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Background: Extreme-heat events are increasing as a result of climate change. Prior studies, typically limited to urban settings, suggest an association between extreme heat and cardiovascular mortality. However, the extent of the burden of cardiovascular deaths associated with extreme heat across the United States and in different age, sex, or race and ethnicity subgroups is unclear.Methods: County-level daily maximum heat index levels for all counties in the contiguous United States in summer months (May-September) and monthly cardiovascular mortality rates for adults ≥20 years of age were obtained. For each county, an extreme-heat day was identified if the maximum heat index was ≥90 °F (32.2 °C) and in the 99th percentile of the maximum heat index in the baseline period (1979-2007) for that day. Spatial empirical Bayes smoothed monthly cardiovascular mortality rates from 2008 to 2017 were the primary outcome. A Poisson fixed-effects regression model was estimated with the monthly number of extreme-heat days as the independent variable of interest. The model included time-fixed effects and time-varying environmental, economic, demographic, and health care-related variables.Results: Across 3108 counties, from 2008 to 2017, each additional extreme-heat day was associated with a 0.12% (95% CI, 0.04%-0.21%; P=0.004) higher monthly cardiovascular mortality rate. Extreme heat was associated with an estimated 5958 (95% CI, 1847-10 069) additional deaths resulting from cardiovascular disease over the study period. In subgroup analyses, extreme heat was associated with a greater relative increase in mortality rates among men compared with women (0.20% [95% CI, 0.07%-0.33%]) and non-Hispanic Black compared with non-Hispanic White adults (0.19% [95% CI, 0.01%-0.37%]). There was a greater absolute increase among elderly adults compared with nonelderly adults (16.6 [95% CI, 14.6-31.8] additional deaths per 10 million individuals per month).Conclusions: Extreme-heat days were associated with higher adult cardiovascular mortality rates in the contiguous United States between 2008 and 2017. This association was heterogeneous among age, sex, race, and ethnicity subgroups. As extreme-heat events increase, the burden of cardiovascular mortality may continue to increase, and the disparities between demographic subgroups may widen. [ABSTRACT FROM AUTHOR]

Addressing social determinants of health may help hospitals improve population health and outcomes that are tied to financial incentives, such as readmission rates. Whether this strategy is effective remains unknown. The authors measure the association between nonprofit hospital spending on their community's social needs and Medicare readmission rates. This is a retrospective cohort study (July 2013 to June 2014) that combines Internal Revenue Service tax reports of community benefit spending by private, acute care, nonprofit hospitals with Medicare readmissions data for residents of their surrounding community, the hospital's zip code. Total community benefit spending and 2 of the largest subsets of spending—health care-related and community-directed spending—were measured and normalized as the proportion of each hospital's total expenditure. Associations between quintiles of community benefit spending and Medicare readmission rates were measured using discharge-level multivariate linear regression, adjusting for patient, hospital, community characteristics, and local public health department spending. The sample consisted of 1405 nonprofit hospitals with 341,913 discharges. Associations between readmission rates and total community benefit spending and the health care-related subset were not statistically significant. Discharges from hospitals in the upper quintiles of community-directed spending were associated with lower readmission rates by 0.82 to 1.21 absolute percentage points (P = 0.01 to <0.001) compared to the lowest quintile. The magnitude of associations between community-directed spending and readmissions was larger for preventable readmissions and smaller when including beneficiaries beyond the hospital's zip code. These associations suggest that community-directed spending may be associated with better health care outcomes. [ABSTRACT FROM AUTHOR]

Background: Hospitals are increasingly at risk for post-acute care outcomes and spending, such as those in skilled nursing facilities (SNFs). While hospitalists are thought to improve patient outcomes of acute care, whether these effects extend to the post-acute setting in SNFs is unknown.Objective: To compare longer term outcomes of patients discharged to SNFs who were treated by hospitalists vs. non-hospitalists during their hospitalization.Design: This was a retrospective cohort study.Participants: Participants are Medicare fee-for-service beneficiaries over 66 years of age who were hospitalized and discharged to a SNF in 2012-2014 (N = 2,839,779).Main Measures: We estimated the effect of being treated by a hospitalist on 30-day rehospitalization and mortality, 60-day episode Medicare payments (Parts A and B), and successful discharge to community. Patients discharged to the community within 100 days of SNF admission who remained alive and not readmitted to a hospital or SNF for at least 30 days were considered successfully discharged. All outcomes were adjusted for demographics and clinical characteristics. To account for heterogeneity across facilities, we included hospital fixed effects.Key Results: The 30-day rehospitalization rate was 17.59% for hospitalists' vs. 17.31% for non-hospitalists' patients (adjusted difference, 0.28%; 95% CI, 0.13 to 0.44). Sixty-day payments were $26,301 for hospitalists' vs. $25,996 for non-hospitalists' patients (adjusted difference, $305; 95% CI, $243 to $367). There was a non-significant trend toward lower successful discharge to the community rate (adjusted difference, - 0.26%; 95% CI, - 0.48 to - 0.04) and lower mortality for patients of hospitalists (adjusted difference, - 0.12%; 95% CI, - 0.22 to - 0.02).Conclusions: Among hospitalized Medicare beneficiaries who were discharged to SNFs, readmissions and Medicare costs were slightly higher for stays under the care of hospitalists compared with those of non-hospitalist generalist physicians, but there was a non-significant trend toward lower mortality. [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: To test for differences in patient outcomes when hospital and post-acute care (PAC) providers participate in accountable care organizations (ACOs).Data/setting: Using Medicare claims, we examined changes in readmission, Medicare spending, and length of stay among patients admitted to ACO-participating hospitals and PAC providers.Design: We compared changes in outcomes among patients discharged from ACO-participating hospitals/PACs before and after participation to changes among patients discharged from non-participating hospitals/PACs over the same time period.Results: Patients discharged from an ACO-participating hospitals and skilled nursing facilities (SNF) had lower readmission rates (-1.7 percentage points, p-value = .03) than before ACO participation and non-participants; and lower per-discharge Medicare spending (-$940, p-value = .001), and length of stay (-3.1 days, p-value <.001) in SNF. Effects among ACO-participating hospitals without a co-participating SNF were smaller. Patients discharged from an ACO-participating hospital and home health agency had lower Medicare per-discharge spending (-$209; p-value = .06) and length of stay (-1.6 days, p-value <.001) for home health compared to before ACO participation and non-participants. Discharge from an ACO-participating hospital and inpatient rehabilitation facility did not impact patient outcomes or spending.Conclusions: Hospital and SNF participation in an ACO was associated with lower readmission rates, Medicare spending on SNF, and SNF length of stay. These results lend support to the ACO payment model. [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]

