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Objective: To assess the effects of eLongTermCare (eLTC), a telehealth program implemented by an integrated health system in 45 nursing homes across the Midwest, on the use of acute hospital services and total expenditures for Medicare residents., Data Sources: Minimum Data Set, Medicare fee-for-service claims, and enrollment data from 2013 to 2018., Study Design: We used a longitudinal difference-in-differences design to estimate the changes in outcomes for treatment beneficiaries before and after participating in the eLTC program, relative to changes for the matched comparison beneficiaries over the same period. We measured outcomes over a 24-month follow-up period, including total Medicare spending, emergency department (ED) visits, hospitalizations, and the likelihood of readmission., Data Collection/extraction Methods: Using administrative data, we identified treatment beneficiaries who stayed at participating nursing facilities during the program period and matched comparison beneficiaries with similar baseline characteristics from non-participating facilities in the same geographic locations., Principal Findings: For long-term care residents, the eLTC program led to an estimated reduction of 73 ED visits per 1000 beneficiaries (p < 0.01, 8.6% effect) over the two-year follow-up period. The estimated effects for this group were concentrated among beneficiaries who entered the nursing home after program startup, with sizable reductions in hospitalizations, ED visits, and spending. For skilled care residents, the program was associated with an estimated reduction of 85 ED visits per 1000 beneficiaries (p = 0.03, 9.7% effect), but had no discernible effect on their hospitalizations or total Medicare spending., Conclusions: Telehealth can be a valuable tool for nursing homes to enhance care coordination and provide timely access to care, leading to lower spending for nursing home residents. Future research needs to explore payment methods that encourage telehealth expansion in nursing homes., (© 2022 Health Research and Educational Trust.)

Background: The Centers for Medicare & Medicaid Services launched the 4-year Comprehensive Primary Care Initiative (CPC Classic) in 2012 and its 5-year successor, CPC Plus (CPC+), in 2017 to test whether improving primary care delivery in five areas-and providing practices with financial and technical support-reduced spending and improved quality. This is the first study to examine long-term effects of a primary care practice transformation model., Objective: To test whether long-term primary care transformation-the 4-year CPC Classic and the first 2 years of its successor, CPC+-reduced hospitalizations, emergency department (ED) visits, and spending over 6 years., Design: We used a difference-in-differences analysis to compare outcomes for beneficiaries attributed to CPC Classic practices with outcomes for beneficiaries attributed to comparison practices during the year before and 6 years after CPC Classic began., Participants: The study involved 565,674 Medicare fee-for-service beneficiaries attributed to 502 CPC Classic practices and 1,165,284 beneficiaries attributed to 908 comparison practices, with similar beneficiary-, practice-, and market-level characteristics as the CPC Classic practices., Interventions: The interventions required primary care practices to improve 5 care areas and supported their transformation with substantially enhanced payment, data feedback, and learning support and, for CPC+, added health information technology support., Main Measures: Hospitalizations (all-cause), ED visits (outpatient and total), and Medicare Part A and B expenditures., Key Results: Relative to comparison practices, beneficiaries in intervention practices experienced slower growth in hospitalizations-3.1% less in year 5 and 3.5% less in year 6 (P < 0.01) and roughly 2% (P < 0.1) slower growth each year in total ED visits during years 3 through 6. Medicare Part A and B expenditures (excluding care management fees) did not change appreciably., Conclusions: The emergence of favorable effects on hospitalizations in years 5 and 6 suggests primary care transformation takes time to translate into lower hospitalizations. Longer tests of models are needed., (© 2021. Society of General Internal Medicine.)

Objectives: This study examines 14 independent and diverse health care interventions funded under the second round of Health Care Innovation Awards by CMS to determine if any organizational, model, or implementation features were strongly associated with the programs' estimated impacts on total expenditures, hospitalizations, or emergency department visits., Study Design: We estimated program impacts using awardee-specific difference-in-differences models based on Medicare and Medicaid enrollment and claims data for treatment and matched comparison groups from 2012 to 2018., Methods: We used 2 analytic approaches to identify program features associated with favorable impacts. The first method identified program characteristics that were common among programs that had estimated reductions in costs and service use and uncommon among those that did not. The second approach compared median impacts among awardees with a given distinguishing feature with median impacts among awardees that lacked the characteristic., Results: Of the 23 program features examined, 7 were associated with favorable estimated impacts: 3 intervention components (behavioral health, telehealth, and health information technology) and 4 program design and organizational characteristics (having prior experience implementing similar programs, targeting patients with substantial nonmedical needs in addition to medical problems, being focused on individual patient care rather than transforming provider practice, and using nonclinical staff as frontline providers of the intervention)., Conclusions: Innovative health care service delivery models with 2 or more of these 7 identified features were more likely than programs without them to reduce Medicare and Medicaid beneficiaries' needs for costly health care services.

