals participate in MSSP ACOs and 3103 non-ACO hospitals.Participants: A national sample of 11,683,573 Medicare beneficiaries experiencing 26,503,086 hospital admissions from 2010 to 2013.Exposure: Admission to a hospital participating in an MSSP ACO.Main Measures: The probability of discharge and Medicare payments to inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), and home health agencies (HHA).Key Results: For beneficiaries admitted to hospitals that joined an ACO, the likelihood of being discharged to PAC did not change after the hospital joined the ACO compared with non-ACO hospitals over the same period (differential change in probability of discharge to any PAC was 0.000 (P = 0.89), SNF was 0.000 (P = 0.73), IRF was 0.000 (P = 0.96), and HHA was 0.001 (P = 0.57)). Payments reduced significantly for PAC overall (- $130.41, P = 0.03), but not for any individual PAC type alone. These results were consistent in samples that were conditional on discharge to any PAC, across conditions with high PAC use nationally, and among ACO-participating hospitals that also had a PAC participant.Conclusions: Hospital participation in an ACO did not result in spillovers in PAC utilization or payments to all beneficiaries, even when considering high PAC-use conditions and ACO hospitals that also have an ACO-participating PAC. [ABSTRACT FROM AUTHOR]

The authors analyze the relationship between acute and postacute medical care in the U.S. The authors discuss the problems associated with patient transition between acute and postacute care settings and the medical policies that have been implemented to reduce fragmentation between the two patient care settings. They recommend their own solutions to reducing fragmentation, including integrating acute and postacute care into a single financial entity.

Little is known about how real-time online rating platforms such as Yelp may complement the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which is the US standard for evaluating patients' experiences after hospitalization. We compared the content of Yelp narrative reviews of hospitals to the topics in the HCAHPS survey, called domains in HCAHPS terminology. While the domains included in Yelp reviews covered the majority of HCAHPS domains, Yelp reviews covered an additional twelve domains not found in HCAHPS. The majority of Yelp topics that most strongly correlate with positive or negative reviews are not measured or reported by HCAHPS. The large collection of patient- and caregiver-centered experiences found on Yelp can be analyzed with natural language processing methods, identifying for policy makers the measures of hospital quality that matter most to patients and caregivers. The Yelp measures and analysis can also provide actionable feedback for hospitals. [ABSTRACT FROM AUTHOR]

Background: The range of hospital charges for similar diagnoses show tremendous variability across U.S. hospitals. This charge variability remains unexplained.Objective: We aimed to describe hospital charge variability in the U.S. and examine its relationship to local health factors.Design: This was a descriptive study of the 2011 Medicare Inpatient Charge data summarizing inpatient hospital charges billed to Medicare. This data was evaluated using 29 county-level measures of health status, health behavior, clinical access and quality, built environment, and socioeconomic status in a clustered, multivariate linear regression.Participants: 2871 U.S. hospitals registered with Medicare and with at least ten discharges for diagnosis-related groups (DRGs) of six common inpatient conditions.Main Measure: Inpatient hospital charges were assessed.Key Results: No community health measures were associated with hospital charges. The one notable exception associated with higher charges was higher rates of uninsured status ($344.84 higher charges for every one-percentage point increase in prevalence (p < 0.001)). One variable was associated with lower hospital charges: the percentage of children living in poverty [$309.30 lower charges for every one-percentage point increase in prevalence (p < 0.001)].Conclusions: Overall, hospital charges lacked an association with population health measures, and their variability remains largely unexplained. However, the association of higher charges with uninsured status raises concerns about hospitals' price-setting strategies, such as price discrimination and cost-shifting strategies that expose vulnerable populations to great financial risks. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effects of Medicare's hospital pay-for-performance demonstration project on hospital revenues, costs, and margins and on Medicare costs. Data Sources/Study Setting All health care utilization for Medicare beneficiaries hospitalized for acute myocardial infarction ( AMI; ICD-9- CM code 410.x1) in fiscal years 2002-2005 from Medicare claims, containing 420,211 admissions with AMI. Study Design We test for changes in hospital costs and revenues and Medicare payments among 260 hospitals participating in the Medicare hospital pay-for-performance demonstration project and a group of 780 propensity-score-matched comparison hospitals. Effects were estimated using a difference-in-difference model with hospital fixed effects, testing for changes in costs among pay-for-performance hospitals above and beyond changes in comparison hospitals. Principal Findings We found no significant effect of pay-for-performance on hospital financials (revenues, costs, and margins) or Medicare payments (index hospitalization and 1 year after admission) for AMI patients. Conclusions Pay-for-performance in the CMS hospital demonstration project had minimal impact on hospital financials and Medicare payments to providers. As P4P extends to all hospitals under the Affordable Care Act, these results provide some estimates of the impact of P4P and emphasize our need for a better understanding of the financial implications of P4P on providers and payers if we want to create sustainable and effective programs to improve health care value. [ABSTRACT FROM AUTHOR]

Long-term acute care hospitals (LTACs) are an increasingly common discharge destination for patients recovering from intensive care. In this article the authors use U.S. Medicare claims data to examine regional- and hospital-level variation in LTAC utilization after intensive care to determine factors associated with their use. Using hierarchical regression models to control for patient characteristics, this study found wide variation in LTAC utilization across hospitals, even controlling for LTAC access within a region. Several hospital characteristics were independently associated with increasing LTAC utilization, including increasing hospital size, for-profit ownership, academic teaching status, and colocation of the LTAC within an acute care hospital. These findings highlight the need for research into LTAC admission criteria and the incentives driving variation in LTAC utilization across hospitals. [ABSTRACT FROM PUBLISHER]

