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Objective Data Sources Study Design Data Extraction Methods Principal Findings Conclusion 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.National Medicare claims, Medicaid claims, nursing home assessment data, and home health assessment data from 2016 to 2018.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.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.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.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. [ABSTRACT FROM AUTHOR]

Objective: Racial and ethnic minority enrollees in Medicare Advantage (MA) plans tend to be in lower‐quality plans, measured by a 5‐star quality rating system. We examine whether differential access to high‐rated plans was associated with this differential enrollment in high‐rated plans by race and ethnicity among MA enrollees. Data Sources: The Medicare Master Beneficiary Summary File and MA Landscape File for 2016. Study Design: We first examined county‐level MA plan offerings by race and ethnicity. We then examined the association of racial and ethnic differences in enrollment by star rating by controlling for the following different sets of covariates: (1) individual‐level characteristics only, and (2) individual‐level characteristics and county‐level MA plan offerings. Data Collection/Extraction Methods: Not applicable Principal Findings: Racial and ethnic minority enrollees had, on average, more MA plans available in their counties of residence compared to White enrollees (16.1, 20.8, 20.2, vs. 15.1 for Black, Asian/Pacific Islander, Hispanic, and White enrollees), but had fewer number of high‐rated plans (4‐star plans or higher) and/or more number of low‐rated plans (3.5‐star plans or lower). While racial and ethnic minority enrollees had lower enrollment in 4–4.5 star plans than White enrollees, this difference substantially decreased after accounting for county‐level MA plan offerings (−9.1 to −0.5 percentage points for Black enrollees, −15.9 to −5.0 percentage points for Asian/Pacific Islander enrollees, and −12.7 to 0.6 percentage points for Hispanic enrollees). Results for Black enrollees were notable as the racial difference reversed when we limited the analysis to those who live in counties that offer a 5‐star plan. After accounting for county‐level MA plan offerings, Black enrollees had 3.2 percentage points higher enrollment in 5‐star plans than White enrollees. Conclusions: Differences in enrollment in high‐rated MA plans by race and ethnicity may be explained by limited access and not by individual characteristics or enrollment decisions. [ABSTRACT FROM AUTHOR]

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]

The COVID-19 pandemic revealed fundamental problems with the structure of long-term care financing and payment in the United States. The piecemeal system that exists suffers from several key problems, including underfunding, fragmentation across types and sites of care, and substantial variation in payment across states and populations. These problems result in inefficient allocation of resources, limited access to care, substandard quality, and inequities in both access and quality. We propose a new federal benefit for long-term care, most likely as part of the Medicare program. Essential features of this benefit include taxpayer subsidies, along the lines of other Medicare benefits, and coverage across the range of long-term care services, including both residential and home- and community-based care. A new federal benefit has the most potential to break down administrative barriers and improve resource allocation, to ensure adequate payment rates across all states, to expand access to care by spreading risk across the entire Medicare population, and to improve equity by extending coverage to all Medicare beneficiaries who want it. A new federal benefit is politically challenging, requiring bold action by Congress, and entails the risks of administrative challenges and unintended consequences. However, in this case, retaining the status quo remains the far greater risk. [ABSTRACT FROM AUTHOR]

Informal care, or care provided by family and friends, is the most common form of care received by community-dwelling older adults with functional limitations. However, less is known about informal care provision within residential care settings including residential care facilities (for example, assisted living) and nursing homes. Using data from the Health and Retirement Study (2016) and the National Health and Aging Trends Study (2015), we found that informal care was common among older adults with functional limitations, whether they lived in the community, a residential care facility, or a nursing home. The hours of informal care provided were also nontrivial across all settings. This evidence suggests that informal caregiving and some of the associated burdens do not end when a person transitions from the community to residential care or a nursing home setting. It also points to the large role that families play in the care and well-being of these residents, which is especially important considering the recent visitor bans during the COVID-19 epidemic. Family members are an invisible workforce in nursing homes and residential care facilities, providing considerable front-line work for their loved ones. Providers and policy makers could improve the lives of both the residents and their caregivers by acknowledging, incorporating, and supporting this workforce. [ABSTRACT FROM AUTHOR]