Background: Performance feedback is central to data-driven models of quality improvement, but the use of claims-based data for feedback has received little attention., Purpose: To examine the challenges, uses, and limitations of quarterly Medicare claims-based performance feedback reports generated for practices participating in the Comprehensive Primary Care (CPC) initiative from 2012 to 2015., Methods: Mixed methods study of nearly 500 CPC practices in seven regions, combining pilot testing; systematic monitoring; surveys; in-depth interviews; user feedback; and input from data feedback team., Results: Designing reports required addressing issues about timing, data completeness and reliability, variations in patient risk across practices, and use of benchmarks and metrics understandable to users. Practices' ability to use reports constructively depended on their experience, analytic resources, expectations, and perceptions about the role of primary care in improving reported outcomes., Conclusions: Generating claims-based feedback reports that support practices' quality improvement efforts requires a significant investment of analytic expertise, time, resources, continuous improvement, and technical assistance., Implications: Claims-based performance feedback can provide insight into patterns of patients' care across provider settings and opportunities for improvement, but practices need data from other sources to manage patients in real time or assess the short-term effects of specific changes in care delivery.

Objectives: To provide actionable recommendations for improving care coordination programs for children with special healthcare needs (CSHCN) in Medicaid managed care., Study Design: Literature review and interviews with stakeholders and policy experts to adapt lessons learned from Medicare care coordination programs for CSHCN in Medicaid managed care., Methods: We reviewed syntheses of research on Medicare care coordination programs to identify lessons learned from successful programs. We adapted findings from Medicare to CSHCN in Medicaid based on an environmental scan and discussions with experts. The scan focused on Medicaid financing and eligibility for care coordination and how these intersect with Medicaid managed care. The expert discussions included pediatricians, Medicaid policy experts, Medicaid medical directors, and a former managed care executive, all experienced in care coordination for CSHCN., Results: We found 6 elements that are consistently associated with improved outcomes from Medicare care coordination programs and relevant to CSHCN in Medicaid: 1) identifying and targeting high-risk patients, 2) clearly articulating what outcomes programs are likely to improve, 3) encouraging active engagement between care coordinators and primary care providers, 4) requiring some in-person contact between care coordinators and patients, 5) facilitating information sharing among providers, and 6) supplementing care coordinators' expertise with that of other clinical experts., Conclusions: States and Medicaid managed care organizations have many options for designing effective care coordination programs for CSHCN. Their choices should account for the diversity of conditions among CSHCN, families' capacity to coordinate care, and social determinants of health.

Background: The 4-year, multipayer Comprehensive Primary Care Initiative was started in October 2012 to determine whether several forms of support would produce changes in care delivery that would improve the quality and reduce the costs of care at 497 primary care practices in seven regions across the United States. Support included the provision of care-management fees, the opportunity to earn shared savings, and the provision of data feedback and learning support., Methods: We tracked changes in the delivery of care by practices participating in the initiative and used difference-in-differences regressions to compare changes over the first 2 years of the initiative in Medicare expenditures, health care utilization, claims-based measures of quality, and patient experience for Medicare fee-for-service beneficiaries attributed to initiative practices and a group of matched comparison practices., Results: During the first 2 years, initiative practices received a median of $115,000 per clinician in care-management fees. The practices reported improvements in approaches to the delivery of primary care in areas such as management of the care of high-risk patients and enhanced access to care. Changes in average monthly Medicare expenditures per beneficiary did not differ significantly between initiative and comparison practices when care-management fees were not taken into account (-$11; 95% confidence interval [CI], -$23 to $1; P=0.07; negative values indicate less growth in spending at initiative practices) or when these fees were taken into account ($7; 95% CI, -$5 to $19; P=0.27). The only significant differences in other measures were a 3% reduction in primary care visits for initiative practices relative to comparison practices (P<0.001) and changes in two of the six domains of patient experience--discussion of decisions regarding medication with patients and the provision of support for patients taking care of their own health--both of which showed a small improvement in initiative practices relative to comparison practices (P=0.006 and P<0.001, respectively)., Conclusions: Midway through this 4-year intervention, practices participating in the initiative have reported progress in transforming the delivery of primary care. However, at this point these practices have not yet shown savings in expenditures for Medicare Parts A and B after accounting for care-management fees, nor have they shown an appreciable improvement in the quality of care or patient experience. (Funded by the Department of Health and Human Services, Centers for Medicare and Medicaid Services; ClinicalTrials.gov number, NCT02320591.).