Importance: Medicare's Bundled Payments for Care Improvement (BPCI) initiative for lower extremity joint replacement (LEJR) surgery has been associated with a reduction in episode spending and stable-to-improved quality. However, BPCI may create unintended effects by prompting participating hospitals to increase the overall volume of episodes paid for by Medicare, which could potentially eliminate program-related savings or prompt them to shift case mix to lower-risk patients.Objective: To evaluate whether hospital BPCI participation for LEJR was associated with changes in overall volume and case mix.Design, Setting, and Participants: Observational study using Medicare claims data and a difference-in-differences method to compare 131 markets (hospital referral regions) with at least 1 BPCI participant hospital (n = 322) and 175 markets with no participating hospitals (n = 1340), accounting for 580 043 Medicare beneficiaries treated before (January 2011-September 2013) and 462 161 after (October 2013-December 2015) establishing the BPCI initiative. Hospital-level case-mix changes were assessed by comparing 265 participating hospitals with a 1:1 propensity-matched set of nonparticipating hospitals from non-BPCI markets.Exposures: Hospital BPCI participation.Main Outcomes and Measures: Changes in market-level LEJR volume in the before vs after BPCI periods and changes in hospital-level case mix based on demographic, socioeconomic, clinical, and utilization factors.Results: Among the 1 717 243 Medicare beneficiaries who underwent LEJR (mean age, 75 years; 64% women; and 95% nonblack race/ethnicity), BPCI participation was not significantly associated with a change in overall market-level volume. The mean quarterly market volume in non-BPCI markets increased 3.8% from 3.8 episodes per 1000 beneficiaries before BPCI to 3.9 episodes per 1000 beneficiaries after BPCI was launched. For BPCI markets, the mean quarterly market volume increased 4.4% from 3.6 episodes per 1000 beneficiaries before BPCI to 3.8 episodes per 1000 beneficiaries after BPCI was launched. The adjusted difference-in-differences estimate between the market types was 0.32% (95% CI, -0.06% to 0.69%; P = .10). Among 20 demographic, socioeconomic, clinical, and utilization factors, BPCI participation was associated with differential changes in hospital-level case mix for only 1 factor, prior skilled nursing facility use (adjusted difference-in-differences estimate, -0.53%; 95% CI, -0.96% to -0.10%; P = .01) in BPCI vs non-BPCI markets.Conclusions and Relevance: In this observational study of Medicare beneficiaries who underwent LEJR, hospital participation in Bundled Payments for Care Improvement was not associated with changes in market-level lower extremity joint replacement volume and largely was not associated with changes in hospital case mix. These findings may provide reassurance regarding 2 potential unintended effects associated with bundled payments for LEJR. [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.

Objective: Limited consumer use of health care report cards may be due to the large amount of information presented in report cards, which can be difficult to understand. These limitations may be overcome with summary measures. Our objective was to evaluate consumer response to summary measures in the setting of nursing homes.Data Sources/study Setting: 2005-2010 nursing home Minimum Data Set and Online Survey, Certification and Reporting (OSCAR) datasets.Study Design: In December 2008, Medicare converted its nursing home report card to summary or star ratings. We test whether there was a change in consumer demand for nursing homes related to the nursing home's star rating after the information was released.Principal Findings: The star rating system was associated with a significant change in consumer demand for low- and high-scoring facilities. After the star-based rating system was released, 1-star facilities typically lost 8 percent of their market share and 5-star facilities gained over 6 percent of their market share.Conclusions: The nursing home star rating system significantly affected consumer demand for high- and low-rated nursing homes. These results support the use of summary measures in report cards. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the perceived usefulness of publicly reported nursing home quality indicators.Study Setting: Primary data were collected from October 2013 to August 2014 among a convenience sample of persons (or family member) recently admitted or anticipating admission to a nursing home within 75 miles of the city of Philadelphia.Study Design: Structured interviews were conducted to assess the salience of data on the Medicare Nursing Home Compare website, including star ratings, clinical quality measures, and benchmarking of individual nursing home quality with state and national data.Data Collection: Interviews were transcribed verbatim, independently coded by two reviewers, and agreement determined. A thematic analysis of transcripts was undertaken.Principal Findings: Thirty-five interviews were completed. Eighty-three percent (n = 29) were caregivers and 17 percent (n = 6) were residents. Star ratings, clinical quality measures, and benchmarking information were salient to decision making, with preferred formats varying across participants. Participants desired additional information on the source of quality data. Confusion was evident regarding the relationship between domain-specific and overall star quality ratings.Conclusions: The Nursing Home Compare website provides salient content and formats for consumers. Increased awareness of this resource and clarity regarding the definition of measures could further support informed decision making regarding nursing home choice. [ABSTRACT FROM AUTHOR]

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]

The article discusses research regarding the prevalence of nursing home specialists in American between 2012 and 2015, and it mentions a strategy for improving medical care which involves the employment of medical professionals who specialize in treating hospitalized patients. Nursing home care costs and quality are addressed, along with U.S. Medicare health insurance fee-for-service billing and the claim that 21 percent of the nursing home clinicians in 2015 were nursing home specialists.