To examine the effect of the COVID-19 pandemic on post-acute care utilization and spending. We used a large national multipayer claims data set from January 2019 through October 2020 to examine trends in posthospital discharge location and spending. We identified and included 975,179 hospital discharges who were aged ≥65 years. We summarized postdischarge utilization and spending in each month of the study: (1) the percentage of patients discharged from the hospital to home for self-care and to the 3 common post-acute care locations: home with home health, skilled nursing facility (SNF), and inpatient rehabilitation; (2) the rate of discharge to each location per 100,000 insured members in our cohort; (3) the total amount spent per month in each post-acute care location; and (4) the percentage of spending in each post-acute care location out of the total spending across the 3 post-acute care settings. The percentage of patients discharged from the hospital to home or to inpatient rehabilitation did not meaningfully change during the pandemic whereas the percentage discharged to SNF declined from 19% of discharges in 2019 to 14% by October 2020. Total monthly spending declined in each of the 3 post-acute care locations, with the largest relative decline in SNFs of 55%, from an average of $42 million per month in 2019 to $19 million in October 2020. Declines in total monthly spending were smaller in home health (a 41% decline) and inpatient rehabilitation (a 32% decline). As a percentage of all post-acute care spending, spending on SNFs declined from 39% to 31%, whereas the percentage of post-acute care spending on home health and inpatient rehabilitation both increased. Changes in posthospital discharge location of care represent a significant shift in post-acute care utilization, which persisted 9 months into the pandemic. These shifts could have profound implications on the future of post-acute care. [ABSTRACT FROM AUTHOR]

Critical access hospitals are important providers of care for rural and other underserved communities, but they face staffing and quality challenges while operating with low margins. Medicaid expansion has been found to improve hospital finances broadly and therefore may have permitted sustained investments in staffing and quality improvement at these vulnerable hospitals. In this difference-in-differences analysis, we found that critical access hospitals in Medicaid expansion states did not have statistically significant postexpansion increases in operating margins relative to hospitals in nonexpansion states. Nor did we see evidence of statistically significant differential improvement at critical access hospitals in expansion versus nonexpansion states on either staffing measures (physicians and registered nurses per 1,000 patient days) or quality measures (percentage-point changes in readmissions and mortality within thirty days of admission for pneumonia or heart failure). These findings suggest that critical access hospitals may need to take additional measures to bolster finances to provide continued support for the delivery of high-quality care to rural and other underserved communities. [ABSTRACT FROM AUTHOR]

The columns display the monthly percent of all scheduled post-discharge primary care visits that were telemedicine. Among patients discharged after June 1, 2020, those who had telemedicine visits scheduled were more likely to be Black, female, and slightly younger compared to patients who had in-person follow-up scheduled (Table 1). The average time from discharge to first scheduled appointment was 1.4 days shorter for telemedicine than in-person visits ( I p i < 0.0001), the rate of scheduled follow-up within 7 days was 8.2% higher ( I p i < 0.001), visit completion rates were 22.5% higher ( I p i < 0.001), and the rate of seeing one's assigned PCP was 2.6% higher ( I p i = 0.04). [Extracted from the article]

The article presents the discussion on reforming nursing home financing. Topics include providing safe, affordable, equitable, high-quality, person centered care in the facilities emerged as a national priority; and addressing non-compliance by facilities such as denial of payment for new admission and civil monetary penalties.

Prior research and the popular press have anecdotally reported inadequate nursing home staffing levels during the COVID-19 pandemic. Maintaining adequate staffing levels is critical to ensuring high-quality nursing home care and an effective response to the pandemic. We therefore sought to examine nursing home staffing levels during the first nine months of 2020 (compared with the same period in 2019), using auditable daily payroll-based staffing data from the Centers for Medicare and Medicaid Services. We found that the total number of hours of direct care nursing declined in nursing homes during the COVID-19 pandemic, as did the average nursing home census. When we accounted for changes in census, the number of nurse staff hours per resident day remained steady or, if anything, increased slightly during the pandemic. The observed increases in staff hours per resident day were small but concentrated in nursing homes operating in counties with high COVID-19 prevalence, in nursing homes with low Medicaid census (which typically have more financial resources), and in not-for-profit nursing homes (which typically invest more in staffing). These findings raise concerns that although the number of staff hours in nursing homes did not decline, the perception of shortages has been driven by increased stresses and demands on staff time due to the pandemic, which are harder to quantify. [ABSTRACT FROM AUTHOR]