As policy makers seek to slow the growth in Medicare spending, they have appropriately focused attention on beneficiaries with multiple chronic conditions. Many care coordination and disease management programs designed to improve beneficiaries' care and reduce their need for hospitalizations have been tested, but few have been successful. This study, however, found that four of eleven programs that were part of the Medicare Coordinated Care Demonstration reduced hospitalizations by 8-33 percent among enrollees who had a high risk of near-term hospitalization. The six approaches practiced by care coordinators in at least three of the four programs were as follows: supplementing telephone calls to patients with frequent in-person meetings; occasionally meeting in person with providers; acting as a communications hub for providers; delivering evidence-based education to patients; providing strong medication management; and providing timely and comprehensive transitional care after hospitalizations. When care management fees were included, the programs were essentially cost-neutral, but none of these programs generated net savings to Medicare. Our results suggest that incorporating these approaches into medical homes, accountable care organizations, and other policy initiatives could reduce hospitalizations and improve patients' lives. However, the approaches would save money only if care coordination fees were modest and organizations found cost-effective ways to deliver the interventions.

As one of the initial fifteen participants in the Medicare Coordinated Care Demonstration, the Washington University School of Medicine in St. Louis was not able to demonstrate any reduction in hospitalizations or Medicare spending for the patients it served. In fact, the Washington University program increased total Medicare spending by 12 percent. But after a redesign, the results changed. The program stopped conducting care management of most of its patients via telephone from a remote site in California and, instead, served all patients through frequent phone and occasional in-person contact from local care managers in St. Louis. Care management efforts were focused especially on patients deemed at greatest risk of hospitalization, and stronger hospital transition planning and medication reconciliation were provided, among other changes. After that point, the program reduced hospitalizations by 12 percent and monthly Medicare spending by $217 per enrollee-more than offsetting the program's monthly $151 care management fee. The results underscore findings from the overall Medicare Coordinated Care Demonstration that suggest that programs with more in-person contacts were more likely than others to build trusting relationships with patients and providers, improve patient adherence to care plans, and address additional needs and barriers that entirely telephonic contacts had been unable to identify. The results also indicate that programs can be more effective by focusing on the highest-risk patients, for whom the largest savings resulted.

Medicare beneficiaries in fee-for-service (FFS) who had chronic illnesses and volunteered to participate in 15 care coordination programs were randomized to treatment or control status. Nurses provided patient education (mostly by telephone) to improve adherence and ability to communicate with physicians. Patients were contacted an average of two times per month. The findings after 2 years are not encouraging. Few programs improved patient behaviors, health, or quality of care. The treatment group had significantly fewer hospitalizations in only one program; no program reduced gross or net expenditures. However, effects may be observed when 4 years of followup are available and sample sizes increase.

Well-documented racial disparities in use of medical services raise concerns about such disparities in other aspects of health care. We compare the difference in Medicaid pharmacy use between black and white dually eligible Medicare beneficiaries. Controlling for the presence of chronic illnesses, we find that black beneficiaries have significantly fewer prescriptions filled and lower pharmacy costs in 8 of the 10 States examined, despite having higher physician costs. If this disparity stems from a lack of provider or beneficiary knowledge, programs to educate providers or beneficiaries may hold the greatest promise for reducing it, whether pharmacy coverage is obtained from Medicaid or from a new Medicare benefit.

Background: The Centers for Medicare & Medicaid Services launched the 4-year Comprehensive Primary Care Initiative (CPC Classic) in 2012 and its 5-year successor, CPC Plus (CPC+), in 2017 to test whether improving primary care delivery in five areas-and providing practices with financial and technical support-reduced spending and improved quality. This is the first study to examine long-term effects of a primary care practice transformation model.Objective: To test whether long-term primary care transformation-the 4-year CPC Classic and the first 2 years of its successor, CPC+-reduced hospitalizations, emergency department (ED) visits, and spending over 6 years.Design: We used a difference-in-differences analysis to compare outcomes for beneficiaries attributed to CPC Classic practices with outcomes for beneficiaries attributed to comparison practices during the year before and 6 years after CPC Classic began.Participants: The study involved 565,674 Medicare fee-for-service beneficiaries attributed to 502 CPC Classic practices and 1,165,284 beneficiaries attributed to 908 comparison practices, with similar beneficiary-, practice-, and market-level characteristics as the CPC Classic practices.Interventions: The interventions required primary care practices to improve 5 care areas and supported their transformation with substantially enhanced payment, data feedback, and learning support and, for CPC+, added health information technology support.Main Measures: Hospitalizations (all-cause), ED visits (outpatient and total), and Medicare Part A and B expenditures.Key Results: Relative to comparison practices, beneficiaries in intervention practices experienced slower growth in hospitalizations-3.1% less in year 5 and 3.5% less in year 6 (P < 0.01) and roughly 2% (P < 0.1) slower growth each year in total ED visits during years 3 through 6. Medicare Part A and B expenditures (excluding care management fees) did not change appreciably.Conclusions: The emergence of favorable effects on hospitalizations in years 5 and 6 suggests primary care transformation takes time to translate into lower hospitalizations. Longer tests of models are needed. [ABSTRACT FROM AUTHOR]