Research Objective: To compare the outcomes of post‐acute care between home health (HH) and skilled nursing facilities (SNFs) following hospitalization among Medicare beneficiaries with dementia. Despite the fact that both post‐acute care use and dementia are highly prevalent in the Medicare population, very few studies have compared the outcomes of different post‐acute care settings for patients with dementia, leaving patients, caregivers, and clinicians uncertain how to make optimal decisions around hospital discharge. Study Design: Retrospective analysis of secondary data using an instrumental variable design to compare outcomes of HH versus SNF following an acute hospitalization. We used a 100% sample of Medicare inpatient, outpatient, and post‐acute care claims and assessment data from January 1, 2015 to December 31, 2016 and used differential distance between home health and SNF as the instrumental variable to account for nonrandom allocation of patients (F‐statistic: 26.5). Outcomes included unplanned 30‐day readmission, 30‐ and 100‐day mortality, and a composite measure of readmission and mortality to address competing risks. Our analysis adjusted for beneficiary characteristics and year of analysis, included fixed effects for hospital and year, and adjusted for clustering at the hospital level. Population Studied: We used MedPAR to identify hospitalizations and Minimum Data Set and Outcome and Assessment Information Set assessments to identify SNF and HH stays following hospital discharge. We excluded beneficiaries younger than age 65, admitted to the hospital from a nursing home, or were enrolled in hospice. We identified dementia using validated diagnostic codes with a three‐year look‐back. We also measured demographics, comorbidities, characteristics of the index hospital stay, prior health care utilization, and both cognitive and physical function on admission to post‐acute care. Principal Findings: Our sample included 1,369,192 beneficiaries with a diagnosis of dementia; 404,539 (29.5%) received HH, while 964,653 (70.5%) went to SNF. The cohort was older (mean age 83), approximately 70% were cognitively impaired on SNF admission, and only 30.4% of patients were independent in Activities of Daily Living. Overall, 16.1% were readmitted to the hospital and 5.9% died within 30 days, while 19.5% died within 100 days of hospital discharge. In the instrumental variable analysis, there were no differences in any outcome between the two post‐acute care settings. These findings were similar when the analysis was stratified by degree of cognitive impairment. Conclusions: In a sample of more than 1.6 million Medicare beneficiaries discharged to post‐acute care following hospitalization, use of home health services and SNF were equivalent in terms of unplanned readmissions and 30‐ and 100‐day mortality. These are important findings given more than 7 in 10 Medicare beneficiaries with dementia are currently discharged to SNF for post‐acute care at much higher cost than HH, and the prevalence of both dementia and post‐acute care use are increasing in the United States. Implications for Policy or Practice: Our findings suggest HH may provide similar outcomes at lower cost following hospitalization for Medicare beneficiaries with a diagnosis of dementia, and that home‐based models of care may provide increased post‐acute care value. Primary Funding Source: University of Pennsylvania Institute on Aging. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effect of medical home implementation on primary care delivery in the Veterans Health Administration ( VHA). Data Sources/Study Setting/Study Design We link interview-based qualitative data on medical home implementation to quantitative outcomes from VHA clinical encounter data. We use a longitudinal analysis with provider fixed effects (taking advantage of variation in timing of implementation and allowing each provider to serve as a control for him or herself) to test whether patient-aligned care team ( PACT) implementation was associated with changes in organizational processes and patient outcomes. Principal Findings Among 683 PCPs, caring for 321,295 patients, the uptake of eight of nine PACT structural changes significantly increased from July 2010 to June 2012 as did the percentage of primary care appointments occurring by telephone and hospital discharges contacted within 2 days of discharge. We found that PACT implementation was associated with significant improvements in 2-day post-hospital discharge contact, but not primary care visits occurring by telephone or within 3 days of the requested date. We found no association between medical home implementation and rates of emergency department use by patients. Conclusions Medical home implementation at the VHA resulted in large changes in the structure of care but few changes in patient-level outcomes. These results highlight both the complexity of studying the effect of the medical home as well as implementing this model to change primary care delivery. [ABSTRACT FROM AUTHOR]

Objectives To assess whether reductions in physical restraint use associated with quality reporting may have had the unintended consequence of increasing antipsychotic use in nursing home ( NH) residents with severe cognitive impairment. Design Retrospective analysis of NH clinical assessment data from 1999 to 2008 comparing NHs subject to public reporting of physical restraints with nonreporting NHs. Setting Medicare- and Medicaid-certified NHs in the United States. Participants Observations (N = 3.9 million) on 809,645 residents with severe cognitive impairment in 4,258 NHs in six states. Intervention Public reporting of physical restraint use rates. Measurements Use of physical restraints and antipsychotic medications. Results Physical restraint use declined significantly from 1999 to 2008 in NH residents with severe cognitive impairment. The decline was larger in NHs that were subject to reporting of restraints than in those that were not (-8.3 vs -3.3 percentage points, P < .001). Correspondingly, antipsychotic use in the same residents increased more in NHs that were subject to public reporting (4.5 vs 2.9 percentage points, P < .001). Approximately 36% of the increase in antipsychotic use may be attributable to public reporting of physical restraints. Conclusion This analysis suggests that public reporting of physical restraint use had the unintended consequence of increasing use of antipsychotics in NH residents with severe cognitive impairment. [ABSTRACT FROM AUTHOR]