Background: Several policymakers have suggested that the Affordable Care Act (ACA) has fueled the opioid epidemic by subsidizing opioid pain medications. These claims have supported numerous efforts to repeal the ACA.Objective: To determine the effect of the ACA's young adult dependent coverage insurance expansion on emergency department (ED) encounters and out-of-hospital deaths from opioid overdose.Design: Difference-in-differences analyses comparing ED encounters and out-of-hospital deaths before (2009) and after (2011-2013) the ACA young adult dependent coverage expansion. We further stratified by prescription opioid, non-prescription opioid, and methadone overdoses.Participants: Adults aged 23-25 years old and 27-29 years old who presented to the ED or died prior to reaching the hospital from opioid overdose.Main Measures: Rate of ED encounters and deaths for opioid overdose per 100,000 U.S. adults.Key Results: There were 108,253 ED encounters from opioid overdose in total. The expansion was not associated with a significant change in the ED encounter rates for opioid overdoses of all types (2.04 per 100,000 adults [95% CI - 0.75 to 4.82]), prescription opioids (0.60 per 100,000 adults [95% CI - 1.98 to 0.77]), or methadone (0.29 per 100,000 adults [95% CI - 0.78 to 0.21]). There was a slight increase in the rate of non-prescription opioid overdoses (1.91 per 100,000 adults [95% CI 0.13-3.71]). The expansion was not associated with a significant change in the out-of-hospital mortality rates for opioid overdoses of all types (0.49 per 100,000 adults [95% CI - 0.80 to 1.78]).Conclusions: Our findings do not support claims that the ACA has fueled the prescription opioid epidemic. However, the expansion was associated with an increase in the rate of ED encounters for non-prescription opioid overdoses such as heroin, although almost all were non-fatal. Future research is warranted to understand the role of private insurance in providing access to treatment in this population. [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]

The past several decades have seen significant policy efforts to improve the quality of care in nursing homes, but the patient safety movement has largely ignored this setting. In this study we compared nursing homes' performance on several composite quality measures from Nursing Home Compare, the most prominent recent example of a national policy aimed at improving the quality of nursing home care, to their performance on measures of patient safety in nursing homes such as pressure sores, infections, falls, and medication errors. Although Nursing Home Compare captures some aspects of patient safety, we found the relationship to be weak and somewhat inconsistent, leaving consumers who care about patient safety with little guidance. We recommend that Nursing Home Compare be refined to provide a clearer picture of patient safety and quality of life, allowing consumers to weight these domains according to their preferences and priorities. [ABSTRACT FROM AUTHOR]

The article offers information on the challenges faced by the Nursing Home Crisis amid the Covid-19 pandemic in the U.S. It mentions that U.S. regulatory policies, including the Federal Nursing Home Reform Act of 1987, have attempted to address deficiencies in the quality of care amid the pandemic in the U.S.

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.

Accurate measurement of performance in health care must account for patient characteristics. Wallace and colleagues reported a study that suggested that current methods for risk adjustment are inadequate. The editorialists discuss the findings and the need to better match policy tools, such as performance measurement, with policy goals. [ABSTRACT FROM AUTHOR]

Objective: Performance thresholds are commonly used in pay-for-performance (P4P) incentives, where providers receive a bonus payment for achieving a prespecified target threshold but may produce discontinuous incentives, with providers just below the threshold having the strongest incentive to improve and providers either far below or above the threshold having little incentive. We investigate the effect of performance thresholds on provider response in the setting of nursing home P4P.Data Sources: The Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) datasets.Study Setting and Design: Difference-in-differences design to test for changes in nursing home performance in three states that implemented threshold-based P4P (Colorado, Georgia, and Oklahoma) versus three comparator states (Arizona, Tennessee, and Arkansas) between 2006 and 2009.Principal Findings: We find that those farthest below the threshold (i.e., the worst-performing nursing homes) had the largest improvements under threshold-based P4P while those farthest above the threshold worsened. This effect did not vary with the percentage of Medicaid residents in a nursing home.Conclusions: Threshold-based P4P may provide perverse incentives for nursing homes above the performance threshold, but we do not find evidence to support concerns about the effects of performance thresholds on low-performing nursing homes. [ABSTRACT FROM AUTHOR]

The article discusses a study which examines the impact of value-based purchasing programs which aim to reduce hospital readmission. Topics include the incorporation of social risk dimensions into the hospital readmissions reduction program (HRRP) models, the differences in risk of readmission between safety-net hospitals and nonsafety-net hospitals and the conflicting evidence on the extent of HRRP in reducing readmission rates.