Objective: To identify the most robust methods for evaluating alternative payment models (APMs) in the emerging health care delivery system environment.Study Design (approach): We assess the impact of widespread testing of alternative payment models on the ability to find credible comparison groups. We consider the applicability of factorial research designs for assessing the effects of these models.Principal Findings: The widespread adoption of alternative payment models could effectively eliminate the possibility of comparing APM results with a "pure" control or comparison group unaffected by other interventions. In this new environment, factorial experiments have distinct advantages over the single-model experimental or quasi-experimental designs that have been the mainstay of recent tests of Medicare payment and delivery models.Conclusions: The best prospects for producing definitive evidence of the effects of payment incentives for APMs include fractional factorial experiments that systematically vary requirements and payment provisions within a payment model. [ABSTRACT FROM AUTHOR]

The article presents a research study which examined whether health care coordination programs reduced Medicare expenditures and hospitalizations and improved quality of care for chronically ill Medicare beneficiaries. Fee-for-service Medicare patients in 15 care coordination programs were randomly assigned to treatment by nurses who provided patient education and monitoring or to control specified as usual care. The main outcome measures were monthly Medicare expenditures, hospitalizations, and patient-reported and care process indicators. Researchers found that coordination programs without a strong transitional care component were unlikely to produce net Medicare savings. Programs for moderate to severe patients that have substantial interperson contact can improve aspects of care.

The Medicare+Choice program was created to expand choice and encourage beneficiaries to more actively consider the choices they have. This article assesses how "salient" choice is to Medicare beneficiaries. More than half of all Medicare beneficiaries in 2000 reported that they either have never considered their options to join a Medicare HMO or get supplemental coverage (44 percent) or did so last when they first became Medicare eligible (14 percent). Overall, 14 percent of Medicare beneficiaries found choice salient in 2000. Those new to Medicare or forced to switch because their plan left the program were more likely to consider choice, as expected. The multi-variate analysis shows that existing HMO enrollment is most strongly associated with salience of choice and also that this effect operates especially in the individual market. The findings of this research are consistent with the literature in highlighting the limited salience of choice to Medicare beneficiaries and the even more limited extent of actual switching that occurs in that market. There is little reason to believe that choice is more salient now than when the study was done. Policymakers who seek to encourage market-based solutions confront a dilemma: How to create incentives for a choice that most beneficiaries do not find particularly salient. [ABSTRACT FROM AUTHOR]

Examines Medicare managed care from beneficiary perspectives and provides information on access to care for the general Medicare population. Percentage increase in Medicare enrollments from 1994-1997; Why the percentage of Medicare beneficiaries enrolled in Health Maintenance Organizations may increase; Results on study of the Medicare program.

Explores the use of fixed versus cost-based per visit payment as an interim payment method for medical care in the United States. Growth of Medicare payment per visit; Difference between the prospective payment and the cost for each visit; Demonstration of a fixed per visit payment method for Medicare home health care.

Focuses on a study to assess the effects of an alternative method of paying home health agencies for services to Medicare beneficiaries, based on a demonstration program. Methodology used in the study; Findings from the study; Conclusion of study.

Reports on preliminary impacts during the first year of a demonstration in which home health agencies (HHAs) were paid a prospectively set rate for each Medicare home health visit rendered, rather than being reimbursed for costs. Comparison of experiences of randomly assigned treatment agencies with control agencies; Absence of demonstration impact on any factors.

Discusses the Health Care Financing Administration's (HCFA) encouragement of health maintenance organizations (HMO) to provide Medicare coverage to enrolled beneficiaries for fixed prepaid premiums. Medicare risk program; Increase in costs to Medicare; Impact of HMOs on service utilization, hospital days, and quality of care; Implications for Medicare risk contracting.

The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative's effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions. The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures. As CMS and other payers increasingly use alternative payment models that reward quality and value, CPC provides important lessons about supporting practices in transforming care. [ABSTRACT FROM AUTHOR]