Objective Pay-for-performance (P4P) is commonly used to improve health care quality in the United States and is expected to be frequently implemented under the Affordable Care Act. However, evidence supporting its use is mixed with few large-scale, rigorous evaluations of P4P. This study tests the effect of P4P on quality of care in a large-scale setting-the implementation of P4P for nursing homes by state Medicaid agencies. Data Sources/Study Setting 2001-2009 nursing home Minimum Data Set and Online Survey, Certification, and Reporting ( OSCAR) datasets. Study Design Between 2001 and 2009, eight state Medicaid agencies adopted P4P programs in nursing homes. We use a difference-in-differences approach to test for changes in nursing home quality under P4P, taking advantage of the variation in timing of implementation across these eight states and using nursing homes in the 42 non-P4P states plus Washington, DC as contemporaneous controls. Principal Findings Quality improvement under P4P was inconsistent. While three clinical quality measures (the percent of residents being physically restrained, in moderate to severe pain, and developed pressure sores) improved with the implementation of P4P in states with P4P compared with states without P4P, other targeted quality measures either did not change or worsened. Of the two structural measures of quality that were tied to payment (total number of deficiencies and nurse staffing) deficiency rates worsened slightly under P4P while staffing levels did not change. Conclusions Medicaid-based P4P in nursing homes did not result in consistent improvements in nursing home quality. Expectations for improvement in nursing home care under P4P should be tempered. [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]

Medicare's new hospital pay-for-performance program for all acute care hospitals will begin in October 2012. It will be the largest Medicare quality improvement initiative for hospitals to date. Using 2009 data on hospital performance, we calculated hospital performance scores and projected payments under the new program for all eligible hospitals. Despite differences across hospitals in terms of performance, expected changes in payments were small, even for hospitals with the best and worst performance scores. Almost two-thirds of hospitals would experience changes of just a fraction of 1 percent. Although the program will in effect redistribute resources among hospitals, our data suggest that the redistribution is not likely to cause major problems because the amount being redistributed is also small. These results raise questions about whether the new pay-for-performance program will substantially alter the quality of hospital care, and they highlight the challenges of designing effective quality improvement incentives. [ABSTRACT FROM AUTHOR]

To test whether public reporting in the setting of postacute care in nursing homes results in changes in patient sorting. All postacute care admissions from 2001 to 2003 in the nursing home Minimum Data Set. We test changes in patient sorting (or the changes in the illness severity of patients going to high- versus low-scoring facilities) when public reporting was initiated in nursing homes in 2002. We test for changes in sorting with respect to pain, delirium, and walking and then examine the potential roles of cream skimming and downcoding in changes in patient sorting. We use a difference-in-differences framework, taking advantage of the variation in the launch of public reporting in pilot and nonpilot states, to control for underlying trends in patient sorting. There was a significant change in patient sorting with respect to pain after public reporting was initiated, with high-risk patients being more likely to go to high-scoring facilities and low-risk patients more likely to go to low-scoring facilities. There was also an overall decrease in patient risk of pain with the launch of public reporting, which may be consistent with changes in documentation of pain levels (or downcoding). There was no significant change in sorting for delirium or walking. Public reporting of nursing home quality improves matching of high-risk patients to high-quality facilities. However, efforts should be made to reduce the incentives for downcoding by nursing facilities. [ABSTRACT FROM AUTHOR]

To examine whether high performance or improvement on quality measures leads to economic rewards for nursing homes in the presence of public reporting. Data from 6,286 freestanding Medicare-certified nursing homes between 1999 and 2005 were identified in Medicare Cost Reports, Minimum Data Set, and Online Survey and Certification Reporting System. Using a facility-level fixed-effects model, the effect of public reporting on financial performance was measured by comparing each of four financial outcomes (revenues, expenses, operating, and total profit margins) before (1999-2002) to after (2003-2005) public reporting was initiated. The effects were estimated separately by level of performance and improvement over time. Facilities that improved on publicly reported performance had increased revenues and higher profit margins after public reporting, mainly through increased Medicare admissions. High-scoring facilities showed similar patterns, though differences were not statistically significant. Providers that improve their performance under public reporting may receive a return on their investment in quality improvement. This supports the business case for public reporting. [ABSTRACT FROM AUTHOR]

The Centers for Medicare and Medicaid Services publicly reports so-called process performance at all U.S. hospitals, such as whether certain recommended treatments are given to specific types of patients. We examined whether hospital performance on key process indicators improved during the three years since this reporting began. We also studied whether or not these changes improved patient outcomes or yielded other quality improvements, such as reduced hospital readmission rates. We found that, from 2004 to 2006, hospital process performance improved and was associated with better patient and quality outcomes. Most notably, for acute myocardial infarction, performance improvements were associated with declines in mortality rates, lengths-of-stay, and readmission rates. Although we cannot conclude that public reporting caused the improvement in processes or outcomes, these results are encouraging, since improving process performance may improve quality more broadly. [ABSTRACT FROM AUTHOR]

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]

Recent trends in U.S. long-term care policy reflect three broad goals Americans have for the quality of long-term care: improving quality of life, reducing fragmentation of delivery and financing, and increasing use of home and community-based care. At the same time, market-based reforms-namely, public reporting and pay-for-performance-have taken on their own momentum, aimed at improving the clinical quality of care among nursing home and home health care providers. The focus of reporting systems should be broadened to include quality of life in addition to clinical quality and to make measures less dependent on the setting in which care is delivered. [ABSTRACT FROM AUTHOR]

A growing body of evidence documents pervasive racial, ethnic, and class disparities in long-term care in the United States. At the same time, major quality improvement initiatives are being implemented that rely on market-based incentives, many of which may have the unintended consequence of exacerbating disparities. We review existing evidence on disparities in the use and quality of long-term care services, analyze current market-based policy initiatives in terms of their potential to ameliorate or exacerbate these disparities, and suggest policies and policy modifications that may help decrease disparities. We find that racial disparities in the use of formal long-term care have decreased over time. Disparities in quality of care are more consistently documented and appear to be related to racial and socioeconomic segregation of long-term care facilities as opposed to within-provider discrimination. Market-based incentives policies should explicitly incorporate the goal of mitigating the potential unintended consequence of increased disparities. [ABSTRACT FROM AUTHOR]