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]

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]

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]

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]

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]

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]

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

Abstract: Public reporting of quality information is designed to address information asymmetry in health care markets. Without public reporting, consumers may have little information to help them differentiate quality among providers, giving providers little incentive to compete on quality. Public reporting enables consumers to choose highly ranked providers. Using a four-year (2000–2003) panel dataset, we examine the relationship between report card scores and patient choice of nursing home after the Centers for Medicare and Medicaid Services began publicly reporting nursing home quality information on post-acute care in 2002. We find that the relationship between reported quality and nursing home choice is positive and statistically significant suggesting that patients were more likely to choose facilities with higher reported post-acute care quality after public reporting was initiated. However, the magnitude of the effect was small. We conclude that there has been minimal consumer response to information in the post-acute care market. [Copyright &y& Elsevier]

The authors argue that public reporting of health-care quality measures will not inform and educate patients. They cite current limitations of public quality reports, including patient perceptions of quality differ from definitions used in public reporting, and reported measures may not be relevant to a number of patients. They mention potential solutions to these limitations, including promoting the benefits of selecting high-quality health-care providers.

The payment approach known as "pay-for-performance" has been widely adopted with the aim of improving the quality of health care. Nonetheless, little is known about how to use the approach most effectively to improve care. We examined the effects in 260 hospitals of a pay-for-performance demonstration project carried out by the Centers for Medicare and Medicaid Services in partnership with Premier Inc., a nationwide hospital system. We compared these results to those of a control group of 780 hospitals not in the demonstration project. The performance of the hospitals in the project initially improved more than the performance of the control group: More than half of the pay-for- performance hospitals achieved high performance scores, compared to fewer than a third of the control hospitals. However, after five years, the two groups' scores were virtually identical. Improvements were largest among hospitals that were eligible for larger bonuses, were well financed, or operated in less competitive markets. These findings suggest that tailoring pay-for-performance programs to hospitals' specific situations could have the greatest effect on health care quality. [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]

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]

Whereas numerous policies have been adopted to improve quality of care in nursing homes over the past several decades—with varying degrees of success—health care payment has been a largely untapped but potentially powerful policy tool to improve quality of care. Recently, however, payers have invested significant resources in the development and implementation of pay—for—performance (P4P) programs for nursing homes. The authors present results from a survey of state Medicaid agencies documenting the use and structure of P4P in nursing homes. Although the number of states that are implementing nursing home P4P is growing, the structure of these incentives varies across states, and little evidence exists to guide the planning or implementation of these initiatives. [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]

Although pay-for-performance (P4P) is being widely adopted, little is known about how different P4P strategies affect provider payment. These differences may be essential in motivating and maximizing quality improvement across all providers. We review hospitals' P4P strategies and describe differences in payments by size of reward; payment differences between high- and low-performing providers; ability to reward improvement in the absence of high performance; and the percentage of payments based on performance. Bonuses vary considerably by payment strategy, which suggests that the strategy selected should vary depending on program goals. These findings are relevant to P4P for any type of provider. [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]

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]

Background: Recent work has shown that clinically complex patients are more likely to receive recommended care, but it is unknown whether higher achievement on individual performance goals results in improved care for complex patients or detracts from other important but unmeasured aspects of care, resulting in unmet needs and lower satisfaction with care.Objective: To examine the relationship between measured performance and satisfaction with care among clinically complex patientsDesign and Participants: An observational analysis of a national sample of 35,927 veterans included in the External Peer Review Program in fiscal years 2003 and 2004.Measurements: First, compliance with individual performance measures (breast cancer screening with mammography, colorectal cancer screening, influenza vaccination, pneumococcal vaccination, lipid monitoring, use of ACE inhibitor in heart failure, and diabetic eye examination), as well as overall receipt of recommended care, was estimated as a function of each patient's clinical complexity. Second, global satisfaction with care was estimated as a function of clinical complexity and compliance with performance measures.Main Results: Higher clinical complexity was predictive of slightly higher overall performance (OR 1.13, 95% CI 1.09 to 1.18) and higher performance on most individual performance measures, an effect that was mediated by increased visit frequency. High measured performance was associated with higher satisfaction with care among patients with high clinical complexity. In fact, as complexity increased, the effect of achieving high performance on the odds of being satisfied with care also increasedConclusions: Not only was measured performance higher in clinically complex patients, but satisfaction with care was also higher among clinically complex patients with high measured performance, suggesting that compliance with performance measures in clinically complex patients does not crowd out unmeasured care. [ABSTRACT FROM AUTHOR]