The traditional approaches to improving the quality of care at U.S. nursing homes-regulation, inspection, and accountability through public reporting-have produced modest results. Greater progress could be made by focusing incentives on broader processes related to improving quality. This could foster a culture of upstream identification and solving of problems that would supplement existing downstream requirements to meet specific safety and care standards. [ABSTRACT FROM AUTHOR]

Objective: Quality measures may be associated with improved outcomes for two reasons. First, measured activities may directly improve care. Second, success on these measures may be a marker for other unmeasured aspects of high quality care. Our objective is to test the contribution of both possible effects.Data Sources: 2004 Medicare data on hospital performance from Hospital Compare and risk-adjusted mortality rates from Medicare Part A claims.Study Design: We studied 3,657 acute care U.S. hospitals and compared observed differences in condition-specific hospital mortality rates based on hospital performance with expected differences in mortality from the clinical studies underlying the measures.Principal Findings: Differences in observed mortality rates across U.S. hospitals are larger than what would be expected if these differences were due only to the direct effects of delivering measured care.Conclusions: Performance measures reflect care processes that both improve care directly and are also markers of elements of health care quality that are otherwise unmeasured. This finding suggests that process measures capture important information about care that is not directly measured, and that these unmeasured effects are in general larger than the measured effects. [ABSTRACT FROM AUTHOR]

The article focuses on the results of research which compared hospital care at 3,657 acute care hospitals which were included in Hospital Care, the website of the United States Center for Medicare and Medicaid Services. The research looked at the number of cases of myocardial infarction, heart failure and pneumonia which were treated at the hospitals and compared the mortality rates which were seen in the cases. A discussion of concerns about the quality of medical care in the U.S. which were seen by the Center for Medicare and Medicaid Services, and led to the creation of Hospital Compare and the research, is presented.

In this paper we examine empirically the effect of integration on Medicare payment and rehospitalization. We use 2005-2013 data on Medicare beneficiaries receiving post-acute care (PAC) in the U.S. to examine integration between hospitals and the two most common post-acute care settings: skilled nursing facilities (SNFs) and home health agencies (HHA), using two measures of integration-formal vertical integration and informal integration representing preferential relationships between providers without formal relationships. Our identification strategy is twofold. First, we use longitudinal models with a fixed effect for each hospital-PAC pair in a market to test how changes in integration impact patient outcomes. Second, we use an instrumental variable approach to account for patient selection into integrated providers. We find that vertical integration between hospitals and SNFs increases Medicare payments and reduces rehospitalization rates. However, vertical integration between hospitals and HHAs has little effect, nor does informal integration between hospitals and either PAC setting. [ABSTRACT FROM AUTHOR]

Background: Use of social media has become widespread across the United States. Although businesses have invested in social media to engage consumers and promote products, less is known about the extent to which hospitals are using social media to interact with patients and promote health. Objective: The aim was to investigate the relationship between hospital social media extent of adoption and utilization relative to hospital characteristics. Methods: We conducted a cross-sectional review of hospital-related activity on 4 social media platforms: Facebook, Twitter, Yelp, and Foursquare. All US hospitals were included that reported complete data for the Centers for Medicare and Medicaid Services Hospital Consumer Assessment of Healthcare Providers and Systems survey and the American Hospital Association Annual Survey. We reviewed hospital social media webpages to determine the extent of adoption relative to hospital characteristics, including geographic region, urban designation, bed size, ownership type, and teaching status. Social media utilization was estimated from user activity specific to each social media platform, including number of Facebook likes, Twitter followers, Foursquare check-ins, and Yelp reviews. Rsults: Adoption of social media varied across hospitals with 94.41% (3351/3371) having a Facebook page and 50.82% (1713/3371) having a Twitter account. A majority of hospitals had a Yelp page (99.14%, 3342/3371) and almost all hospitals had check-ins on Foursquare (99.41%, 3351/3371). Large, urban, private nonprofit, and teaching hospitals were more likely to have higher utilization of these accounts. Conclusions: Although most hospitals adopted at least one social media platform, utilization of social media varied according to several hospital characteristics. This preliminary investigation of social media adoption and utilization among US hospitals provides the framework for future studies investigating the effect of social media on patient outcomes, including links between social media use and the quality of hospital care and services. [ABSTRACT FROM AUTHOR]

Abstract: Public reporting of health care quality has become a popular tool for incenting quality improvement. A fundamental question about public reporting is whether it causes providers to select healthier patients for treatment. In the nursing home post-acute setting, where patients must achieve a minimum length of stay to be included in quality measures, selection may take the form of discharge from the nursing home using rehospitalization, a particularly costly and undesirable outcome. We study the population of post-acute patients of skilled nursing facilities nationwide during 1999–2005 to assess whether selective rehospitalization occurred when public reporting was instituted in 2002, using multiple quasi-experimental designs to identify effects. We find that after public reporting was implemented, rehospitalizations before the length-of-stay cutoff increased. We conclude that nursing homes rehospitalize higher-risk post-acute patients to improve scores, providing evidence for selection behavior on the part of nursing home providers in the presence of public reporting. [Copyright &y& Elsevier]