Objective. Evidence supporting the use of public reporting of quality information to improve health care quality is mixed. While public reporting may improve reported quality, its effect on quality of care more broadly is uncertain. This study tests whether public reporting in the setting of nursing homes resulted in improvement of reported and broader but unreported quality of postacute care. Data Sources/Study Setting. 1999–2005 nursing home Minimum Data Set and inpatient Medicare claims. Study Design. We examined changes in postacute care quality in U.S. nursing homes in response to the initiation of public reporting on the Centers for Medicare and Medicaid Services website, Nursing Home Compare. We used small nursing homes that were not subject to public reporting as a contemporaneous control and also controlled for patient selection into nursing homes. Postacute care quality was measured using three publicly reported clinical quality measures and 30-day potentially preventable rehospitalization rates, an unreported measure of quality. Principal Findings. Reported quality of postacute care improved after the initiation of public reporting for two of the three reported quality measures used in Nursing Home Compare. However, rates of potentially preventable rehospitalization did not significantly improve and, in some cases, worsened. Conclusions. Public reporting of nursing home quality was associated with an improvement in most postacute care performance measures but not in the broader measure of rehospitalization. [ABSTRACT FROM AUTHOR]

Background: Studies suggest that most hospitals now have relatively high adherence with recommended acute myocardial infarction (AMI) process measures. Little is known about hospitals with consistently poor adherence with AMI process measures and whether these hospitals also have increased patient mortality.Methods and Results: We conducted a retrospective study of 2761 US hospitals reporting AMI process measures to the Center for Medicare and Medicaid Services Hospital Compare database during 2004 to 2006 that could be linked to 2005 Medicare Part A data. The main outcome measures were hospitals' combined compliance with 5 AMI measures (aspirin and beta-blocker on admission and discharge and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use at discharge for patients with left ventricular dysfunction) and risk-adjusted 30-day mortality for 2005. We stratified hospitals into those with low AMI adherence (ranked in the lowest decile for AMI adherence for 3 consecutive years [2004-2006, n=105]), high adherence (ranked in the top decile for 3 consecutive years [n=63]), and intermediate adherence (all others [n=2593]). Mean AMI performance varied significantly across low-, intermediate-, and high-performing hospitals (mean score, 68% versus 92% versus 99%, P<0.001). Low-performing hospitals were more likely than intermediate- and high-performing hospitals to be safety-net providers (19.2% versus 11.0% versus 6.4%; P=0.005). Low-performing hospitals had higher unadjusted 30-day mortality rates (23.6% versus 17.8% versus 14.9%; P<0.001). These differences persisted after adjustment for patient characteristics (16.3% versus 16.0% versus 15.7%; P=0.02).Conclusions: Consistently low-performing hospitals differ substantially from other US hospitals. Targeting quality improvement efforts toward these hospitals may offer an attractive opportunity for improving AMI outcomes. [ABSTRACT FROM AUTHOR]

Objective. The impact of quality improvement incentives on nontargeted care is unknown and some have expressed concern that such incentives may be harmful to nontargeted areas of care. Our objective is to examine the effect of publicly reporting quality information on unreported quality of care. Data Sources/Study Setting. The nursing home Minimum Data Set from 1999 to 2005 on all postacute care admissions. Study Design. We studied 13,683 skilled nursing facilities and examined how unreported aspects of clinical care changed in response to changes in reported care after public reporting was initiated by the Centers for Medicare and Medicaid Services on their website, Nursing Home Compare, in 2002. Principal Findings. We find that overall both unreported and reported care improved following the launch of public reporting. Improvements in unreported care were particularly large among facilities with high scores or that significantly improved on reported measures, whereas low-scoring facilities experienced no change or worsening of their unreported quality of care. Conclusions. Public reporting in the setting of postacute care had mixed effects on areas without public reporting, improving in high-ranking facilities, but worsening in low-ranking facilities. While the benefits of public reporting may extend beyond areas that are being directly measured, these initiatives may also widen the gap between high- and low-quality facilities. [ABSTRACT FROM AUTHOR]

To describe recent trends in post-acute care provision within nursing homes, focusing specifically on nursing homes' degree of specialization in post-acute care. Retrospective cohort study. All US nursing homes between 2001 and 2017 and all fee-for-service Medicare admissions to nursing homes for post-acute care during that time. We measured post-acute care specialization as annual Medicare admissions per bed for each nursing home and examined changes in the distribution of specialization across nursing homes over the study period. We described the characteristics of nursing homes and the patients they serve based on degree of specialization. The average number of Medicare admissions per bed increased from 1.2 in 2001 to 1.6 in 2017, a relative increase of 41%. This upward trend in the number of Medicare admissions per bed was largest among new nursing homes (those established after 2001), increasing 68% from 2001 to 2017. In contrast, nursing homes that eventually closed during the study period experienced no meaningful growth in the number of admissions per bed. Over time, the number of Medicare admissions per bed increased among highly specialized nursing homes. The number of Medicare admissions per bed grew by 66% at the 95th percentile and by 25% at the 99th percentile. Nursing homes delivering the most post-acute care were more likely to be for-profit or part of a chain, had higher staffing levels, and were less likely to admit patients who were Black, Hispanic, or dually enrolled in Medicare and Medicaid. Over the last 2 decades, post-acute care has become increasingly concentrated in a subset of nursing homes, which tend to be for-profit, part of a chain, and less likely to serve racial and ethnic minorities and persons on Medicaid. Although these nursing homes may benefit financially from higher Medicare payment, it may come at the expense of equitable access and patient care. [ABSTRACT FROM AUTHOR]

The article presents a study examining trends in disparities in the quality of medical care between hospitals with a high and low percentage of Medicaid patients. The design and setting of the longitudinal study using public data on hospital performance for Medicaid patients between 2004 and 2006 are detailed. The outcomes measured changes in medical performance to estimate disparities in hospital quality during the period studied. Results showed that hospitals that treated a high percentage of Medicaid patients had a reduced chance of achieving high-performance status and were more likely to incur financial penalties for low performance ratings.