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

The article 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.

Performance measurement has been widely advocated as a means to improve health care delivery and, ultimately, clinical outcomes. However, the evidence supporting the value of using the same quality measures designed for patients with a single clinical condition in patients with multiple conditions is weak. If clinically complex patients, defined here as patients with multiple clinical conditions, present greater challenges to achieving quality goals, providers may shun them or ignore important, but unmeasured, clinical issues. This paper summarizes the proceedings of a conference addressing the challenge of measuring quality of care in the patient with multiple clinical conditions with the goal of informing the implementation of quality measurement systems and future research programs on this topic. The conference had three main areas of discussion. First, the potential problems caused by applying current quality standards to patients with multiple conditions were examined. Second, the advantages and disadvantages of three strategies to improve quality measurement in clinically complex patients were evaluated: excluding certain clinically complex patients from a given standard, relaxing the performance target, and assigning a greater weight to some measures based on the expected clinical benefit or difficulty of reaching the performance target. Third, the strengths and weaknesses of potential novel measures such change in functional status were considered. The group concurred that, because clinically complex patients present a threat to the implementation of quality measures, high priority must be assigned to a research agenda on this topic. This research should evaluate the impact of quality measurement on these patients and expand the range of quality measures relevant to the care of clinically complex patients. [ABSTRACT FROM AUTHOR]

The article discusses the clinical concerns of clinical performance measurement as one of the foundations to improve health care quality. It is stated that eventhough performance measurement achieved success in clinical applications, many physicians remain apprehensive of its use since it gets in the way of delivering good care. It is also suggested that performance measurement is better suited to improve measured care.

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.

Health care report cards publicly report information about physician, hospital, and health plan quality in an attempt to improve that quality. Reporting quality information publicly is presumed to motivate quality improvement through 2 main mechanisms. First, public quality information allows patients, referring physicians, and health care purchasers to preferentially select high-quality physicians. Second, public report cards may motivate physicians to compete on quality and, by providing feedback and by identifying areas for quality improvement initiatives, help physicians to do so. Despite these plausible mechanisms of quality improvement, the value of publicly reporting quality information is largely undemonstrated and public reporting may have unintended and negative consequences on health care. These unintended consequences include causing physicians to avoid sick patients in an attempt to improve their quality ranking, encouraging physicians to achieve “target rates” for health care interventions even when it may be inappropriate among some patients, and discounting patient preferences and clinical judgment. Public reporting of quality information promotes a spirit of openness that may be valuable for enhancing trust of the health professions, but its ability to improve health remains undemonstrated, and public reporting may inadvertently reduce, rather than improve, quality. Given these limitations, it may be necessary to reassess the role of public quality reporting in quality improvement. [ABSTRACT FROM AUTHOR]

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.

The decline in the number of medical students choosing to enter the field of child neurology is a concern. We undertook this study to learn more about the qualities of highly regarded medical schools that may play a role in attracting students to the field of child neurology. We surveyed child neurologists at top U.S. medical schools that were most successful and least successful at attracting students to child neurology to determine what factors influenced the number of students entering the field of child neurology. We determined that the medical schools that produced the most child neurologists had stronger neuroscience curricula, stronger academic reputations, and larger Divisions of Child Neurology. Our findings suggest that our attention should be focused on academic centers that have more resources to create an atmosphere that is appealing to prospective applicants. These schools should implement a curriculum in neuroscience and child neurology that specifically exposes students early and maintains their interest in the field of child neurology. [Copyright &y& Elsevier]

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.