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.

Discusses why physicians are unwilling to acknowledge the presence the scarcity or the influence that it has on their practice in the U.S. Potential consequences of this denial on patients and the health care system; Patient placement on organ waiting lists; Fiscal scarcity in primary care; Prevention of the development of fair allocation systems.

Current workforce projections estimate that there is a shortage of child neurologists. We surveyed child neurology residents to learn more about the entry point for a career in child neurology: what attracts current residents to the field of child neurology and what the future career plans of child neurology residents are. Most respondents (52%) were exposed to child neurology for the first time in their third or fourth year of medical school, with 41% reporting that they chose the specialty at that time. US medical graduates identified having a mentor as one of the most influential exposures in their career choice. Respondents predict that they will spend less time on patient care and more time on research than current practicing child neurologists report. When asked about what could improve the attractiveness of the field, residents responded that medical students should get increased and earlier exposure to child neurology. Given the declining number of individuals pursuing a career in child neurology and that current residents predict that they will spend less time seeing patients than their predecessors do, understanding how to attract more candidates to child neurology will be essential to alleviate future shortages in child neurology. (J Child Neurol 2004;19:6-13). [ABSTRACT FROM AUTHOR]

Presents the findings of a survey which assessed public attitudes regarding physician deception of insurance companies in Philadelphia, Pennsylvania. Percentage of respondents who sanctioned deception; Association between preferences regarding insurance company deception and perceptions of physician workload.

Patient engagement is an integral part of patient-centered care and focuses on active patient involvement by supporting patient participation in health care decisions.[3] Patient engagement is also a part of the VHA's current strategic plan which states that VHA should provide health care that "engages and inspires Veterans to their highest possible level of health and well-being."[4] After collecting data through semi-structured, qualitative interviews and site visits, transcripts were coded and analyzed to produce a list of patient engagement activities used by VHA Primary Care staff nationwide. [Extracted from the article]

In this article the authors discuss strategies to improve the quality of medical care in the U.S. They are critical of a lack of progress which has been made in improving the quality of medical care in the U.S. Also discussed are incentives that could be initiated which could provide incentives to improve quality and to reward excellent medical care.

This study uses MedPAR data to characterize trends in use of skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) after acute care hospitalizations and trends in hospital and SNF/IRF lengths of stay among Medicare beneficiaries. [ABSTRACT FROM AUTHOR]

OBJECTIVES: First, to assess whether hospitals expand the network breadth of their health information exchange (HIE) partners after joining an accountable care organization (ACO). Second, to analyze whether this HIE network expansion effect varies across markets with differing levels of ACO penetration. STUDY DESIGN: Difference-in-differences analyses of US nonfederal acute care hospitals, 2014-2017. METHODS: We used data from the American Hospital Association Annual Survey and Information Technology Supplement to measure hospital ACO participation, HIE network breadth (defined as number of different partner types), and ACO market penetration at the hospital referral region level. We implemented a difference-in-differences model to estimate changes in hospitals' HIE network breadth with ACO participation in different years. We estimate these effects combined across all markets and stratified by markets with high and low ACO market penetration. RESULTS: In combined analyses, HIE breadth increased by 0.35 partner types with ACO participation, a 30.7% increase (P < .001). In stratified analyses, this effect was larger for hospitals in high--ACO penetration markets (0.41 partner types, a 32.0% increase; P < .001) and smaller for hospitals in low--ACO penetration markets (0.25 partner types, a 24.8% increase; P < .05). We found dynamic effects of ACO adoption illustrating an immediate effect in high--ACO penetration markets and a 2-year delayed effect in low--ACO penetration markets. CONCLUSIONS: Hospitals that joined ACOs increased their HIE breadth, but this effect was heterogenous across markets and across time. Our findings illustrate a "network effect," with large, immediate effects in HIE breadth following ACO participation in high--ACO penetration markets and smaller, delayed effects in low--ACO penetration markets. [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]

Early evidence suggested that accountable care organizations (ACOs) could improve health care quality while constraining costs, and ACOs are expanding throughout the United States. However, if disadvantaged patients have unequal access to physicians who participate in ACOs, that expansion may exacerbate health care disparities. We examined the relationship between physicians' participation in both Medicare and commercial ACOs across the country and the sociodemographic characteristics of their likely patient populations. Physicians' participation in ACOs varied widely across hospital referral regions, from nearly 0 percent to over 85 percent. After we adjusted for individual physician and practice characteristics, we found that physicians who practiced in ZIP Code Tabulation Areas where a higher percentage of the population was black, living in poverty, uninsured, or disabled or had less than a high school education--compared to other areas--had significantly lower rates of ACO participation than other physicians. Our findings suggest that vulnerable populations' access to physicians participating in ACOs may not be as great as access for other groups, which could exacerbate existing disparities in health care quality. [ABSTRACT FROM AUTHOR]

Market-based reforms in health care, such as public reporting of quality, may inadvertently exacerbate disparities. We examined how the Centers for Medicare and Medicare Services' five-star rating system for nursing homes has affected residents who are dually enrolled in Medicare and Medicaid ("dual eligibles"), a particularly vulnerable and disadvantaged population. Specifically, we assessed the extent to which dual eligibles and non-dual eligibles avoided the lowest-rated nursing homes and chose the highest-rated homes once the five-star rating system began, in late 2008. We found that both populations resided in better- quality homes over time but that by 2010 the increased likelihood of choosing the highest-rated homes was substantially smaller for dual eligibles than for non-dual eligibles. Thus, the gap in quality, as measured by a nursing home's star rating, grew over time. Furthermore, we found that the benefit of the five-star system to dual eligibles was largely due to providers' improving their ratings, not to consumers' choosing different providers. We present evidence suggesting that supply constraints play a role in limiting dual eligibles' responses to quality ratings, since high-quality providers tend to be located close to relatively affluent areas. Increases in Medicaid payment rates for nursing home services may be the only long-term solution. [ABSTRACT FROM AUTHOR]

Increasing recognition of the adverse events older adults experience in post-acute care in skilled nursing facilities (SNFs) has led to multiple efforts to improve care integration between hospitals and SNFs. We sought to measure current care integration activities between hospitals and SNFs. Cross-sectional survey. A total of 500 randomly selected Medicare-certified SNFs in the United States in 2019. The survey inquired about 12 care integration activities with the 2 highest volume referring hospitals for each SNF. We collapsed survey responses into 5 categories of integration based on high correlations between the individual measures. These were: (1) formal integration (co-location or co-ownership); (2) informal integration (eg, formal affiliation, participation in SNF collaborative, shared pay for performance, or clinical leadership meetings between hospital and SNF); (3) shared quality/safety activities (eg, initiatives to improve medication safety or reduce hospital admission); (4) shared care coordinators; and/or (5) shared supervising clinicians. We then conducted multivariate regressions to examine associations between different care integration activities and hospital/SNF characteristics. Our overall response rate was 53.0%, including 265 SNFs that represented 487 SNF-hospital pairs. Informal integration was most common (in 53.3% of pairs), whereas shared clinicians (43.0%), care coordinators (36.5%), shared quality/safety activities (35.1%), and formal integration (7.4%) were present in a minority. Hospital-SNF pairs had lower odds of being formally integrated if the SNF was for-profit compared with not-for-profit [odds ratio (OR) 0.11, 95% confidence interval (CI) 0.03–0.42, adjusted P =.04)] and higher odds of sharing quality improvement activities in metropolitan rather than rural areas (OR 4.06, 95% CI 1.80–9.17, adjusted P =.02) and in the Midwest compared with West (OR 2.95, 95% CI 1.44–6.06, adjusted P =.049). These findings raise important questions about what is driving variability in hospital-SNF integration activities, and which activities may be most effective for improving transitional care outcomes. [ABSTRACT FROM AUTHOR]

Background: Efforts to increase transparency and accountability of nursing homes, and thus improve quality, now include information about changes in nursing home ownership. However, little is known about how change in ownership affects nursing home quality., Methods: We conducted a retrospective cohort study of 15,471 U.S. nursing homes between January 2016 and December 2022, identifying all changes in ownership during that period. We used logistic regression to measure the association between nursing home characteristics and the odds of a change in ownership. A difference-in-differences model with multiple time periods was used to examine the impact of a change in ownership on the Medicare Nursing Home Compare 5-star ratings., Results: One in five (23%) facilities changed ownership between 2016 and 2022. Nursing homes that were urban, for-profit, part of a chain, located in the South, had >50 beds, lower occupancy, higher percentage of stays covered by Medicaid, higher percentage of residents with non-white race, or a 1-star (poor) rating were more likely to undergo a change in ownership. There was a small statistically significant decrease in 5-star ratings after a change in ownership (-0.09 points on a 5-point scale; 95% CI -0.13 to -0.04; p < 0.001), driven primarily by a decrease in staffing ratings (-0.19 points; 95% CI -0.24 to -0.14; p < 0.001), and health inspections ratings (-0.07 points; 95% CI -0.11 to -0.03; p = 0.001). This was mitigated by an increase in quality measure ratings (0.15 points; 95% CI 0.10-0.20; p < 0.001)., Conclusion: Nursing Home Compare ratings decreased slightly after a change in facility ownership, driven by lower staffing and health inspection ratings and mitigated somewhat by higher quality measure ratings. These conflicting trends underscore the need for transparency around changes in facility ownership and a better understanding of consequences of changes in ownership that are salient to patients and families., (© 2024 The American Geriatrics Society.)

Objective: Medicaid-funded long-term services and supports are increasingly provided through home- and community-based services (HCBS) to promote continued community living. While an emerging body of evidence examines the direct benefits and costs of HCBS, there may also be unexplored synergies with Medicare-funded post-acute care (PAC). This study aimed to provide empirical evidence on how the use of Medicaid HCBS influences Medicare PAC utilization among the dually enrolled., Data Sources: National Medicare claims, Medicaid claims, nursing home assessment data, and home health assessment data from 2016 to 2018., Study Design: We estimated the relationship between prior Medicaid HCBS use and PAC (skilled nursing facilities [SNF] or home health) utilization in a national sample of duals with qualifying index hospitalizations. We used inverse probability weights to create balanced samples on observed characteristics and estimated multivariable regression with hospital fixed effects and extensive controls. We also conducted stratified analyses for key subgroups., Data Extraction Methods: The primary sample included 887,598 hospital discharges from community-dwelling duals who had an eligible index hospitalization between April 1, 2016, and September 30, 2018., Principal Findings: We found HCBS use was associated with a 9 percentage-point increase in the use of home health relative to SNF, conditional on using PAC, and a meaningful reduction in length of stay for those using SNF. In addition, in our primary sample, we found HCBS use to be associated with an overall increase in PAC use, given that the absolute increase in home health use was larger than the absolute decrease in SNF use. In other words, the use of Medicaid-funded HCBS was associated with a shift in Medicare-funded PAC use toward home-based settings., Conclusion: Our findings indicate potential synergies between Medicaid-funded HCBS and increased use of home-based PAC, suggesting policymakers should cautiously consider these dynamics in HCBS expansion efforts., (© 2024 The Author(s). Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Dual-eligible beneficiaries have insurance through two distinct and uncoordinated programs: Medicaid, which pays for long-term care; and Medicare, which pays for medical care, including hospital stays. Concern that this system leads to poor quality and inefficient care, particularly for dual-eligible nursing home residents, has led policy makers to test managed care plans that provide incentives for coordinating care across Medicare and Medicaid. We examined enrollment in three such plans among dual-eligible beneficiaries receiving long-term nursing home care. Two of those plans, Medicare-Medicaid plans and Fully Integrated Dual Eligible Special Needs Plans, are integrated care plans that establish a global budget including Medicare and Medicaid spending. The third, Institutional Special Needs Plans, puts insurers and nursing homes at risk for Medicare spending but not Medicaid spending. Among dual-eligible nursing home residents, enrollment in these plans increased from 6.5 percent of residents per month in 2013 to 16.9 percent in 2020. Enrollment varied across counties but did not vary appreciably with respect to nursing home characteristics, including the share of residents with Medicaid. As policy makers pursue strategies to coordinate medical and long-term care for dual-eligible beneficiaries, it remains critical to evaluate how these plans influence the care of dual-eligible nursing home residents.

Importance: Treating low back pain (LBP) often involves a combination of pharmacologic, nonpharmacologic, and interventional treatments; one approach is acupuncture therapy, which is safe, effective, and cost-effective. How acupuncture is used within pain care regimens for LBP has not been widely studied., Objective: To document trends in reimbursed acupuncture between 2010 and 2019 among a large sample of patients with LBP, focusing on demographic, socioeconomic, and clinical characteristics associated with acupuncture use and the nonpharmacologic, pharmacologic, and interventional treatments used by patients who utilize acupuncture., Design, Setting, and Participants: This cross-sectional study included insurance claims of US adults in a deidentified database. The study sample included patients diagnosed with LBP between 2010 and 2019. Data were analyzed between September 2023 and June 2024., Main Outcomes and Measures: Changes in rates of reimbursed acupuncture utilization between 2010 and 2019, including electroacupuncture use, which involves the electrical stimulation of acupuncture needles. Covariates included age, sex, race and ethnicity, income, educational attainment, region, and a chronic LBP indicator. Secondary analyses tracked other nonpharmacologic treatments (eg, physical therapy, chiropractic care), pharmacologic treatments (eg, opioids, gabapentinoids), and interventional treatments (eg, epidural steroid injections)., Results: The total sample included 6 840 497 adults with LBP (mean [SD] age, 54.6 [17.8] years; 3 916 766 female [57.3%]; 802 579 Hispanic [11.7%], 258 087 non-Hispanic Asian [3.8%], 804 975 non-Hispanic Black [11.8%], 4 974 856 non-Hispanic White [72.7%]). Overall, 106 485 (1.6%) had 1 or more acupuncture claim, while 61 503 (0.9%) had 1 or more electroacupuncture claim. The rate of acupuncture utilization increased consistently, from 0.9% in 2010 to 1.6% in 2019; electroacupuncture rates were relatively stable. Patients who were female (male: odds ratio [OR], 0.68; 99% CI, 0.67-0.70), Asian (OR, 3.26; 99% CI, 3.18-3.35), residing in the Pacific region (New England: OR, 0.26; 99% CI, 0.25-0.28), earning incomes of over $100 000 (incomes less than $40 000: OR, 0.59; 99% CI, 0.57-0.61), college educated (high school or less: OR, 0.32; 99% CI, 0.27-0.35), and with chronic LBP (OR, 2.39; 99% CI, 2.35-2.43) were more likely to utilize acupuncture. Acupuncture users were more likely to engage in other nonpharmacologic pain care like physical therapy (39.2%; 99% CI, 38.9%-39.5% vs 29.3%; 99% CI, 29.3%-29.3%) and less likely to utilize prescription drugs, including opioids (41.4%; 99% CI, 41.1%-41.8% vs 52.5%; 99% CI, 52.4%-52.5%), compared with nonusers., Conclusions and Relevance: In this cross-sectional study, we found that acupuncture utilization among patients with LBP was rare but increased over time. Demographic, socioeconomic, and clinical characteristics were associated with acupuncture utilization, and acupuncture users were more likely to utilize other nonpharmacologic treatments and less likely to utilize pharmacologic treatments.

Nursing homes serve both long-term care and post-acute care (PAC) patients, two groups with distinct financing mechanisms and requirements for care. We examine empirically the effect of nursing home specialization in PAC using 2011-2018 data for Medicare patients admitted to nursing homes following a hospital stay. To address patient selection into specialized nursing homes, we use an instrumental variables approach that exploits variation over time in the distance from the patient's residential ZIP code to the closest nursing home with different levels of PAC specialization. We find that patients admitted to nursing homes more specialized in PAC have lower hospital readmissions and mortality, longer nursing home stays, and higher Medicare spending for the episode of care, suggesting that specialization improves patient outcomes but at higher costs., (Copyright © 2023. Published by Elsevier B.V.)

We sought to explore the heterogeneity among patients hospitalized with pneumonia, a condition targeted in payment reform. In a retrospective cohort study of Medicare beneficiaries hospitalized for pneumonia, we compared postacute care utilization and costs of 90-day episodes of care among patients with and without comorbidities of chronic obstructive pulmonary disease (COPD) and/or heart failure. Of the 1,926,674 discharges, 28.1% had COPD, 14.3% had heart failure, and 14.6% carried both diagnoses. Patients with pneumonia were more likely to be discharged to a facility than those with pneumonia and COPD with or without heart failure, though less likely than those with pneumonia and heart failure only. Compared to patients with pneumonia only, patients with COPD and/or heart failure had higher episode payments. Acute conditions such as pneumonia may hold promise for episode-based care payment reform; however, the heterogeneity within this diagnosis indicates the need to consider other patient characteristics in interventions to improve value-based care., (© 2023 Society of Hospital Medicine.)